Rate of Maltreatment Among Children with Disabilities

Children and youth with disabilities are 3.44 times more likely to be victims of child maltreatment than children without disabilities. They are 3.75 times more likely to be neglected, 3.79 times more likely to be physically abused, 3.87 times more likely to be emotionally abused and 3.14 times more likely to be sexually abused than nondisabled children.

These data are from a population-based study of 40,211 children and youth enrolled in a public school system in the Midwest in 1995. A computer merger of these 40,211 names with child abuse and neglect central registry and police databases indicated an overall maltreatment prevalence rate of 11%. Some 22% of the 4,503 maltreated children had an identified disability for which they were receiving special education services. Among the children without an identified disability, 9% were victims of maltreatment. In contrast, 31% of the children with disabilities had records of maltreatment.

Source:

Sullivan, P.M. & Knutson, J.F. (1997). Maltreatment and disabilities: A school-based epidemiological study. Washington, DC: National Center on Child Abuse and Neglect Clearinghouse.

A hospital-based epidemiological study of 39,352 children seen at the Boys Town National Research Hospital from 1982 through 1992. A computer merger of these 39,352 names with child abuse and neglect central registry and police databases indicated a 15% prevalence rate of maltreatment for this hospital-based population. Maltreated children were 2.2 times more likely to have a disability than nonmaltreated children. Children with disabilities were 1.8 times more likely to be neglected, 1.6 times more likely to be physically abused, and 2.2 times more likely to be sexually abused than children without disabilities.

Source:

Sullivan, P.M. & Knutson, J.F. (1998). The association between child maltreatment and disabilities in a hospital-based epidemiological study. Child Abuse & Neglect, 22(4), 271-288.

In both population-based studies, police and child abuse registry case records indicated that intrafamilial perpetrators (i.e., immediate and extended family members) accounted for the majority of the neglect (98.7%), physical abuse (88.2%), emotional abuse (95.4%), and sexual abuse (53.1%). Extrafamilial perpetrators (non-family members) accounted for almost half (46.9%) of the sexual abuse indicating that disabled children are victims of sexual assaults by non-family members including, baby-sitters, clergy, van and bus drivers, care attendants, friend of parents, older students, peers, neighbors, houseparents, and strangers.

Thus, please consider adding children and youth with disabilities to Objectives 6, 8, and 9.

In the school-based population study, essentially equal numbers of disabled and nondisabled maltreated children (20%) had records of domestic violence in either central registry or police records of the maltreatment. Among the disabled maltreated children, neglect, physical abuse, parental alcohol and/or drug abuse, and a record of running away were significantly associated with domestic violence.

Thus, please consider adding children and youth with disabilities to Objectives 5 and 7.

A population-based study in Massachusetts (i.e., the Disabled Persons Protection Commission) found that 48% of 9,609 disabled adults utilized a Protection Commission Hotline to report abuse by caretakers or violence within the home: Family violence (40%), spouse abuse (13%), intimate partner violence (4%), and child abuse and neglect (43%).

Thus, please consider adding adults with disabilities to Objectives 5, 6, 7, and 8.

Developmental Objectives

Given the increased incidence of maltreatment among children and youth with disabilities and the current trend to educate the majority of these children in inclusive or regular school settings, please consider adding children and youth with disabilities to Objectives 12 and 16.

WASHINGTON STATE DEPARTMENT OF HEALTH

Chapter 4: Educational and Community-Based Programs

Proposal: Recommend a more consistent definition and use of the terms "health promotion program" and "health promotion initiative." These need to be clarified so that the most appropriate term is used consistently for an agreed upon meaning.

Proposal: Disagree with eliminating HP 2000 Objective 8.9, family discussion of health issues. We should keep this objective and raise the goal.

Rationale: While it is true the goal was exceeded, the current baseline is only 83 percent. There is still room for improvement. Studies show that, contrary to appearances, children and adolescents care very much about their parents views on risk behaviors, and that parents still have a great deal of influence over the choices made by their children and adolescents.

