Promoting safety in children with disabilities

INTRODUCTION — Children with disabilities are at increased risk for unintentional injuries, intentional (inflicted) injuries, and child neglect. Behavioral, physical, and cognitive characteristics of the child and environments that are not well adapted for individuals with disabilities contribute to the increased risk.

Given the prevalence of disability among children in the United States (approximately 8 percent) [1], it is important that parents, caregivers, and health care providers understand the factors that increase the risk of injury and the potential strategies to minimize it. Primary care providers play a key role in improving the safety of children with disabilities through anticipatory guidance, counseling, treatment, and referral.

The epidemiology, contributing factors, and strategies to prevent unintentional and intentional injuries in children with disabilities will be reviewed here. The principles of injury control and the biologic implications of chronic conditions in childhood are discussed separately. (See "Pediatric injury prevention: Epidemiology, history, and application" and "Children and youth with special health care needs".)

UNINTENTIONAL INJURY

Epidemiology — In a national survey, approximately 17 percent of children in the United States were reported by their caregivers to have a disability [2]. Unintentional injuries are more frequent among children with disabilities than those without disabilities. In another survey, students with disabilities reported more injuries than those without (67 versus 51 percent per year) [3]. They also sustained more severe injuries and required medical attention more frequently than their nondisabled peers, findings that have been noted in other studies [4-8].

Predisposing factors

Behavioral factors — Children with behavior disorders (eg, increased activity, impulsivity) are more likely than those without behavior disorders to engage in hazardous behaviors that may result in unintentional injury [9-11].

●Attention deficit hyperactivity disorder – Attention deficit hyperactivity disorder (ADHD) is perhaps the best studied behavioral disorder with an increased risk of injury. Potential contributing factors for increased risk of injury include impulsive, hyperactive, and inattentive behaviors, as well as potentially compromised caregiver-child relationships (secondary to ADHD) and comorbid disorders (such as oppositional defiant disorder [ODD]) [9]. (See "Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis", section on 'Prognosis'.)

●Self-injurious behavior – Self-injurious behaviors, such as head-banging, biting, scratching, and hair-pulling, occur at increased rates in individuals with developmental disabilities, particularly autism spectrum disorders (ASD) and intellectual disability (ID) [12,13]. Risk factors for self-injurious behavior in children with ASD include younger age, increased delay in attainment of daily living skills, level of irritability, and increased severity of autism [14,15]. Children with ASD also are predisposed to injury because of potential concomitant ID. (See 'Intellectual factors' below.)

●Other behavioral disorders – Other behavioral and emotional disorders have been associated with increased risk of injuries in some studies, but the mechanisms are not as well understood as those for ADHD. In a national cohort study, ODD was associated with an increased risk for burns and poisonings (perhaps because children with ODD may fail to heed the warnings or instructions of supervising adults); anxiety was associated with an increased risk for poisoning and head injury; and depression was associated with an increased risk of fractures [16].

Intellectual factors — The prevalence of injury, including those requiring hospitalization, in children and adolescents with ID is 1.5 to 2 times that of children and adolescents without IDs [12,13,17-19]. The types of injuries that occur with increased prevalence among children and adolescents with IDs include burns, poisonings, foreign body injuries, fractures, dislocations, and internal injuries [16]. The risk of injury is particularly increased in children with IDs and comorbid disruptive behaviors, anxiety, difficulties with social interactions, impaired communication, or ADHD symptoms [18].

Cognitive skills that are necessary to prevent injury and that may be impaired in children with IDs include the ability to learn and obey safety rules, accurately estimate physical abilities (eg, strength, balance), attend to and understand the risks of a given situation, and understand the cause of injury after it occurs [9].

In addition to compromised hazard recognition and coping skills, children with IDs may have concomitant physical disabilities (eg, poor gross motor skills or coordination, obesity, visual impairment) and psychopathology (ie, behavioral or emotional problems) that contribute to their increased risk of injury [18].

Biologic factors — Biologic features of certain conditions may increase the risk or severity of injury [20]. Osteopenia in cerebral palsy and sensorimotor deficits in various disorders are two examples.

