Economics of Child Protection: Maltreatment, Foster Care, and Intimate Partner Violence

Protocol: Interventions aimed at preventing out-of-home placement of children: A systematic review

This is the protocol for a Campbell systematic review. The objectives are as follows. The aim of the present review is to synthesize evidence on the effectiveness of interventions for at-risk families aimed at preventing the out-of-home placement of children or increasing the likelihood that children are reunited with their birth families following temporary care arrangements. The review has two objectives: (1) To assess the effectiveness of interventions for at-risk families with children aged between 0 and 17 years old on measures of out-of-home placement and on secondary outcomes. (2) To identify factors that modify intervention effectiveness (e.g., prior placements, parental risk factors such as substance abuse, mental health issues, age, minority status, child risk factors such as disabilities, age, and gender).

Examining the role of firearm involvement in repeat intimate partner violence assaults

BACKGROUND

Intimate partner violence (IPV) remains a pervasive and complex issue with significant social and public health implications. The nexus of firearms and intimate partner violence (IPV) is an especially dangerous one. However, little is known about how firearm involvement can influence the risk of repeat IPV assaults.

METHODS

We use data from 346 male perpetrated IPV incidents reported to the Detroit Police Department between December 2016 and April 2017 to examine the role of firearm involvement in IPV recidivism during a 5 and half year follow up period. Employing a conditional gap-time frailty model that accommodates heterogeneity among individuals through a frailty term, we analyze time to multiple IPV assaults that occur over the follow up period. We identify various pathways through which firearms impact the likelihood of subsequent IPV incidents, including intimidation, threats, and use of firearms, while controlling for observable perpetrator characteristics to understand the explicit roles of firearms.

RESULTS

Firearm involvement at the index assault was not associated with IPV recidivism. However, involvement of firearms in past IPV assaults significantly increased the risk of subsequent physical IPV. The discrepancy is likely arising from a high degree of censoring among individuals who were armed with a firearm during the index assault.

CONCLUSION

Our research reveals a nuanced relationship between firearm involvement and IPV recidivism, shedding light on the multifaceted dynamics at play. By elucidating the intricate dynamics at the intersection of firearms and intimate partner violence, our study underscores the need for targeted policy interventions and preventative measures aimed at reducing IPV recidivism.

Association of preschool children behavior and emotional problems with the parenting behavior of both parents

BACKGROUND

Parental behaviors are key in shaping children's psychological and behavioral development, crucial for early identification and prevention of mental health issues, reducing psychological trauma in childhood.

AIM

To investigate the relationship between parenting behaviors and behavioral and emotional issues in preschool children.

METHODS

From October 2017 to May 2018, 7 kindergartens in Ma'anshan City were selected to conduct a parent self-filled questionnaire - Health Development Survey of Preschool Children. Children's Strength and Difficulties Questionnaire (Parent Version) was applied to measures the children's behavioral and emotional performance. Parenting behavior was evaluated using the Parental Behavior Inventory. Binomial logistic regression model was used to analyze the association between the detection rate of preschool children's behavior and emotional problems and their parenting behaviors.

RESULTS

High level of parental support/participation was negatively correlated with conduct problems, abnormal hyperactivity, abnormal total difficulty scores and abnormal prosocial behavior problems. High level of maternal support/participation was negatively correlated with abnormal emotional symptoms and abnormal peer interaction in children. High level of parental hostility/coercion was positively correlated with abnormal emotional symptoms, abnormal conduct problems, abnormal hyperactivity, abnormal peer interaction, and abnormal total difficulty scores in children (all P < 0.05). Moreover, paternal parenting behaviors had similarly effects on behavior and emotional problems of preschool children compared with maternal parenting behaviors (all P > 0.05), after calculating ratio of odds ratio values.

