UNIDADES DE MODULO

Introduction

The previous chapter highlighted how disabled children’s identities and aspirations are largely similar to those of non-disabled children (Stalker, 2012), It also reviewed research findings regarding some of the challenges associated with growing up with a disability. These include pressure on family relationships and restricted access to friendship and other opportunities, often at least as much related to negative attitudes concerning disability and a lack of appropriate support as to children’s impairments themselves (Davis, et al, 2003). Although, despite these stresses, the vast majority of disabled children report feeling happy and well supported by their families (Connors and Stalker, 2003; Wickenden, 2011; Foley et al, 2012).

As well as other forms of adversity there is clear evidence that disabled children’s overall risk of violence and maltreatment is significantly higher than that of non- disabled children (Jones et al, 2012). Moreover, research suggests that maltreatment involving disabled children is particularly likely to go un-recognised and be under- reported (Miller and Brown, 2014). Disabled children are also less likely than other children to be receiving support via a child protection plan (Ofsted, 2012), but more likely to be placed in out-of-home care (Baker, 2007; Kelly et al, 2016). This concerning situation therefore justifies this study’s focus on the experiences of the minority of disabled children receiving support via child protection processes.

This chapter reviews what is known about how maltreatment involving disabled children is recognised and responded to within child protection systems in the UK and elsewhere. This is in order to contextualise this study’s research question concerning disabled children’s views and experiences of receiving help and support during and following child protection enquiries. It starts by briefly outlining how child maltreatment is defined and the circumstances under which it is seen as justifying professional intervention into family life. Research specifically linking disability with maltreatment is then reviewed and potential explanations for this association evaluated.

In the second part of the chapter the iCAN framework (ican.uea.ac.uk), for understanding the processes of recognition, telling and help from the child’s perspective (Cossar et al, 2013), is used to analyse evidence regarding practice

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responses towards maltreated disabled children. A similar approach was used to review the literature about maltreatment and childhood disability in an earlier article by Hernon et al (2015) (Appendix 3). However, the material used here has been updated to reflect changes in Cossar et al‘s (2013) framework, as well as research published since that time.

Child maltreatment and child protection

As outlined in the preceding chapter, child maltreatment has received increasing attention in the UK and other high-income countries from the 1960s onwards. This has come about partly as a result of growing evidence regarding both the prevalence and adverse consequences of maltreatment for children’s long-term health and development (Gilbert et al, 2009a). This evidence, and an understanding of children as inherently vulnerable, has been seen as justifying and driving state-legislated intervention into family life through the setting up of child protection systems to protect children from such harm (Daniel, 2010). Social workers in the UK and other countries have a central role in administering and delivering these services in practice. This includes applying thresholds and helping to make decisions, alongside other professionals, as to what constitutes child maltreatment for individual children. Understanding of what constitutes child maltreatment has developed over time, and continues to be subject to some variation, in a similar way to how debates regarding how disability is defined have evolved. From Kempe’s (1962) ‘discovery” of battered child syndrome, which focused on parental physical abuse, child maltreatment has generally come to be seen as including “any acts of commission or omission by a parent or another caregiver that result in harm, potential for harm, or threat of harm to a child (usually interpreted as up to 18 years of age), even if the harm is not the intended result” (Gilbert, 2009a).

Maltreatment is widely recognised as encompassing four types of abuse: physical abuse; sexual abuse; emotional or psychological abuse and neglect. Although, children witnessing intimate partner violence is increasingly also considered a form of maltreatment. The Adoption and Children Act (2002), for example, broadened the Children Act (1989) definition of “harm”, used to guide child protection enquiries and assessments in England under Section 47 of the Children Act (1989), to:

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“Harm means ill-treatment or impairment of health or development, including for

example, impairment suffered from seeing or hearing the ill-treatment of another”

Section 31 (9) Children Act (1989)

Moreover, most policy definitions place an onus on all caregivers to safeguard children from maltreatment, including teachers and childminders (e.g. Working Together, HM Government 2018). In practice, however, parents are responsible for over 80% of child maltreatment, except for sexual abuse, which is mostly perpetrated by non-relatives or extended family members (Gilbert et al, 2009a).

There is much less consensus, however, regarding at what level of severity parent or caregivers acts of commission or omission are recognised as maltreatment and as requiring a child protection response. Gilbert et al (2009b) found high income countries with a “child-safety” approach (US, most of Canada and Australia), where the child protection services’ focus is on investigating/responding to reported maltreatment, had higher referral and substantiated maltreatment rates and lower levels of ongoing service provision than those with a “child and family welfare” approach (UK, Japan, New Zealand, and most European Countries), where child protection enquiries and decision-making processes form part of wider service provision for vulnerable children and their families.

