Symptom Sequelae Following Violence Against Youth With Disabilities

Abstract

The objective of this study was to examine the physical and mental health impact of violence against youth with and without disabilities. We analyzed data from the National Crime Victimization Survey (2008–2016), a nationally representative survey on crime in the United States. Respondents included 729 adolescents (12–17 years) and 953 young adults (18–24 years) who experienced violence in the previous 6 months. Disability status was determined using a six-item screener. Outcome measures included several physical and mental health symptoms experienced for at least one month following violence. Data were analyzed using multivariable logistic, Poisson, and negative binomial regression models. The results indicated that, for at least one month following a violent incident, adolescents and young adults with disabilities were more likely to experience headaches, sleep difficulty, changes in eating or drinking habits, fatigue, muscle pain, and severe distress compared to peers without disabilities. Young adults with disabilities were also more likely to experience stomach problems, depression, and anxiety. Adolescents and young adults with disabilities experienced a greater number of concurrent physical and mental health symptoms compared to peers without disabilities. The results suggest that the health effects of violence are worse for youth with disabilities compared to their nondisabled peers. These findings emphasize the importance of screening young people with disabilities for violence exposure and ensuring that trauma and health services are universally accessible.

Keywords

adolescents young adults disabilities violence well-being

Violence is a leading cause of nonfatal injuries and death among young people (Carter et al., 2015; National Center for Health Statistics, 2016). In 2016, more than 5,000 youth aged 10 to 24 years were murdered (Centers for Disease Control and Prevention, 2018) and approximately 500,000 were treated in an emergency department for violence-related injuries (David-Ferdon et al., 2018). At a societal level, violence against youth is estimated to have an annual cost of nearly $18.2 billion, accounting for medical expenditures and lost wages and productivity (David-Ferdon et al., 2016). This evidence has led to an increasing recognition of violence against youth as a serious public health problem (American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention, 2009; American Public Health Association, 2009; David-Ferdon et al., 2016).

Among youth, however, the risk of violence is not equally distributed. Children, adolescents, and young adults with disabilities are considerably more likely to experience violence than their peers without disabilities. Epidemiological data reveal that youth with disabilities experience violence at approximately 3 times the rate of young people without disabilities (Harrell, 2017; Jones et al., 2012). Previous studies have found a heightened risk of violent bullying (Hong & Espelage, 2012), peer victimization (Turner et al., 2011), sexual abuse (Alriksson-Schmidt et al., 2010), intimate partner and dating violence (Anderson & Kobek Pezzarossi, 2012; Mitra et al., 2013), and serial violence victimization (Reiter, Lapidot-Lefler, 2007) among youth with various disabilities. Researchers have proposed several possible reasons for why youth with disabilities face a higher risk of violence, including power differences between youth and their offenders (Alriksson-Schmidt et al., 2010), stigma and discrimination (Jones et al., 2012), and more limited abilities for self-defense (Blake et al., 2012). A perception that young people with disabilities will not or cannot report their victimization may also increase their vulnerability to violent offenses.

There is mounting evidence that violence poses a serious threat to both the short- and long-term health of youth survivors (American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention, 2009). Studies of young people from the general population report that violence victimization is associated with a range of adverse psychosocial, behavioral, and physical health outcomes (Boynton-Jarrett et al., 2008), including smoking and substance use (Exner-Cortens et al., 2013), depression (Ford et al., 2010), high-risk sexual behaviors (David-Ferdon et al., 2016), binge-eating (Ackard et al., 2007), suicidal ideation (Litwiller & Brausch, 2013), somatic symptoms (Haynie et al., 2013), and greater illness burden in later life (Olofsson et al., 2012). To date, however, studies have not considered the extent to which youth with disabilities experience physical and psychological sequelae following violence victimization. This represents a critical gap in knowledge, as there is increasing recognition of the pivotal role that adolescence and young adulthood play in laying the foundation for future health (Sawyer et al., 2012; Viner et al., 2012). There has been some speculation that exposure to violence may contribute to the development of secondary health conditions among young people with disabilities (Rowland, 2012), but this assertion remains largely uncorroborated. This lack of information poses a challenge for clinicians as well. While the American Academy of Pediatrics (AAP) has issued guidance to aid clinicians in addressing the residual impacts of violence (American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention, 2009), it reports that, for youth with disabilities, the symptoms exhibited following violence are “commonly ignored, misinterpreted, or misunderstood” (Hibbard et al., 2007, p. 1021).