Objective 2 School Health Education

Proposal: Add the following reference to this as part of a coordinated school health program.

To maximize health and learning in schools, eight components of a coordinated school health program need to exist and reinforce each other. These eight components include health instruction, health services, healthy environment, physical education, food service, counseling, school-community collaboration and staff wellness.

Rationale: The eight components of comprehensive school health have been adopted by CDC, and are now the basis for measurement.

Proposal: Change references to "health education" to "health and physical education."

Rationale: Health and physical education are of equal importance in a comprehensive school health program. This also promotes our national health objective to encourage youth to be more active.

Objective 3 Undergraduate health risk behavior information

Proposal: Add "vocational-technical schools."

Rationale: Considering health disparities related to educational completion, this objective should not be limited to colleges and universities.

Objective 4 School nurse-to-student ratio

Proposal: Add the following sentence to the end of paragraph #2:

While ratios are a place to start, assessing each school using critical need would give a more accurate picture of what is needed for delivery of comprehensive health care. This could lead into serious consideration of alternative staffing models using trained, competent paraprofessionals and building staff to perform delegated duties under the supervision of a nurse, and allow more time for a nurse to attend to students with critical health needs who require skilled nursing care."

Rationale: The use of ratios has always been arbitrary and controversial. There is no real basis to support the ratio of 1:750, and it assumes that every building has similar student populations with similar needs. We know this is not the case. Based on assessed need, there may be a need for having a nurse placed in the majority of school buildings because of the need for nursing care for an increasing number of students. There is growing interest in Washington State to look at different models of staffing for delivery of health services in schools. This could mean using paraprofessional staff and other building staff to perform tasks that are non-nursing in nature or ones that can be delegated by the school nurse to non-nursing personnel. The successful use of alternative models for delivery of comprehensive health care in schools assumes that training and supervision will occur and that staff performing delegated duties will have met competency criteria.

Objective 6 Participation in employer-sponsored health promotion activities

Proposal: Last paragraph discusses reasons for disparity in participation between salaried and hourly employees, and suggests more appropriate marketing to hourly employees. Recommend we define "marketing" to specifically mention timing of activities in relation to shift work.

Rationale: Publicity alone will not address systemic barriers, which include the scheduling of activities that exclude a portion of the workforce.

Objective 12 Elderly Participation in Community Health Promotion

Proposal: With a current baseline of 12 percent, the goal of 90 percent participation should be lowered to a more attainable figure.

Proposal: Add a new objective related to elderly practicing good nutrition and physical activity behavior outside a structured setting. (Data Source: Behavioral Risk Factor Surveillance System)

Rationale: This objective is too narrow, and the goal of 90 percent is too high. By focusing on an "organized health promotion program" we leave out a large segment of the population that prefers to participate in health promotion learning and behavior outside of a structured setting. Research is clear that men’s participation in classes and programs is significantly lower than women’s. If we aim for this objective as written, we will promote a "joining" behavior, to the exclusion of a large segment of the target population. This is also contrary to current Surgeon General’s that recommendations for making physical activity a part of our every day lives.

WASHINGTON STATE DEPARTMENT OF HEALTH

Diabetes Chapter 18

Objective 23 Diabetes education

Proposal: Change wording to read "Increase to 52% the proportion of persons with diabetes mellitus who have received formal diabetes education within the last five years."

Rationale: Given the changes in diabetes knowledge, it is not enough to get diabetes education once, as implied in the original wording of this objective. The baseline data for this goal is highly suspect that 43% receive formal diabetes education. The National Health Interview Survey is clearly self-report and should be compared to administrative data for billings for this service. The Diabetes Control Program will have a population-based evaluation of education delivery from our Washington multi-health plan study by the end of 1998.

