934442

research-article2020
JIVXXX10.1177/0886260520934442Journal of Interpersonal ViolenceChristoffersen

Original Research
Journal of Interpersonal Violence

Sexual Crime Against

1­–29
© The Author(s) 2020
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DOI: 10.1177/0886260520934442
https://doi.org/10.1177/0886260520934442
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Nationwide Prospective
Birth Cohort Study

Mogens Nygaard Christoffersen1

Abstract
Numerous studies have shown that the rate of sexual victimization against
children with disabilities is higher than the rate for children without
disabilities. The study focuses on examining sexual crime against children
with disabilities and explaining differences in victimization to elucidate
to what extent types of disability, family disadvantages, gender, high-risk
behavior, and location influence adolescents’ risk of sexual victimization.
Data are based on a national study of reported sexual crime against
children in Denmark aged between 7 and 18 years using total birth cohorts
(N = 679,683). The statistical analysis is a discrete-time Cox model. An
extended list of potential risk factors was included in the analysis to adjust
for confounding. The potentially confounding risk factors were collected
independently from various population-based registers, for example,
employment statistics, housing statistics, education statistics, income
compensation benefits, and population statistics (e.g., gender, age, location).
Hospital records with information on types of disability based on the
national inpatient register and national psychiatric register were collected
independently of the collection of law enforcement records about reported
sexual offenses under the Danish Central Crime Register. Among total birth

1
VIVE—The Danish Center for Social Science Research, Copenhagen K, Denmark

Corresponding Author:
Mogens Nygaard Christoffersen, VIVE—The Danish Center for Social Science Research,
Herluf Trolles Gade 11, 1052 Copenhagen K, Denmark.
Email: mc@vive.dk
2 Journal of Interpersonal Violence 00(0)

cohorts, 8,039 persons or 1.18%. were victims of a reported sexual crime

once or several times. Children with intellectual disabilities were more likely
to be victimized of a reported sexual crime than non-disabled children were:
attention-deficit/hyperactivity disorder (ADHD), odds ratio: 3.7 (3.5–3.9);
mental retardation, odds ratio: 3.8 (3.6–4.0); and autism, odds ratio: 3.8
(3.6–4.0). This contrasts with children with speech disability, stuttering,
and dyslexia who were less likely to be victimized when adjusted for family
vulnerability and other confounding risk factors. Intellectual disability and
family vulnerability, for example, parental substance abuse, parental violence,
family separation, the child in care, and parental unemployment, indicate
an increased risk of being a victim of a sexual crime, while speech disability
seems to be ensuring protection.

Keywords
disabilities, sexual violence, child maltreatment, longitudinal study

Introduction
Children and adolescents with disabilities face all forms of violence such as
mental, physical, and sexual violence, social exclusion, and hate crimes in
all settings, including the family, schools, institutions, work environment,
and community at large, according to the European Union Agency for
Fundamental Rights (Fundamental Rights Agency [FRA], 2015). In the
present study, we focused on one particular type of violence—sexual vio-
lence. There has been limited research on sexual violence against children
and adolescents with disabilities (Alriksson-Schmidt et al., 2010). In the
present study, we will explore the prevalence of sexual offenses against
children and adolescents aged 7 to 17 years with and without disabilities,
and identify risk and protective factors the year before a first-time sexual
assault and thereby illuminate underlying causes of sexual violence against
a child with mental and/or physical disabilities.
Previous studies estimate that children aged 0 to 17 years with disabili-
ties have a significantly higher risk of being a victim of a sexual crime.
Statistics on crime against children and adolescents show that persons with
disabilities have a higher risk of sexual abuse than other children have
(Alriksson-Schmidt et al., 2010; Blum et al., 2001; Brunnberg et al., 2012;
Cuevas et al., 2009; L. Jones et al., 2012; S. E. Jones & Lollar, 2008; Miller,
1993; Reiter et al., 2007; Spencer et al., 2005; Sullivan & Knutson, 2000;
Surís et al., 1996). A systematic review and meta-analysis of 11 observa-
tional studies found that odds ratio (OR) for pooled risk estimates was 2.88
Christoffersen 3

(95% confidence interval [CI] = [2.24, 3.69]) for sexual violence against
children with disabilities in comparison with children without disabilities
(L. Jones et al., 2012). The type of disability appeared to affect the risk of
violence although the evidence was not conclusive. Children with mental or
intellectual disabilities were 4.6 times (OR = 4.62, 95% CI = [2.08, 10.23])
more likely to be victims of sexual violence than other non-disabled chil-
dren (L. Jones et al., 2012; United Nations Children’s Fund, 2013). In these
studies, intellectual disabilities are specified as learning disabilities (e.g.,
mental retardation), attention-deficit/hyperactivity disorder (ADHD),
autism spectrum disorder (ASD), for example, childhood autism, Rett syn-
drome, Asperger’s syndrome (L. Jones et al., 2012), while mental disabil-
ity, for example, depression, anxiety disorder, post-traumatic stress disorder
(PTSD), and substance use disorder could be associated with victimization
of violence (Cuevas et al., 2009).
The vast majority of studies are cross-sectional and do not include infor-
mation on the timing of sexual assault relative to disability (Leeb et al.,
2012). Some of these studies of mental disabilities may mistake cause and
effect. Psychological disorders such as PTSD, depression, anxiety disorder,
and low self-esteem resulting in self-harm have been emphasized as a con-
sequence of victimization (Browne & Finkelhor, 1986; Cuevas et al., 2009).
Several writers have suggested that sexual assault may produce post-trau-
matic symptoms (Briere, 1996; Briere & Runtz, 1993; Lindberg & Distad,
1985; Rowan & Foy, 1993; Saywitz et al., 2000; Schaaf & McCanne, 1998).
Sexual victimization is a frightening, painful, and psychologically over-
whelming experience for many children (Briere, 1996; Finkelhor, 2010).
Depression and anxiety disorder, negative self-evaluation, and guilt are pos-
sible consequences of sexual abuse. Child sexual abuse places children at
increased risk for suffering potential lifelong difficulties (Briere, 1996;
Cohen et al., 2004; Kendall-Tackett et al., 1993). Victimization is a known
contributor to the development of substance use disorders (Davis et al.,
2019; Polusny & Follette, 1995), and suicide attempts and non-suicidal self-
inflicted injury (Christoffersen et al., 2015; Paivio & McCulloch, 2004;
Ystgaard et al., 2004).
Many studies of sexual violence against children and adolescents with dis-
abilities are based on small-scale studies (Brunnberg et al., 2012). However,
many of the large-scale population studies lack scientifically sound research
design and methodology (Leeb et al., 2012). There are poor standards of
measurement of disability and insufficient assessment in the studies whether
sexual abuse preceded the development of disabilities. Longitudinal panel
data are rarely available. Previous studies of sexual crime against children
have mainly been based on self-reported victim surveys or studies of offender
4 Journal of Interpersonal Violence 00(0)