CONCLUSION

Our study found that parenting behaviors are associated with behavioral and emotional issues in preschool children. Overall, the more supportive or involved the parents are, the fewer behavioral and emotional problems the children experience; conversely, the more hostile or controlling the parents are, the more behavioral and emotional problems the children face. Moreover, the impact of fathers' parenting behaviors on preschool children's behavior and emotions is no less significant than that of mothers' parenting behaviors.

Growth in Suicide Rates Among Children During the Illicit Opioid Crisis

This article documents child suicide rates from 1980 to 2020 in the United States using the National Vital Statistics System Multiple Cause of Death database. After generally declining for decades, suicide rates among children aged 10-17 accelerated from 2011 to 2018 in an unprecedented rise in both duration and magnitude. I consider the role of the illicit opioid crisis in driving this mental health crisis. In August 2010, an abuse-deterrent version of OxyContin was introduced and the original formulation was removed from the market, leading to a shift to illicit opioids and stimulating growth in illicit opioid markets. Areas more exposed to reformulation-as measured by pre-reformulation rates of OxyContin misuse in the National Survey on Drug Use and Health-were more affected by the transition to illicit opioids and experienced sharper growth in child suicide rates. The evidence suggests that children's illicit opioid use did not increase, implying that the illicit opioid crisis engendered higher suicide propensities by increasing suicidal risk factors for children, such as increasing rates of child neglect and altering household living arrangements. In complementary analyses, I document how living conditions declined for children during this time period.

Medical Professional Reports and Child Welfare System Infant Investigations: An Analysis of National Child Abuse and Neglect Data System Data

Background

Medical professionals are key components of child maltreatment surveillance. Updated estimates of reporting rates by medical professionals are needed.

Methods

We use the National Child Abuse and Neglect Data System (2000-2019) to estimate rates of child welfare investigations of infants stemming from medical professional reporting to child welfare agencies. We adjust for missing data and join records to population data to compute race/ethnicity-specific rates of infant exposure to child welfare investigations at the state-year level, including sub-analyses related to pregnant/parenting people's substance use.

Results

Between 2010 and 2019, child welfare investigated 2.8 million infants; ∼26% (n=731,705) stemmed from medical professionals' reports. Population-adjusted rates of these investigations stemming doubled between 2010 and 2019 (13.1-27.1 per 1000 infants). Rates of investigations stemming from medical professionals' reports increased faster than did rates for other mandated reporters, such as teachers and police, whose reporting remained relatively stable. In 2019, child welfare investigated ∼1 in 18 Black (5.4%), 1 in 31 Indigenous (3.2%), and 1 in 41 White infants (2.5%) following medical professionals' reports. Relative increases were similar across racial groups, but absolute increases differed, with 1.3% more of White, 1.7% of Indigenous, and 3.1% of Black infants investigated in 2019 than 2010. Investigations related to substance use comprised ∼35% of these investigations; in some states, this was almost 80%.

Discussion

Rates of child welfare investigations of infants stemming from medical professional reports have increased dramatically over the past decade with persistent and notable racial inequities in these investigations.

A drop of love? Rainfall shocks and spousal abuse: Evidence from rural Peru

We investigate whether exposure to rainfall shocks affects the experience of physical intimate partner violence (P-IPV) among women in rural areas of the Peruvian Andes. Using data from the Demographic and Health Surveys over 2005-2014, we track changes in the probability that a woman experiences recent instances of P-IPV after being exposed to a rainfall shock during the last cropping season. Our results indicate that the probability that a woman experiences P-IPV increases by 8.5 percentage points (65 percent) after exposure to a dry, but not a wet, shock during the cropping season. We identify two complementary causal pathways of this effect: increased economic insecurity and poverty-related stress that deteriorates men's emotional well-being and mental health, and reduced female empowerment that affects women's ability to negotiate their preferences within the relationship.

