About CE
"CE Corner" is a continuing education article offered by the APA Office of CE in Psychology.
To earn CE credit, after you read this article, purchase the online exam at www.apa.org/ed/ce/resources/ce-corner.
Upon successful completion of the test — a score of 75 percent or higher — you can immediately print your CE certificate.
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Overview
CE credits: 1
Learning objectives: After reading this article, CE candidates will be able to:
- Discuss how common violence is among people with disabilities.
- Discuss the risk factors that make people with disabilities more prone to be victims of violence.
- Discuss strategies to prevent violence against people with disabilities.
Fifteen to 20 percent of the population—an estimated 53 million Americans, and some one billion people worldwide—live with some form of disability. Among the varied challenges they face is an increased risk of violence.
Despite that link, there's a paucity of research to describe who is most at risk, the types of threats they face, and how to prevent abuse and violence. "We live in a society which disrespects disabled people. Violence toward them is a function of that, and lack of research is a function of that," says Tom Shakespeare, PhD, a professor of disability research at Norwich Medical School at the University of East Anglia.
Maltreatment of people with disabilities is a preventable tragedy that's been hiding in plain sight for far too long, advocates say. "It's a complex problem bound up with social inequality and a lot of other stuff," Shakespeare adds. "We should be taking this very seriously."
Victims of violence
In a previous position with the World Health Organization, Shakespeare reviewed studies from around the world to explore the connections between disability and violence in both children and adults.
In one analysis, he and his colleagues found that children with disabilities are 3.7 times more likely than nondisabled children to be victims of violence ( The Lancetopens in new window , 2012). "That's an astounding figure that merits much greater investigation," he says.
In a second paper, they reported that adults with disabilities had about a 50 percent greater risk of having been the victim of violence within the past year. Adults with mental illness were particularly vulnerable, with nearly four times higher risk of violence ( The Lancetopens in new window , 2012). "It's a cliché that mentally ill people cause violence. They're actually more likely to be victims of violence," Shakespeare says.
Those statistics outline the problem in broad strokes. But drilling down into the specifics is much more difficult. "Statistical reporting is muddied at the federal level," says Jennifer Reesman, PhD, a pediatric neuropsychologist at the Kennedy Krieger Institute, faculty member at Johns Hopkins University School of Medicine and chair of APA's Committee on Disability Issues in Psychology.
The broad category of "disability" can include physical, sensory, cognitive, psychiatric and developmental/intellectual impairments. In other words, while people with blindness might face very different risks than people with spinal cord injuries or people with autism, there is no easy way to tease those differences apart within the available datasets.
It's virtually impossible, for instance, to know how many deaf children are placed into foster care, or how many women with psychiatric illnesses are the victims of homicide. "We have over 40 federal definitions of disability," says Michelle Ballan, PhD, professor of social welfare and family, population and preventive medicine at Stony Brook Medical School, whose research focuses on individuals with intellectual and developmental disabilities. "This causes extensive problems with research."
Despite that challenge, researchers can point to certain factors that put people with disabilities at greater risk of violence, abuse and neglect. Poverty is a known risk factor for abuse and neglect, and people with disabilities are more likely than those without to live below the poverty line, says Rhoda Olkin, PhD, a professor at the California School of Professional Psychology at Alliant International University. "This is an impoverished group. They are more likely to be isolated, unemployed or underemployed, and receiving government assistance."
People with disabilities are also often reliant on caregivers to help them meet their daily needs. For children who require aides to help with activities such as feeding, toileting or catheterization, that can mean increased opportunities for abuse, Reesman says. "When an adult is alone with a child without other eyes around, there's more opportunity for abuse to take place," she says. That's especially true when the child is nonverbal or has difficulty communicating.
Adults, too, can suffer maltreatment from caregivers, including aides, health-care workers and family members. A number of studies have found women with disabilities are at risk of both domestic abuse and sexual violence from romantic partners. A study of more than 7,000 Canadian women by Douglas Brownridge, PhD, at the University of Manitoba, for instance, found those with disabilities had a 40 percent greater risk of partner violence than women without disabilities (Violence Against Women, 2006).
Given the limitations of the data, however, there's still much we don't know about partner violence among people with disabilities, says Ballan. She and her students spent three years combing through data in New York City, much of it handwritten case files, just to describe the basic demographic characteristics of women with disabilities who were the victims of intimate partner violence. They found that those women were socially, culturally and demographically diverse ( Journal of Interpersonal Violenceopens in new window , 2014). That diversity should be taken into consideration when developing programs to help such women, Ballan says. For instance, two-thirds of the women had children, and the majority of women with physical disabilities also had psychiatric disabilities—factors that can be of key importance when developing interventions.