This study examined whether reports of symptoms differ for youth with and without disabilities in the months immediately following a violent incident. We expected to find group variation in the health outcomes of violence for several reasons. First, people with disabilities have been described as having a “thinner margin of health” (Pope & Tarlov, 1991, p. 283) which exposes them to a heightened risk of comorbidities and secondary conditions (Burns et al., 2010). Youth with disabilities may therefore have an increased susceptibility to medical complications following a health shock, such as the exposure to violence (Dembo et al., 2018). Second, people with disabilities are more likely to experience violent incidents that are repeated, more severe, and over longer periods of time (Breiding & Armour, 2015; Brownridge, 2006; Fluke et al., 2008; Smith et al., 2017). These crime characteristics have been associated with adverse physical and psychological outcomes in the general population (Boynton-Jarrett et al., 2008; Eshelman & Levendosky, 2012; Turner et al., 2010), and may contribute to a gradient in the health impact of violence between youth with and without disabilities.

Third, health care providers play an important role in violence screening and intervention (Miller et al., 2015), as well as in the provision of information and referrals to trauma-informed supports and services (O’Campo et al., 2011). Yet, many youth with disabilities encounter significant barriers to high-quality medical and mental health care services (Chiri & Warfield, 2012; Inkelas et al., 2007). Among youth with disabilities, access barriers can lead to delayed or forgone care and unmet health care needs (Boudreau et al., 2014; Okumura et al., 2013; Strickland et al., 2009). Hence, disparate impacts of violence may partly reflect broader inequities in the health care system; youth with disabilities might exhibit greater symptom sequelae following victimization because they have less access to urgent or emergent health care services. Guided by this past literature, we hypothesized that young people with disabilities would be more likely to experience symptom sequelae, and would report a greater number of symptoms, following violence victimization than their peers without disabilities.

Method

Data

This study analyzed data from the National Crime Victimization Survey (NCVS; U.S. Bureau of Justice Statistics, 2018), an ongoing, nationally representative survey about nonfatal criminal victimization among the noninstitutionalized population aged 12 years and older. Households in the sampling frame are screened to determine whether any member experienced a victimization in the previous 6 months. Positively screened respondents are then interviewed by telephone about the characteristics of the crime and the offender, as well as consequences of the victimization. If a respondent reported experiencing more than one victimization, details were only collected for the most recent incident. Additional information about the survey design are available elsewhere (U.S. Bureau of Justice Statistics, 2017).

Sample

Our analysis used the NCVS concatenated files which include only those households in which an individual experienced a criminal victimization. Consistent with the U.S. Department of Justice definition (U.S. Bureau of Justice Statistics, 2017), violence victimization was operationalized as rape or sexual assault, robbery, aggravated or simple (nonsexual) physical assault, or verbal threats of violence. Based on this typology, respondents who reported property crime, pocket picking, or purse snatching were excluded from analyses. The sample was further restricted to only include youth respondents. We focused on respondents aged 12 to 24 years, which is similar to the range used by U.S. federal agencies (Aud et al., 2011; Fernandes-Alcantara, 2018; Interagency Working Group on Youth Programs, 2016) as well as past studies about youth well-being (Gonzales et al., 2012; Olson et al., 2015). We combined data from the 2008–2016 NCVS to obtain an adequate sample size of youth with disabilities who experienced a victimization.

Our final sample size was 1,682 youth. We stratified the sample into subgroups of adolescents aged 12 to 17 years and young adults aged 18 to 24 years. There were a few rationales guiding our decision to partition the sample by age group. First, there is increasing recognition in developmental research and theory that adolescence and young adulthood constitute unique life stages warranting distinct analytic attention (Jaworska & MacQueen, 2015; Tanner & Arnett, 2017). In the context of this study, the exposure to and consequences of violence may vary at different developmental periods (Fletcher, 2010; Halpern et al., 2009). Furthermore, because health care needs and experiences are known to differ between adolescents and young adults (Brindis & Moore, 2014; Park et al., 2014), the Society for Adolescent Health and Medicine (2017) has recommended that data on these groups be analyzed and reported separately. The present sample included 729 adolescents (n = 134 with disabilities) and 953 young adults (n = 148 with disabilities).