The COVID-19 Pandemic in the Nawalparasi District of Nepal: a mixed methods assessment of increased alcohol use and violence against women

BACKGROUND

In Nepal and across the globe, the COVID-19 pandemic has primed an environment for increased rates of violence against women (VAW). This paper explores pandemic-driven economic insecurity and increased alcohol use as instigators of VAW and Intimate Partner Violence (IPV) within newly married households in the rural, Nawalparasi region of Nepal.

METHODS

This study is a secondary analysis of data obtained from the Sumadhur Intervention pilot study that has been previously described and demonstrates successful implementation of group-based, household-level intervention for women's empowerment and sexual and reproductive health education (1). Our three sets of data were collected before and during the COVID-19 pandemic. The first set is from a Longitudinal Cohort of 200 newly married women who were surveyed twice a year from February 2017 through July 2020. The second data set is a subset cohort of newly married women, their husbands, and their mothers-in-law (31 women, 31 husbands and 31 mothers-in-law) who participated in Sumadhur in January 2021. The third data set was obtained through in-depth interviews in July 2021 from 15 households following Sumadhur. The interviews were thematically coded, and subthemes were identified. A t-test of the January 2021 survey data set was run to look at correlations between income loss, alcohol consumption and experience of IPV among newly married women. All other survey data was analyzed for change over time.

RESULTS

At three months after the onset of the pandemic (July 2020), the Longitudinal Cohort survey data from newly married women reported increased rates of husbands' alcohol use as well as personal experiences of IPV as compared to pre-pandemic averages. There was a statistically significant difference (p < 0.001) in the effects of income loss on increased alcohol use and experience of IPV. Qualitative results iterated the common theme of alcohol use and economic insecurity as upstream instigators of VAW in the community.

CONCLUSIONS

In the Nawalparasi district of Nepal, the pandemic has led to unstable economic situations that have instigated alcohol use among men, and increased rates of IPV among young, newly married women, and reports of VAW in the community. We have demonstrated a need for urgent programmatic and policy responses aimed at reducing VAW and IPV and protecting women during times of uncertainty and crisis.

COVID-19 lockdowns and children's health and well-being

This paper studies the health and well-being of children during the COVID-19 lockdowns in a developing country context. Using surveys for low-income households in rural areas of Pakistan, we find that lockdowns are associated with worsened health and well-being of children. Exploring potential economic and noneconomic mechanisms behind this negative association, we find that children participating in the labor market due to extreme poverty suffer the worst impact from lockdowns. These results call for policies that target resources towards households where children's participation in the labor market is more likely since leaving vulnerable children behind will have a lasting economic impact for developing economies.

The lasting consequences of childhood sexual abuse on human capital and economic well-being

Childhood sexual abuse is a prevalent problem, yet understanding of later-in-life outcomes is limited due to unobservable determinants. I examine impacts on human capital and economic well-being by estimating likely ranges around causal effects, using a nationally representative U.S. sample. Findings suggest that childhood sexual abuse leads to lower educational attainment and worse labor market outcomes. Results are robust to partial identification methods applying varying assumptions about unobservable confounding, using information on confounding from observables including other types of child abuse. I show that associations between childhood sexual abuse and education outcomes and earnings are at least as large for males as for females. Childhood sexual abuse by someone other than a caregiver is as influential or more so than caregiver sexual abuse in predicting worse outcomes. Considering the societal burden of childhood sexual abuse, findings could inform policy and resource allocation decisions for development and implementation of best practices for prevention and support.

