Child maltreatment is an important cause of pediatric morbidity and mortality, and may have lifelong adverse consequences on a child. Many studies have evaluated risk factors for various forms of abuse, and children with disabilities and/or with special healthcare needs are recognized as having increased risk of child maltreatment.1,2, 5, 6, 7, 8 With 14% of American children and adolescents having special healthcare needs and nearly 22% of US households having at least 1 child with special healthcare needs, this represents a large opportunity for intervention from medical providers who are often in frequent contact with this population.1,2 In this review, the general term “children with disabilities” refers to children with any significant impairment in any area of motor, sensory, communicative, cognitive, social, or emotional functioning; “children with special healthcare needs” refers to children with chronic medical issues who generally require more healthcare than children with typical health and developmental needs.1

The Centers for Disease Control and Prevention (CDC) defines child maltreatment as “any act or series of acts of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child.”9 The broad term “child maltreatment” encompasses physical abuse, sexual abuse, medical child abuse (also known as caregiver fabricated illness in a child or Munchausen by proxy), and all forms of child neglect. There are numerous previously published studies and reviews on this topic. However, maltreatment of children with complex medical needs is less commonly evaluated; recent studies published in this niche area include a strong focus on risk factor identification. The goals of this article are to review what is known and to summarize recommendations and implications for medical providers.

The rate of abuse and neglect is frequently reported as being at least 3-4 times higher for children with disabilities than in children without disabilities, and children with disabilities tend to experience more frequent and more serious physical and sexual violence than children without disabilities.1,2, 10, 11, 12 Additionally, the risk of abuse or neglect varies with the type and severity of disability or medical needs. For example, children with intellectual disabilities (ID) or psychological problems are at increased risk of physical and emotional maltreatment; children with congenital defects suffer neglect, particularly supervisory neglect, at higher rates; and children who are nonverbal are at increased risk of sexual abuse. 1, 2,10, 12, 13 Children with medical complexity are at increased risk of neglect, especially medical neglect. 1, 2,3,5, 10, 11, 12, 13, 14, 15, 16, 17

In general, the causes of maltreatment in children with medical complexities and/or disabilities are those that increase the risk for child abuse for all children, and are typically related to family stressors. One of the most frequently cited stressors related to any form of child maltreatment is poverty.1, 2, 3, 4, 5, 18, 19 Families and caregivers experiencing poverty can have significant hardships, which may result in toxic stress that can impact neurocognitive development of children and can impede caregivers’ abilities to meet the needs of their children.1,2,4 Further, marital stress, employment stress, and fatigue are also reported as contributors to child maltreatment risk and demonstrate stronger positive correlation when involving a child with disabilities.1 Financial constraints exacerbate the increased caregiving demands for parents of children with disabilities, in addition to struggles with time limitations, transportation difficulties, and increased physical and emotional burdens.2,10

Additional risk factors have been suggested by authors to explain the higher rates of child maltreatment in children with medical complexities. Children with special healthcare needs may be more vulnerable to abuse due to the nature of their conditions. They may be more isolated from the community and rely more on caregivers for basic needs. Caregivers may have the false perception that these children do not sense pain or that individuals will not harm them. Children with complex medical conditions and disabilities may be unable to disclose abuse due to communicative impairments, or may be unaware of what constitutes abusive or inappropriate contact due to intellectual disability or lack of child education on this topic.1

Risk factors for child maltreatment may also stem from limitations in parental understanding of their child's medical conditions. Misalignment in developmental capacities of a child and parental demand can result in children being pushed to achieve at higher standards than congruent with their developmental capabilities.5, 6 In a survey of parents of children with special needs, respondents repeatedly listed requests incongruent with their child's developmental stage, revealing less awareness for their child's needs, in comparison to a normative sample.6 This decreased awareness of a child's needs and feelings was associated with lower levels of empathy for their child's limitations, which may contribute to increased risk of maltreatment. However, parents seem to have more realistic and developmentally congruent expectations when their children have more severe disabilities.

Data from Child Protective Services (CPS) indicates increased rates of CPS reporting in children with chronic medical conditions.1,7, 15, 16 A study found that children with autism spectrum disorder (ASD) were 2.5 times more likely to be reported to the child abuse hotline by age 8, when compared to children without ASD.8 Other authors have also reported increased rates of CPS reporting for children with mental or behavioral disorders.1

Children with special healthcare needs are also more likely to have recurrent and substantiated reports to CPS than children without special healthcare needs, and are significantly overrepresented in the US foster care system.1, 2, 7, 8 It is well-recognized that children who experience neglect or abuse are at increased risk for future maltreatment. However, the substantiated re-reporting rate is nearly double for children with disabilities compared to children without disabilities, indicating higher incidence of reported and substantiated child maltreatment for children with disabilities.7 As the authors of this study noted, children with complex healthcare needs and their families may possess inherent social risk factors for recurrent abuse, but the provision of services may be associated with an increased likelihood of recurrent reporting, regardless of the disability status of the child. Children who received an initial report may be more likely to experience a re-report due to more frequent contact with professional reporters.