population, which also suffer from risks of selection biases. These gaps need
to be addressed through a whole population sample with standardized mea-
sures of disability and sexual violence (L. Jones et al., 2012).
The insufficient knowledge of causes and settings of sexual violence ham-
pers the development of initiatives for preventing violence against children
with disabilities. Information about risk factors, the years preceding a crime
incident against children with disabilities, is limited in crime victimization
surveys and existing databases. Furthermore, risk of estimates might overes-
timate the association between violence and disability because of inadequate
adjustment for confounding (L. Jones et al., 2012; J. R. Petersilia, 2001).
There is a critical need for a theory-driven research with access to crimi-
nal justice record, medical records, and reliably family and community risk
variables to identify associations and pathways between child disabilities
and violence against children as an important step toward planning targeted
and appropriate prevention and intervention activities (Leeb et al., 2012;
Sullivan, 2009).

Theory
Bronfenbrenner’s social-ecological model includes responses to violence
influenced by local childhood development norms in family, community,
and culture (Bronfenbrenner & Morris, 1998; Njelesani, 2019). Social-
ecological theory posits that a complex interaction of familial characteris-
tics, social biases, and other environmental factors sets the stage for response.
The model allows examination of factors through multiple level of influence
(Sallis et al., 2008).
Children with disabilities are especially vulnerable because of their depen-
dence, and isolation from parents and families. Their communication or intel-
lectual impairments increase their vulnerability (Senn, 1988; Sobsey, 1994).
Parents or others taking care of the child may be under considerable pres-
sure because of financial and emotional issues in caring for the child (FRA,
2015) and reduce their ability to protect a child from negative social environ-
ments, and in particular from environments that are hostile toward children
with disabilities (Lightfoot, 2014).
Overburden of parents and lack of support, overextended and under-
trained care personnel, risk factors relating to perpetrators seeing children
with disabilities—physical as well as intellectual disabilities—as “easy
targets,” lack of knowledge about disability, isolation and segregation
from the community, societal attitudes based on prejudice, and fear of
“otherness” are all potential causes of sexual violence against children
with disabilities identified by respondents from various stakeholders in
Christoffersen 5

13 European Union (EU) member states (FRA, 2015; Senn, 1988).

However, to date, there has been little empirical investigation of the men-
tioned specific elements (Leeb et al., 2012).
Hostile behavior toward children with disabilities, and segregation and iso-
lation of adults and children with disabilities could be causes of violence
against children with physical and mental disabilities. Social factors stemming
from the way children with disabilities are viewed and treated set the stage for
maltreating behaviors (Sidebotham et al., 2003; Westcott, 1991; Westcott &
Jones, 1999). In some theories, hate crimes committed against a person with a
disability are seen as cultural ideology about disability, which lead to violence,
including crimes of sexual nature (McMahon et al., 2004; Waxman, 1991).
Surveys of offenders revealed that they select victims according to their
lack of confidence as an easy target (Conte et al., 1989; Elliott et al., 1995;
Niehaus et al., 2013).
Children with intellectual disabilities can have difficulties in communica-
tion both in routine, adverse and emergency situations. Individuals with intel-
lectual disabilities are more vulnerable due to personal and family risk
factors, which leads to an imbalance of power between them and their envi-
ronment that increase their probability of becoming a victim of sexual abuse
(Niehaus et al., 2013). Their limited cognitive capacity reduces the ability to
appropriately interpret danger signals, for example, when they are intoxi-
cated (Tyler et al., 1998) and their low self-esteem makes it harder to set
limits and successfully fending off violence (Niehaus et al., 2013).
Children can be vulnerable because of physical disabilities or specific
developmental disorders of speech and language, stuttering and other behav-
ioral and emotional disorders with onset usually occurring in childhood and
adolescence. The intellectual disability may also be an invisible disability,
which may cause misunderstandings and hostilities from peers and others (J.
Petersilia, 2000). Examples of such invisible disability are ADHD, ASD, or
mild mental retardation.
A child with ADHD often has serious problems getting along with other
children and they often have no friends. Social skills like sharing, cooperat-
ing, taking turns, and expressing an interest in another person generally do
not seem very valuable to them (Barkley, 2000). Negative feedback during
childhood may be associated with low self-esteem in adolescence. Young
people with hyperactivity and attention disorders show more risky sexual
behavior, more partners, and risk of sexually transmitted diseases, and a
higher percentage of teenage pregnancies compared with peers without
ADHD (Barkley, 2010; Barkley et al., 2008; Biederman et al., 2006; De
Quiros & Kinsbourne, 2001). In a Dutch study, ADHD patients reported
about sexual abuse, rape, and assaults/inappropriate touching from family
6 Journal of Interpersonal Violence 00(0)

members, acquaintances, and strangers (Kooij, 2012). ADHD symptoms are

found to be associated with greater sexual victimization during adolescence
and were linked with sexual victimization through engagement in risky sex-
ual behavior (Snyder, 2015; White & Buehler, 2012).
People with ASD find it difficult to deal with symbols, and in the lan-
guage, symbols stand for thoughts and feelings. People with autism live in an
environment in which they are unable to make themselves understood
(Peeters & Gillberg, 1999). Deficits in emotions and inability to detect viola-
tions in social exchange rule may increase the risk of interpersonal victimiza-
tion (Roberts et al., 2015). Individuals with autism may be disproportionately
at risk of experiencing sexual abuse and victimization, but sexual abuse is
much more difficult to detect among adolescents with autism (Edelson, 2010;
Mandell et al., 2005). Parents indicate concern that others will take advan-
tage of their child or that their child will act in an inappropriate sexual way
toward another (Sevlever et al., 2013). There are no previous prospective
population studies assessing the frequency with which children with autism
specifically are sexually abused; there is information about those with devel-
opmental disabilities in general (Edelson, 2010).
People with intellectual disabilities have higher risk of sexual victimiza-
tion due to their limitations that lower the risk of the offender being reported,
charged, and prosecuted for an offense. The child’s disability may be a chal-
lenge to the willingness of the system to adjust to an otherness to compensate
the disadvantages that this otherness may entail (Niehaus et al., 2013).
Some children with physical and mental disabilities have low self-esteem
related to their disability and may feel that they somehow deserve maltreat-
ment (Lightfoot, 2014). Negative feedback from their social environment
contributes to low self-esteem (Niehaus et al., 2013). The broader society’s
response to disability, including discrimination, lack of support, and lack of
opportunities, could increase the risk (Lightfoot, 2014). Children with some
types of disability are more likely to experience maltreatment. Children with
emotional, behavioral, mental health disabilities, and intellectual or develop-
mental disabilities are more likely to have experienced substantiated mal-
treatment (Lightfoot, 2014).
These associations may include situations where some children acquire a
permanent disability as a result of maltreatment, for example, depression,
anxiety, and PTSD (Gilbert et al., 2009; L. Jones et al., 2012). In the present
study, we try to establish the actual onset of disabilities and the actual onset
of sexual violence (the year of the first-time police report).
It is repeatedly found that childhood violence in all its forms was a risk
factor for later victimization (Thoresen et al., 2015). Child maltreatment is
found to be associated with greater physical and sexual peer victimization
Christoffersen 7