The COVID-19 Pandemic in the Nawalparasi District of Nepal: A Mixed Methods Assessment of Increased Alcohol Use and Intimate Partner Violence

Background In Nepal and across the globe, the COVID-19 pandemic has primed an environment for increased rates of intimate partner violence (IPV). This paper examines how the upstream factors of alcohol use and economic insecurity in the Nawalparasi district of Nepal has brought about higher rates of IPV among newly married women. Methods This study is a secondary analysis of data obtained from the Sumadhur Intervention pilot study that has been previously described and demonstrates successful implementation of group-based, household-level intervention for women's empowerment and sexual and reproductive health education (1). Our three sets of data were collected before and during the COVID-19 pandemic. The first set is from a longitudinal cohort of 200 newly married women who were surveyed twice a year from February 2017 through July 2020. The second data set is from a cohort of newly married women, their husbands, and their mothers-in-law (31 women, 31 husbands and 31 mothers-in-law) who participated in Sumadhur in January 2021. The third data set was obtained through in-depth interviews in July 2021 from 15 households following Sumadhur . The interviews were thematically coded, and subthemes were identified. The survey data was analyzed for change over time. Results In households in the Nawalparasi district of Nepal, between 2019 and 2020 there was an increase in alcohol consumption with reports of drinking every day increasing from 9.2% to 13.6%. In July 2020, 30% (N=31/102) of newly married women said their husbands' alcohol consumption had increased since the pandemic. In 2019, 47.06% (N=88/187) of participants reported that they had experienced any form of IPV. In July 2021, 74% (N=23/31) of women reported being physically forced to have sexual intercourse with their husband when they did not want to and in the past four months, 68% (N=21/31) reported being forced to perform sexual acts against their will. The interviews highlighted the presence of alcohol use in the community as well as increased concerns over economic insecurity. Mothers-in-law consistently described increased rates of IPV and community violence since the pandemic. Conclusions The pandemic has led to precarious economic situations that have influenced alcohol use among men, and instances of IPV among young, newly married women. We have demonstrated a need for urgent programmatic and policy responses aimed at reducing IPV, which has increased during the pandemic. Family interventions centering on women, such as Sumadhur , are critical to implement along with community-wide emergency preparedness to ensure autonomy, safety, and wellbeing now and in future times of uncertainty.

"Two Hours on a Sunday": Fatherhood Following an Intimate Partner Violence Incident-A Theory of Excision

Fathers who are arrested after an intimate partner violence (IPV) incident must navigate multiple systems, including child welfare, criminal justice and family court, that regulate their interactions with their family members post-arrest. Contact between fathers and their children is highly regulated in the name of safety, often creating lengthy separations and putting strain on already frayed parent-child relationships. While concerns for the safety of victims and survivors of IPV are warranted, there is increased acknowledgement of the important role that fathers, including those with a history of IPV, play in their children's lives. This exploratory study used grounded theory methodology to interrogate how fathers seeking treatment at an abusive partners' program maintained a relationship with their child(ren) and their identities as fathers. Fourteen fathers with experience in the phenomenon of interest completed in-depth qualitative interviews, focus groups, and demographic questionnaires. These data were analyzed along with observational memos to develop a four-stage theory of excision which captured the four stages of routine and effective separation of fathers from their children's lives observed: (a) extraction; (b) re-assignment of identity; (c) exclusion; and (d) what remains. The presence of a single negative case in this study allowed for a discussion of this excision appearing to operate differently along racial lines. The urgent need to redress the institutional racism within these systems that has resulted in extraordinary burden and injustice to families of color is detailed. Implications for policies and practice with families living with IPV are discussed.

Trading off fiscal budget adherence and child protection

Many countries delegate a substantial part of social service decisions to local administrative levels, while federal laws provide the overall framework for service levels. Strict regulations to reduce budget overruns may however leave local governments with a potential trade-off between adhering to fiscal budgets and supplying critical welfare services as e.g. programs to protect vulnerable children. We investigate if budgetary constraints influence child protection decisions using high-quality register data. We show that the introduction of fiscal sanctions to improve budget adherence contributed to a sharp decline in budget overruns on child protective services by reducing the number of children in out-of-home care. Our results further show that monthly variation in budget adherence within a fiscal year affects the probability of a placement in out-of-home care for children in need of help towards the end of a fiscal year. We estimate that a budget overrun of 10 percentage points by mid-year leads to a 1.2 percent reduction in the number of children in care over the remaining part of the fiscal year. Municipalities reduced child protection expenditure by choosing cheaper types of care and ending placement for children in out-of-home care, particularly for children turning 18. Our paper contributes to the literature on fiscal federalism by documenting the trade-off between managing public expenditure and providing safety and equal opportunity for vulnerable children. We thus highlight that enforcing strict budget adherence may be in conflict with social policy goals. Our results raise an important discussion about centralization versus delegation of critical public services.

