Abuse of Children with Disabilities

Facts to Consider 

-   A recent American study found that caregivers abused children with disabilities 1.7 times more than children without disabilities.1 Research in Canada suggests that the risk estimate of abuse of people with disabilities may be as high as five times greater than the risk for the general population.2

-   Parents of children with disabilities come from every social class and value system. They are as likely as any other person in society to subscribe, either consciously or unconsciously, to widespread negative myths about their child and his or her limitations.

-   Feelings of shame and denial may be so strong in some cultures that a child’s disability will be hidden by members of his or her family. As a result, the child may be denied access to normal developmental opportunities as well as important support or treatment.

-   Maltreatment and abuse of institutionalized children with physical and intellectual disabilities are well-documented facts in Canadian history.3, 4 Protective measures are now in place in Canadian institutions to prevent the reoccurrence of these past events. However, children growing up in residential facilities continue to be at higher risk of abuse than children growing up in their own homes.5

What Is Child Abuse?

Child abuse occurs when a parent, family member, guardian, caregiver or other adult (teacher, doctor, neighbour, etc.) causes physical, sexual, emotional or psychological harm to a child, or places a child at serious risk of harm.

Child abuse always involves the misuse of power. Adults are more powerful than children – both physically and socially. Adults who use their power to help, guide and support the development of children are using their power appropriately. However, adults who punish children harshly, insult them, neglect their needs, abuse them physically or sexually, or ignore, isolate, ridicule, humiliate or manipulate them, are using their power in ways that are harmful and destructive to children.

Are Children with Disabilities More Vulnerable to Abuse?

For children with disabilities, the usual risk factors for child abuse (i.e. dependence and vulnerability), are intensified. Children who are unable to perform the same tasks as other children of their age are more vulnerable for many reasons:

-   Their inability to see, hear, move, communicate, dress, toilet or bathe themselves independently makes them vulnerable to rough, careless or intrusive personal care, or neglect of their personal needs.

-   These differences also make them vulnerable to unfair and disrespectful comparisons with siblings or other children of the same age. Needing help to do things others can do independently makes them vulnerable to low self-esteem – a major risk factor for abuse.

-   Their differences may make it difficult for them to participate in family and community activities without assistance, leading to social isolation from their natural peer group and adults other than their primary caregiver(s). Isolation is another major risk factor for abuse.

-   Their differences make it more likely that their personal care and even their residence will be provided by people who are not related to them, and/or who lack an affective relationship with them.6 Being cared for outside the home is another major risk factor for abuse.

-   Children with intellectual or communication differences are vulnerable to being ignored, disbelieved or misunderstood if they attempt to report abuse.

-   Parents/caregivers of a disabled child may feel very much on their own. They may be stressed by ongoing health care needs, difficulties in finding suitable child care, financial burdens and social isolation, along with related difficulties such as depression and marital discord. Although the role of stress in triggering or causing abuse of children with disabilities is still controversial, studies indicate that caregivers who perceive themselves as severely stressed are more likely to commit abuse.

-   Children with disabilities are more likely to be viewed in terms of their disability. This places severe limits on a child’s sense of his or her own capabilities, interests and ability to dream and imagine future possibilities. Being depersonalized in this way makes a child vulnerable to some of the most severe forms of abuse, including homicide.9

-   Children with disabilities are often taught to be compliant with adults, especially at the doctor’s or therapist's office or clinic. Compliance for intrusive or painful procedures that a child would naturally resist may sometimes be obtained through force, coercion or bribery. As a result, it becomes very difficult for a child to distinguish between legitimate and abusive adult demands.10

-   Myths abound regarding the sexuality of people with disabilities. People with disabilities are presumed to not have sexual feelings and desires like everyone else or, conversely, to be “over-sexed.” Children with disabilities, particularly intellectual disabilities, are presumed to not understand anything at all about their bodies, or to be “precocious” about sex. These myths place children at significantly increased risk of sexual abuse.

-   Children with disabilities may have reduced opportunity to set their own personal boundaries. For example, caregivers of either sex may have responsibility for undressing or bathing a child, regardless of the child’s chronological age or level of development.

What Can Be Done to Prevent Abuse of Children with Disabilities?

Prevention of child abuse is in everyone’s interest. The most vital component of prevention is a multi-level approach to education.

