An event history analysis of recurrent child maltreatment reports in Florida

Event history analysis on racial disparities in the path to adoption for Black and White children

BACKGROUND

Black children are significantly overrepresented in many phases of the U.S. child welfare system.

OBJECTIVE

The purpose of this study is to investigate racial disproportionality and disparities in the adoption process and factors that predict the length of time to adoption.

PARTICIPANTS AND SETTING

This study utilized administrative data from the 2014 year of the Adoption and Foster Care Analysis and Reporting System (AFCARS) collected in 50 States, the District of Columbia, and Puerto Rico.

METHODS

The disproportionality metric (DM) and disparity index (DI) were constructed for Black and White children, and event history analyses were conducted to calculate the probability of adoption while considering the time to adoption finalization.

RESULTS

DM indicated that Black children (0.81) were underrepresented in adoption, and DI indicated that the likelihood of adoption for Black children (0.73) was one third lower than that for White children. The event history analyses revealed that White children were 1.27 times more likely to be adopted than Black children. White children had considerably fewer days from termination of parental rights to adoption finalization with a median time of 273.5 days compared to 328 days for Black children. Factors that extended adoption time included child intellectual, physical, and emotional/behavioral disabilities, visual and hearing impairments, parental alcohol abuse and disability, and child maltreatment histories, while parental drug abuse and longer stays in out-of-home care shortened the adoption process. We also found a significant interaction effect of race and neglect on adoption. Neglected Black children had a longer time to adoption than neglected White children.

CONCLUSIONS

More dedicated outreach programs and resources must be developed to ensure the effectiveness of adoption services and cultural continuity for Black children.

Kinship Care and Child Protection in High-Income Countries: A Scoping Review

Kinship care is a global phenomenon with a long history, which in high-income countries (HICs) at least, is being increasingly formalized through legislation and policy. There are many benefits to kinship care, including improved child mental health and well-being when compared to other types of out-of-home care. Despite this, kinship care is not without its risks with a lack of support and training for kinship carers putting children at an increased risk of abuse and neglect. This scoping review was conducted across 11 databases to explore the breadth and depth of the literature about abuse and neglect within kinship care in HICs and to provide initial indications about the relationship between kinship care and abuse. Of the 2,308 studies initially identified, 26 met the inclusion criteria. A majority of studies were from the United States, and most used case review methods. From the included studies, rates of re-abuse, and particularly rates of physical and sexual abuse, appear to be lower in kinship care settings when compared to other out-of-home care settings, but rates of neglect are often higher. This review has demonstrated that a small but significant number of children living in kinship care experience neglect or abuse.

Family outcomes in alternative response: A multilevel analysis of recurrence

Alternative response (AR) is preventative, family-centered, strengths-based approach within child protective services (CPS). When AR is offered it typically creates a two-track system where low- to moderate-risk families are not subjected to a traditional, fact-finding response that concludes with a determination of child abuse/neglect. One area that continues to concern child welfare administrators and researchers is recurrence, or when a family returns to CPS. Yet, it is unclear whether AR families have the same or different predictors of recurrence than TR families. Using a multilevel analytic approach, the present study followed 17,741 families in one mid-Atlantic state for 18-months post-response to determine what child, family, and county-level predicted a reported re-investigation and a substantiated re-investigation. We found few differences in predictors at the child and family level but found distinct differences at the county level for AR families. Recommendations are provided for policy, practice, and research, including a suggestion for further inquiry on what makes an optimal AR track.

Neglect subtypes in relation to rereport and foster care entry outcomes

BACKGROUND

There have been mixed findings on whether neglect increases the risk of re-report and foster care entry compared with other child maltreatment types. Studies suggest that child neglect can be broken into subtypes which, in turn, may lead to different child welfare outcomes.

OBJECTIVE

The purpose of this study was to examine whether the re-report and foster care entry outcomes varied by child maltreatment type, specifically the subtypes of neglect.

PARTICIPANTS AND SETTING

Data were derived from a regional longitudinal study with linked CPS and state-level administrative data. Participants (n = 4867) included children with reports of physical abuse, sexual abuse, and six neglect subtypes. Cox regression models were used to assess the probability of recurrence and foster care entry outcomes.

RESULTS

Most neglect subtypes were more likely to be re-reported than physical abuse and sexual abuse, and physical neglect was more likely to be re-reported than lack of supervision (HR = 1.20). Children reported for physical neglect was more likely to be placed in foster care than children with reports of physical abuse and other subtypes of neglect.

CONCLUSIONS

This study provides new insight on whether families with child neglect allegations are at increased risk of re-report or foster care entry outcomes compared with other child maltreatment allegations. Given the significant individual, system, and societal costs of neglect, we hope this study facilitates rigorous investigation of child neglect and the potentially modifiable factors or targets for intervening to prevent the re-report of child maltreatment and foster care entry.

Re-referrals to Child Protective Services for children born to young parents

BACKGROUND

Children of teenage parents are at increased risk for child maltreatment but there is limited information about the risks teenage parenthood poses for maltreatment recurrence after prior Child Protective Service (CPS) involvement.

OBJECTIVE

Determine whether children born to teenage parents are at increased risk of maltreatment re-referral to CPS compared to children born to older parents.