Long-term Health and Social Outcomes in Children and Adolescents Placed in Out-of-Home Care

IMPORTANCE

Children who are placed in out-of-home care may have poorer outcomes in adulthood, on average, compared with their peers, but the direction and magnitude of these associations need clarification.

OBJECTIVE

To estimate associations between being placed in out-of-home care in childhood and adolescence and subsequent risks of experiencing a wide range of social and health outcomes in adulthood following comprehensive adjustments for preplacement factors.

DESIGN, SETTING, AND PARTICIPANTS

This cohort and cosibling study of all children born in Finland between 1986 and 2000 (N = 855 622) monitored each person from their 15th birthday either until the end of the study period (December 2018) or until they migrated, died, or experienced the outcome of interest. Cox and Poisson regression models were used to estimate associations with adjustment for measured confounders (from linked population registers) and unmeasured familial confounders (using sibling comparisons). Data were analyzed from October 2020 to August 2021.

EXPOSURES

Placement in out-of-home care up to age 15 years.

MAIN OUTCOMES AND MEASURES

Through national population, patient, prescription drug, cause of death, and crime registers, 16 specific outcomes were identified across the following categories: psychiatric disorders; low socioeconomic status; injuries and experiencing violence; and antisocial behaviors, suicidality, and premature mortality.

RESULTS

A total of 30 127 individuals (3.4%) were identified who had been placed in out-of-home care for a median (interquartile range) period of 1.3 (0.2-5.1) years and 2 (1-3) placement episodes before age 15 years. Compared with their siblings, individuals who had been placed in out-of-home care were 1.4 to 5 times more likely to experience adverse outcomes in adulthood (adjusted hazard ratio [aHR] for those with a fall-related injury, 1.40; 95% CI, 1.25-1.57 and aHR for those with an unintentional poisoning injury, 4.79; 95% CI, 3.56-6.43, respectively). The highest relative risks were observed for those with violent crime arrests (aHR, 4.16; 95% CI, 3.74-4.62; cumulative incidence, 24.6% in individuals who had been placed in out-of-home care vs 5.1% in those who had not), substance misuse (aHR, 4.75; 95% CI, 4.25-5.30; cumulative incidence, 23.2% vs 4.6%), and unintentional poisoning injury (aHR 4.79; 95% CI, 3.56-6.43; cumulative incidence, 3.1% vs 0.6%). Additional adjustments for perinatal factors, childhood behavioral problems, and traumatic injuries, including experiencing violence, did not materially change the findings.

CONCLUSIONS AND RELEVANCE

Out-of-home care placement was associated with a wide range of adverse outcomes in adulthood, which persisted following adjustments for measured preplacement factors and unmeasured familial factors.

The economic costs of child maltreatment in UK

Child maltreatment is a major public health problem with significant consequences for individual victims and for society. In this paper, we quantify for the first time the economic costs of fatal and nonfatal child maltreatment in the UK in relation to several short-, medium-, and long-term outcomes ranging from physical and mental health problems to labor market outcomes and welfare use. We combine novel regression analysis of rich data from the National Child Development Study and the English Longitudinal Study of Aging with secondary evidence to produce an incidence-based estimate of the lifetime costs of child maltreatment from a societal perspective. The discounted average lifetime incidence cost of nonfatal child maltreatment by a primary caregiver is estimated at £89,390 (95% uncertainty interval £44,896 to £145,508); the largest contributors to this are costs from social care, short-term health, and long-term labor market outcomes. The discounted lifetime cost per death from child maltreatment is estimated at £940,758, comprising health care and lost productivity costs. Our estimates provide the first comprehensive benchmark to quantify the costs of child maltreatment in the UK and the benefits of interventions aimed at reducing or preventing it.