-   Children with disabilities, like all children, need training in safety, self-protection, healthy sexuality and assertiveness. Children need to know that they have a right to protect themselves and a right to tell an adult if they are not being protected or if their needs are not being met. Children need to understand clearly that they deserve to be treated with respect in every situation – at home, at school, in hospitals or treatment centres, in their social environments, etc.

-   Parents and others who contribute to a child’s care may need education and support, including special training relevant to a child’s particular physical, sensory or intellectual needs.

-   Parents/caregivers may also need education regarding the potential risks and signs of abuse. Their child may be at an increased risk of abuse from caregivers and others in the community. Learning to listen to a child is always important, especially if a child has a communication or intellectual disability. Children may communicate about abuse in indirect ways – through regressive behaviours, resistance, or angry “acting out” behaviour. Punishment for these behaviours is inappropriate and counter-productive.

-   Parents must also be very careful about choosing caregivers – and about observing their child’s response to these individuals. As well, parents can ask questions to assess the openness of professionals and care facilities to their ongoing involvement in their child’s care and development.

-   Professionals need to “unlearn” old myths that may negatively affect their attitudes toward children with disabilities and/or their families. Children with disabilities must be seen as individuals first, not as “diagnoses.”

-   Medical professionals need to take sufficient time and care to explain procedures and listen to objections, to ensure that the child’s cooperation reflects a genuine level of informed consent.

-   People working with children and families need to improve their ability to detect child abuse and neglect and to improve mechanisms for alerting authorities to intervene.

-   Our broader society must take responsibility for providing adequate support to families so that they can meet the needs of children who have disabilities. Because a disability often entails extraordinary expenses from birth and throughout life, resources must be made available so that families can access the qualified and reliable services and equipment they need – services such as respite care; equipment and medications needed for health, mobility, seeing, hearing and learning; as well as sensitive and responsive social services.

Reporting Abuse of a Child with a Disability

Although some people think that child abuse is a private family matter, it is not. Every member of the public has a responsibility to safeguard the well- being of all children, including children with disabilities.

Some adults find it easier to empathize with the caregiver than with the child with a disability. They may hesitate to judge a caregiver’s actions as abusive, wondering what they would do if they had to deal with the stress of caring for a child with disabilities. These self-doubts must be set aside when the dignity, safety or physical integrity of a child with a disability has been violated in any way. Children with disabilities are entitled to the same protection and security as all other children.

If you have reasonable grounds to suspect that a child is being abused or neglected, promptly report your concerns to the child welfare agency, provincial or territorial social services department or police force in your community. If necessary, a report can be made anonymously.

Reporting is not difficult or time consuming. In all cases, the person making the report is protected from legal action, provided the report is not made falsely or motivated by malice.

Resources

IN THE COMMUNITY

Parents and/or caregivers of children with disabilities must not allow themselves to be held back by fear or shame in seeking help to deal with problems around self-control, anger or abuse.

In many communities, support groups are already active. In others, all that may be needed is one person to take the lead in forming a new support group.

Parents, caregivers and advocates for children with disabilities can obtain help and support by calling:

-   Their local Association for Community Living

-   Their local Independent Living Centre for people with disabilities

-   Organizations dealing with specific disabilities, such as the Federation for Cerebral Palsy, the Spina Bifida and Hydrocephalus Association and the Epilepsy Association.

For other information on this topic, or to locate appropriate services, contact your local child welfare or social service agency, the police department, hospital, mental health centre, distress centre, or other community service organization that provides counselling and support to children and families. Many of these organizations are listed among the emergency telephone numbers on or near the first page of your local telephone directory.

Children and young people anywhere in Canada who want to talk with a trained counsellor about what is happening in their lives, or who want to know where they might go for support in their community, can contact:

Kids’ Help Phone
Telephone: 1 (800) 668-6868
Web site: http://kidshelp.sympatico.ca/

A number of organizations across Canada have particular expertise in understanding and preventing abuse of children with disabilities. These include:

Suspected Child Abuse and Neglect Program (SCAN)

A team of health care professionals at The Hospital for Sick Children in Toronto provides care to children and their families where abuse or neglect is suspected. For acute cases, a SCAN member is available for consultation 24 hours a day through the hospital’s locating operator. For more information, contact:

Suspected Child Abuse and Neglect Program
Telephone: (416) 813-7500
Web site: http://www.sickkids.on.ca/scan/default.asp