PARTICIPANTS AND SETTING

Children under 6 years with substantiated reports of parental maltreatment between 2002 and 2018 were identified from National Child Abuse and Neglect Data System (NCANDS) data.

METHODS

Youngest known parental age at child's birth, in years, was categorized as <20, 20-24, 25-29, or ≥30 (referent group). The number of re-referrals within 5 years was the outcome of interest. Negative binomial regression analyses assessed whether being born to a teen parent was associated with a greater risk of re-referral.

RESULTS

In a study population of 2,680,961 children, having a teen parent, one aged 20-24 years, or 25-29 years at birth was associated with 19% (95% CI 1.18-1.19), 16% (95% CI 1.16-1.17), and 11% (95% CI 1.11-1.12) greater risk of re-referral compared to having a parent aged 30 years or older adjusting for child age, gender, race-ethnicity, state, and initial maltreatment type.

CONCLUSION

The small, but significant increased risk for re-referral to CPS for child maltreatment in young children with at least one teenage or young parent at the time of birth compared to children with older parents suggests that specifically targeting young parents with appropriate services when initially referred to CPS may help reduce the risk of maltreatment recurrence.

A latent class analysis of modifiable risk factors associated with child maltreatment re-reporting and recurrence

BACKGROUND

Maltreatment re-reporting and recurrence represent missed opportunities for prevention and early intervention in child welfare settings.

OBJECTIVES

This study identified latent classes of risk among families who experienced a child maltreatment re-report or maltreatment recurrence within 12-months of initial case closure.

PARTICIPANTS AND SETTING

Administrative child welfare data from a large urban county were subject to secondary analysis. Samples included children who experienced a maltreatment re-report (n = 4390), and children who experienced a second maltreatment substantiation (n = 694).

METHODS

Five modifiable risk factors (i.e., mental health, substance abuse, domestic violence, disability, parenting challenges) were extracted from the initial investigation and subject to latent class analysis. Case characteristics (i.e., age, gender, race, ethnicity, maltreatment type) were then compared across the latent classes in a post-hoc analysis.

RESULTS

Re-report classes were characterized by (1) "Few Identified Challenges" (56%, n = 2458), (2) "Mental Health and Domestic Violence Challenges" (26%, n = 1133), and (3) "Substance Abuse, Domestic Violence, Mental Health, and Parenting Challenges" (18%, n = 790). Re-report classes differed according to child age, race, ethnicity, neglect and physical abuse allegations. Recurrence classes were characterized by (1) "Domestic Violence Challenges" (48%, n = 333), (2) "Mental Health Challenges" (15%, n = 104), and (3) "Domestic Violence, Mental Health, and Parenting Challenges" (37%, n = 257). Recurrence classes differed according to child race and age.

CONCLUSIONS

Findings underscore the complex and co-occurring nature of maltreatment risk, and provide insights to strengthen assessment and intervention practices to reduce repeated contacts with child welfare systems.

Understanding factors associated with re-referral of youth for commercial sexual exploitation

BACKGROUND

Since the passage of the Victims of Trafficking and Violence Prevention Act of 2000 in the United States, awareness has increased about the problem of commercial sexual exploitation of children (CSEC). Moreover, United States Federal law calls upon child welfare agencies to establish policies and practices that help identify and provide services to minors at risk of CSEC. Although awareness has increased about the problem of CSEC, little attention has been paid to understanding why some youths are re-referred to CSEC programs after initial referral and intervention.

OBJECTIVE

The present study examines which factors drive re-referrals of youths for CSEC concerns.

PARTICIPANTS AND SETTING

Data about a population of high-risk youths (n = 416) referred to a CSEC-specific program in the Northeast of the United States between 2011 and 2018.

METHODS

Using logistic regression analyses, we investigate what factors are associated with youth having multiple referrals.

RESULTS

Youths with multiple referrals were more likely to have histories of missing from care (OR = 2.996, p < 0.001), substance misuse (OR = 2.802, p < 0.01), and greater agency involvement (OR = 1.260, p < 0.05). However, youths with multiple referrals were not at heightened risk of CSEC as compared to youths that were not re-referred.

CONCLUSION

The results demonstrate that re-referred youths meet the profile of a victim as depicted on screening and assessment instruments, which has important implications for victim services and referral systems dedicated to identifying CSEC and protecting youths who may experience re-victimization for CSEC.

Sibling Child Protective Services Involvement Following a Child Maltreatment Fatality

OBJECTIVE

This study examined CPS involvement of children surviving the CMF of a sibling as well as predictors of subsequent CPS reports.

METHOD

Department of Human Services and Child Death Review Board data about children who died from a CMF during 1993-2003 (n = 416) and their siblings in the state of Oklahoma were used to examine CPS involvement and predictors of subsequent CPS reports for surviving siblings.

RESULTS

Surviving siblings of a victim of a CMF experienced substantial CPS involvement; 81% of the original victims had siblings who were subsequently reported to CPS (n = 1,840). Original victim and family characteristics that predicted a greater rate of siblings' subsequent reports to CPS included younger original victim age, greater number of children in the original victim's home, and more previous reports of the original victim to CPS.

DISCUSSION

A large portion of families with a CMF struggle to adequately care for their surviving children. Such families may need additional support after a CMF.