(Yoon et al., 2018). It has therefore been suggested that the substantiated
maltreatment and some types of disability might form a vicious cycle in
which victimization may lead to behavioral and emotional problems that
increase the risk for future victimization (Chan et al., 2018; Harkness &
Lumley, 2008).
The theory summarized here constitutes the overall frame of reference that
we will use to select potential risk factors; however, the present study can
only include a substantially restricted part of the mentioned elements.

Method
Research Design
The aim of the study program is to understand the magnitude, distribution,
and consequences of sexual crime against children with disabilities. One study
of violence against children with disabilities has recently been published
(Christoffersen, 2019). In the present study, we want to explore the prevalence of
sexual offenses against children with disabilities and identify risk and protective
factors for, and underlying causes of, violence against a child with mental and/or
physical disabilities. The study is based on longitudinal panel data, including the
whole population sample. Data consist of administrative records with standard-
ized measures of disability and sexual violence. The study examines the risk fac-
tors proceeding the first-time sexual offending against a child.

Study Population
Eleven national birth cohorts of children born 1984 to 1994, aged 7 to 18, are
followed (N = 679,683), and parental and familial risk factors of victimiza-
tion during adolescence are included. The possibility of describing victims is
possible after 2001. In the present study, we are looking into the window
from 2001 to 2012 where victims are tracked (Figure 1).
All other data, which are indicating disadvantage during adolescence, fac-
tors associated with the person, and options of high-risk groups, current situ-
ations and possibilities, and location or neighborhood, are available from
1980 and forward for both children and their parents.

Data
The nationwide registers used are the following: Population Statistics,
Medical Register on Vital Statistics, Causes of Death Register, Population
and Housing Census, Unemployment Statistics, Education Statistics, Social
8 Journal of Interpersonal Violence 00(0)

Figure 1. Potential victims.

Note. Birth cohorts 1984 to 1994 followed between calendar years 2001 to 2012, aged 7 to
18 years old.

Assistance Act Statistics, Income Compensation Benefits, Labour Market

Research, Fertility Research, Criminal Statistic Register, National Patient
Register, Danish Psychiatric Nationwide Case Register, and Medical Birth
Register. Professional agencies decide to incorporate data into the files based
on established criteria and manualized decisions. Data are registered prospec-
tively and assumed to be collected independently from various numbers of
agencies (Table 1).

Analysis
The purpose of the present analysis is to locate relevant risk factors, such as
background factors, and disabilities. Some of the children may have comor-
bidities. The regression model provides a possibility to isolate associations
between disabilities and risk of sexual assaults. We will describe both the
strength (OR) of different disabilities and risk factors, and the overall expo-
sure of covariates in the population. These two components decide the risk
factors’ contribution to the number of victimized persons, and attributable
fractions (AFs) are calculated (Greenland, 2008). AFs express the reduction
in incidence of reported sexual violence that would be achieved if the popula-
tion had not been exposed at all compared with the current exposure pattern
(Greenland & Drescher, 1993).
Christoffersen 9

Table 1. Information Selected From the Population-Based Registers Used in the

Danish Cohort Study.

Register Variables Years Included

Police archives Victims, police records under the 2001–2012
Penalty Code
Population statistics Gender, age, marital status, 1980–2012
address
Medical register on vital Cause of death, suicide 1979–2012
statistics
Employment statistics Unemployment, branch of trade, 1980–2012
occupation
Education statistics School achievements, education, 1981–2012
vocational training
Social Assistance Act Children in care, preventive care 1977–2012
statistics
Crime statistics Violation, adjudication, 1980–2012
imprisonment
Income compensation Social benefit, duration 1984–2012
benefits
Income statistics tax Income 1980–2012
register
Fertility database Number of siblings, parity, link to 1980–2012
parents
National inpatient ICD-8/10 diagnoses (somatic) 1977–2012
register
National psychiatric ICD-8/10 diagnoses (psychiatric) 1979–2012
register

Note. Information in registers includes both children and parents. The Outcome, Risk Factors,
and Their Definitions, see Appendix A.

The data are analyzed by the discrete-time Cox model (Allison, 1982). A
discrete-time model treats each individual history as a set of independent
observations. It has been shown that the maximum likelihood estimator can
be obtained by treating all the time units for all individuals as though they
were independent, when studying first-time events (Allison, 1982). An event
is a police report on a sexual crime. Individuals’ event history is broken up
into 12 set of discrete-time units (aged 7–18 years) in which an event either
did or did not occur (Christoffersen, 2019).
Each individual is observed until either an event occurs or the observation
is censored, by reaching the age limit, because of death, or the individual is
lost to observation for other reasons (e.g., immigrated). Consequently, indi-
viduals are excluded from the case group and controls after the first event.
10 Journal of Interpersonal Violence 00(0)

The person-years at risk were constructed for the total birth cohorts. Pooling
the non-censored years of all individuals, the person-years, made the num-
bers at risk (N = 4,342,561).
The discrete-time Cox model is used to allow for changing covariates over
time. The risk factors and measures of disability are divided into three types
for the purpose of this study. The Type I risk factors and disabilities are those
that are taken to be indicative throughout all the years in the risk period, irre-
spective of the year when the covariates were notified (e.g., parental sub-
stance abuse or child’s autism). Covariates of Type II, in contrast, identify the
presence of that factor in the year prior to the event, for example, parental
long-term unemployment during a calendar year, moving into or moving out
of a disadvantaged housing area. Finally, the Type III risk factors and mea-
sures of disabilities act on the following year and all the subsequent years
when observed the first time, for example, family separation or brain injury
(Christoffersen, 2019).

Data protection. In order to secure privacy extensive training for all staff
working with data and procedures only few staff members have access to
identifiable data or personal identification numbers. The series of admin-
istrative registers are linked together based on personal identity numbers.
Information for individuals are linked together with information about
their parents. Before analyzing data, the personal identity numbers are
substituted with an encrypted number for security and ethical reasons
(Christoffersen, 2019).