●Cerebral palsy – Children with cerebral palsy frequently have decreased bone density (osteopenia), which increases their risk of fracture with minimal trauma. Factors that contribute to decreased bone density in children with cerebral palsy include decreased weight bearing, feeding dysfunction resulting in poor nutritional status, abnormal muscle tone, and use of anticonvulsants (which increase the catabolism of vitamin D). (See "Cerebral palsy: Classification and clinical features", section on 'Osteopenia' and "Etiology of hypocalcemia in infants and children".)

●Sensorimotor deficits – Children with sensorimotor deficits (eg, myelomeningocele and other neurologic conditions) are at increased risk for burns and an increased risk of complications when burns occur [21]. (See "Overview of hereditary neuropathies".)

●Sensory impairments – Children with vision and hearing impairments are at increased risk of injury, particularly when they do not use prescribed sensory aids (eg, glasses, hearing aids) [22,23].

Environmental factors — Environmental factors may increase the risk of injury if the environment is not adapted to the needs of individuals with disabilities [7]. Environments that may require adaptation include streets, sidewalks, motor vehicles, school, and home.

●Transportation – Children with disabilities are at increased risk of injury during transportation, whether they are walking, riding a bicycle, using a wheelchair, or riding in a motor vehicle.

In a national study of almost 300 children with disabilities, the risk of vehicle-pedestrian or vehicle-bicyclist collisions was almost five times greater for children with disabilities than for those without disabilities, after adjusting for age, sex, and family income [24]. Collisions were more frequent among children with and without disabilities who reported traffic difficulties (eg, too few/missing sidewalks, lack of knowledge of when it is safe to cross the street, insensitive/unaware drivers). Children with visual and hearing impairment are at particular risk of pedestrian injury [25]. Children with ADHD may exhibit behaviors and executive function deficits that place them at risk for pedestrian injuries [26]. Children with ID and ASD may have differences in understanding road safety rules that place them at risk for pedestrian injuries [27].

The design and performance of motor vehicle child restraint systems are regulated by Federal Motor Vehicle Safety Standard (FMVSS) 213 [28]. However, FMVSS 213 does not take the needs of children with disabilities into account. In addition, children with disabilities may have medical conditions or treatments (eg, placement in a spica cast for hip dislocation) that preclude proper use of a conventional car seat or restraint system [29].

Few studies have examined the risks of injury and the restraint patterns of children with disabilities traveling in motor vehicles. In an observational study, 70 percent of 115 children with special health care needs were unrestrained or inappropriately restrained in the private motor vehicle in which they arrived at a pediatric rehabilitation center [30]. In another observational study, nearly three-quarters of children with special health care needs in vehicles exiting the garage at a tertiary-care children's hospital had at least one misuse of the child safety seat (eg, harnesses not in a proper location, incorrectly anchored, etc), and only 8 percent of medical equipment was properly secured [31].

Studies exploring the risk of injury and restraint pattern among children with developmental disabilities in motor vehicle crashes revealed that, compared with children without special health care needs, a greater proportion of children aged 4 to 15 years with special health care needs likely to affect behavior (eg, ASD, intellectual disabilities) and children aged zero to eight years with special physical needs (eg, cerebral palsy) were reported by their driver to be appropriately restrained at the time of the crash. However, the risks of significant injury from the crash were similar in children with and without special health care needs, despite the increased usage of appropriate restraint [32,33].

Environmental risk factors related to injury among children who use motorized wheelchairs include traffic patterns, the condition of the wheelchair, whether it is properly adjusted and maintained, and whether items (such as knapsacks) are placed on the back of the chair (thereby altering the center of gravity) [20,34,35]. Host risk factors include younger age, male sex, and paraplegia or spina bifida.

Wheelchair securement and standards for special education school buses have been incorporated into national recommendations (FMVSS 222) [36]. Wheelchairs themselves, however, are not subject to mandatory crash-testing requirements.

●Child care and school – Young children with disabilities have higher rates of injuries in child care settings than do children without disabilities (4.8 versus 2.5 injuries per child per year) [37].

A review of data from pupil accident reports and school records describes the epidemiology of school-related injury in a large cohort of students from 17 special education schools in an urban school district [38]:

•The overall rate of injury was 4.7 per 100 students per year.