WASHINGTON STATE DEPARTMENT OF HEALTH

Chapter 1 Physical Activity and Fitness

Terminology section

Proposal: Add definitions for sustained physical activity, moderate physical activity, vigorous physical activity and leisure time in the Terminology section.

Objective 1 Leisure time physical activity

Proposal: Measure all physical activity -- take out the words "leisure time."

Rationale: Our recent focus groups revealed that people do not perceive themselves to have "leisure" time, and that "leisure" and "active" are mutually exclusive.

Objective 2 Sustained physical activity

Proposal: Use "moderate" instead of "sustained," and incorporate the concept of being active for 10 minute bouts for a total of 30 minutes a day.

Rationale: The word moderate is consistent with the language used in "Physical Activity and Health" a report released by the Surgeon General in 1996.

Objective 3 Vigorous physical activity

Proposal: Sixty percent of maximum heart rate is not vigorous, this amount should be increased.

Rationale: A more commonly used definition for vigorous physical activity is 70 to 85% of maximum heart rate.

Objective 12 Access to school physical activity facilities

Proposal: Add baseline information and percentages for objective 12. Also, put the documentation about objective 12 after objective 12 rather than after objective 13.

Rationale: Baseline information is needed for objective 12 to be consistent with the other objectives. Moving the documentation will make the information more understandable.

Add objective following Objective 14

Proposal: Proposed new objective #15: Increase to at least 10 percent the proportion of walking trips taken by adults for transportation, and to at least 15 percent the proportion of walking trips taken by children for transportation, as a percentage of all trips taken.

(Baseline: Walking accounted for 5.4 percent of all trips taken in 1995 for adults, and 9.9 percent of all trips taken in 1995 for children.)

Data Source: National Personal Transportation Survey conducted by the US Department of Transportation.

Rationale: Walking is a very popular form of physical activity in the United States. However, people need to be given the opportunity to walk safely in order to make the decision to do so. According to the National Personal Transportation Survey conducted by the US Department of Transportation, walking trips as a percentage of all trips taken has declined over the years since the surveys were first taken. Walking dropped from 9.3 percent in 1977, to 7.2 percent of all trips in 1990 and again to just 5.4 percent of all trips for adults in 1995. Walking declined even more sharply for children. This documented decline in walking has wide implications for the health of adults and children.

The 1996 Surgeon General’s report on Physical Activity and Health revealed that in 1992 just 26 percent of youth aged twelve to twenty-one walked or bicycled for 30 minutes in a given week, and the number declined to 21 percent in the 1995 survey. Only about half of American youth aged twelve to twenty-one participate in vigorous physical activity, while 25 percent participate in no vigorous physical activity at all. It also concluded that physical activity "declines strikingly as age or grade in school increases." At the same time, the National Health and Nutrition Survey shows a marked increase in child obesity since 1963, with the biggest increase in the most recent edition of the survey. Childhood obesity is now a very serious problem among US children, with almost a quarter (22 percent) of American children considered obese. This is of concern because it is likely that many of these youths will go on to become sedentary, overweight adults. Compared with people who are most active, sedentary people experience between a 1.2 fold to a 2 fold increased risk of dying prematurely from factors associated with being overweight.

The justification for objective 15 is from the "Mean Streets 1998 Children at Risk Report". An annual report on pedestrian safety and federal transportation spending as part of the Surface Transportation Policy Project.

Add objective following 15

Proposal: Proposed new objective #16: Increase to X% the opportunities for all people, including children, to walk and bicycle by promoting the development of sidewalks, trails and bike lanes in communities.

Data Source: To be developed.

Rationale: The Washington State Department of Health considers environmental supports to be essential to promoting behavior change, and recommends that factors which enable people to practice healthy behaviors be included in every chapter. For example, Chapter 1 Physical Activity and Fitness, makes no mention of such essential elements as sidewalks, bike and walking paths and trails, or partnerships with urban planning and public works agencies, which are key to creating walkable and bikable communities. Without such environmental supports, people cannot safely practice this health promoting behavior and make it a part of their every day lives.

