In a recently released issue of Pediatrics, Dr. Miriam McLean and colleagues explore maltreatment risk among children with disabilities in Western Australia 1990-2010 using large population-based registries (10.1542/peds.2016-1817). The authors accessed 4 administrative databases which included a range of disability diagnoses identified or recorded at birth or hospital admission, and through receipt of educational services or mental health care. Diagnoses included intellectual disability, Down syndrome (coded as a separate disorder), birth defect or cerebral palsy, autism, conduct disorder, and other mental health or behavioral disorders. Among all children with disabilities, 15.6% had at least one co-morbidity, and among those with intellectual disability, 62.6% had one or more co-morbidities. Basic demographic information about parents included socioeconomic level based on neighborhood census tract, and any history of hospital contact for mental health, substance abuse or interpersonal violence. Finally, episodes of maltreatment allegation and substantiation were obtained from the Department for Child Protection and Family Support.
Overall, and after controlling for other risk factors, children with a disability diagnosis did have a significantly higher risk of both maltreatment allegation and substantiation than children without disability. While this result makes sense, it is not the whole answer, since risk was not distributed evenly across diagnoses, and not all disabilities appeared to confer added risk. I will note, for example, that children with Down syndrome were not at increased risk. The authors speculate on causes for the uneven distribution of maltreatment risk across the spectrum of disabilities, but clearly more research will be needed since large databases lack many details such as the child’s age of diagnosis, the chronicity and severity of the disorder, and data on parental resources, supports and stressors, that might shed light on the question.
What interests me most is the issue of causality, which the authors do address in their Discussion. Children with mild or moderate intellectual disability, mental/behavioral problems and those with conduct disorder had a higher risk of maltreatment, even after accounting for family and neighborhood risk factors. The authors also noted that the disabilities most strongly associated with maltreatment appeared to co-occur with clusters of social risk, such as parental mental health problems, living in poor neighborhoods and having young parents. Is it possible that the mental/behavioral problems, intellectual disability and conduct problems are actually a result of rather than a cause of maltreatment? While risk could be bi-directional (i.e. maltreatment could both cause and result in mental/behavioral health issues), good evidence causally links childhood physical abuse with childhood (and adult) mental health problems.1-3 Both family stress and lower socioeconomic status, even without physical maltreatment, are causally linked to lowered childhood IQ.4,5 The public health impact of sorting out the direction of the association (between maltreatment and both childhood mental/behavioral problems and IQ) is not trivial, since presumably preventive programming should be focused on the cause rather than the result of the problem. I believe this study has raised more questions than it has answered, and hopefully more excellent research will follow.
- McCrory E, De Brito SA, Viding E. The link between child abuse and psychopathology: A review of neurobiological and genetic research. Journal of the Royal Society of Medicine. 2012;105: 151-156.
- Mulvaney MK, Mebert CJ. Parental corporal punishment predicts behavior problems in early childhood. J Fam Psychol. 2007; 21:389-97.
- Teicher MH, Samson JA. Annual Research Review: Enduring neurobiological effects of childhood abuse and neglect. J Child Psychol Psychiatry. 2016; 57: 241-66.
- Marcus Jenkins JV, Woolley DP, Hooper SR, De Bellis MD. Direct and Indirect Effects of Brain Volume, Socioeconomic Status and Family Stress on Child IQ. J Child and Adolesc Behav. 2013;1:1000107.
- Ursache A, Noble KG, Pediatric Imaging, Neurocognition and Genetics Study. Socioeconomic status, white matter, and executive function in children. Brain Behav. 2016 Aug 2;6(10):e00531.