•Most injuries occurred on the playground and during organized play. The most common mechanisms of injury were falls (34 percent) and physical contact with other children, such as biting, kicking, pushing, tripping, and striking (31 percent).

•Most injuries were minor: superficial bruises (28 percent), cuts (28 percent), and abrasions (18 percent). The most common site of injury was the face.

•After adjusting for age, sex, school, and year of enrollment, children with multiple disabilities had the highest rates of injuries (odds ratio 1.7, 95% CI 1.3-2.3).

●Home – Individuals with a physical or cognitive disability have a two- to six-times higher risk of dying in a house fire compared with the risk of the general population [39]. Physical disability may impede an individual's ability to successfully execute an escape plan without help. Cognitive disabilities may impede an individual's awareness of the danger and/or the ability to implement the escape plan. Impaired physical and cognitive abilities also may increase the risk of drowning [20].

●Elopement – Among individuals receiving developmental disabilities services, the prevalence of elopement (or repeated attempts to leave designated areas without permission) is approximately 5 percent [40]. Prevalence among children with ASD and/or ID ranges from 30 to nearly 70 percent [41,42]. Children may elope from school or home. Elopement can lead children into life-threatening situations (eg, street traffic). (See 'Prevention of elopement' below.)

Elopement in children with ASD is discussed separately. (See "Autism spectrum disorder in children and adolescents: Overview of management", section on 'Routine care'.)

Prevention of unintentional injury

Overview — The declining rate of unintentional injuries among the general pediatric population suggests that injury prevention strategies have been effective. However, there is no central database tracking injuries among children with disabilities. General prevention strategies that are effective for all children should be strongly encouraged for families of children with disabilities [20]. (See "Pediatric injury prevention: Epidemiology, history, and application", section on 'Principles of injury prevention and control'.)

The most effective injury prevention strategies for all children are "passive interventions": those that do not require action by the child or caregiver (eg, guardrails, child-proof containers, air bags). Health care providers also should promote "active interventions," such as car safety restraint, smoke detectors, and bicycle helmets. For risky or self-injurious behaviors that cannot be managed with these general strategies, referral to a developmental pediatrician and/or behavioral psychologist may be warranted.

In addition to anticipatory guidance regarding general injury prevention strategies, primary care providers should tailor injury prevention advice to the patient's disability. As an example, caregivers of children with ADHD should be educated about the increased risk of injury in their children and the need for protective gear in certain situations (eg, bicycle helmets). (See "Bicycle injuries in children: Prevention" and "Attention deficit hyperactivity disorder in children and adolescents: Overview of treatment and prognosis", section on 'Prognosis'.)

To the extent that interventions are available, primary care clinicians also should provide interventions to address the biologic factors that increase their patients' risk of injury (eg, physical therapy, calcium, and vitamin D supplementation in children at risk for osteopenia). (See "Cerebral palsy: Classification and clinical features", section on 'Osteopenia'.)

Safe transportation — Promotion of awareness of the potential risk of injury during transportation is the first step in the prevention of such injuries.

Conventional restraint systems usually meet the safety needs of the child when the disability does not significantly impair muscle tone, posture, or breathing [28]. Older children with challenging behavior (eg, ADHD, ASD, or emotional problems) may require a safety restraint system that is less likely to be unbuckled by the child (eg, vests with rear back closure, high-back booster seats with internal harnesses).

General guidelines for safe transportation of infants and young children with disabilities are provided in the figure (figure 1). Safe transportation of premature infants is described separately. (See "Discharge planning for high-risk newborns", section on 'Car seat/bed use'.)

Alternatives for older children and adolescents who have outgrown car safety seats depend upon the level of head, neck, and trunk support that is needed [28]. Tethers, additional lap seat belts, or appropriate tie-down systems may be necessary. A physical-needs belt-positioning booster seat or conventional belt-positioning booster seat can ensure proper positioning of the lap and shoulder belts (lap belts should be positioned low and flat across the child's hips; shoulder belts should be snug across the child's chest). The shoulder belt should not be placed underneath the child's arms or behind the child's back.

Consultation with child passenger safety technicians may be helpful for children with disabilities that affect motor tone, posture, or breathing [31]. Passenger safety technicians can evaluate the fit of a restraining system to identify children who need specialized seating. Information on specialized seating and a national list of child passenger safety technicians can is available from the Indiana University School of Medicine Automotive Safety Program. (See 'Resources' below.)