Repeat reports among cases reported for child neglect: A scoping review

BACKGROUND

In the United States (US), child welfare policy prioritizes prevention of future harm (e.g., repeat reports) after a report of maltreatment. The majority of reports include some form of child neglect, but no prior review of the recurrence literature has focused on neglect.

OBJECTIVE

This review sought to help guide future research, policy and practice by summarizing recurrence findings related to child neglect with attention to the broader ecological context in which maltreatment occurs.

PARTICIPANTS

The final review included 34 US studies of maltreatment recurrence. Twenty-eight studies compared child neglect with at least one other form of maltreatment and six studies examined recurrence among neglect cases.

METHODS

Eleven online databases were searched to locate relevant empirical studies. This review attended specifically to contextualizing findings according to other modifiable factors as well as methodological variation. A scoping review approach was used to summarize findings.

RESULTS

Of the 28 studies comparing neglect to other types of maltreatment, 14 found increased risk for neglect, 12 found no association, and two reported a lower risk. When significant, the effect size ranged from 10% to over three times higher risk for neglect. Poverty or material need was the most commonly included control (15 studies), with two thirds finding that lower resource families had higher risk.

CONCLUSION

Methodological variability across studies confounds current ability to guide practice or policy. More research is needed that can replicate and extend findings with comparable samples and model specifications that take into account the regional and policy context.

Recurrence of Maltreatment After Newborn Home Visiting: A Randomized Controlled Trial

OBJECTIVES

To investigate whether a newborn home visiting program for primiparous adolescent mothers (aged 16-20 years at childbirth) reduced recurrence of child maltreatment in child protective services (CPS) reports.

METHODS

We conducted a randomized controlled trial of Healthy Families Massachusetts, a statewide home visiting program for young parents. A total of 704 first-time young mothers were randomly assigned to a home visiting group, or to a control group who we referred to other services and who received child development and parenting information. The outcome variable was CPS reports (2008-2016) available for 688 families-specifically, rereports following an initial report (up to mean child age of 7 years).

RESULTS

Of the 52% of families who experienced initial CPS reports, 53% experienced additional CPS reports. Children of mothers in the home visiting group were less likely to receive a second report and had a longer period of time between initial and second reports.

CONCLUSIONS

The home visiting program reduced the recurrence of CPS maltreatment report by 32% and increased the length of time between initial and additional CPS reports. Home visiting parenting support and prevention programs may reduce the likelihood of recurrent maltreatment following completion of program services.

Parents' experiences of childhood abuse and neglect are differentially associated with behavioral and autonomic responses to their offspring

Although childhood maltreatment has been shown to compromise adaptive parental behavior, little is known what happens in terms of physiological regulation when parents with a history of childhood maltreatment interact with their offspring. Using a sample of 229 parents (131 women), the present study examined whether childhood maltreatment experiences are associated with parents’ behavioral and autonomic responses while resolving conflict with their offspring. Self‐reported experienced child maltreatment was measured using a questionnaire assessing abuse and neglect. Parents (M_age = 52.7 years, range_age = 26.6–88.4 years) and their offspring (M_age = 24.6 years, range_age = 7.5–65.6 years) participated in a videotaped parent–offspring conflict interaction task. Parental warmth, negativity, and emotional support were coded. In addition, their pre‐ejection period and respiratory sinus arrhythmia were measured as indicators of underlying sympathetic and parasympathetic nervous system reactivity, respectively. Findings demonstrated that experiences of abuse and neglect were associated with behavioral and physiological responses in different ways. Separating these two types of maltreatment in research and in clinical practice might be important.

Implementation of routine electronic health record-based child abuse screening in General Emergency Departments

BACKGROUND

Routine child abuse screening is an approach to early identification of abuse. Previous studies evaluated paper-based screens; the widespread use of electronic health records suggests that screening is more likely to succeed if integrated into the electronic record.

OBJECTIVE

To implement an electronic health record-based child abuse screen in a diverse hospital system and to evaluate the screening rate, rate of positive screens, and number of reports to Child Protective Services and assess whether hospital and patient characteristics are associated with these rates.

PARTICIPANTS AND SETTING

Children <13 years of age evaluated at one of 13 Emergency Departments within University of Pittsburgh Medical Center Health System.

METHODS

A previously validated child abuse screen was slightly modified and integrated into Cerner. Multivariable logistic regression models were used to estimate the odds of the outcomes of interest, controlling for key covariates.

RESULTS

Of 17,163 eligible children: 68% received the screen of which 1.9% were positive. The rate of reports to Child Protective Services was higher among children who were screened (p < 0.0001). Younger children were more likely to be screened, have a positive screen, and have a report filed. There was no difference in the odds of being screened according to hospital teaching status, size or urban vs rural location.

CONCLUSIONS

A child abuse screening tool can be integrated into the electronic health record in a large health-care network. The increased number of reports among children who were screened suggests that screening facilitates detection of suspected maltreatment.