The Sobriety Treatment and Recovery Teams program for families with parental substance use: Comparison of child welfare outcomes through 12 months post-intervention

BACKGROUND

The 2018 Family First Prevention Services Act (FFPSA) shifted child welfare funding to interventions proven effective in preserving families with parental substance use and child welfare involvement. The Sobriety Treatment and Recovery Teams (START) program serves this population with FFPSA aligned goals.

OBJECTIVE

This study was the first to test the sustained effects of START from the initial CPS report through 12-months post-intervention.

PARTICIPANTS AND SETTING

Children (n = 784) receiving START services in four sites were compared to 784 children receiving child welfare treatment as usual (TAU).

METHODS

Using child welfare administrative data, children in START were matched to children in TAU using propensity score matching. Outcomes were tested during the intervention period, and at six- and 12-months post-intervention using comparative statistics and multilevel logistic regression.

RESULTS

The odds of START children being placed in out-of-home care (OOHC) during the intervention period were half those of children in TAU (20.3% vs. 35.2%, p < .001, OR = 0.47, 95% CI [0.37, 0.59]). When placed in OOHC, START children were more likely to be reunified with their parents (p = .042, OR = 1.44, 95% CI [0.99, 1.62]). At 12-months post-intervention, 68.5% of START and 56.0% of TAU-served children remained free from both OOHC placement and child abuse and neglect (after multilevel clustering adjustment: p < .001, OR = 1.85, 95% CI [1.41, 2.43]).

CONCLUSION

The primary impact of START was significantly reduced rates of OOHC placement, with results sustained through 12-months post-intervention and after accounting for family clusters and site differences.

Protocol for a randomized controlled trial evaluating the impact of the Nurse-Family Partnership's home visiting program in South Carolina on maternal and child health outcomes

Background

Policy-makers are increasingly seeking rigorous evidence on the impact of programs that go beyond typical health care settings to improve outcomes for low-income families during the critical period around the transition to parenthood and through early childhood.

Methods

This study is a randomized controlled trial evaluating the impact of the Nurse-Family Partnership’s expansion in South Carolina. The scientific trial was made possible by a “Pay for Success” program embedded within a 1915(b) Waiver from Medicaid secured by the South Carolina Department of Health and Human Services. This protocol describes study procedures and defines primary and secondary health-related outcomes that can be observed during the intervention period (including pregnancy through the child’s first 2 years of life). Primary study outcomes include (1) a composite indicator for adverse birth outcomes including being born small for gestational age, low birth weight (less than 2500 g), preterm birth (less than 37 weeks’ gestation), or perinatal mortality (fetal death at or after 20 weeks of gestation or mortality in the first 7 days of life), (2) a composite outcome indicating health care utilization or mortality associated with major injury or concern for abuse or neglect occurring during the child’s first 24 months of life, and (3) an indicator for an inter-birth interval of < 21 months. Secondary outcomes are defined similarly in three domains: (1) improving pregnancy and birth outcomes, (2) improving child health and development, and (3) altering the maternal life course through changes in family planning.

Discussion

Evidence from this trial on the impact of home visiting services delivered at scale as part of a Medicaid benefit can provide policy-makers and stakeholders with crucial information about the effectiveness of home visiting programs in improving health and well-being for low-income mothers and children and about novel financing mechanisms for cross-silo interventions.

Trial registration

The trial was registered prospectively on the American Economic Association Trial Registry (the primary registry for academic economists doing policy trials) on 16 February 2016 (AEARCTR-0001039). ClinicalTrials.gov NCT03360539. Registered on 28 November 2017.