Ethical considerations. We have no information whether an alleged perpetrator

could be a caregiver, peers, or others. A limited number of the alleged perpe-
trators can be identified with the help of the Danish Central Crime Register,
but we have chosen not to include information about the alleged perpetrator
in the present study to avoid selection bias. The study only contains informa-
tion about the victims, their families, and only few structural risk factors,
while background factors about the perpetrator are missing. These limits
must be kept in mind, when results are interpreted, because the data structure
imposes a risk of blaming the victim as a superficial examination of results.

Measures
Sexual crime (dependent variable)
Article 19 of the Convention on the Rights of the Child (CRC). Violence is
understood as any form of physical or mental violence, injury, abuse, neglect
or negligent treatment, maltreatment, or exploitation, including sexual abuse
Christoffersen 11

(Committee on the Rights of the Child, 2011). In the present study, we have
for practical reasons narrowed the definition of violence to sexual offenses,
that is, rape, sexual assault, sexual exploitation, incest, and indecent exposure.
Sexual assault includes intercourse/penetration without consent or defined
unlawful because of the age of the victim and/or the relationship between the
victim and the offender. Sexual crimes are reported criminal offenses against
the person according to law enforcement records. The crime data in the pres-
ent study are collected from the criminal records, which include children
who have been victims of sexual crimes within or without the family. Violent
crime (excludes sexual offenses) against adolescents was analyzed in another
study using the same population (Christoffersen, 2019).

Disabilities (covariates). The types of disability are based on a database man-

dated, compiled, and maintained by Danish hospitals in accordance with the
international statistical classification of diseases and health-related problems
(World Health Organization [WHO], 1992).
We classified disabilities into 13 main groups, which did not cover all dis-
abilities (Table 2). The categories did not include disabilities, which could be
consequences of maltreatment such as internalizing disorders, depression, anx-
iety, post-traumatic stress disorder (PTSD), and other emotional disorders.
Table 2 shows ICD-10 for the mentioned disabilities categorized in 13
groups: (a) physical disabilities, that is, orthopedic impairment, symptoms
and signs involving the nervous and musculoskeletal systems, injuries of
neck and trunk, limp; (b) loss of hearing, that is, conductive and sensorineu-
ral hearing loss, or other disorders of ear; (c) blindness, that is, low vision;
(d) speech disability, that is, specific developmental disorders of speech and
language, infantile cerebral palsy, speech disturbances, lack of expected nor-
mal physiological development; (e) stuttering, that is, stuttering and other
behavioral and emotional disorders with onset usually occurring in child-
hood and adolescence; (f) dyslexia, that is, specific developmental disorders
of scholastic skills, dyslexia, and other dysfunctions, not elsewhere classi-
fied; (g) epilepsy, that is, acquired aphasia with epilepsy or epilepsy; (h)
mental retardation; (i) Down’s syndrome, that is, chromosomal abnormali-
ties not elsewhere classified; (j) congenital malformations, deformations,
and chromosomal abnormalities; (k) brain injury, that is, intracranial injury,
other mental disorders due to brain damage and dysfunction and to physical
disease, post-concussion syndrome, chronic post-traumatic headache; (l)
ASD, that is, autism, Rett syndrome, and Asperger’s syndrome; and (m)
ADHD, that is, diagnosed with ADHD in a psychiatric ward according to the
Danish Psychiatric Nationwide Case Register, Hyperkinetic disorders, and/
or receiving ADHD drugs.
12 Journal of Interpersonal Violence 00(0)

Table 2. Classification of Indicators of Disabilities.

International Statistical Classification of Diseases and

Disabilities Related Health Problems (ICD-10)
Autism spectrum Autism F84 Pervasive developmental disorders
disorder
Speech disability Specific developmental disorders of speech and language
ICD-10:F80, Infantile cerebral palsy ICD-10:G80,
Speech disturbances ICD-10:R47, Lack of expected
normal physiological development ICD-10:R62
ADHD Diagnosed with ADHD in a psychiatric ward according
to the Danish Psychiatric Nationwide Case Register.
ADHD F90 Hyperkinetic disorders and/or receiving
ADHD drugs “N06BA04” or “N06BA09”
Loss of hearing Conductive and sensorineural hearing loss ICD-10:H90–
H91, Other disorders of ear ICD-10:H93–H95
Epilepsy Acquired aphasia with epilepsy ICD-10:F80.3, Epilepsy
ICD-10:G40
Mental retardation Mental retardation ICD-10:F70–F79
Down’s syndrome Chromosomal abnormalities not elsewhere classified:
ICD-10:Q90
Brain injury Intracranial injury S06, Other mental disorders due to
brain damage and dysfunction and to physical disease
F06, Post-concussion syndrome ICD-10:F07.2, Chronic
post-traumatic headache ICD-10:G44.3
Stuttering Stuttering and other behavioral and emotional disorders
with onset usually occurring in childhood and
adolescence ICD-10:F98
Physical disabilities Symptoms and signs involving the nervous and
musculoskeletal systems ICD-10:R25–R29, Injuries of
neck and trunk, limp, ICD-10:T91–T94
Dyslexia Specific developmental disorders of scholastic skills
ICD-10:F81. Dyslexia and other dysfunctions, not
elsewhere classified ICD-10:R47
Blindness Low vision ICD-10:H54
Congenital Congenital malformations, deformations, and
malformations chromosomal abnormalities ICD-10:Q00–Q99

Source. World Health Organization (1992).

Note. Example: ICD-10 diagnosis “F84” includes all diagnoses F84.0–F84.9. ADHD =
attention-deficit/hyperactivity disorder.

Disabilities that may hinder an adolescent’s ability to communicate, were

grouped under speech disability. For example, cerebral palsy was grouped under
speech disability (i.e., developmental disorders of speech and language).
Christoffersen 13

Disability measures including ASD, ADHD, mental retardation, and dys-

lexia were diagnosed in psychiatric wards in accordance with the Danish
Psychiatric Nationwide Case Register. Cases of ADHD are also recorded if a
child has received ADHD medication prescribed by medical practitioner.
The statistical model allows for that individuals can have multiple diagno-
ses. When viewing the effect of a specific type of disability in the regression
analysis, the referent group would be the person-years without that specific
type of disability.
The statistical model allows for changing risk factors and changing dis-
ability over time (see Table 3). The measures of disability are divided into
two types for the purpose of this study. Some of the disabilities are lifelong
disabilities attributable to mental and/or physical impairments, manifested
before 18 years of age (Type I). Examples of this are the ASD, ADHD, men-
tal retardation, epilepsy, sensory impairment (e.g., loss of hearing, blindness),
Down’s syndrome, and other congenital malformations.
Some disabilities are assumed to be acquired (Type III) and are therefore
only recorded when found. These include speech disability (e.g., develop-
mental disorders of speech and language, cerebral palsy), brain injury (e.g.,
mental disorders due to brain damage and dysfunction, post-concussion syn-
drome, chronic post-traumatic headache), stuttering (e.g., behavioral and
emotional disorders with onset usually occurring in childhood and adoles-
cence), and dyslexia and physical disabilities (i.e., orthopedic impairment).