Using time-to-event analysis to identify preconception and prenatal predictors of child protective services contact

We examined preconception and prenatal predictors of time to first child protective services (CPS) contact among Alaska children. Data were from the Alaska Longitudinal Child Abuse and Neglect Linkage (ALCANLink) project, a population-representative data source linking 2009-2011 Alaska Pregnancy Risk Assessment Monitoring System (PRAMS) data with administrative data sources through 2015. We examined the incidence CPS contact using the Kaplan-Meier method and predictors of CPS contact using Cox proportional hazards regression. Using data from the Alaska Permanent Fund Dividend and Child Death Review, we censored children who emigrated out-of-state or died during the study period. Significant predictors included low socioeconomic status (HR = 2.23, 95% CI 1.68, 2.96), maternal smoking during pregnancy (HR = 1.87, 95% CI 1.55, 2.24), unmarried maternal marital status (HR = 1.62, 95% CI 1.31, 1.99), urban residence (HR = 1.59, 95% CI 1.32, 1.92), lower maternal education (HR = 1.54, 95% CI 1.24, 1.92), maternal experience of intimate partner violence in the 12 months before childbirth(HR = 1.32, 95% CI 1.01, 1.74), Alaska Native/American Indian race (HR = 1.40, 95% CI 1.15, 1.71), a greater number of living children (HR = 1.20, 95% CI 1.13, 1.29), a greater number of stressful life eventsin the 12 months before childbirth (HR = 1.16, 95% CI 1.11, 1.21), and younger maternal age at childbirth (HR = 0.95, 95% CI 0.93, 0.97). Use of multiple linked data sources and time-to-event analysis methods adds to the growing literature regarding predictors of CPS contact. Results suggest that assessing for and addressing clinical, social, and environmental indicators during the prenatal period may aid prevention efforts in mitigating family need for involvement with CPS.

Factors associated with child protection recurrence in Australia

The aim of the current research was to advance understanding of child protection in Australia by examining the factors associated with recurrence of child protection notifications to the formal child protection system. Extant research has been primarily undertaken in the USA and it is important to understand whether similar factors associated with recurrence actually hold in the Australian context. Administrative data were obtained for a sample of 9608 children first subject to a screened-in report in 2011-12. Children were followed for 12 months. Cox Proportional Hazard models were used to measure associations between 26 independent variables and four types of recurrence: subsequent reports, subsequent investigations, subsequent substantiations, and subsequent intervention. Factors associated with recurrence in Australia were broadly similar to those identified in other jurisdictions, including reports and substantiation for neglect, younger age, prior child protection involvement in the household, and parental characteristics including drug use, mental health problems, and history of maltreatment as a child. As in previous studies, post-investigative service provision was positively associated with recurrence. In prior US research, race did not predict recurrence. However, in the present study, Indigenous Australian children were significantly more likely to be subject to all types of recurrence measured. Future research on recurrence should aim to disentangle the complex relationships between child protection recurrence, child maltreatment, and service delivery. Recurrence is not a good proxy indicator of child safety. The findings have implications for the equity of recurrence-based risk assessment tools as they are applied to indigenous populations.

The relationship between child protection contact and mental health outcomes among Canadian adults with a child abuse history

Despite being a primary response to child abuse, it is currently unknown whether contact with child protection services (CPS) does more good than harm. The aim of the current study was to examine whether contact with CPS is associated with improved mental health outcomes among adult respondents who reported experiencing child abuse, after adjusting for sociodemographic factors and abuse severity. The data were drawn from the 2012 Canadian Community Health Survey-Mental Health (CCHS-2012), which used a multistage stratified cluster design (household-level response rate = 79.8%). Included in this study were individuals aged 18 years and older living in the 10 Canadian provinces (N = 23,395). Child abuse included physical abuse, sexual abuse, and exposure to intimate partner violence (IPV). Mental health outcomes included lifetime mental disorders, lifetime and past year suicidal ideation, plans, and attempts, and current psychological well-being and functioning and distress. All models were adjusted for sociodemographic factors and severity of child abuse. For the majority of outcomes, there were no statistically significant differences between adults with a child abuse history who had CPS contact compared to those without CPS contact. However, those with CPS contact were more likely to report lifetime suicide attempts. These findings suggest that CPS contact is not associated with improved mental health outcomes. Implications are discussed.

The relative safety of paternal, maternal, and traditional foster care placements

When children are placed into foster care the caseworker must give preference to an adult relative, many of whom are grandparents, over an unrelated caregiver. This kinship preference is based in evolutionary biology, which suggests that the imperative to care for a child should be greater for kin versus non-kin. However, not all kin are related to a child in the same way, and level of paternity uncertainty may influence level of care provided. For instance, maternal grandparents can be assured that they share genetic material with their grandchild, while paternal grandparents may not have the same level of certainty. Owing to the possibility of paternity uncertainty, we hypothesize that out-of-home placements with paternal grandparents will be at a greater risk of subsequent investigations than placements with maternal grandparents or with foster parents. We secured data on placements n=560 of children ages 1.5 to 17 following a maltreatment investigation from a merger of the National Survey of Child and Adolescent Well-Being NSCAW II and the National Child Abuse and Neglect Data System NCANDS. Kaplan-Meier and multivariate Cox regression were used to examine the difference in time to the first new investigation by type of out-of-home placement while controlling for covariates. Consistent with our hypothesis, placements with paternal grandparents were at a higher risk of a subsequent investigations than placements with maternal grandparents or non-kin foster parents. Results suggest a need for further considerations of child safety in foster care based on genetic relatedness of caregivers.