It is plausible to assume that because the environment does not adequately provide opportunities for safe and spontaneous physical activities such as walking and biking, adults and children are spending more time indoors. According to a study by Anderson et al., over a quarter of US children spend four hours or more watching television daily. Sedentary activities such as television watching, playing video games, and using personal computers have contributed to increasing the prevalence of overweight Americans (Anderson, Crespo, Bartlett, Cheskin and Pratt, 1998). However, if the environment provides safe sidewalks and bicycle pathways, more children may be engaging in moderate physical activities such as walking and biking. Consequently, such environments provide health benefits to American children, adults and communities. Walking provides benefits to both the walker and the community. People who walk regularly are measurably healthier, and every time a walking trip replaces a car trip, it helps reduce auto congestion and pollution.

My name is Ann Pobutsky and I am a faculty research associate with the Oregon Office on Disability and Health, located at Oregon Health Sciences University in Portland, Oregon. Our office works in conjunction with the Oregon Health Division on a state capacity building project funded by the Centers for Disease Control (CDC).

Our office assesses the prevalence of disability and secondary conditions associated with disability, in order to address the prevention of such secondary conditions and expand assessment, policy and health promotion and wellness activities for people with disabilities in Oregon.

Our program, along with others in over 65 programs and research projects in the U.S. and its territories, is a member of the American Association on Health and Disability (AAHD). The AAHD has encouraged all members to send a representative to this regional meeting to ensure that Chapter 19: Disability and Secondary Conditions is included in Healthy People 2010 Objectives. Moreover, all members were encouraged to communicate the need to include people with disabilities in all Chapters. That is, people with disabilities need to be included as a select population, like ethnic minorities, people of low socio-economic status and gender. Overall, in assessing the Chapters, people with disabilities are left out as a select population except for access to health care.

The fact is, people with disabilities are not only a minority group in terms of their primary disability or secondary medical or social conditions, but are also disproportionately more likely to be of low socioeconomic status. Attempting to "eliminate disparities in health care" means attempting to eliminate the very social resource and status disparities among people. This means including select populations or minority groups in all the Chapter objectives for health promotion, disease and disability prevention.

Based upon US Census data (1990, 1997) for the U.S. as a whole, about 49 million people have a disability (1 in 5 persons), and the disability rate is 19.4% (McNeil, 1997). Yet, disability rates differ by age, sex, race/ethnicity and income. Rates are higher for older people and women; women’s longer life expectancy "...means that women make up a large share of older persons with a disability (65.2% of persons 65 years old and over with a severe disability are women)(McNeil, 1997)." Disability is associated with lower income levels and poverty, a reduced chance for employment, and an increased likelihood of having health insurance from the Federal Government (Medicare/Medicaid). Disability also varies by race/ethnicity, with the highest rates among American Indians, Eskimos, Aleuts and Blacks and the lowest among Asians and Pacific Islanders.

It is for these reasons that our office encourages not only the inclusion of Chapter 19, with the recommendations and changes, but also the inclusion of people with disabilities as a special population in all the Chapters as well.

I have attached our specific comments and suggestions about Chapter 19, as well as the operational definition about disabilities, which were also sent via electronic mail. If additional feedback is appropriate, please do not hesitate to contact our office.

Reference cited:

McNeil, John. (1997) Disability. U.S. Department of Commerce, Bureau of the Census. Washington, D.C.

My biggest concern is that these Chapter 19 objectives are 'developmental' but they should definitely be included, not just proposed. For example, re: #11, these

additions to the BRFSS as a "participation and environmental" portion of the disability module are keys to what was being developed and pushed as a focus by

people with disabilities and the disabilities researchers at the National Conference on Disabilites and Health in Dallas, TX in October 1998 and the Disability forum at the American Public health Association Conference in November 1998.

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