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Special Needs, Higher Abuse Risks :

October 26, 2017

Child maltreatment is a challenging issue to address in the office or hospital setting, and children with special health care needs and disabilities can be at higher risk for maltreatment.

Figure 1. A landmark study published in 2000 noted that children with disabilities were nearly 4 times more likely to be physically abused or neglected and more than 3 times more likely to be sexually abused when compared to children without disabilities.Child maltreatment is a challenging issue to address in the office or hospital setting, and children with special health care needs and disabilities can be at higher risk for maltreatment. Just as importantly, they also are at higher risk for injuries that can happen during routine care, for example, because of immobility and osteopenia, or bleeding abnormalities due to the adverse effects of chronic medications on liver function.

The October issue of Pediatrics in Review includes a wonderful review, “Child Abuse in Children and Youth with Special health Care Needs,” by Drs. Brodie, McColgan, Spector and Turchi. It highlights the vital role that the primary care physician plays for special needs children and their families: Providing a trusted medical home, ensuring access to general and subspecialty care, and advocating for access to community-based services and, of course, financial coverage for medical and behavioral services across the life span.

This is an important review that highlights a number of educational gaps and provides a number of resources for the primary care provider. What stands out in this review for our readers and young physicians and trainees? I will highlight two key points here.

First, there are many resources within the American Academy of Pediatrics, including the AAP Council on Child Abuse and Neglect, that can provide continuing education as well as quick office-based resources for making the diagnosis.

For example, there are bruising patterns that may raise concerns for physical abuse. Sentinel injury literature reminds us that bruising over soft tissue surfaces, head, neck, face, and torso must be evaluated carefully for the possibility of inflicted injury, which often can occur in the context of frustration during care or discipline.

Figure 2. Teaching slides, including the slide above, are available as a supplement to this important review. Other teaching slide sets to accompany a broad range of PIR reviews are available via the Teaching Slide link on the journal’s table of contents site, or link directly  at: http://pedsinreview.aappublications.org/content/teaching-slides. A number of years ago, in collaboration with the parent of a child with autism spectrum disorder, I helped create a community-based educational video on self-injurious behavior (SIB). As a child abuse pediatrician, I rarely get consulted on children with disabilities and physical abuse injuries, but from working with this parent I learned firsthand how challenging behaviors may lead to frustration on the part of a caregiver and harm for the child. We often forget these children may be in the care of babysitters, residential treatment facilities, or respite placements—caregivers who may not know the child or be able to cope with the behaviors as well as the child’s parents.

Second, making this video reminded me of the important partnership between parents of a special needs child and their medical home pediatrician. Practical office-based suggestions include making sure SIB is on the problem list, with examples of the specific injury patterns; placing photos in the chart to document injury; and developing a short explanatory letter that could be in the record as a flag or “FYI” regarding the need to be aware of SIB as a presentation for injuries.

Advocating for health, welfare and safety for children with disabilities or special health care needs is inherent to our makeup as pediatricians and includes ensuring the child is safe from abuse and/or neglect. As AAP members, we have a wealth of resources for this task. Check out the practice resources and parenting resources from the AAP, listed at the end of the review, as well as the teaching slides that accompany this worthwhile article.

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