Predictors of substantiated re-reports in a sample of children with initial unsubstantiated reports

Many children with unsubstantiated reports of child abuse and neglect repeatedly return to the child protection system, indicating that unsubstantiated reports may represent actual child maltreatment or risk for future maltreatment. Identifying patterns of re-reporting and predictors that may be associated with later substantiated re-reporting could help to identify children who are very likely to be maltreated. This knowledge may guide the development of policies and interventions to prevent further maltreatment and the risk for re-reports. The aims of this study were to: (1) measure the period between the time of the initial reports that were not substantiated and the time of first substantiated re-reports; and (2) identify factors associated with the risk of later substantiated re-reporting. The study analyzed secondary data from the Longitudinal Studies on Child Abuse and Neglect (LONGSCAN) through survival analysis. Of the 378 children with initially unsubstantiated reports, 81% were re-reported, of which almost two-thirds were substantiated. Children who were younger, non-white, and had caregivers with more depressive symptoms were at increased risk of a substantiated re-report. Among those that were later substantiated, 20% were substantiated within one year. Findings suggest that targeted preventative services should be developed and provided for families who are reported for the first time, even if not substantiated.

The complexity of child protection recurrence: The case for a systems approach

OBJECTIVE

Research on child protection recurrence has found consistent child, family, and case characteristics associated with repeated involvement with the child protection system. Despite the considerable body of empirical research, knowledge about why recurrence occurs, and what can be done to reduce it, is limited.

METHOD

This paper reviews the empirical literature and analyses the approaches of prior recurrence research. Four related conceptual challenges are identified: (1) a tendency to conflate child protection recurrence with repeated child maltreatment; (2) uncertainty about how best to operationalize and measure child protection recurrence in research; (3) inconsistency between prevailing explanations for the most frequently observed patterns of recurrence; and (4) difficulty in developing coherent strategies to address child protection recurrence based on research.

RESULTS

Addressing these challenges requires a greater consideration of the effects of decision-making in the child protection system on recurrence. This paper proposes a methodology based in systems theory and drawing on existing administrative data to examine the characteristics of the child protection system that may also produce recurrence.

Risk factors for child maltreatment recurrence: An updated systematic review

OBJECTIVES

Children who have been maltreated are at increased risk of further maltreatment. Identification of those at highest risk of further maltreatment is a priority for professionals working in child protection services. The current study is intended to consolidate and expand on previous work on recurrence of child maltreatment. It has sought to identify risk factors for maltreatment recurrence in the recent literature in the expectation that this may help in the practical identification of children at risk.

METHODS

We conducted a systematic review of cohort studies published between 2003 and 2009, identifying factors associated with maltreatment recurrence in children. Studies included demonstrated differing levels of substantiation of maltreatment.

RESULTS

Fifteen studies met inclusion criteria but showed significant heterogeneity, varying in setting, recruitment of subjects, types of maltreatment considered and length of follow-up. Previous findings were replicated and expanded in the current study in relation to a range of factors, including rates of maltreatment recurrence, maltreatment types, frequency of previous episodes of maltreatment, child and family considerations, home environment and service provision. Factors were identified irrespective of level of maltreatment substantiation.

CONCLUSION

This study provides further systematic evidence of the existence of a number of factors associated with child maltreatment recurrence. It points to the possibility of practical application of its findings within the wider context of decision making in child protection services, with the ultimate aim of reducing recurrence of maltreatment in individual cases.

Predictors of re-entry into the child protection system in Singapore: a cumulative ecological-transactional risk model

This study examines the risk factors of re-entry for 1,750 child protection cases in Singapore using a cumulative ecological-transactional risk model. Using administrative data, the present study found that the overall percentage of Child Protection Service (CPS) re-entry in Singapore is 10.5% based on 1,750 cases, with a range from 3.9% (within 1 year) to 16.5% (within 8 years after case closure). One quarter of the re-entry cases were observed to occur within 9 months from case closure. Seventeen risk factors, as identified from the extant literature, were tested for their utility to predict CPS re-entry in this study using a series of Cox regression analyses. A final list of seven risk factors (i.e., children's age at entry, case type, case closure result, duration of case, household income, family size, and mother's employment status) was used to create a cumulative risk score. The results supported the cumulative risk model in that higher risk score is related to higher risk of CPS re-entry. Understanding the prevalence of CPS re-entry and the risk factors associated with re-entry is the key to informing practice and policy in a culturally relevant way. The results from this study could then be used to facilitate critical case management decisions in order to enhance positive outcomes of families and children in Singapore's care system.

Early childhood maltreatment and trajectories of behavioral problems: exploring gender and racial differences

The current study aimed to examine the trajectory of child behavior problems over time as a function of early maltreatment. We anticipated that early alleged maltreatment would have a substantial impact on both internalizing and externalizing behaviors. The impact of gender and racial differences in the trajectories were also examined. Using the LONGSCAN archived data, a total of 484 children were selected for the study from varying sites. Two groups were formed: children with early allegations of maltreatment from birth to age 4 and children without any report. Children included did not have further allegations of maltreatment from ages 4 to 12. Additionally, they must have completed a behavioral assessment using the Child Behavior Checklist at the age 4 baseline interview. Multilevel modeling using the SAS PROC MIXED procedure was used to examine the effects of early allegations of maltreatment on the trajectories of both internalizing and externalizing problems. Although race was not significant, gender was found to differ in trajectory of behavioral problems among children with early allegations of maltreatment. For boys, the impact of early maltreatment was strongest at the most proximal assessment of behavioral outcomes and then decreased gradually over the course of subsequent periods. For girls, although no significant impact was observed at each measurement point, the impact of early maltreatment increased and became pronounced over time. Findings support the importance of early intervention/prevention to decrease the likelihood of presenting behavioral problems in later childhood years with consideration to gender.

