Introduction

There is a significant amount of scientific research that shows disabled children are more vulnerable to
abuse and neglect as compared to normal children (Jones et al., 2012; Hibbard & Desch, 2007). There is
an association between disability and maltreatment of a children, however, the current studies does not
explain the characteristics of disability that increase the risk of children’s maltreatment. Furthermore, it
is imperative to note that in addition to disabilities, there are other factors that enhances the risk of
abuse in disabled children.

The United Nation Convention on the Rights of Child has endorsed the protection of children with
disabilities from abusive treatment. According to the Article 19 of the UN Convention it is cardinal to
protect the children from any sort of mental or physical abuse, violence, maltreatment and sexual
abuse. Likewise, Article 2 of the UN Convention all the children are entitled to equal rights with any
discrimination. Article 23, specifically endorses the rights of disabled children to promote their self-
reliance and ensure their active participation in social activities in the community.

The UN Convention on the Rights of Persons with Disabilities reaffirms that all disabled people must
enjoy all human rights and fundamental freedoms, and Article 7 states that all necessary measures
should be taken to ensure the full enjoyment by children with disabilities of all human rights and
fundamental freedoms on an equal basis with other children. Article 16 details the right of all disabled
people, in accordance with the Convention, to be free from exploitation, violence and abuse (Miller &
Brown NSPCC, 2014).

Several authors indicate that individuals with disabilities are more likely to be maltreated than
individuals without disabilities, and that individuals with ID are especially at risk (Horner-Johnson &
Drum, 2006). Moreover, it seems that this risk is even higher in the case of sexual abuse (besides other
types of maltreatment) (Khemka, Hickson, & Reynolds, 2005). A few studies specifically focused on
children with ID and also indicated that they seemed more vulnerable for sexual abuse (e.g., Furey,
Granfield, & Karan, 1994; Sullivan & Knutson, 2000). Despite this vulnerability, not much is known about
the extent and nature of sexual abuse in children with ID and the institutional reactions following sexual
abuse of these children. In a broader research project encompassing the current study, sexual abuse was
defined as ‘sexual contact of (young) adults with children younger than 18 years old. These hands on
contacts are againstthe will of the child or without the possibility of the child to refuse these contacts.
Perpetrators use emotional pressure towards the child, force the child or, by their greater power,the
child is afraid to say no when approached’ (Committee-Samson, 2012, p. 49; Wissink, Moonen, Van
Vugt, Stams, & Vergeer, 2012). Because many of the children with ID receive youth care, it was
considered important to also include abuse committed by children living in the same youth care
institution, group home or (foster) family, because children should be protected against such types of
sexual abuse as well (Committee-Samson, 2012).

Several explanations have been suggested for this increased risk of sexual victimization for children with
intellectual disabilities. First of all, people with an intellectual disability may have a lower understanding
of sexuality (Healy et al. 2009; Isler et al. 2009), which may decrease their ability to discriminate
between appropriate and inappropriate sexual contacts (Kim 2010; McGuire & Bayley 2011). If they do
recognize unwanted sexual advances, their lower cognitive abilities may prevent them from disclosing
the abuse. Indeed, in the Spanish sample, the highest risk of sexual abuse was found for children with
the largest speech defect (Verdugo et al. 1995). Furthermore, children with a mental disability are more
dependent on their caregivers than other children (Kim 2010). It is therefore more common for them
that others make decisions about their lives, and they may believe that others also decide about their
sexual activities (McCabe et al. 1994). In addition, some people who work with children with an
intellectual disability may do so to take advantage of these children (Westcott & Jones 1999). This,
together with the inexperience and lack of confidence of caregivers to provide sexual education to
children with a mental disability (Lafferty et al. 2012; Schaafsma et al. 2013), may increase the risk of
sexual exploitation of this vulnerable population.

Literature Review

Violence threatens children’s health and development, and can last into adulthood. Traumatic childhood
experiences such as violence exposure, abuse and neglect are common pathways to social, emotional
and cognitive impairment, leading to increased risk of unhealthy behaviours, disability and premature
mortality (Almuneef et al. 2014). These experiences also increase the risk of further victimization and
perpetration of violence. According to the UN Secretary-General’s report on violence against children,
most children aged 0–14 years who have experienced violence experienced it at home, inflicted by their
parents, caregivers and other family members (World Health Organization 2006). However, in the Arab
world, research about child maltreatment is scarce including that perpetrated by caregivers and
available research shows that child abuse and neglect (CAN) is common and underreported (Al-Mahroos
& Al-Amer 2011). Although maltreatment against children across multiple settings is not disputed, no
countries in the Middle East and North Africa region (MENA) or similar others with developing systems
have adequate population-level data on its prevalence nor associated characteristics. As such, the
current study focuses on the prevalence of maltreatment among children by adult caregivers at home in
the Kingdom of Saudi Arabia (KSA).