Measures

Outcome measures

Six physical symptoms associated with victimization were considered: headaches, trouble sleeping, changes to eating or drinking habits, upset stomach, fatigue, and muscle tension or back pain. These outcomes were measured based on youths’ responses (yes/no) about whether they “experience[d] any of the following physical problems associated with being a victim of this crime for A MONTH OR MORE?” Two mental health symptoms we considered were youths’ responses (yes/no) to items asking whether, associated with being the victim of this crime, they felt “worried or anxious” or “sad or depressed” for a month or more following the victimization. The third mental health symptom was youth reports of severe distress. Respondents were asked “how distressing was being a victim of this crime?” with response options of not at all, mildly, moderately, and severely. To identify reports of “severe distress,” we dichotomized this variable by collapsing the first three categories. Finally, we assessed the co-occurrence of symptoms with two count variables that measured the number of physical (range: 0–6, M = 1.31, SD = 1.78) and mental health (range: 0–3, M = 1.39, SD = 1.08) complaints.

Disability

Disability status was measured with a widely used screener adopted from the American Community Survey (ACS; Erickson, 2012). Consistent with previous research (e.g., Brault, 2009), we identified adolescents (12–17 years) as having a disability if they responded positively to at least one of the following: that they (a) are deaf or have serious difficulty hearing; (b) are blind or have serious difficulty seeing even when wearing glasses; (c) have serious difficulty in concentrating, remembering, or making decisions because of a physical, mental, or emotional condition; (d) have difficulty walking or climbing stairs; or (e) have difficulty dressing or bathing. Young adults (18–24 years) were identified as having a disability based on the same five questions above, or if they reported having (f) a physical, mental, or emotional condition that impedes doing errands alone. The six-item screener is considered by federal policymakers to be the “standard” for identifying people with disabilities in survey data (Assistant Secretary for Planning and Evaluation, 2011).

Control variables

Potentially confounding variables were considered based on previous research (Boynton-Jarrett et al., 2008; Exner-Cortens et al., 2013; Fletcher, 2010). Household and sociodemographic characteristics included urbanicity (urban, suburban, or rural), household income, the number of household members, region (Northeast, Midwest, South, West), sex (male, female), age, and race/ethnicity (White non-Hispanic, Black non-Hispanic, Hispanic, other race/ethnicity). American Indian and Alaska Natives, Asian, Native Hawaiian, and other Pacific Islander respondents were categorized as “other” due to small cell sizes.

Data on youth with disabilities were more likely to be collected by a proxy respondent than through direct interviews as compared to youth without disabilities (χ² = 15.36, p < .001). Proxy respondents may underreport or omit details about criminal incidents (U.S. Bureau of Justice Statistics, 2017). Hence, we included a variable indicating whether the interview was conducted through a proxy to adjust for potential systematic variation. The analyses also adjusted for characteristics of the crime, including the type of violence (sexual assault, physical assault, robbery, threat of violence), familiarity with the offender (knew offender, offender was a stranger, don’t know or did not see the offender), and whether it was a series crime, defined as a high-frequency, repeat victimization occurring more than 5 times within 6 months. Finally, we included a set of year dummy variables to account for possible differences in population distributions across NCVS waves.

Statistical Analysis

Both offender familiarity and household income variables included missing data, 0.71% and 16.11% respectively. There were few differences across covariates of interest with respect to the missing data; respondents with missing income data were an average of 1 year older (t = 3.63, p < .001) and were more likely to be Black than White (χ² = 4.46, p = .03). The missing data were multiply imputed with 10 data sets to obtain accurate standard errors and unbiased estimates (Schafer & Olsen, 1998). We used chained equations which allowed each variable to be modeled according to its own posterior predictive distribution (Lee & Carlin, 2010).