Specific recommendations for wheelchair and occupant safety in school buses have been outlined in guidelines published by the American Academy of Pediatrics [28,36,43]. Children who can be "reasonably" transferred from the wheelchair to a vehicle seat equipped with dynamically tested occupant restraints or child restraint system that meets FMVSS requirements should be transferred for transportation. Guidelines for safe transportation of children who cannot be transferred from the wheelchair are provided in the table (table 1). Liquid oxygen tanks should be securely fastened to prevent damage and exposure to intense heat. The bus should display a sign indicating that oxygen is in use.

School safety — The Centers for Disease Control and Prevention (CDC) has published school health guidelines to prevent unintentional injuries, violence, and suicide [44]. The recommendations focus on establishing healthy social and physical environments, promoting health and physical education, providing health services, establishing crisis response systems, integrating family and community members, and training staff members. However, school injury prevention programs generally are not directed toward children with disabilities.

Fire safety — Environmental modifications that decrease the risk of fire injury among individuals with a disability include the presence of a potential rescuer, a working smoke alarm, a working telephone in an easily accessible location, a fire extinguisher, and an escape route that is planned in advance [39]. If there is a child with a disability in the home, the fire department should be contacted before an emergency occurs and asked to keep the information about the child's special health care needs on file [20,45]. Additional information on fire safety plans is available from the CDC and the United States Fire Administration.

Water safety — Children with disabilities should be closely supervised around bathtubs, pools, and any other bodies of water. More children with disabilities are participating in swimming programs alongside children without disabilities [12,13]. Children with disabilities can participate in a broad range of aquatic recreational activities with appropriate adaptation of both swimming/ water safety instruction and the use of adaptive personal flotation devices as needed. Specific recommendations on how to adapt aquatic programs to be inclusive of children with disabilities have been described [12,13].

Prevention of elopement — Strategies to prevent elopement, or to minimize the risk of serious injury if elopement occurs, include:

●Marking entryways and exits visually (eg, with yellow tape or large stop signs) to help children with disabilities to learn the boundaries of safety

●Identification tags should be worn or identification cards carried in wallets at all times

●Maintaining a current and easily accessible list of emergency contacts

●Alerting the local police that a child with disability lives in or attends school in the neighborhood

●Assigning adults who supervise children with disabilities specific roles in the event of an elopement and having the adults rehearse these roles in various elopement scenarios

The risk of elopement among children with ASD is discussed separately. (See "Autism spectrum disorder in children and adolescents: Overview of management", section on 'Routine care'.)

A referral to a behavioral psychologist for functional behavioral analysis of the child's behavior may be warranted for children prone to elopement [46]. Functional behavioral analysis looks for reinforcers of elopement behavior, which can then serve as the basis for prevention.

MALTREATMENT OR NEGLECT

Epidemiology — Children with disabilities are at higher risk for physical/emotional abuse, sexual abuse, and neglect than children without disabilities [47-53]. The prevalence of maltreatment is difficult to calculate because the definitions of child abuse, neglect, and disability may vary from state to state; disability status may not be included in the abuse record; maltreatment (including maltreatment that occurs outside of the family) may go underreported, and assessment of whether maltreatment occurred before the disability is often inadequate [47,54,55].

In a systematic review of observational studies of violence against children with disabilities from the United States and European region, the pooled prevalence of any type of violence was 27 percent (95% CI 14-42 percent) [55]. The pooled prevalence of physical violence was 20 percent (95% CI 13-29 percent), the pooled prevalence of sexual violence was 14 percent (95% CI 9-19 percent), the pooled prevalence of emotional abuse was 18 percent (95% CI 12-26 percent), and the pooled prevalence of neglect was 10 percent (95% CI 3-20 percent). The odds of violence among children with disabilities were three to four times those among children without disability.

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Children with intellectual disability (ID), autism spectrum disorder (ASD), mental or behavioral problems, and conduct disorder appear to be at particular risk [52,53,55-57]. In an analysis of children who were subjects of child abuse and neglect investigation in the United States, nearly one-half of the children had ID or emotional or behavioral impairments (eg, anxiety/depression, attention problems) [58].