A developmental approach to the risk of a first recurrence in child protective services

The objective of this study is to estimate the risk of a first recurrence over a five-year period following initial child protective services (CPS) intervention and identify the characteristics associated with the risk of recurrence for three different age groups. Recurrence is defined as the first substantiated report within the observation period after initial services have ended. The study involved a cohort of 25,897 Quebec children who received postinvestigation services for the first time and whose cases were closed between 2005 and 2009. Survival analysis was used to estimate the five-year risk of recurrence and Cox regression to model the risk of recurrence for three age groups. The covariates introduced into the regression analyses were characteristics of the child and initial services. The risk of recurrence in the five years following termination of initial CPS services was 36% for the entire cohort and varied depending on the child's age at the time of case closure. Children aged 6-11 when their cases were closed had the highest risk of recurrence. Although Aboriginal descent and prior CPS investigations have a consistent effect on the risk of recurrence in all three age groups, the effects of other covariates, such as out-of-home placement and court involvement, vary or are even reversed, depending on the child's age. These findings highlight the need to adopt a differential approach that takes into account the child's age, both in the provision of protective services and in research involving the population receiving such services.

Preventing the recurrence of maltreatment

In the context of the federal child welfare performance measurement system, recurrence of maltreatment refers to circumstances in which children that have previously been substantiated as victims of abuse or neglect experience another incident of substantiated maltreatment. Multiple episodes of maltreatment can lead to: (1) more serious short and long term negative consequences, (2) entry into the juvenile justice system, and (3) juvenile delinquency. In this literature review the authors summarize the research on child, family, and systemic factors related to maltreatment recurrence and promising practices for improving performance. Promising practices aimed at preventing recurrence of maltreatment include interventions at multiple levels (e.g., the child, caregiver, family, and agency) and include a range of service modalities.

Services and recurrence after psychological maltreatment confirmed by child protective services

Recurrence rates of psychological maltreatment (PM) and the services that may reduce those rates have not been systematically evaluated. The National Child Abuse and Neglect Data System was used for 2003-2007 to study a cohort of children in 18 states with PM reports first confirmed by child protective services (CPS) during 2003. PM recurrence rates after counseling and other referrals were assessed while controlling for factors associated with service referral and other maltreatment. A total of 11,646 children had a first CPS-confirmed report with PM, and 9.2% of them had a second-confirmed PM report within 5 years. Fewer than one fourth of families were referred for services after PM, with service referrals being more likely for families with poverty, drug or alcohol problems, or other violence. Controlling for these factors, counseling referral was associated with a 54% reduction in PM recurrence, but other services were not associated with statistically significant reductions. Few families in which PM was confirmed receive any services, and most services provided were not associated with reductions in PM recurrence. Clarification of key services associated with efficacious prevention of PM is needed.

Household, family, and child risk factors after an investigation for suspected child maltreatment: a missed opportunity for prevention

OBJECTIVE

To determine whether a Child Protection Services investigation for suspected child maltreatment is associated with subsequent improvements in household, caregiver, and child risk factors.

DESIGN

Retrospective cohort study.

SETTING

The Longitudinal Studies of Child Abuse and Neglect, a multicenter cohort study of the antecedents and consequences of child maltreatment.

PARTICIPANTS

A total of 595 children with the same maternal caregiver responding to Longitudinal Studies of Child Abuse and Neglect surveys at ages 4 and 8 years.

MAIN EXPOSURE

Investigation for suspected child maltreatment between ages 4 and 8 years.

MAIN OUTCOME MEASURES

Adjusted differences in 7 modifiable risk factors (social support, family functioning, poverty, maternal education, maternal depressive symptoms, anxious or depressive child behaviors, and aggressive or destructive child behaviors) at age 8 years.

RESULTS

Of 595 subjects, 164 (27.6%) experienced an investigation for suspected child maltreatment between ages 4 and 8 years. At age 8 years, investigated subjects were not perceptibly different from noninvestigated subjects in social support, family functioning, poverty, maternal education, or child behavior problems after adjusting for baseline risk factors. Mothers of investigated subjects did have more depressive symptoms than mothers of noninvestigated peers at the child's age of 8 years. Substantiation of child maltreatment by Child Protective Services did not alter these findings.

CONCLUSIONS

Our finding that an investigation for suspected child maltreatment is not associated with relative improvements in common, modifiable risk factors suggests that we may be missing an opportunity for secondary prevention of maltreatment and maltreatment consequences.

Screening injured children for physical abuse or neglect in emergency departments: a systematic review

BACKGROUND

Screening markers are used in emergency departments (EDs) to identify children who should be assessed for possible physical abuse and neglect. We conducted three systematic reviews evaluating age, repeat attendance and injury type as markers for physical abuse or neglect in injured children attending EDs.