Prevalence of Sexual Abuse of Disabled Children

The presence of disability is associated with risk of all forms of abuse, especially neglect. In a systematic
review and meta-analysis of observational studies, Jones et al. (2012) found a prevalence of 20.4% (OR:
3.56) for physical violence and 13.7% (OR: 2.88) for sexual violence against children with disabilities, but
the authors noted huge heterogeneity across the sample. A population-based epidemiological study in
Nebraska found a rate of maltreatment of 31% with children with disabilities, with disabled children
being ‘maltreated multiple times and in multiple ways’ (Sullivan & Knutson, 2000, p. 1258). This study
included all forms of disability, including intellectual disability, physical disability, sensory problems,
communication disorders and autism. There is thought to be significant under-reporting, however the
extent of the problem is unknown.

The impact of age, gender, social and cultural factors on the relationship between disability and abuse is
poorly understood. Unlike the pattern associated with non-disabled children, disabled boys are at
greater risk of maltreatment than girls. Children with communication disorders, sensory impairments,
learning disabilities and behavioural disorders have increased risk, however some of the disability and
behaviour may be secondary to the maltreatment (Stalker & McArthur, 2012). Children in residential
care are also thought to be at increased risk (Miller & Brown, 2014). Disabled children are more likely to
be abused by an immediate family member and are more likely to be abused at a younger age (Sullivan
& Knutson, 2000). In a population study of all children born in Western Australia between 1990 and
2005 (total 397,345), there were 3.4% of child maltreatment allegations. In the non-aboriginal families,
children with an abuse allegation were more likely to be female and three times more likely to be
disabled (O’Donnell et al., 2010). Aboriginal children with an intellectual disability had almost double the
risk of a substantiated allegation of abuse. There are limited studies regarding child abuse in low- and
middle-income countries and those that were included in reviews were very limited in their sample
ascertainment.

The prevalence of CSA is on the rise around the world. However, individually, the prevalence of CSA
varies between countries because of cultural differences. The prevalence of CSA in Morocco was
9.2%,4 while it was 9.2% in Europe, 10.1% in Asia, 15.8% in the US, and 23.9% in Oceania.11 Several
studies have indicated that the highest prevalence of CSA is in Africa (34.4%).11 Recently, Al-Eissa et al.
measured the prevalence of CSA among school students in KSA and reported a prevalence of CSA of
16%.12 Similarly, a retrospective study in 2009 recognised several cases of CSA in KSA in a paediatric
surgery unit between 1987 and 2007.13 On the other hand, a cross-sectional survey conducted by
Alquaiz et al. among 419 teenage girls in two schools in the capital city of KSA reported that 10% of the
girls had been exposed to some form of sexual violence.14 A study from Turkey identified 101 cases of
CSA and found that 66.3% of the victims had been abused by an acquaintance.15 A recent population-
based survey of 1028 Lebanese children (54% boys, 46% girls) documented CSA in 249 (24%) of
them.16 It is advisable for a broad literature review to identify the prevalence and the health
consequences of CSA, for the improvement of prevention programmes and the provision of appropriate
support.17

Indicators of Sexual Abuse in Disabled Children

Children who have experienced sexual abuse can exhibit a variety of indicators that can be broadly
classified as behavioural or physical (Briggs and Hawkins 1997). Behavioural indicators of CSA can
include depression, anxiety, poor self-esteem, substance abuse, destructive behaviour, serious school
problems, severe social skill problems, lower levels of interpersonal trust in people (Claudia and Martine
2014; Steel et al. 2004), changes in sleeping or eating patterns; knowledge of sex or sexualised acting-
out that is age-inappropriate; withdrawn, isolating; frequent absences from school, finding reasons to
stay at school and not go home (Brilleslijper-Kater, Friedrich, and Corwin 2004), and suicide (Young,
Allen, and Ashbaker 2004). Physical indicators of sexual abuse can consist of bruising, pain or itching in
the genital area; recurrent urinary tract infections; or persistent headaches, difficulty walking or sitting,
and bruises on wrists, arms and legs (Brilleslijper-Kater, Friedrich, and Corwin 2004).