Children with ASD are also at risk for bullying. In a national survey of 1200 caregivers of children with ASD, almost two-thirds of respondents reported that their children with ASD had experienced bullying at some point in their childhood and were bullied three times more frequently than their siblings without ASD [59]. Bullying occurred most frequently between 5^th and 8^th grade, though it occurred at every grade level. Bullying was more frequent in public school than in private or special education settings. In a meta-analysis of observational studies, the prevalence of school bullying victimization among children with ASD was 44 percent, the prevalence of school bullying perpetration was 10 percent, and the prevalence of both victimization and perpetration was 16 percent [60]. Factors associated with bullying perpetration include social skills deficits, externalizing symptoms (eg, hyperactivity, aggression, conduct problems), and depressive symptoms (rather than ASD severity itself) [61].

Contributing factors — Several factors may contribute to the increased risk of maltreatment among children with disabilities [54]. Some of these are related to the stresses associated with caring for a child with a disability; others are related to the child's increased vulnerability.

Stressors — In combination, the multiple stressors associated with raising a child with a disability may increase the risk of maltreatment. The stressors may include [20,54,62,63]:

●The child's challenging behaviors (eg, aggression, noncompliance) and reduced response to traditional means of reinforcement (eg, verbal praise or reprimands)

●The need for high levels of supervision and skilled care

●The need for specialized care and educational services

●Restricted opportunities for recreational activities for the child and family

●Financial challenges associated with increased costs of care of the child and decreased career advancement opportunities for the caregivers

●Limited opportunities for caregiver respite

●Social isolation, particularly for single caregivers

These stressors are discussed separately. (See "Children and youth with special health care needs", section on 'Types of special needs'.)

Vulnerability — Factors related to increased vulnerability include [20,54]:

●Limited communication skills – Children with disabilities that limit communication skills may be perceived as "easy targets" because of their limited ability to disclose abuse [64,65]. Children with limited communication skills also may not respond to traditional means of reinforcement (eg, praise, verbal reprimand). Parents and other caregivers may perceive this as intentional failure to respond to verbal guidance and, in their frustration, resort to physical discipline.

●Limited cognitive abilities – Intellectual limitations may prevent the child from being able to recognize abusive behaviors. Children with physical disabilities who are dependent on caregivers for physical needs may be unable to discern appropriate from inappropriate touching. In addition, the impaired judgment or impulse control of children or adolescents who have sustained brain injury may be exploited by peers who recruit them as accomplices to acts of violence [20].

●Exposure to multiple caregivers – Exposure to multiple caregivers in multiple settings increases the opportunity for abuse, including sexual abuse, and decreases the child's ability to develop a trusting relationship with an adult to whom they may disclose maltreatment.

●Limited capacity for self-defense – Personal safety information and self-defense techniques may not be easily accessible to children with disabilities. A cognitive disability may impede the ability to understand personal safety information; a motor disability may preclude the use of self-defense techniques or the ability to move away from emotionally charged or angry perpetrators.

●Sociocultural attitudes of peers – The sociocultural attitudes of peers may increase the risk of bullying, ridicule, or acts of violence against children with disabilities.

Foster care — Children in foster care may be at increased risk for abuse or neglect if the foster parents do not receive adequate information about the child's medical or emotional problems and are not prepared to deal with specific problems. (See "Comprehensive health care for children in foster care", section on 'Exposure to maltreatment'.)

Prevention of maltreatment — The American Academy of Pediatrics (AAP) clinical report on maltreatment of children with disabilities provides some guidelines for prevention and early detection [54]. These include:

●Remember that disability is a risk factor for child abuse or neglect, and remain vigilant for indications of abuse. Encourage parents to carefully select and screen the child's caregivers and to monitor the child's care regularly; this may include sporadic, unscheduled visits to the child's school, treatment, or residential facility.

●Establish a proactive role with caregivers and schools to foster improved communication should concerns arise.

●Encourage training and education of staff and personnel who may interact with children with disabilities (to increase awareness and improve detection). Help care providers identify the subtle signs of neglect and abuse.

●Address medical needs and family well-being at each health supervision visit. Provide referrals to a mental health specialist as indicated for caregivers with symptoms of depression or other emotional disorders.