National Clearinghouse on Family Violence

The National Clearinghouse on Family Violence provides referral services and distributes numerous publications and videos on issues of child abuse and neglect, child sexual abuse, emotional abuse, violence against women, abuse of older adults and family violence in general. The Clearinghouse can be reached at:

National Clearinghouse on Family Violence
Public Health Agency of Canada (PHAC), Health Canada
Address Locator: 1909D1
Jeanne Mance Building,
Tunney’s Pasture, Ottawa, ON
K1A 1B4

Telephone: (613) 957-2938
Toll-free: (800) 267-1291
TTY: (800) 561-5643
Fax: (613) 941-8930
Web site: http://www.phac-aspc.gc.ca/nc-cn

J.P. Das Developmental Disabilities Centre

The J.P. Das Centre conducts research, training and publishing, and provides clinical services for children and adults with intellectual disabilities. The Centre maintains a library of journals and books and publishes a semi-annual journal entitled the Developmental Disabilities Bulletin. As well, the Centre invites visiting professors and international scholars, and organizes lectures, workshops, symposia and conferences.

J.P. Das Developmental Disabilities Centre
6-123 Education North
University of Alberta
Edmonton, AB T6G 2G5

Telephone: (403) 492-4505
Fax: (403) 492-1318
Web site: http://www.quasar.ualberta.ca/ddc/INDEX.html

Sexual Health Resource Network

The Sexual Health Resource Network provides information on sexual abuse prevention and intervention for children and young people with disabilities and can be reached at:

Sunny Hill Health Centre for Children
3644 Slocan Street
Vancouver, BC V5M 3E8

Telephone: (604) 434-1331
Toll-free: (800) 331-1533
Fax: (604) 431-7395

Web site: http://www.sunnyhill.bc.ca/Sunny_Hill/Sexual_Health/Sexual_ Health.html

The Family Alliance

This is a support network representing people with disabilities, their families and friends. The Alliance aims to increase the confidence and skills of families and people with disabilities by providing emotional and informational support. The Alliance can be reached at:

Family Alliance
96 Arnold Crescent
Richmond Hill, ON L4C 3R8
Email: alliance@family-alliance.com

Web site: http://family-alliance.com/index.html

The Disabled Women’s Network (DAWN)

“For most women and girls with disabilities, violence is a way of life.”11 A Overview Paper from DAWN Toronto states that of the one million women with disabilities in Canada, two-thirds were physically or sexually assaulted before puberty. In adulthood, women with disabilities have organized themselves locally, provincially and nationally as members of the DisAbled Women’s Network (DAWN). Mentoring, research, advocacy, peer support and networking are some of the important elements of DAWN’s work.

For more information, contact your local DAWN chapter or:

DAWN Canada
P.O. Box 93558
Nelson Park RPO
Vancouver, BC V6E 4L7
Telephone: (604) 873-1564

Web site: http://indie.ca/dawn/index.html

IN THE LITERATURE

1. The following three publications are available in both English and French, either in print or on cassette, from the Canadian Association of Independent Living Centres (CAILC). They can be ordered directly from the Association’s Web site at:

http://www.cailc.ca/publicn.htm

or by mail at:

Canadian Association of Independent Living Centres
1004-350 Sparks Street
Ottawa, ON K1R 7S8
Telephone: (613) 563-2581
Fax: (613) 235-4497

Responding to Family Violence and Abuse: An Independent Living Approach, 1995 is a training resource for front-line staff working with people with disabilities who have experienced family violence and abuse.

Youth Speak Up! Youth Speak Out!, 1995 is a detailed description of a participatory research study on abuse against youth with disabilities – developed, conducted and described by youth with disabilities.

A Prevention Handbook for Young People with Disabilities, 1995 is a publication written for and by young people with disabilities, sharing their experiences and feelings.

2. The following two publications are available from the Roeher Institute. They can be ordered directly from the Institute’s Web site at:

http://indie.ca/roeher/catalogue.cfm

or by mail from:

Roeher Institute
Kinsmen Building
York University
4700 Keele Street
Toronto, ON M3J 1P3

Telephone: (416) 661-9611
Fax: (416) 661-5701
TTY: (416) 661-2023
Email: info@roeher.ca

Out of Harm’s Way: A Safety Kit for People with Disabilities Who Feel Unsafe and Want to Do Something About It, 1997 is written in plain language and includes questions to help people think about their safety and makes suggestions for change. (To be translated into French.)