Bivariate differences by disability status were examined for adolescents and young adults on each covariate; the significance of group differences was tested with χ² and adjusted Wald test statistics for categorical and continuous variables, respectively. Logistic regression models were used to estimate the association between disability status and physical and mental health symptoms following violence victimization. Poisson regression models were used to examine differences by disability status in the number of mental health symptoms. Negative binomial regression models were estimated to examine the association between disability status and the number of physical health symptoms, as there was evidence of overdispersion in the outcome. Age-group-stratified unadjusted and adjusted models were run for each outcome. Survey weights were used for all analyses to account for the complex, stratified, multistage design of the NCVS.

We report the results of the adjusted models; unless otherwise noted, they were consistent with the unadjusted results in direction, magnitude, and significance. Results are reported as adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for the logistic regression models and incidence rate ratios (IRRs) and CIs for the count models. We include predicted probabilities and average marginal effects in the supplementary appendix to facilitate the interpretation of relative likelihood that a given outcome occurred (see Supplementary Appendix Tables A1–A2). All analyses were conducted with Stata 14 (StataCorp, 2015). This study’s use of public, secondary, de-identified data was considered exempt from IRB (institutional review board) review.

Results

Study Sample

In the United States, a disproportionate number of youth who experience violence have disabilities. According to estimates from the ACS, 5.60% of adolescents aged 12 to 17 years and 6.18% of young adults aged 18 to 24 years have a disability (U.S. Census Bureau, 2018). In the NCVS sample, 17.38% of adolescents and 13.91% of young adults who experienced a violent victimization had a disability. Among young adults with disabilities who experienced violence, 69.52% were White and 5.75% were Black, compared to 57.90% and 16.02% of those without disabilities, respectively (p = .02). The racial composition did not differ by disability status among adolescents. Both adolescents and young adults with disabilities were more likely to report knowing their offenders compared to adolescents (90.70% vs. 81.63%, p = .047) and young adults (80.96% vs. 67.19%, p = .01) without disabilities. The types of violence experienced by adolescents and young adults did not differ by disability status. However, a greater percentage of both adolescents and young adults with disabilities reported experiencing a high-frequency series victimization compared to adolescents (8.47% vs. 4.26%, p = .041) and young adults (5.65% vs. 1.70%, p = .003) without disabilities, respectively (Table 1).

Table 1.

Descriptive Statistics of Adolescents and Young Adults With and Without Disabilities.

	Adolescents (12–17 Years Old)Weighted %^a			Young Adults (18–24 Years Old)Weighted %^a
	With Disabilities	Without Disabilities	p	With Disabilities	Without Disabilities	p
Type of disability^b
Hearing	3.81	—		17.21	—
Vision	18.82	—		9.36	—
Ambulatory	5.09	—		11.15	—
Cognitive	85.86	—		80.33	—
Self-care	2.29	—		6.77	—
Independent living	—			29.16
Female	48.49	50.68	.69	57.44	61.06	.53
Race/ethnicity			.39			<.05
White, non-Hispanic	51.91	54.53		69.52	57.90
Black, non-Hispanic	16.17	17.54		5.75	16.02
Hispanic	19.72	20.80		19.47	19.52
Other^c	12.19	7.13		5.23	6.56
Urbanicity			.34			.28
Urban	23.26	30.90		40.13	42.27
Suburban	56.45	50.27		39.80	43.83
Rural	20.29	18.83		20.07	13.90
Household income			.55			.65
$0–29,999	47.65	41.47		52.73	49.61
$30,000–$49,999	15.83	21.60		24.82	21.11
$50,000–$74,999	14.96	15.29		8.68	11.80
$75,000 and over	21.56	21.64		13.77	17.49
Age (M, years)	14.19	14.46	.17	21.07	20.84	.30
Household members (M, count)	4.38	4.02	.06	3.33	3.15	.30
Type of violence			.14			.94
Sexual assault/rape	6.71	5.95		8.52	7.27
Robbery	14.19	12.47		17.58	16.76
Assault	66.77	59.81		59.12	59.90
Threat of violence	12.33	21.77		14.79	16.07
Series victimization^d	8.47	4.26	<.05	5.65	1.70	<.01
Offender familiarity			<.05			<.05
Knew offender	90.70	81.63		80.96	67.19
Offender was stranger	9.30	16.06		19.04	30.60
Don’t know	0.0	2.32		0.0	2.21
Region			.14			.06
Northeast	16.30	14.68		21.70	12.26
Midwest	20.64	26.82		29.21	25.44
South	27.62	35.23		25.05	35.10
West	35.44	23.27		24.04	27.21
Proxy^e	27.91	19.85	.06	16.86	5.44	<.01

Note. Year dummy variables not presented.