Risk factors (other covariates). Parental background factors such as parental

violence (domestic and otherwise), parental inpatient mental illness, parental
suicidal behavior or alcohol abuse, parental long-term unemployment, family
separation, and child in (public) care outside the family are included into the
regression analysis. Structural factors such as the victim living in a disadvan-
taged area and non-Danish citizens are included. Substance abuse indicated
risk-taking behavior as a precursor of becoming a victim of sexual violence
during adolescence.

Results
The population followed (N = 679,683) comprised 8,039 or 1.18% victims
of a sexual assault during 2001 to 2012 when they were between 7 and 18
years old. The number of person-years was 4,342,561.
Table 3 presents differences in victimization rates between person-years
with and without various disabilities. The most common disability was
ADHD: 10.8% of the person-years, the adolescent suffered from ADHD,
8.9% the individual suffered from ASD, while 8% of the person-years the
child suffered from mental retardation.
14 Journal of Interpersonal Violence 00(0)

Table 3. Indicators of Disability.

Factors Associated
With Disability Type % of Controls % of Cases OR 95% CI
Autism spectrum (I) 8.9 27.0 3.8 [3.6, 4.0]
disorder
Speech disability (i.e., (III) 8.2 10.2 1.3 [1.2, 1.4]
cerebral palsy)
ADHD (I) 10.8 30.8 3.7 [3.5, 3.9]
Loss of hearing (I) 1.1 1.8 1.6 [1.4, 1.9]
Epilepsy (I) 1.6 2.1 1.9 [1.6, 2.1]
Mental retardation (I) 8.0 24.7 3.8 [3.6, 4.0]
Down’s syndrome (I) 0.1 — ns
Brain injury (III) 5.7 8.1 1.5 [1.3, 1.6]
Stuttering (III) 2.8 5.9 2.1 [1.9, 2.3]
Physical disabilities (III) 1.3 1.6 1.2 [1.0, 1.5]
(i.e., orthopedic
impairment)
Dyslexia (III) 1.4 2.7 1.9 [1.7, 2.2]
Blindness (I) 0.06 0.12 2.0 [1.1, 3.7]
Congenital (I) 0.4 0.6 ns
malformations

Note. Some of the victims had multiple disabilities. OR for types of disability prior to first-time
victim of a sexual crime. Person-years for children born in 1984 to 1994 (aged 7–18 years
old). Bivariate results from a discrete-time Cox analysis. OR = odds ratio; CI = confidence
interval; ADHD = attention-deficit/hyperactivity disorder; ns = non-significant.
Type of time dependency
Type I: Disability factor observed at time t also covers the years before and after the years
under investigation.
Type II: Exposed to risk factor at time t, then the risk factors are also present at t + 1.
Type III: Exposed to disability factor at time t then risk factor is also present at all the
following years.

Associations with victimization vary across different disabilities. Children’s

person-years with disability had significantly higher rates of victimization
relative to children with no disability. Exceptions from this pattern were
Down’s syndrome and other congenital malformations probably because of
very few observations (approximately 0.5% of the surveyed person-years).
Table 3 shows that 27% among the victims were adolescents with ASD, 30%
among the victims were adolescents with ADHD, while 24% of the victims
were adolescents with mental retardation. These figures correspond to OR of
3.7 to 3.8 (95% CI = [3.5, 4.0]). Speech disability was found among 10% of
the victims, which corresponds to OR of 1.3 (95% CI = [1.2, 1.4]). Some of
the victims had multiple disabilities.
Christoffersen 15

Table 4. Family Vulnerability.

Risk Factors Type % of Controls % of Cases OR 95% CI AF %

Disadvantages during adolescence
Parental suicidal (I) 10.4 21.4 ns —
behavior
Mother mental (I) 4.8 9.9 ns —
retardation
Father mental (I) 3.9 8.4 ns —
retardation
Parental inpatient (I) 16.9 31.9 ns —
mental illness
Parental substance (I) 17.4 34.2 1.4 [1.3, 1.5] 6.5
abuse
Parent diagnosed (I) 8.4 14.8 ns —
with ADHD
Parental violence (III) 13.9 28.5 1.4 [1.3, 1.4] 5.3
Child ever in care (III) 2.1 7.9 1.9 [1.8, 2.1] 1.9
Family separation (III) 36.2 59.5 1.8 [1.7, 1.9] 22.5
Mother teenager (I) 2.0 5.1 1.8 [1.6, 2.0] 1.6
Parent unemployed (II) 7.0 11.0 1.3 [1.2, 1.4] 2.1
> 21 weeks

Note. OR for risk factors prior to first-time victim of a sexual crime. Person-years for
children born in 1984 to 1994 (aged 7–18 years old). Adjusted results from a discrete-time
Cox analysis. AF can only be estimated for OR >1. OR = odds ratio; CI = confidence
interval; AF = attributable fraction; ns = non-significant; ADHD = attention-deficit/
hyperactivity disorder.
Type of time dependency
Type I: Risk factor observed at time t also covers the years before and after the years under
investigation.
Type II: Exposed to risk factor at time t, then the risk factors are also present at t + 1.
Type III: Exposed to risk factor at time t, then the risk factor is also present at all the
following years.

Table 4 shows that family vulnerability such as parental substance abuse,

parental violence, teenage motherhood, child in public care, family separa-
tion, and long-term unemployment predicted an elevated risk of victimiza-
tion of a sexual assault. ORs were found between 1.2 and 2.0, when accounted
for multiple disabilities and other risk factors. The AFs were estimated to be
6.5%, 5.3%, and 22.5% for parental substance abuse, parental violence, and
family separations, respectively.
Table 5 shows that females were between 8 and 9 times more at risk for
being a victim of a sexual assault (95% CI = [8.2, 9.4]). Adolescents with an
alcohol abuse situation, the risk of sexual assault, were significantly higher
16 Journal of Interpersonal Violence 00(0)

Table 5. Individual Vulnerability, Disadvantaged Area, and Minority.