METHODS

We included studies comparing markers in physically abused or neglected children and non-abused injured children attending ED or hospital. We calculated likelihood ratios (LRs) for age group, repeat attendance and injury type (head injury, bruises, fractures, burns or other). Given the low prevalence of abuse or neglect, we considered that an LR of 10 or more would be clinically useful.

RESULTS

All studies were poor quality. Infancy increased the risk of physical abuse or neglect in severely injured or admitted children (LRs 7.7-13.0, 2 studies) but was not strongly associated in children attending the ED (LR 1.5, 95% CI: 0.9, 2.8; one study). Repeat attendance did not substantially increase the risk of abuse or neglect and may be confounded by chronic disease and socio-economic status (LRs 0.8-3.9, 3 studies). One study showed no evidence that the type of injury substantially increased the risk of physical abuse or neglect in severely injured children.

CONCLUSIONS

There was no evidence that any of the markers (infancy, type of injury, repeated attendance) were sufficiently accurate (i.e. LR >or= 10) to screen injured children in the ED to identify those requiring paediatric assessment for possible physical abuse or neglect. Clinicians should be aware that among injured children at ED a high proportion of abused children will present without these characteristics and a high proportion of non-abused children will present with them. Information about age, injury type and repeat attendances should be interpreted in this context.

Needs and outcomes for low income youth in special education: Variations by emotional disturbance diagnosis and child welfare contact

Despite the high rates of service for emotional disturbance among child welfare involved youth, much remains to be understood about this population. This study is the first to use longitudinal data to examine the needs and outcomes of children in special education (comparing those with emotional disturbance (ED) and those without) according to child welfare involvement (none, child abuse and neglect report but no services, in-home child welfare services, and foster care). Administrative data linked with special education case file data on 471 youth found that those involved with child welfare were most likely to have an ED diagnosis. Special education assessments revealed that children with in-home services or reports of maltreatment without services generally had equal or greater levels of needs indicated than those placed in foster care. Youth with an ED diagnosis were more likely to experience a negative outcome, such as emergency room treatment for mental health, school problems, or juvenile delinquency. Almost all of the ED youth had child welfare contact by the end of the study period. These findings underline the unmet needs of this population and the need for system coordination to improve their outcomes.

Maltreatment following reunification: predictors of subsequent Child Protective Services contact after children return home

OBJECTIVES

This study examined risk of maltreatment among children exiting foster care using a statewide sample of children reunified between 2001 and 2004 in Rhode Island. The objectives were: (1) to compare rates of maltreatment following parental reunification for youth in care as a result of maltreatment with those in care for other reasons; and (2) to assess the effects of child, family, and case characteristics on rates of re-maltreatment among children placed in foster care due to maltreatment.

METHOD

A longitudinal dataset of all reunified cases was matched with state records of substantiated Child Protective Service (CPS) investigations. Two Cox proportional hazards models were tested. The first model compared rates of subsequent maltreatment for two groups: children in foster care as a result of maltreatment, and those in care for other reasons. The second model investigated the effects of child, family, and case characteristics on re-maltreatment rates for those in care as a result of maltreatment.

RESULTS

Children in foster care due to maltreatment were significantly more likely to be maltreated following reunification. Among children in foster care due to maltreatment, factors that raised risk for re-maltreatment included a previous foster care placement, exiting care from a non-relative foster home, and removal due to neglect. Older adolescents had lower rates of re-maltreatment than infants. Child neglect was the primary type of recurrent maltreatment that occurred following reunification.

CONCLUSIONS

Supports are needed for families about to be reunified, particularly when the removal was prompted by incidents of abuse or neglect. Incidents of neglect are particularly likely and appropriate services should specifically target factors contributing to neglect. Cases involving youth with a history of repeated foster care placement or in which non-relative placements are utilized may need additional supports.

PRACTICE IMPLICATIONS

This study suggests that services should be developed to minimize the risk for recurrent maltreatment following reunification. Services would be most useful for high-risk cases prior to reunification and during the first year following reunification. Understanding the risks associated with maltreatment will help guide development of appropriate interventions.

Time to leave substantiation behind: findings from a national probability study

Data from the National Survey of Child and Adolescent Well-being, a national probability study of children and families investigated for child maltreatment, were analyzed to answer the question: Do substantiated and unsubstantiated cases differ in rates of recidivism over 36 months? Recidivism was classified as (a) any re-reports, (b) substantiated re-reports and (c) subsequent foster care placements. Bivariate (survivor functions estimated by the Kaplan-Meier method) and multivariate (Cox regression modeling) analyses were conducted. The results revealed that risk of recidivism was similar regardless of substantiation status of the index investigation. We suggest that the substantiation label be removed from field use. Instead, we suggest that agencies record service needs in the families they serve, and also record whether or not the family meets criteria for referral to the family court. These would be far more practical and meaningful ways to measure child welfare services.