●Provide support for the caregivers. Acknowledge the difficulties of caring for children with disabilities. Recognize and foster family strengths. Identify family stressors, and make appropriate referrals for support services (eg, support groups, stress management, respite care, home health services).

Management of suspected maltreatment — When child abuse or neglect is suspected, the child should undergo careful assessment by an experienced professional [54]. The evaluation should consist of a structured interview with the child, a thorough physical examination, and appropriate radiology and/or laboratory testing. (See "Physical child abuse: Recognition" and "Physical child abuse: Diagnostic evaluation and management".)

To prevent the misdiagnosis of child abuse, the evaluating clinician must be familiar with disorders that can mimic abuse. The evaluating clinician also must carefully consider the unique aspects of the child's disability that may predispose them to injury or delay in seeking medical attention (eg, osteopenia, impaired pain sensation, etc) [54]. A developmental and behavioral pediatrician, pediatric neurologist, and/or child abuse pediatrician may be consulted for additional guidance. (See "Differential diagnosis of suspected child physical abuse" and "Differential diagnosis of the orthopedic manifestations of child abuse".)

Suspected neglect or abuse must be reported to the appropriate child protective services agency. (See "Child abuse: Social and medicolegal issues", section on 'Reporting suspected abuse'.)

INJURY IN THE CRIMINAL JUSTICE SYSTEM — Individuals with disabilities represent a growing percentage of individuals in the criminal justice system [66]. The prevalence of intellectual disability (ID) in the criminal justice population is estimated to be 4 to 10 percent compared with 1 to 2 percent in the general population [67]. Although individuals with disabilities and individuals without disabilities commit crimes with similar frequency, the felonies committed by individuals with disabilities are usually less severe [67]. Studies examining the prevalence of individuals with autism spectrum disorder (ASD) in the criminal justice population are mixed, with some studies suggesting that individuals with ASD are overrepresented [68] in the criminal justice system and other studies showing that autistic with ASD are not more likely to commit crimes [69].

Individuals with IDs may be more vulnerable to arrest due to misunderstanding during questioning, reacting to intimidation by giving answers they believe officers want to hear, and not fully understanding their Miranda rights [70,71]. Individuals with ASD have reported that the emotional impact of the custody environment, communication barriers, and sensory differences contribute to the negative experiences with police [72].

Addressing criminal justice interventions is beyond the scope of this review. However, individuals with disabilities who participate in case management programs have lower rates of subsequent arrest [73]. Several case management programs are geared toward offenders with disabilities during the pretrial period (eg, the Developmental Disabilities Offenders Program in New Jersey, sponsored by the Arc of New Jersey [74]).

RESOURCES — Resources for the promotion of safety in children with disabilities are provided in the table (table 2).

SUMMARY AND RECOMMENDATIONS

●Introduction – Children and adolescents with disabilities have an increased risk of injuries compared with their nondisabled peers. Primary care providers play a key role in promoting the safety of children with disabilities through anticipatory guidance, treatment, counseling, and referral. (See 'Introduction' above.)

●Predisposing and contributing factors – Factors that may contribute to the increased risk of injury include behavioral problems, cognitive impairment, medical conditions, environments not well adapted to the needs of children with disabilities, psychosocial stressors associated with caring for a child with disability, and the increased vulnerability of a child with disability. (See 'Predisposing factors' above and 'Contributing factors' above.)

●Prevention of unintentional injury – Prevention of unintentional injury in children with disabilities encompasses the injury prevention strategies that are recommended for all children. In addition, primary care providers should tailor injury prevention advice to their patients' specific disabilities (eg, osteopenia, attention deficit hyperactivity disorder, visual impairment). (See 'Prevention of unintentional injury' above and "Pediatric injury prevention: Epidemiology, history, and application", section on 'Principles of injury prevention and control'.)

●Prevention of maltreatment – Prevention of maltreatment entails provision of anticipatory guidance regarding the increased risk of maltreatment in children with disabilities, provision of support to the families of children with disabilities, recognition and fostering of family strengths, and provision of developmentally appropriate self-protection training for children with disabilities. (See 'Prevention of maltreatment' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Nathan J Blum, MD, who contributed to an earlier version of this topic review.