Risk Factors Type % of Controls % of Cases OR 95% CI AF %

Adolescent is (I) 48.3 89.1 8.8 [8.2, 9.4] —
femalea
High risk behavior
Suicide (III) 2.0 4.6 ns —
attempt
Drug abuse (II) 0.6 2.3 ns —
Alcohol abuse (II) 0.9 3.1 1.6 [1.4, 1.9] 0.5
Convicted of (III) 0.4 0.3 ns —
violence
Location or neighborhoods
Disadvantaged (II) 2.2 2.6 ns —
area
Non-Danish (II) 8.5 5.4 0.7 [0.6, 0.7] —

Note. OR for risk factors prior to first-time victim of a sexual crime. Person-years for
children born in 1984 to 1994 (aged 7–18 years old). Adjusted results from a discrete-time
Cox analysis. AF can only be estimated for OR >1. OR = odds ratio; CI = confidence
interval; AF = attributable fraction; ns = non-significant.
a
The AF is not calculated because the risk factor is not changeable.
Type of time dependency
Type I: Risk factor observed at time t also covers the years before and after the years under
investigation.
Type II: Exposed to risk factor at time t, then the risk factors are also present at t + 1.
Type III: Exposed to risk factor at time t, then risk factor is also present at all the following
years.

(OR = 1.6, 95% CI = [1.4, 1.9]) when accounted for other risk variables.
Only few of the control person-years were exposed to alcohol abuse. On the
contrary, being a member of an ethnic minority seems to be a protective fac-
tor. The adjusted ORs were estimated to be 0.7 (95% CI = [0.6, 0.7]) for
non-Danish person-years of school-age children. Living in a disadvantaged
area or moving out of a disadvantaged area did not influence the risk of vic-
timization. The individual vulnerability apart from the person-years with dis-
abilities could not explain the variations of victimization.
Table 6 shows that the predicative effect sizes of intellectual disabilities on
victimization were considerably reduced when adjusted for other risk factors.
While the bivariate results in Table 3 showed OR between 3.7 and 3.8 for
ASD, ADHD, and mental retardation, the adjusted effect sizes were estimated
to be 1.4, 1.9, and 1.2, respectively. Even when adjusted for comorbidity,
family vulnerability, and other risk factors, the attributable contributions of
ASD, ADHD, and mental retardation were 3.4%, 8.9%, and 1.6% of the cases
of sexual assaults, respectively.
Christoffersen 17

Table 6. Indicators of Disability.

Risk Factors Type % of Controls % of Cases OR 95% CI AF %

Factors associated with disability
Autism spectrum (I) 8.9 27.0 1.4 [1.2, 1.5] 3.4
disorder
Speech disability (III) 8.2 10.2 0.9 [0.8, 0.9] —
ADHD (I) 10.8 30.8 1.9 [1.7, 2.1] 8.9
Loss of hearing (I) 1.1 1.8 1.4 [1.1, 1.6] 0.4
Epilepsy (I) 1.6 2.9 1.4 [1.2, 1.5] 0.6
Mental retardation (I) 8.0 18.6 1.2 [1.1, 1.3] 1.6
Down’s syndrome (I) 0.1 — ns —
Brain injury (III) 5.7 8.1 1.1 [1.0, 1.2] 0.6
Stuttering (III) 2.8 5.9 0.8 [0.7, 0.9] —
Physical disabilities (III) 1.3 1.6 1.2 [1.0, 1.5] 0.3
(i.e., orthopedic
impairment)
Dyslexia (III) 1.4 2.7 0.8 [0.7, 1.0] —
Blindness (I) 0.06 0.12 1.6 [1.1, 2.4] —
Congenital (I) 0.4 0.6 ns —
malformations

Note. OR for risk factors prior to first-time victim of a sexual crime. Person-years for children
born in 1984 to 1994 (aged 7–18 years old). Adjusted results from a discrete-time Cox
analysis. AF can only be estimated for OR >1. OR = odds ratio; CI = confidence interval;
AF = attributable fraction; ADHD = attention-deficit/hyperactivity disorder; ns = non-
significant.
Type of time dependency
Type I: Risk factor observed at time t also covers the years before and after the years under
investigation.
Type II: Exposed to risk factor at time t, then the risk factors are also present at t + 1.
Type III: Exposed to risk factor at time t, then risk factor is also present at all the following
years.

The bivariate results showed that speech disability, stuttering, and dys-
lexia were significant predictors of victimization of sexual assault during
adolescence. When other disabilities and confounders were taken into
account, these communicative disabilities turned out to be protective factors
with ORs significantly lower than 1.0 (compare Table 3 with Table 6).

Discussion
The study focuses on examining sexual crime against school-age children
with disabilities and explaining minority differences in victimization to pro-
vide a basis for national prevention policies and programs. The study
18 Journal of Interpersonal Violence 00(0)

demonstrates the importance of examining the effects of individual forms of

disability rather than combining multiple types into a few single measures.
We estimate that the prevalence of sexual offenses against schoolchildren
with intellectual disabilities (autism, ADHD, and mental retardation) are 3.7
to 3.8 times higher than the prevalence among their peers without these dis-
abilities. Their communication or intellectual impairment seems to increase
their vulnerability as were expected from theories.
When you are studying relatively rare incidences (sexual assaults) and asso-
ciations with relative rare disabilities (e.g., blindness, physical disabilities, and
various types of intellectual disabilities), and furthermore have ambitions of
controlling for relatively rare overlapping risk factors such as parental violence
and substance abuse, you need large samples. The present study followed 11
birth cohorts (N = 679,683) and found 8,039 first-time reported sexual assaults.
Compared with previous studies of sexual assault against school-age children
with and without disabilities, the present study presents some robust findings.
Our findings provided supportive evidence that children with intellectual dis-
abilities such as ADHD, ASD, and mental retardation were more vulnerable to
sexual assaults than their contemporaries without these disabilities were.
Previous research finds that children with these intellectual disabilities and
mental disabilities such as depression, anxiety, PTSD, emotional disorder, or
conduct disorder are 4.6 times more likely to be exposed to sexual assaults (L.
Jones et al., 2012). We suppose that these figures overestimate the association
between type of disability and risk of sexual assaults because the mentioned
mental disabilities (i.e., depression, anxiety, PTSD) may very well be a reaction
to child maltreatment (e.g., sexual or violent victimization). We decided not to
include the mentioned disabilities into the list of independent risk factors
because the cause-and-effect relationship might be mistaken.
We assume that our estimate of the OR between ADHD, ASD, or mental
retardation of 3.7 to 3.8 (95% CI = [3.5, 4.0]) is a more accurate estimate,
and this estimate is furthermore based on a relatively large population regis-
ter data collected prospectively. The data are not dependent on retrospective
interview of victim or offenders.
To examine the association between disabilities and child victimization,
we conducted a series of logistic regression analyses taking the time-ordering
into consideration. To provide basis for prevention policies, we included a
series of risk factors (confounders), which have been manifested in the time
schedule before the reported sexual assault.
The search for risk factors in the enormous amount of administrative data
was theory-driven to find pathways between child disabilities and risk of sexual
assaults. The ecological model inspired us to include individual risk factors,
family vulnerability, and local community factors into the risk-finding process.
Christoffersen 19