The Right to Control What Happens to Your Body: A Straightforward Guide to Issues of Sexuality and Sexual Abuse, 1991 is written in plain language, and assists readers to learn about sexuality and the risks of sexual abuse. (Also available in French.)

3. The following two publications are available in both English and French from the Canadian Institute of Child Health (CICH). They can be ordered directly from the Institute’s Web site at: http://www.cich.ca/

or by mail from:

Canadian Institute of Child Health
885 Meadowlands Drive
Suite 512
Ottawa, ON K2C 3N2

Child Sexual Abuse Prevention: A Resource Kit (1994) is a kit developed to assist parents, community groups and professionals with planning, implementing and enhancing child sexual abuse prevention programs. Seven handbooks cover different aspects of program planning, evaluation and prevention and 20 case studies describe how prevention programs have been implemented across Canada.

Safe and Happy Personal Safety Kit (1990) is a resource designed to assist educators in addressing the subject of child sexual abuse with preschoolers. A 52-page manual includes teaching guidelines, activities and games for discussing feelings, learning body awareness and acquiring abuse prevention skills. A hand puppet and 14 full-colour posters are included as teaching tools.

VIDEOS

The Person Within (1999) is a video production documenting childhood experiences of institutional abuse and neglect from the perspective of three adults with disabilities in British Columbia. It is accompanied by a handbook that addresses issues of vulnerability and abuse prevention at both the personal and societal levels. For more information about this video, contact the:

British Columbia Institute against Family Violence
517-409 Granville Street
Vancouver, BC V6C 1T2
Telephone: (604) 669-7055
Fax: (604) 669-7054
Email: bcifv@bcifv.org
Web site: http://www.bcifv.org/

Sharing Secrets (1992) is a video production demonstrating how deaf youth can end the isolation of sexual abuse that may otherwise destroy their self-esteem. Deaf role models encourage deaf young people to report abuse and to seek help. This video is available from:

National Clearinghouse on Family Violence
Public Health Agency of Canada (PHAC), Health Canada
Address Locator: 1909D1
Jeanne Mance Building
Tunney’s Pasture, Ottawa, ON
K1A 1B4
Telephone: (613) 957-2938
Toll-free: (800) 267-1291
TTY: (800) 561-5643
Fax: (613) 941-8930

Web site: http://www.phac-aspc.gc.ca/nc-cn

No! How (1996) is a video production designed to help young adults with intellectual disabilities to recognize the difference between appropriate and inappropriate sexual behaviour, to understand what actions they can take, and to know how to say no. It is available from the National Clearinghouse on Family Violence (see contact information above).

ON THE INTERNET

Beyond Abuse: Treatment Approaches for People With Disabilities
http://www.quuxuum.org/~greg/journal/ focht_new.html

This article by Virginia Focht-New, from Issues in Mental Health Nursing, 1996, Vol. 17(5), is reprinted in the Pennsylvania Journal on Positive Approaches, at the Web address shown above.

International Coalition on Abuse and Disability
http://www.quasar.ualberta.ca/ddc/ICAD/icad.html#icadmenu

This is an electronic mail network on the topic of abuse and disability, active since 1993. Currently, about 200 people in 12 countries have joined. They include researchers, clinicians, people with disabilities, parents and others interested in this topic.

On the Road to Healing
http://www.addr.com/~sariaa/onroad/index.htm

A disabled woman from Alberta who is a survivor of childhood abuse talks about her healing process and offers links to various resources dealing with the subject of abuse and disability.

The Abuse Prevention Project
http://www.pacer.org/app/abusea.htm

A special initiative of the Parent Advocacy Coalition for Educational Rights – a non-profit organization in Minnesota mandated to “improve and expand opportunities that enhance the quality of life for children and young adults with all disabilities.” The Abuse Prevention Project includes training and resources for early childhood development professionals working with families at risk of maltreatment. It also includes puppet programs for children and resources for parents and professionals on child abuse prevention.

The Child Abuse Monument
http://www.childabusemonument.org/

An international artistic project dedicated to assist with the personal and social healing of the ravages of child abuse.