Although most research on intimate partner violence focuses on women, men can also be victims. Monika Mitra, PhD, at the University of Massachusetts Medical School, examined population-based data from the United States and found that men with disabilities were more likely to report lifetime intimate partner violence than men without disabilities. Men with disabilities were also more likely to report past-year partner violence than either men or women without disabilities ( Journal of Interpersonal Violenceopens in new window , 2014).
When people with disabilities experience abuse, it can take forms that people might not automatically recognize as domestic violence, says Ballan. Partners or caregivers might do things such as withhold medication, overmedicate, take batteries from a wheelchair or leave the person naked as a form of humiliation, she says. Such acts aren't always captured by domestic violence laws, but they are forms of abuse that professionals such as psychologists and social workers should be sensitive to, Ballan says.
Barriers to safety
One important barrier for people with disabilities is the challenge of reaching out for help. Some people fear that if they speak out about abuse, they won't be believed. This is especially true for people with psychiatric disabilities, Ballan says.
People who rely on caregivers for daily needs might also fear that if they speak out, they'll have no one to care for them. "A lot of people [with disabilities] say things like, 'I have to choose. My personal care assistant might steal $10 from me, or might sit there texting instead of bringing me my lunch, but at least she doesn't hurt me.' There's a constant cost-benefit analysis that doesn't happen in other populations," Ballan says.
Another challenge is that people who might be in a position to recognize abuse aren't always aware of the risks. Mandated reporters in schools, for instance, might not clue into signs that a child with disabilities is being mistreated, especially if the child is nonverbal. "I think there's a mistaken belief that no one would hurt a person with a disability. It's seen as a protective factor, when in fact it's a risk factor," says Olkin.
Unfortunately, the research literature is of little help in pointing to solutions. In a review of interventions to prevent violence against people with disabilities, Shakespeare and colleagues found mostly poor-quality studies, and no evidence that any of the interventions were effective at reducing violence ( Journal of Interpersonal Violenceopens in new window , 2014). "It's an urgent priority to find things that work to reduce violence for disabled people," he says.
Another research priority, Shakespeare suggests, is to better understand the pressures that face families of people with disabilities. Such families are often socially disadvantaged, he says, compounding the strain on parents who are struggling to care for a child with special needs.
APA has recognized the urgent need for more data. The association's Resolution on the Maltreatment of Children with Disabilities makes a number of recommendations, including the creation of a national strategy to collect data, more investment in research, and greater development of evidence-based prevention and intervention methods.
While more research is sorely needed, psychologists can't ignore the problem until more data roll in, Olkin says. "All mental health professionals should assess for abuse at intake, and that's especially important for people with disabilities." That means asking clients about types of abuse that aren't always obvious, she adds, such as whether a woman's spouse makes efforts to limit her mobility or whether a child is ever left alone with the van driver. "I had a client who was dependent on her husband for mobility, and he would put her on the toilet and leave her there [for long periods]," Olkin says. "It's abusive, but not the kind of thing we're on the lookout for."
When clients with disabilities are in abusive situations, psychologists have to consider their unique needs as they help them develop safety plans and escape plans, Olkin and Ballan add. Many domestic violence shelters, for instance, aren't accessible to someone with a wheelchair or medical needs. People in shelters might not know sign language or be able to accommodate a person with visual impairments. Those barriers can make it difficult for people with disabilities to flee an abusive situation.
"Clients who are abused often tell us they were more traumatized when they tried to seek help," because of the challenges of finding accessible shelters and services, says Ballan.
Psychologists can also help by taking a proactive approach to help clients avoid abusive situations, says Reesman. For instance, they can help parents of disabled children seek support and learn coping strategies to manage their frustrations, so their child doesn't end up in a potentially dangerous situation.
In addition, psychologists can help children with disabilities learn to advocate for themselves and find ways to communicate when something is wrong. "We can help guide independence, teach them to say no to unwanted touch and have more autonomy over their own bodies," Reesman says.
Meanwhile, disability advocates say the fields of health care, social work and psychology should do more to teach trainees about disability issues and raise awareness of the risk of violence toward this population. One place to start, Olkin adds, is to open the doors to people who walk in those shoes. "People with disabilities are underrepresented in psychology," she says. "Psychology has to become a lot more welcoming of students with disabilities."