The results indicated that changing factors such as schoolchildren and their
families moving into or moving out of disadvantaged areas were not followed
by a changed risk of sexual assaults, when disabilities and other covariates
were taken into account. In a previous study using same methodology, we
found, as expected, that ethnic minorities and males were more exposed to
violence in police records than their contemporaries (Christoffersen, 2019).
The present study found that being a member of an ethnic minority seems to
be a protective factor against rape. An explanation could be that it could be a
positive side effect of social control practiced in some minority societies. Due to
gendered conventions regarding minority schoolgirls’ mobility in public space,
such girls may be less exposed to sexual assaults according to police records.
A discrepancy between official data and dark figure could also play a role.
Retrospective interview with random samples of adults about child maltreat-
ment during the formative years showed a discrepancy when compared with
estimations based on official Danish records (Christoffersen, 2010). The dis-
crepancy between official data and dark figure could lead to a systematic
distortion with regard to vulnerability of intellectually impaired persons to
sexual victimization. Some German studies have found that the discrepancy
between official data and dark figures in the case of intellectual impairment
is influenced by the social perception of this group of persons (Krüger et al.,
2014; Schröttle et al., 2012).
British studies have found that people with intellectual disabilities are
more likely to be victims of crimes such as abuse but are less likely to afford
justice (Bull, 2010). Some efforts are made to improve the quality of informa-
tion elicited from vulnerable witnesses based on research contributions to
knowledge on this difficult topic (Bull, 2013). Psychological research and the
professional practice have improved the investigative interviewing of chil-
dren and other vulnerable witnesses (Bull, 2010).
In the present study, it is found that the vulnerability of the families pre-
dicted an increased risk of sexual assaults. Schoolchildren with ADHD and
mental retardation may have a risk prone behavior, and in combination with the
pressure on parents and other caretakers, this can reduce the parental ability to
protect a child from a hostile environment. The autism and intellectual disabil-
ity may also be an invisible disability, which may cause misunderstandings and
hostilities from peers and others, while the more glaring shortcomings such as
speech disability, stuttering, and dyslexia may manifest a lack of communica-
tion as demonstrated by the absence of adequate responses. Children with
autism may be disproportionately at risk of experiencing sexual abuse and vic-
timization. Inability to detect violations in social exchange rule may increase
the risk of their interpersonal victimization. This interpretation of data relating
to invisible disability does not support the mentioned “hate crime theory”
20 Journal of Interpersonal Violence 00(0)

where the intent of hate crimes is to send a message of intimidation to an entire

community and not only to harm the victim (McMahon et al., 2004).
The results give supportive evidence that an attributional part of the inci-
dences may be due to family vulnerability or a combination between intellectual
disability and family vulnerability. The AF of family vulnerability such as
parental substance abuse, parental violence, family separation, and long-term
unemployment express the reduction in incidence of reported sexual violence
that would be achieved if the population had not been exposed to family vulner-
ability. The estimates indicate that the link between children with intellectual
disabilities and sexual assaults is considerably weakened when the regression
analyses include information about family vulnerability. The link is likely to
become weaker with a better functioning family. Our findings pointed to the
possibility that family functioning could have critical effect on the overall
increased risk between the mentioned intellectual disabilities and victimization
of sexual assaults consistently found in the literature.

Implications
The finding that children with disabilities had an increased likelihood of victim-
ization and that vulnerable family condition furthermore increases probability of
sexual assaults in the family and outside the family emphasizes the need for fur-
ther research on intervention to prevent violence in any form against adolescents
with disabilities. The WHO (2009) reviews five main strategies with some evi-
dence of effectiveness to prevent sexual assaults against adolescents: (a) develop-
ing safe, stable, and nurturing relationships between children and their parents
and caregivers, for example, parent training includes nurse home visiting and
parent child programs; (b) developing life skills in children and adolescents, for
example, preschool enrichment programs; (c) reducing the availability and harm-
ful use of alcohol, for example, regulating sales of alcohol and raising alcohol
prices; (d) promoting gender equality to prevent violence against girls, for exam-
ple, school-based programs to address gender norms and attitudes; and (e) chang-
ing cultural and social norms that support violence. There is an urgent need to
expand the evidence base and enhance investment in research in violence and
violence prevention. The overall prevalence of permanent disabilities caused by
maltreatment during adolescence are still to be explored. There have been calls
for more research into this connection (Baladerian, 2009; Lightfoot, 2014). Many
studies have demonstrated the link between child abuse and mental disability
such as depression, PTSD, suicide consideration, and non-suicidal self-inflicted
injury (Christoffersen et al., 2015; Murphy et al., 2014). Some researchers argue
that treating and later trying to remedy the effect of child maltreatment are both
less effective and more costly than preventing in the first place (Kilburn &
Karoly, 2008; Mikton et al., 2014).
Christoffersen 21

Limitations
The study focused on the time sequence between disabilities, risk factors,
and victimization; one should still be cautious before drawing conclu-
sions on the causal direction. We have tried to establish the causal direc-
tion in the relationship between disabilities and victimization in the
longitudinal study, as has been recommended by several researchers
(Brown et al., 1998; Chan et al., 2018; L. Jones et al., 2012). Although,
we have included various risk factors associated with the risk for sexual
assaults, we have only examined a limited number of variables and have
therefore been unable to investigate all the possible combined effects of
multiple risk factors for sexual assaults. To fully understand sexual
assaults against children, there is an urgent need for more knowledge
about the perpetrator (Carstensen et al., 1981). The present study includes
both incest and extra-familial abuse in one category without considering
the differences. Further research about the perpetrator, the victim, and the
meeting conditions is needed.
The study uses administrative registers, which are useful because profes-
sional agencies decide to incorporate data into the files on the basis of estab-
lished criteria and manualized decisions, and the data are registered prospectively.
Furthermore, data are assumed to be collected independently from various num-
bers of agencies, and data completely cover all the calendar years from the chil-
dren’s birth until early adulthood. Still, we have a suspicion that Berkson’s bias
may influence the data (Berkson, 1946; Schwartzbaum et al., 2003). Some diag-
noses might only be reported in connection with elucidation of the etiology of
other diagnoses. This could create a spurious association in hospital’s records,
which is not found to that extent in the population.
Finally, assessment of risk factors may permit professionals to facilitate
prevention and treatment interventions. Professionals must recognize that the
present study probably underreports the size of the problem because adoles-
cents with disabilities face barriers when reporting victimization. A substan-
tial number of victims elect not to report to the police because the victims
realize or hope they can minimize their losses by avoiding the legal system
(Doerner & Lab, 2015).