OTHER REFERENCES

Baladerian, N., Abuse of Children and Adults with Disabilities, Disability, Abuse and Personal Rights Project, Culver City, CA, 1993. A prevention and intervention guidebook for parents and other advocates, addressing vulnerability and the identification and reporting of abuse.

Baladerian, N., Abuse of Children and Adults with Disabilities: Guidebook for Parents, Disability, Abuse and Personal Rights Project, Culver City, CA, 1993. A guidebook for parents and advocates on why abuse occurs, how to identify abuse, the reporting process and mental health treatment.

Crawford, C., Answering the Call: Police Response to Violence Against People with Disabilities, Roeher Institute, 1993. A study of awareness of violence against people with disabilities among police; discussion of reporting and other police processes.

Frazee, C. and Seeley, P., All I Really Need: Safeguarding Children at Risk of Abuse, Abilities, No. 38, Spring, 1999.

An article examining the various factors that make children with disabilities particularly vulnerable to abuse. Discusses the complex challenges of keeping disabled children safe.

Frazee, C. and Seeley, P., Aftermath: Domestic Abuse Leaves Destruction in Its Wake, Abilities, No. 39, Summer, 1999.

An article looking at the long-term after-effects of abuse, through the lens of disability. Includes discussion of physical and emotional disabilities resulting from abuse, as well as the consequences for children who witness the abuse of their mother.

Galbally, R., Child Abuse and Children with Disabilities, Mental Health in Australia, 49-53, 1993. In an Australian context, this paper explores a “culture of body perfect” within a “culture of violence” condoned and encouraged through outlets such as television, radio and print media, as well as tolerance of playground and sporting violence. “In a culture where violence and cruelty are illegitimate, the frustrations and pressures…would not as easily transform themselves into child abuse.”

Kline, D. F. & Kline, A. C., The Disabled Child and Child Abuse. Chicago: National Committee for Prevention of Child Abuse, 1991.

Discusses risk factors, forms of abuse, disability as both cause and effect of abuse, educational neglect, prevention and treatment, sources of support for parents, and responsibility of members of the public to report suspected abuse.

Maksym, D., Shared Feelings: A Parent’s Guide to Sexuality Education for Children, Adolescents and Adults Who Have a Mental Handicap, Roeher Institute, Toronto, 1990. A guide to assist parents to discuss sexuality, sexually transmitted diseases, and sexual abuse with their children.

Mansell, S., Sobsey, D., & Calder, P., Sexual Abuse Treatment for Persons with Developmental Disability, Professional Psychology: Research and Practice, pp. 23, 404-409, 1992.

Reviews the need for adapted therapy techniques and recommends approaches for intervention with survivors and perpetrators of abuse who have intellectual disabilities.

McCreary Centre, Sexual Abuse and Young People With Disabilities Project: Results and Recommendations, Vancouver, 1993. Highlights of a major provincially funded research initiative, outlining the project background and scope, needs assessment and methodology. Contains detailed recommendations for the establishment of a specialized resource centre, a registry of professionals and specific guidelines for handling cases within the justice system.

Miles, P., Doubly Silenced: Sexuality, Sexual Abuse and People with Developmental Disabilities, Wisconsin Council on Developmental Disabilities, Madison, WI, 1991. A book about sexuality, sexual assault and abuse and people with intellectual disabilities. It also includes a discussion of barriers to sexual expression.

Roeher Institute, As if Children Matter: Perspectives on Children, Rights and Disability, 1995. A collection of articles by people throughout the Americas exploring the rights of children and, in particular, children with disabilities.

Roeher Institute, Disability and Vulnerability: A Demographic Profile, 1994. A helpful survey that gives partners in community safety – police, social service agencies, consumer organizations, crisis centres and social workers – a look at the demographic profile of people with disabilities at risk of violence.

Roeher Institute, Harm’s Way: The Many Faces of Violence and Abuse against Persons with Disabilities, 1995. This publication provides insight into the way our systemic practices, prejudices and ignorance combine to encourage or support the abuse of our most vulnerable citizens. It has been described as “a must-read for legislators, policy makers and every person whose life is touched by people with disabilities.”

Senn, C., Vulnerable: Sexual Abuse and People with an Intellectual Handicap, Roeher Institute, Toronto, 1988. Discusses the prevalence of child sexual abuse, risk factors for children and adults with disabilities, and the effects and treatment of abuse.