Percentages unless noted otherwise. ^b Hearing (deaf or difficulty hearing), vision (blind or difficulty seeing, even with glasses), ambulatory (difficulty walking or climbing stairs), cognitive (difficulty concentrating, remembering, or making decisions due to a health condition), self-care (difficulty bathing, dressing, getting around inside the home due to a health condition), and independent living (difficulty doing errands alone, for example, shopping or visiting a doctor’s office). ^c Includes American Indian and Alaska Natives, Asian, Native Hawaiian, and other Pacific Islander respondents. ^d Repeat victimization occurring more than 5 times within 6 months. ^e Interview conducted with proxy respondent.

Physical Health Symptoms

Youth with disabilities were more likely to experience physical symptoms for at least one month after surviving a violent victimization compared to youth without disabilities. After adjusting for covariates, adolescents with disabilities had higher odds of experiencing headaches (aOR = 2.12, CI: [1.20, 3.80], p = .01), sleep difficulty (aOR = 2.35, CI: [1.46, 3.79], p = .001), changes in eating or drinking (aOR = 2.07, CI: [1.08, 3.97], p = .03), fatigue (aOR = 2.79, CI: [1.57, 4.97], p = .001), or muscle pain (aOR = 2.94, CI: [1.78, 4.88], p < .001) compared to adolescents without disabilities (Table 2). Similar differences were observed among young adults. Young adults with disabilities had higher odds of reporting headaches (aOR = 2.16, CI: [1.35, 3.46], p = .002), sleep difficulty (aOR = 2.55, CI: [1.73, 3.78], p < .001), changes in eating or drinking (aOR = 3.46, CI: [2.21, 5.42], p < .001), stomach problems (aOR = 1.87, CI: [1.11, 3.13], p = .02), fatigue (aOR = 2.14, CI: [1.38, 3.30], p = .001), and muscle pain (aOR = 2.90, CI: [1.82, 4.63], p < .001) compared to young adults without disabilities (Table 2). Having a disability also increased the expected number of physical symptoms following violence victimization for both adolescents (IRR = 1.79, CI: [1.37, 2.33], p < .001) and young adults (IRR = 1.82, CI: [1.47, 2.25], p < .001).

Table 2.

Associations Between Disability Status and Physical and Mental Health Symptoms Following Violence Victimization.

	Adolescents With Disabilities^a		Young Adults with Disabilities^b
	Unadjusted OR	Adjusted^c OR	Unadjusted OR	Adjusted^c OR
Physical health symptoms
Headaches	2.22** [1.35, 3.64]	2.16* [1.20, 3.80]	2.17** [1.39, 3.38]	2.16** [1.35, 3.46]
Sleep difficulty	2.24*** [1.44, 3.49]	2.35** [1.46, 3.79]	2.43*** [1.66, 3.56]	2.55*** [1.73, 3.78]
Change in eating/drinking	1.99* [1.17, 3.37]	2.07* [1.08, 3.97]	2.84*** [1.80, 4.48]	3.46*** [2.21, 5.42]
Stomach problems	1.16 [0.68, 2.01]	1.09 [0.58, 2.06]	1.92** [1.18, 3.15]	1.87* [1.11, 3.13]
Fatigue	2.58*** [1.65, 4.04]	2.79** [1.57, 4.97]	2.32*** [1.54, 3.50]	2.14** [1.38, 3.30]
Muscle pain	2.57*** [1.59, 4.15]	2.94*** [1.78, 4.88]	2.50*** [1.58, 3.96]	2.90*** [1.82, 4.63]
Mental health symptoms
Worried or anxious	1.25 [0.84, 1.87]	1.24 [0.79, 1.93]	2.67*** [1.71, 4.15]	3.16*** [1.95, 5.12]
Sad or depressed	1.61* [1.05, 2.45]	1.61^† [1.00, 2.60]	2.82*** [1.91, 4.16]	3.29*** [2.12, 5.11]
Severely distressed	1.79* [1.15, 2.79]	2.17** [1.40, 3.37]	1.93** [1.31, 2.85]	2.34*** [1.55, 3.56]
	Unadjusted IRR	Adjusted^c IRR	Unadjusted IRR	Adjusted^c IRR
Number of physical symptoms^d	1.75*** [1.37, 2.22]	1.79*** [1.37, 2.33]	1.78*** [1.45, 2.19]	1.82*** [1.47, 2.25]
Number of mental health symptoms^e	1.24** [1.07, 1.44]	1.25** [1.08, 1.44]	1.43*** [1.29, 1.59]	1.47*** [1.33, 1.63]