Conclusion
The study revealed disability-specific longitudinal pattern of child victimiza-
tion, and intellectual disabilities predicted increased risk of victimization of
sexual assaults. The study found family vulnerability as a predictor of
increased risk of victimization of sexual assaults among schoolchildren with
and without specified disabilities.
22
Appendix A
The Outcome, Risk Factors, and Their Definitions.
Outcome Factor
Sexual crime against a person
younger than 18 years
Risk factor
Parental suicidal behavior
Parental mental retardation
Parental inpatient mental
illness
Parental substance abuse
Parental alcohol abuse
Parental drug abuse
Parent diagnosed with ADHD
Parental violence
Child in (public) care
Family separation
Mother teenager
Journal of Interpersonal Violence 00(0)
Definition
Persons who have been victim of sexual offense under the Danish
Penalty Code recorded by police. Including criminal reports
for rape, sexual abuse, sexual exploitation, incest, indecent
exposure
Family vulnerability
Parents’ suicide attempts according to the National Patient
Register and the Danish Psychiatric Nationwide Case Register,
or suicide according to the Causes of Death Register. Intentional
self-harm according to hospital admissions is also included
Mental retardation ICD-10:F70–F79
One or both parents admitted to a psychiatric ward according to
the Danish Psychiatric Nationwide Case Register
Alcohol abuse or drug abuse (see below)
According to hospital admissions, the following diagnoses were
expected to be associated with long-term alcohol abuse:
Alcoholic psychosis, alcoholism, esophageal varices, cirrhosis
of liver (alcoholic), chronic pancreatitis (alcoholic), delirium,
accidental poisoning by alcohol. Mental and behavior disorder
due to use of alcohol also included
Addiction or poisoning by drugs according to hospital admissions.
Mental and behavioral disorder due to use of drugs (e.g., opioids,
cannabinoids, cocaine). Dependence on morphine was not
included if associated with diseases of chronic pain
Diagnosed with ADHD in a psychiatric ward according to the
Danish Psychiatric Nationwide Case Register
Battered adults according to hospital admissions. Parent exposed
to assault or injuries of undetermined intent. Victims of violence,
which led to hospitalization and professional assessment
that the injury was willfully inflicted by other persons. Parent
convicted for violence: The Criminal Statistic Register records
persons convicted for violence. This category comprises a wide
range of criminal behavior of various degrees of seriousness:
manslaughter, grievous bodily harm, violence, coercion, and
threats. This category does not include accidental manslaughter
in combination with traffic accidents, or rape, which belongs to
the category of sexual offenses
The child is living with the parents under caseworker supervision
according to the children’s acts section, or the child is placed
outside the home living in an institution or in a foster home.
Information from the population-based register of social
assistance to children in care
Information on all children who had experienced divorce,
separation, and/or the death of a parent before they were 18
years old, taken from the Danish Central Population Register
(CPR) that connects children to their parents whether they are
married or not
The mother had been a teenager herself when she gave birth to
the child in focus
(continued)
Christoffersen
Appendix A. (continued)
Outcome Factor
Parental unemployed >21
weeks
Individual vulnerability
Suicide attempt
Drug abuse
Alcohol abuse
Convicted of violence
Ethnicity or neighborhoods
Disadvantaged area
Danish/non-Danish citizenship
Source. Christoffersen (2019).
Note. ADHD = attention-deficit/hyperactivity disorder.
23
Definition
Unemployment for at least one parent: The number of days
unemployed (more than 21 weeks) during a calendar year. From
registers of Income Compensation Benefits, Labour Market
Research, and Unemployment Statistics. Parental unemployment
for one or both parents
Indicators of high-risk behavior
Self-inflicted harm according to hospital admissions. The definition
of suicide attempts also included behavior that conformed to
the following conditions: (a) Suicide attempts that had led to
hospitalization, (b) assessment of the trauma being an act of self-
mutilation according to the international statistical classification
of injuries when discharged from hospital, (c) the trauma had to
be included in a specified list of traumas traditionally connected
with suicide attempts: cutting in wrist (carpus), firearm wounds,
hanging, self-poisoning with drugs, pesticide, cleaning fluids,
alcohol, or carbon monoxide. This does not include non-suicidal
self-harm (Christoffersen et al., 2003)
Addiction or poisoning by drugs according to hospital admissions.
Mental and behavioral disorder due to use of drugs (e.g., opioids,
cannabinoids, cocaine). Dependence on morphine was not
included if associated with diseases of chronic pain
According to hospital admissions, the following diagnoses were
expected to be associated with long-term alcohol abuse:
alcoholic psychosis, alcoholism, esophageal varices, cirrhosis
of liver (alcoholic), chronic pancreatitis (alcoholic), delirium,
accidental poisoning by alcohol. Mental and behavior disorder
due to use of alcohol also included (Christoffersen & Soothill,
2003)
Persons who have been confined with violent personal crimes
under the Danish Penalty Code, for example, offenses against
personal liberty, violence against the person, homicide, assault,
robbery, but not theft
A governmental board has identified the most disadvantaged
housing areas. These are a part of the subsidized housing sector,
consisting of 135 areas. About 4% of the population (200,000
persons) live in these areas. Each area has 1,500 inhabitants, on
average, ranging from 30 to 14,000 persons (Boligministeriet,
1993; Graversen et al., 1997; Hummelgaard et al., 1997).
These disadvantaged housing areas were divided into quintiles,
and the two most disadvantaged quintiles were identified as
disadvantaged areas in the present by this dichotomized variable.
These most disadvantaged areas would thus cover about 80,000
inhabitants or 1.6% of the total population
The definition is based on fulfilling one of the following conditions:
• If at least one of the parents has Danish citizenship and is born
in Denmark
• If there is no information in the registers about any of the
parents and the child himself or herself has Danish citizenship
and is born in Denmark
All others are defined as non-Danish
24 Journal of Interpersonal Violence 00(0)

Authors’ Note
The National Board of Social Services has no involvement in the collection, analysis,
and interpretation of data, nor in the writing of the report, and the decision to submit
the article for publication.

Acknowledgments
I thank the National Board of Social Services for generous research support. My col-
league, senior researcher Henning Bjerregaard Bach, is thanked for his help in analyzing
data, while senior researcher Helle Holt is thanked for her critical and helpful com-
ments. I have received helpful comments and useful critiques from Anika Liversage,
Dorte Damm, Esben Meulengracht Flach, and Britta Kyvsgaard.

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) received no financial support for the research, authorship, and/or publi-
cation of this article.

ORCID iD
Mogens Nygaard Christoffersen https://orcid.org/0000-0003-3792-3952

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Author Biography
Mogens Nygaard Christoffersen has studied parental alcohol abuse, violent crime,
child maltreatment, child abuse and neglect and adolescents’ attempted suicide, non-
suicidal self-injury, and anxiety disorder in schoolchildren.