Predictors of re-referral to child protective services: a longitudinal follow-up of an urban cohort maltreated as infants

Decades of research has identified several psychosocial risk factors for child maltreatment, only some of which are modifiable. The relative importance of the most modifiable psychosocial variables, as compared to more static variables such as demographic characteristics, is not well understood, particularly among children maltreated at a very young age. This study examined predictors of re-referral among 149 urban children originally referred for maltreatment as infants. Of these children, 42.3% were re-referred over a period of 11 to 15 years. Cox regression analyses with time-varying covariates revealed that modifiable psychosocial risk factors failed to predict risk for re-referral in a multivariate model. Demographic characteristics and characteristics of the index incident of maltreatment were the strongest predictors of re-referral. Existing services may not be addressing the underlying reasons for maltreatment, particularly in families with young children. A clearer understanding of the underlying causes of maltreatment is needed.

The use of risk assessment to predict recurrent maltreatment: a Classification and Regression Tree Analysis (CART)

Research has suggested that recurrent maltreatment may be best predicted by a combination of factors that vary across families. The present study set out to determine whether a pattern-centered analytic approach would better predict families at high risk for recurrence when compared to logistic regression methods. Archival data from substantiated investigations during 2003 were collected from a Connecticut Department of Children and Families county branch. Families (n = 244) with a substantiated index case were followed for 18 months to identify the presence of additional substantiated cases within the CPS system. Classification and Regression Tree (CART) analyses revealed that prior CPS involvement was the best predictor of recurrent maltreatment. Further, risk items that were associated with recurrence were different for families with and without previous CPS investigations. Families with only prior unsubstantiated CPS investigations and poor child visibility within the community were at high risk for recurrence. Families without prior CPS involvement that were not actively involved in case planning and had a history of domestic violence were at high risk for recurrence. These findings suggest that pattern-centered analyses may be a useful approach to informing site-specific predictors of maltreatment recurrence by creating clear decision points that delineate high risk subgroups.

Understanding and measuring child welfare outcomes

The new "Children's and Family Services Reviews" (CFSR) process focuses on the effectiveness of services to children and families by measuring client outcomes. This article reviews the research literature related to child welfare outcomes in order to provide a context for federal accountability efforts. It also summarizes the 2001 federal mandate to hold states accountable for child welfare outcomes and describes California's response to this mandate. Implications of the outcomes literature review and measurement problems in the CFSR process suggest CSFR measures do not always capture meaningful outcomes. Recommendations for change are made.

Re-referral to child protective services: the influence of child, family, and case characteristics on risk status

INTRODUCTION

This study examines child, family, and case characteristics that impact rates of re-referral to Child Protective Services (CPS) using data on all closed CPS investigations for the state of Rhode Island between 2001 and 2004.

METHOD

A longitudinal dataset of all referrals to CPS was created using state submissions to the National Child Abuse and Neglect Data System (NCANDS). After excluding children whose initial CPS investigation resulted in removal from the home, a Cox proportional hazards model was tested to examine factors impacting the likelihood of re-referral.

RESULTS

Consistent with other research in this area, the initial 6-month period following case disposition is the period of greatest risk of re-referral. Approximately 13% of cases experienced a recurrent allegation during the first 6-month period; an additional 14% experienced a re-referral over the following 12-month period; 7% during the next 12-month period. Family poverty was the strongest predictor of re-referral, though a number of child and case characteristics were significantly related to recurrence. Cases that were substantiated at index were significantly less likely to result in a new allegation, though substantiated cases of physical abuse or those receiving post-investigation services were at higher risk.

CONCLUSIONS

Children from families facing multiple stressors (e.g., low SES, parental substance abuse child disability) are at highest risk of re-referral to CPS and may benefit from the development of preventive services targeted immediately following case closings within CPS.

Re-reporting of child maltreatment: does participation in other public sector services moderate the likelihood of a second maltreatment report?

OBJECTIVE

This study uses administrative data to track the first re-reports of maltreatment in a low-income, urban child welfare population (n=4957) while controlling for other public service involvement. Service system involvement is explored across the following sectors: Child Welfare, Income Maintenance, Special Education, Juvenile Court, and various forms of Medicaid-reimbursed medical or mental health care. This study builds knowledge by adding the services dimension to an ecological framework for analyses and by following recurrence for a longer period of time than prior investigations (7.5 years).

METHOD

We model the re-reporting of a child for maltreatment as a function of child, caregiver, service, and neighborhood characteristics using data from birth records, child welfare, income maintenance, Medicaid, adult corrections, juvenile court, special education, law enforcement, and census sources. Bivariate and multivariate analyses are presented, the latter using Cox regression with a robust sandwich covariance matrix estimate to account for the intracluster dependence within tracts.

RESULTS

Key results across bivariate and multivariate analyses included a lower rate of re-reporting among children with parents who were high school graduates and/or permanently exited from the first spell on AFDC (p<.0001); and for children in families that received less intensive in-home services compared to those not receiving services, receiving intensive in-home, or foster care services (p<.0001). Higher rates of re-reporting were found for children with Medicaid mental health/substance abuse treatment records (p<.0001) and special education eligibility for emotional disturbance (p<.005).

CONCLUSIONS

Caretaker characteristics and non-child welfare service use patterns had a strong association with the likelihood of a child being re-reported to the child welfare agency and should be more heavily attended to by child welfare workers. High rates of service sector overlap suggest that interagency ties and cooperation should be strengthened. The lower risk associated with less intensive in-home services compared to un-served cases may indicate under-identification of in-home service eligibility following a first report of maltreatment.