Note. 95% confidence intervals in brackets. OR = odds ratio; IRR = incidence rate ratio.

Adolescents without disabilities are the reference group. ^b Young adults without disabilities are the reference group. ^c Models adjusted for sex, race/ethnicity, urbanicity, household income, age, number of household members, type of violence, offender familiarity, U.S. region, series victimization, proxy interview, and survey year. ^d IRR-based Poisson regression models. ^e IRR based on negative binomial models.

†

p < .10. *p < .05. **p < .01. ***p < .001.

Mental Health Symptoms

Youth with disabilities were more likely than youth without disabilities to experience mental health symptoms for at least one month after violent victimization. Adolescents with disabilities had higher odds of experiencing severe distress (aOR = 2.17, CI: [1.40, 3.37], p = .001) compared to adolescents without disabilities (Table 2). Young adults with disabilities had higher odds of feeling worried or anxious (aOR = 3.16, CI: [1.95, 5.12], p < .001), sad or depressed (aOR = 3.29, CI: [2.12, 5.11], p < .001), or experiencing severe distress (aOR = 2.35, CI: [1.55, 3.56], p < .001) compared to young adults without disabilities. Both adolescents (IRR = 1.25, CI: [1.08, 1.44], p = .003) and young adults (IRR = 1.47, CI: [1.33, 1.63], p < .001) with disabilities reported a greater number of mental health symptoms compared to adolescents and young adults without disabilities, respectively, following violence victimization (Table 2).

Discussion

The results of this study demonstrate that having a disability was associated with symptom sequelae in youth following a violent incident. In this nationally representative sample of individuals who survived a violent crime, adolescents and young adults with disabilities were more likely to experience select physical and mental health symptoms following victimization. For both adolescents and young adults, having a disability was also associated with a greater number of total symptoms in the aftermath of violence. Notably, in all but one case (depression among adolescents), results in the unadjusted models remained significant after inclusion of covariates. Although disability in adolescents was not significantly associated with feeling depressed or anxious, the probabilities of these outcomes were very high regardless of disability (Supplementary Appendix Table A1) and should be cause for concern.

Despite a preponderance of evidence suggesting an elevated risk of violent victimization among youth with disabilities (e.g., Harrell, 2017; Jones et al., 2012), there is limited research examining the health impacts in this population. There is growing awareness among researchers that people with disabilities, including children and youth, experience disparities in health and health care (Boulet et al., 2009; Krahn et al., 2015). Previous studies have regarded the heightened exposure to violence as one of many social determinants of health disparities (Krahn et al., 2015). Our analysis builds on this literature by suggesting that it may not be the unequal distribution of violence alone that contributes to health inequities among people with disabilities. Instead, we provide evidence of differential physical and mental health impacts of victimization immediately following the incident. These findings support the notion that youth with disabilities have a “thinner margin of health” which, as the Institute of Medicine described, “must be scrupulously maintained if they are to avert medical complications and new functional limitations” (Pope & Tarlov, 1991, p. 283). Hence, prevention efforts aimed to reduce the incidence of secondary conditions among youth with disabilities should focus on violence as a modifiable risk factor.