In countries with a child and family welfare approach referrals involving neglect, emotional abuse and exposure to intimate partner violence were also more likely to be viewed as in need of support rather than protection (Gilbert et al, 2009b). As well as indicating a higher threshold for child protection intervention, such trends are also suggestive of a different interpretation of the causes of child maltreatment as at least partly related to family stress and/or an accumulation of other difficulties (Thoburn, 2013). A thematic inspection of child protection referrals involving disabled children in England, for example, found evidence of emerging concerns being dealt with effectively at an early stage through multi-agency co-ordination of support as children in need helped negate the need for formal child protection enquiries and intervention (Ofsted, 2012). This was offered as one possible explanation for the relatively low numbers of disabled children identified by this inspection as being the subject of a child protection plan (Ofsted, 2012).

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Conversely, other evidence shows higher levels of child protection enquiries and intervention among children exposed to other forms of adversity. Despite more child and family support-oriented policies since the introduction of the Children Act (1989) and as a result of Every Child Matters (2003), Bywaters (2015) found that over 50% of the variation between English Local Authorities in rates of children who have a child protection plan or who are placed in out of home care is explained by comparative deprivation scores. A child living in a city with high rates of poverty, such as Blackpool, for example, is six to eight times more likely to have a child protection plan or to be placed in out-of-home care than one living in an affluent area, such as Richmond Upon Thames (Department of Education, 2013a; 2013b cited in Bywaters et al, 2016. Higher rates of poverty among disabled children may therefore partly help explain their greater likelihood of being placed in out-of-home care (Baker, 2007; Kelly et al, 2016), despite their apparently lower rates of other types of child protection intervention (Ofsted, 2012).

Evidence linking child maltreatment with other forms of disadvantage, including poverty is persistent, but remains under-researched (Bywaters et al, 2016). It has also received less policy attention in high-income countries, including the UK, since the global financial crisis of 2007, resulting in reduced investment in early help services (Gilbert et al, 2011), including services for disabled children and their families (Stalker, 2015). This has led some to argue for a social model of “child protection” to be applied to understanding and responding to macro-level structural causes of child maltreatment in a similar way to that developed in relation to disability and disabled people (Lonne et al, 2016; Featherstone et al, 2018).

Although, reaffirming the need for child protection systems to encompass both protective and supportive responses, the Munro Review of the child protection system in England also called for a rebalancing away from an individually pathologising over- focus on risk towards more preventive child and family-based approaches to child maltreatment (Munro, 2011). Children’s internationally legislated rights (UNCRC, 1989) to protection from maltreatment (Article 19), to express their views (Article 12) and to achieve a good quality of life (Article 27), including receiving support to aid their recovery from abuse (Article 39) are likewise seen as crucially interconnected within a children’s rights approach to maltreatment (UN Committee on the Rights of the Child, 2003).

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All of the issues outlined above have important implications for this study’s exploration of social work and child protection practice with disabled children. This is especially given evidence outlined in the previous chapter that they are at higher risk of experiencing poverty (Blackburn et al, 2010) and other forms of social exclusion (McLaughlin et al, 2012; Beresford and Clarke, 2009), as well as at increased risk of exposure to violence and maltreatment (Jones et al, 2012). The research evidence specifically linking disability with maltreatment is discussed in the next section, along with a more detailed exploration of the possible causes for this association.

Disabled children and maltreatment

Disabled children have long been considered at greater risk of violence and maltreatment (Kelly, 1992; Sobsey, 1994; Westcott and Jones, 1999). A substantial body of evidence exists to support this assertion. While estimates vary, Jones et al (2012) meta-analysis confirmed Sullivan and Knutson’s (2000) earlier work, finding violence and maltreatment to be 3 to 4 times more common among disabled children, with emotional abuse and neglect most prevalent. Several studies indicate that disabled children’s risk of maltreatment also varies according to impairment type, with having a mental or intellectual disability, communication impairment or behavioural difficulty being more strongly associated with maltreatment (Sullivan and Knutson, 2000; Spencer et al, 2005; Jones et al, 2012).