In Arab countries, the belief that child abuse is rare is unfounded and denial is unacceptable (WHO
2006). For example, a study of 150 abuse victims in Bahrain indicated that 58% of victims experienced
sexual abuse (Al-Mahroos et al. 2005). Aboul-Hagag and Hamed (2012) reported that among a sample of
college students at Sohag University, Egypt, the overall prevalence rate for CSA was 29.8%. AlMadani et
al. (2012) reported that in the maternity and children hospital and the forensic and legal centre in
Dammam, Saudi Arabia, 85% of the reported cases were sexual.

The current study reviews the literature on sexual abuse of children with ID both as victims and
perpetrators. Children with ID are believed to have a higher risk of becoming a victim of sexual abuse,
because some of their characteristics are thought would make them especially vulnerable (among
others: dependency, need to belong, naivety, lack of knowledge regarding sexuality) (Wissink et al.,
2012). Children with ID are also believed to be more at risk of becoming a perpetrator as they are less
able to adequately interpret social situations and understand intentions and emotions of others (Balogh
et al., 2001; Firth et al., 2001; Hofstede, 1995; Lindsay & Taylor, 2005; Timms & Goreczny, 2002).
Moreover, children with ID can sometimes take images quite literally (Janssens, Schakenraad, Lammers,
& Brants, 2009) so that, for instance, pornographic material might function as a frame of reference for
sexual relationships (Gesell, Maris, Van Berlo, & Van Haastrecht, 2010). Finally, children with ID as
perpetrators may have been victim of abuse themselves, which makes them more at risk for becoming a
perpetrator. In the literature, therefore, the blurred distinction between victims and offenders has been
described (Kramer, Janssens, Cinibulak, & Cense, 2007).

Preventive Strategies

Justice System Restrictions

For sex offenders, criminal justice policies extend well beyond probation, incarceration, and parole to
include federally mandated sex offender registration and public notification requirements and, in many
states, additional restrictions on residence and employment. Research generally fails to support the
prevention effects of these policies (Letourneau et al. 2010; Sandler et al. 2008; Zandenbergen et
al. 2010).

Advocacy and Media Campaigns

Numerous advocacy organizations—including Darkness to Light, Stop It Now! and (in Germany)
Prevention Project Dunkelfeld—have developed campaigns designed to prevent CSA by educating
bystanders, potential and actual victims, and potential and actual offenders about how to intervene in
or avoid committing CSA. These efforts have produced promising effects on outcomes such as CSA
knowledge (Stop It Now 2014) and reporting rates (Letourneau et al. 2014b), although impacts on CSA
incidence have not been evaluated.

Youth-Serving Organizations

Many youth-serving organizations have taken steps to address CSA risk within their ranks through
strategies such as staff screening and training (Saul and Audage 2007). The Catholic Church instituted
similar policies to reduce likelihood of CSA by clergy, including a code of conduct and CSA training (Terry
and Ackerman 2008). The impact of such policies on CSA incidence has not yet been assessed
(Finkelhor 2009).

School-Based Programs

Dozens, perhaps hundreds, of school-based CSA prevention programs have been designed to teach
children how to avoid, or respond to, sexual victimization (National Sexual Violence Resource
Center 2005; Plummer 2001; Wurtele 2009). Some programs have been associated with decreased self-
blame and increased reporting, but none has been shown to reduce CSA victimization (Finkelhor et
al. 1995; Finkelhor et al. 2015). Some school-based programs have also targeted prevention of peer
sexual abuse, with mixed results (Espelage et al. 2013; Foshee et al. 1998; Foshee et al. 2004).

Limitation of Prevention Strategies

A key limitation of CSA prevention efforts to date is lack of a systematic prevention research focus.
Programs have generally been developed without careful evaluation of risk and protective factors and
occasionally taken to scale without rigorous evaluation (Finkelhor 2009). Reasons for this pattern
include the urgency that often attends policy decisions in the wake of publicized CSA cases, limited
funds for CSA prevention research, and insufficient integration of offender- and victim-focused efforts
(Letourneau et al. 2014a, b). As a result, programs are often not implemented or funded based on
efficacy or integrated so as to maximize positive impact.

While punishment and monitoring of sex offenders are important, their contribution to prevention is
questionable. A recent study found close to 90 % of offenders imprisoned for CSA had no history of prior
sexual offenses (Wortley and Smallbone 2013), and recidivism rates are lower for CSA perpetrators than
other types of offenders, suggesting that even highly successful efforts to deter known offenders will
have minimal effects on reducing CSA prevalence (Letourneau et al. 2010). Thus, while our most
comprehensive and costly responses to CSA have utility in holding known offenders accountable, they
are unlikely to detect or deter the majority of individuals who perpetrate CSA.