Clinicians may face several challenges in monitoring for violence in this population. In some cases, the natural history or phenotype of a disabling condition may mimic the signs of maltreatment. Distinguishing between accidents, self-injurious behavior, and externally inflicted violence is critical for identifying cases of victimization. Broader education on these topics among clinicians is warranted. It is unclear the extent to which providers serving older adolescents and young adults with disabilities receive training on violence prevention and surveillance as there is scant published literature on the topic; most of the attention appears to be focused on younger children (Brodie et al., 2017; Hibbard et al., 2007).

Researchers (Bloom et al., 2012; Lotstein et al., 2009), professional organizations (AAP et al., 2011), and policymakers (Federal Partners in Transition Workgroup, 2015) have emphasized the importance of ensuring that youth with disabilities successfully transition into adult health care. Given this considerable attention, the transition process may provide opportunities for enhanced monitoring of violence in this population. It is important that adult care providers are made aware of the elevated risks and disparate health impacts of violence victimization and are informed of any previous incidents of exposure when youth transition into their care.

The results of the age-stratified analyses largely converged; however, there were some notable differences. We observed a disability-related gradient in the odds of reporting stomach problems, anxiety, and depression among young adults but not among adolescents. These findings emphasize the value of considering adolescence and young adulthood as distinct developmental periods. Age differences in symptom sequelae should also be taken into account by pediatric and adult health care providers as they monitor the health impacts of violence in their patients.

Although the types of violence experienced by youth were similar regardless of the presence of a disability, the bivariate comparisons suggest that youth with disabilities were more susceptible to serial victimizations. Young people with disabilities continue to experience high levels of segregation in education and employment (Bates-Harris, 2012; National Council on Disability, 2018), and isolation from the broader community may provide offenders with opportunities to commit repeated offenses (Caldas & Bensy, 2014). The descriptive analysis also indicated that youth with disabilities were more likely to know their offenders. Dependence on paid assistants, family caregivers, and other service providers can result in power imbalances that expose youth with disabilities to potential abuses (Brownridge, 2006). As others have suggested (Gorman-Smith, 2012), adopting an ecological approach to violence reduction can help focus intervention efforts on the relationships and social contexts that pose particular risks to youth with disabilities.

It should be noted that the weighted percentages of youth with disabilities in the NCVS data (17% of adolescents and 14% of young adults) were higher than national prevalence estimates of disability among youth (U.S. Census Bureau, 2018). The discrepancy may reflect the heightened risk of victimization among individuals with disabilities (Harrell, 2017), given that the sample we analyzed was composed only of youth who experienced violence. Variation from other national estimates may also be an artifact of differences in data collection or sampling methods. Comparisons between the prevalence statistics reported in this study and those based on other data should take these considerations into account.

This study has several limitations that are worth addressing. Although we are not asserting causal relationships, the analysis does imply a temporality in the associations: the wording of survey questions explicitly connected the health complaints to the crime. Because our data are cross-sectional, we cannot rule out the possibility that a symptom predated the violent incident or that the disability is the result of that violence. Another limitation concerns the construct validity of the health symptom questions in the survey. Respondents are asked whether they experienced symptoms for a month or more following the victimization. However, it is possible that the interview was administered less than one month following the crime. Because the NCVS does not provide the exact date of the incident, we were unable to determine the recency of the victimization. In addition, the NCVS does not inquire about disability-specific violence, such as the manipulation of medication, the destruction of medical equipment, or the denial of caregiving assistance (Dembo et al., 2018). These forms of maltreatment may have direct, adverse health consequences for victims and should be considered in future research on youth with disabilities.

The study is likely subject to a degree of misclassification bias. Although there have been no previous analyses of the sensitivity and specificity with which the NCVS identifies young people with disabilities, evidence suggests that the ACS screener may underestimate the prevalence of disability among youth (Ipsen et al., 2018). Future research is needed to validate the ACS disability screener in surveys that include younger respondents. In addition, the outcomes we examined are self-reported, which may be impacted by recall bias. This concern might be relatively minimal, in part, because the NCVS interviews people who experienced violence within the previous 6 months.