Despite persistent evidence linking disability with maltreatment, the underlying causes for this association are poorly understood. Robust, well-designed studies on this topic are scarce. There are very few population-based studies, with Jones et al’s (2012) systematic review and meta-analysis finding only four out of the 17 studies reviewed had adequately controlling for possible confounding factors, such as birth- weight and socio-economic status (Jones et al, 2012). Wide variation in how disability and maltreatment are defined also makes comparison across different studies difficult, further contributing to a lack of clarity regarding prevalence rates (Jones et

al, 2012). Studies also shed little light on the important question of the extent to which

disability can be a consequence of, rather than a risk factor for maltreatment (Jones

et al, 2012). Moreover, scant consideration is given to theoretical perspectives (Leeb et al, 2012).

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Regardless of the lack of methodologically sound studies, a number of possible explanations for disabled children’s increased risk of maltreatment have been proposed. Early theories suggested that disabled children’s additional difficulties and support needs potentially triggered maltreatment due to increased parental stress (Ammerman, 1991). Empirical evidence has provided little support for this explanation, however, since severity of disability does not necessary correlate with increased parental stress or risk of maltreatment (Benedict et al, 1992; Verdugo et al 1995). Nevertheless, Spencer et al’s (2005), population-based study of 15,8229 children in West Sussex found children with learning difficulties or conduct disorders were 5 and 7 times respectively more likely to have a child protection plan than those without these conditions, which these authors suggested was partly due to a shared etiologic pathway between these conditions and child abuse and neglect.

Later accounts, drawing on transactional-ecological understandings of child development and maltreatment (Cicchetti et al, 2000), explain the association between disability and maltreatment as arising from complex interactions between vulnerability factors in the child, their caregivers and the wider environment. At an individual level, the quality of the attachment relationship between a child and his or her carers is seen as promoting or impeding the potential for both development and maltreatment. Howe (2006) argues it is this factor, rather than the presence of disability per se, that accounts for increased maltreatment rates among disabled children. This assertion is supported by a meta-analysis of 34 studies on attachment classifications within clinical samples finding lower levels of secure attachments and slightly more disorganised attachments among disabled children (van IJzendoorn et

al, 1992).

Transactional-ecological perspectives may also help explain evidence of inter- relationships between disability, maltreatment and other forms of disadvantage. For example, numerous studies have identified increased incidence of both disability and maltreatment among children from lower socio-economic backgrounds (Sidebotham

et al, 2002; Blackburn et al, 2010). As discussed, earlier caregivers of disabled

children are also more likely to experience social isolation and financial problems, due to higher costs and reduced employment opportunities (Leeb et al, 2012). Similar factors have been shown to cumulatively affect maltreatment risk in population-based studies (Stith et al, 2009; MacKenzie et al, 2011). Moreover, a shift towards a relational, ecological interpretation of child maltreatment reflects similar

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developments in how disability is understood as affecting children and their family’s quality of life, as outlined in the previous chapter (Thomas, 1999; Shakespeare and Watson, 2010).

Interactions between disability and other socio-demographic variables may also help account for the different maltreatment patterns noted among disabled children (Stalker and McArthur, 2012). For example, most evidence puts disabled boys at even higher risk of maltreatment than non-disabled boys (Kvam, 2000), in one study making up 70.3% of maltreated disabled children (Sullivan and Knutson, 2000). Herschkowitz et al (2007) also found disabled boys were significantly more likely than disabled girls to experience physical abuse, but less likely to be sexually abused. However, Briggs (2006) found disabled boys were equally likely to experience sexual abuse, but less likely to report it.

Evidence regarding how other factors may influence disabled children’s risk of maltreatment is less clear. For example, while Sullivan and Knutson (2000) found maltreatment of disabled children began at earlier ages, Herschkowitz et al’s (2007) study found no such variation in maltreatment involving disabled and non-disabled according to age. Similarly, although cultural and religious attitudes towards disability have been shown to affect disabled children’s’ experiences and life chances (Danseco, 1997; United Nations, 2006), most research indicates no differences in maltreatment and disability rates between different races (Gourdine, 2013), though there is a noticeable lack of majority world studies. However, one American study found maltreatment rates among disabled children were significantly higher among white children than Hispanic children and those from other ethnic minority backgrounds (Jaudes and Mackey-Bilaver, 2008).

