1) The study examined whether specific chronic health conditions increase the risk of abuse or neglect for young Medicaid-enrolled children under age 6. 2) It found that children with behavioral/mental health conditions were nearly twice as likely to experience abuse or neglect as children without such conditions. 3) Children with physical health conditions were also at a slightly higher risk of abuse or neglect compared to children without conditions. Developmental/intellectual disabilities did not increase the risk of maltreatment.

1. Do chronic conditions increase young children’s risk of being maltreated? Paula Kienberger, Lucy Mackey-Bilaver Reviewed by: Lindsey Mullinax, Heather Jones & Hayfa Kheiry November 11, 2008 Psyc 308

2. Objective - To examine whether and to what extent specific chronic health conditions place young children at risk of maltreatment .

3. Children with special needs are at an increased risk of maltreatment. Several studies have sought to better understand factors that increase the risk of maltreatment. Many findings have shown that added stress can increase the caregivers strain.

4. Background The National Center for Child Abuse and Neglect (NCCAN) found that children with disabilities had maltreatment rates 1.7 times higher than children with out disabilities.

5. The NCCAN defined a child of having a disability if it matched two out of three criteria. The study found that: Rate of physical abuse among children with disabilities was 9 per 1,000, 2.1 times children without disabilities Rate of sexual abuse among children with disabilities was 3.5 per 1,000, or 1.8 times children without disabilities Rate of physical neglect among children with disabilities was 12 per 1,000, or 1.6 times children without disabilities

6. NCCAN Research The NCCAN study was based on casewrokers’ opinions rather than on physicians’ diagnosis codes. Spencer et al. studied the relation between disabling conditions and child maltreatment, but they were unable to diagnosis whether the conduct disorder was diagnosed before or after the neglect.

7. Sullivan and colleagues conducted two different studies, both finding neglect and maltreatment rates higher in children with disabilities. However, both studies had flaws that did not allow for precise results.

8. Studies have focused on the strain on parenting or the household that children with special needs can cause. Although well documented that special needs can increase family stress, few studies have examined the degree to which risk is increased by particular conditions.

9. There is an estimated 18% of children in the US with special needs. The National Association of Children’s Hospitals and Related Institutions found that 23.2% of children enrolled in medicaid had one or more cronic conditions. Illiniois, the site of the current study, more than 300,000 children were reported to have special needs in 1994, which would be 10.1% of all children 0-17 in the state.

10. The main goal of this study is to examine to what extent specific health conditions place young children at risk of maltreatment. There was no formal hypothesis made

11. Methods Sample The study used a sample of 101,189 children born between January 1990 and March 1996, who were through age 3 continuously enrolled in Medicaid. The majority of the sample was African American (54.9%), followed by Caucasian (29.7%), Hispanic (14.2%) and other race/ethnicities (1.2%). The gender of children was almost evenly split 51% male. Through administrative data, records of 11,803 children were identified who were Medicaid recipients and who also a substantiated record of abuse or neglect by age 6. Probabilistic record matching was used to link the Department of Children and Family Services records to the Medicaid study population. Using ICD-9-CM codes from Medicaid paid claims, health conditions were categorized into three groups of chronic conditions: chronic physical illness, developmental delay and mental retardation, and behavior and mental health conditions.

12. Methods Analysis A Cox proportional hazards model was used to assess whether a relationship exists between maltreatment and any of the three categories of chronic conditions. This model estimates the relative risk (RR) of the health conditions on likelihood of child maltreatment for the sample. Model 1: Estimated the relative risk of abuse or neglect at any time between ages of 0 and 6 for the study population conditional on Medicaid enrollment. Model 2: Estimated the relative risk of abuse or neglect between the ages of 3 and 6. Model 3: Controlled for prior abuse or neglect as an infant (under age 1) versus as a young child (age 1 or 2). Model 4: Controlled for having a prior substantiated report of substance exposure in utero Each model used time-varying controls for the first diagnosis of each of the three types of chronic conditions

13. Results

17. Discussion This study shows… that chronic behavioral/mental health conditions place low-income, young children at greater risk of maltreatment than their peers without such conditions. youth under the age of 6 with these conditions are nearly twice as likely to be abused or neglected as those without such conditions. having a chronic physical health condition also places the child at marginally greater risk of abuse or neglect, but the risk is less than for behavioral/mental health conditions.

18. developmental/mental retardation does not place a child at greater risk of maltreatment at any age. children between the ages of 3 and 6, when behavior/mental health problems are more likely to be identified, the risk of maltreatment are also nearly twice that of children without behavior/mental health problems. children with a prior substantiated case of abuse or neglect before age 3 and those who also have a chronic behavior/mental health problem are at even greater risk of subsequent maltreatment than other children. children with behavior problems were more likely to be abused after age 6. preschool aged children (under age 6) with behavioral problems are also more likely than those without such problems to be at higher risk of abuse or neglect.

19. It is surprising that given the physical and cognitive limitations, which can place major demands on families, on their time, work-family balance, finances, and emotions, that this study reveals developmental/mental retardation and physical health conditions placing young children at no or marginally greater risk of maltreatment, given that several studies have found heightened risk regardless of type or disability.

20. Limitations The study was restricted to administrative data that can trace only those children who used services. In this case, the data was limited to children with diagnosed conditions and ignored those who have not visited a doctor reimbursed by Medicaid, or whose doctors did not make the diagnosis. The data provided no information on the severity of the condition or the functional ability of the child. Information about the chronic conditions was only available for the children receiving public health insurance.

21. Limitations The definition of special needs is not uniform in the literature, especially between pediatric and child welfare studies. Children with special needs in some studies may include those who are difficult to place in foster or adoptive homes, such as older children, minority children, multiple children in the family, and those children with medical or behavioral/mental health problems. Therefore, comparisons across studies are difficult and limited.

22. Conclusions Young, low-income children that received public health insurance with an identified behavior/mental health were at an increased risk of child maltreatment. Chronic physical health conditions also placed children at slightly elevated risk of maltreatment. Pediatricians, child welfare professionals, and others who interact regularly with children should be alert to the heightened risk of maltreatment among these groups of children.

23. Resources Jaudes, P., & Mackey-Bilaver, L. (2008). Do chronic conditions increase young children’s risk of being maltreated?. Child Abuse and Neglect (32), 671-681. Miller-Perrin, Cindy. & Perrin, R.D. (2006). Child Maltreatment . Second edition. Thousand Oaks, CA: Sage.