Sobsey, D., What We Know About Abuse and Disabilities, NRCCSA News, 4, 10, 1992. An article presenting a few of the many issues faced by researchers when formulating research questions regarding the relationship between abuse and disability.

Sobsey, D., Violence and Abuse in the Lives of People with Disabilities: The End of Silent Acceptance-, Paul Brookes Publishing Co., Baltimore, MD, 1994. A comprehensive text addressing risk factors for abuse and describing proven prevention strategies to promote the personal safety and well-being of individuals with disabilities.

Sobsey, D., Violence and Disability: An Annotated Bibliography, Paul Brookes Publishing Co., Baltimore, MD, 1995.

An alphabetized, cross-referenced listing of literature pertinent to disability, violence and abuse; for professionals and advocates.

Ticoll, M., No More Victims: Addressing the Sexual Abuse of People with a Mental Handicap, Roeher Institute, Toronto, 1992. A set of four manuals aimed at specific groups concerned with the issue: Counsellors and Social Workers, Families and Friends, the Legal Community, and Police.

Ticoll, M., Violence and People with Disabilities: A Review of the Literature, Roeher Institute, Toronto, 1992.

A useful resource analyzing literature on violence toward people with disabilities and society’s response.

Tomison, A., Child Maltreatment and Disability, National Child Protection Clearinghouse, Issues in Child Abuse Prevention, No. 7, Summer 1996.

This Australian paper provides an overview of research on the relationship between child maltreatment and disability. Specifically, it looks at research that investigates the relationship among children with disabilities, parents with disabilities and the potential for child maltreatment.

ENDNOTES

1.   U.S. National Center on Child Abuse and Neglect, 1993, cited in D. Sobsey and G. Wolbring, Child Abuse and Disability, Rehabilitation Digest, Toronto, March 1996, p. 11

2.   D. Sobsey, Violence and Abuse in the Lives of People with Disabilities: The End of Silent Acceptance-, Paul H. Brookes Publishing Co., Baltimore, 1994, p. 35

3.   D. Park and J. Radford, From the Case Files: Reconstructing a History of Involuntary Sterilisation, Disability & Society, Vol. 13, No. 3, 1998, pp. 317-342

4.   H. Pringle, Alberta Barren, Saturday Night Magazine, Toronto, June 1997, pp. 30-37, 70, 74

5.   D. Sobsey, Violence and Abuse in the Lives of People with Disabilities: The End of Silent Acceptance-, Paul H. Brookes Publishing Co., Baltimore, 1994, p. 89

6.   D. Fréchette, Parent-Child Relationships – Parents, National Clearinghouse on Family Violence, Ottawa, 1993, p. 2 

7.   H. L. Westcott, Abuse of Children and Adults with Disabilities, National Society for the Prevention of Cruelty to Children, London, UK, 1993, p. 33

8.   D. Sobsey, Violence and Abuse in the Lives of People with Disabilities: The End of Silent Acceptance-, Paul H. Brookes Publishing Co., Baltimore, 1994, pp. 147-150, 220

9.   D. Sobsey, The Media and Robert Latimer, ARCHTYPE, Toronto, August 1995, p. 14

10. Galbally, R., Child abuse and children with disabilities, Mental Health in Australia, 1993, p. 50

11. Fact Sheet, Women with Disabilities: Physical and Sexual Assault, DAWN Toronto, 1994

This document was prepared under contract by Catherine Frazee with the assistance of Patricia Seeley.

For additional information, contact

National Clearinghouse on Family Violence
Family Violence Prevention Unit
Health Issues Division
Public Health Agency of Canada (PHAC)
Health Canada
Address Locator: 1909D1
9th Floor, Jeanne Mance Building, Tunney’s Pasture
Ottawa, Ontario, K1A 1B4, Canada

Telephone: 1-800-267-1291 or (613) 957-2938
Fax: (613) 941-8930
Fax Link: 1-888-267-1233 or (613) 941-7285
TTY: 1-800-561-5643 or (613) 952-6396
Website: www.phac-aspc-gc.ca/nc-cn

This publication can be made available in alternate formats upon request.

Ce feuillet de renseignements est également disponible en français sous le titre

Mauvais traitements d’enfants handicapés
August 2000

The opinions expressed in this report are those of the author and do not necessarily reflect the views of Health Canada.