Westcott and Jones (1999) argue that growing up disabled in a society which places value on being able-bodied and discriminates against disabled people, as highlighted by social models of disability, may contribute to disabled children’s increased risk of maltreatment. Since, partly as a result of these attitudes, disabled children are more likely to experience physical and social isolation (including institutional care) and have less control over their lives and bodies than those without disabilities. Negative societal attitudes towards disabled children may also help to explain evidence indicating that maltreatment involving disabled children tends to be more severe (Sullivan and Knuston, 2000; Kvam, 2004), is often more violent (Akbas et al, 2009),

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and is more likely to involve multiple forms and recurrent episodes of abuse than that involving non-disabled children (Sullivan and Knutson, 2000). This explanation is also further supported by research finding that disabled adults are also at elevated risk of experiencing violence and maltreatment compared to adults without disabilities (Jones et al, 2012).

It therefore seems reasonable to conclude from the evidence reviewed above, that disability represents an important risk factor for maltreatment. However, reliable evidence regarding the precise nature of this association is lacking, and its underlying causes are understood to be both complex and variable (Stalker and McArthur, 2012; Leeb et al, 2012). Nevertheless, maltreatment of disabled children represents a significant public health concern. This is especially given the devastating consequences of maltreatment for children’s health and development. These include child mortality and morbidity, enduring effects on mental health, and increased risk of substance mis-use, risky sexual behaviour, obesity and criminal behaviour continuing into adulthood (Gilbert et al, 2009a). Moreover, research indicates that the risks to children’s health and development are greatest where maltreatment involves multiple types and repeated exposure (Glaser, 2000; Lee and Hoaken, 2007), as is more often the case among disabled children (Sullivan and Knutson, 2000).

Recognising and Responding to the Maltreatment of Disabled Children

Given that disabled children are at greater risk of maltreatment, recognising and responding to maltreatment involving disabled children should be a priority. Disabled children have the same rights to protection and to receive support as other children under the United Nations Convention on the Rights of the Child (UNCRC, 1989) as well as under Section 47 of the Children Act (1989) in England and similar legislation in other parts of the UK. The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD, 2006) reinforces states’ responsibilities to provide for disabled children’s additional needs in sustaining their equal rights, including the right to express their views (Article 7) and that of protection (Article 16). Disabled children are specifically identified as a group of children in additional need of support and services under Section 17 (c) of the Children Act (1989). However, despite this legislative rhetoric the overlap between disability and maltreatment has received relatively little attention in policy and research (Mikton et al, 2014).

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Successive reviews have identified areas of concern in relation to child protection practice with disabled children in the UK (Morris, 1998; Cooke and Standen, 2002; Stalker, et al, 2010; Ofsted, 2012; Taylor et al, 2016). Stalker et al (2010) concluded that disabled children were ‘almost invisible’ within mainstream child protection policies in the 4 UK countries and that recording practices regarding cases of maltreatment involving disabled children were poor. Although the issuing of specific practice guidance “Safeguarding disabled children” (Murray and Osbourne, 2009) in England was generally welcomed (Miller and Brown, 2014), it illustrates a continued tendency for childhood disability to be regarded as a separate policy issue (Stalker, 2012). Munro’s comprehensive review of the child protection system in England and Wales (Munro, 2011), following Peter Conolly’s death, likewise made no reference to disabled children’s increased risk of maltreatment.

Taylor et al (2016) concluded that “there has been very little research conducted on child protection and disabled children in Britain over the last decade” (p. 62). Similar statements were also made by Morris in 1998, Cooke and Standen in 2002 and Stalker and McArthur in 2012, reflecting the long-standing dearth of research on this topic. Stalker and McArthur’s (2012) review highlighted a particular lack of knowledge regarding disabled children and young people’s own perspectives of their experiences during child protection enquiries and their aftermath.

There have been some studies published since 2012 whose findings are discussed in detail later in this review. The majority of these have been small-scale qualitative studies, involving case file analysis and interviews or focus groups with practitioners and other adult stakeholders (Ofsted, 2012; Taylor et al, 2014; Kelly and Dowling, 2015). The notable exception being Kelly et al’s (2016) mixed methods study of the characteristics and experiences of disabled children in out-of-home care in Northern Ireland. This study involved quantitative analysis of the characteristics and circumstances of all disabled children placed in out-of-home care compared with their non-disabled peers (n=323). It also included 15 qualitative case studies involving case file analysis and interviews with disabled children, their caregivers and social workers.

Studies focusing on disabled children’s perspectives of maltreatment have also been conducted by Shah et al (2016) (n=15, 18-65 years), Jones et al, (2017) (n=10, 12- 51 years), and Franklin et al (2015; 2018), (n=27, 12-23 years). These study’s findings

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are limited by their small sample size and self-selection being used to recruit participants, who consequently may be more likely to have pre-existing interest in the