There are potential limitations to the operationalization of our outcome measures. For example, we examine depression not with a validated scale but with a single, direct question about the respondents’ feelings. Future research should compare our findings with data sources that contain alternative, reliable health outcome specifications. In addition, because the NCVS only covers the community-dwelling population, our study does not capture the experiences of young people with disabilities who live in residential facilities. Youth living in residential facilities also deserve attention as they often have greater levels of impairment and may therefore be especially vulnerable to mistreatment. We were also unable to assess intragroup variation in outcomes among youth with disabilities due to sample size restrictions. It is important for future research, within an intersectional framework, to consider how membership in multiple marginalized groups may be associated with differences in violence-related health outcomes. Finally, while youth with disabilities are not a monolith, sample size constraints prevented comparisons by type of disability. Additional research is needed to understand how young people with different disabilities respond to and are impacted by violence victimization.

This study also has several strengths, including the assessment of a broad range of physical and mental health outcomes among youth from two developmental periods. In addition, unlike most studies of violence and health, our analysis examined self-reported information from youth as young as 12 years of age. In contrast to the more unidimensional data collected in emergency department claims and many health risk surveillance systems, our analysis is also unique in its ability to estimate health outcomes while accounting for several potentially confounding characteristics of the violent incidents. The findings of this study have important implications for research and clinical practice. It is critical that all youth receive screenings for violence victimization and that appropriate treatment is provided to mitigate residual symptoms. In addition, referrals to secondary prevention programs can help reduce the risk of polyvictimization. Finally, there is a need to ensure that trauma-informed services are accessible to youth with disabilities. While our findings identify disparate, short-term impacts of violence against youth with disabilities, the inaccessibility of victim or health services may prolong violence-associated morbidities and contribute to future health disparities. As others have noted in the literature (Exner-Cortens et al., 2013), it is imperative that youth who experience violence receive clinical intervention as soon as possible to prevent additional health complications.

Conclusion

Violence has a disparate health impact on youth with disabilities. Among youth who experience a violent crime, having a disability is associated with experiencing a range of physical and mental health symptoms following the victimization. The findings emphasize the importance of including violence prevention in broader health promotion initiatives for young people with disabilities. There is a need for additional education regarding the signs of victimization in youth with disabilities, which in some cases can be mistaken for the phenotypic expression or complications related to the disabling condition. Such awareness will support clinicians in ensuring that all cases of victimization are appropriately identified. Finally, the trauma of adverse experiences during youth can reverberate throughout the life course. Thus, future research regarding the longitudinal health consequences of violence against youth with disabilities should be prioritized.

Supplemental Material

jiv-appendix-second_revision-2019-10-31 – Supplemental material for Symptom Sequelae Following Violence Against Youth With Disabilities

Supplemental material, jiv-appendix-second_revision-2019-10-31 for Symptom Sequelae Following Violence Against Youth With Disabilities by Robert S. Dembo, Monika Mitra, Ilhom Akobirshoev and Susan E. Manning in Journal of Interpersonal Violence

Footnotes

Acknowledgements

We are grateful to Bill Erickson for his assistance with the American Community Survey (ACS) PUMS estimates.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by a Brandeis University Provost Research Grant and the Lurie Institute for Disability Policy.

ORCID iD

Robert S. Dembo

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Robert S. Dembo, MA, is a doctoral student in social policy at the Heller School for Social Policy and Management at Brandeis University. His research focuses on the health and well-being of children and youth with disabilities and their caregiving families.

Monika Mitra, PhD, is the Nancy Lurie Marks Associate Professor of disability policy and director of the Lurie Institute for Disability Policy at Brandeis University. Her research examines the health care experiences and health outcomes of people with disabilities, with a particular focus on the sexual and reproductive health of women with disabilities.

Ilhom Akobirshoev, PhD, MA, MSW, is the research scientist at the Lurie Institute for Disability Policy, the Heller School for Social Policy and Management, Brandeis University. His research examines disparities in health care service utilization, quality of care, health outcomes, and economic well-being, including racial/ethnic disparities in these indicators among people with disabilities.

Susan E. Manning, MD, MPH, is a maternal and child health epidemiologist at the Massachusetts Department of Public Health (MDPH), where she works to promote and improve the health and well-being of women, children, and families in Massachusetts by enhancing maternal and child health (MCH) epidemiology and data capacity.

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