Services and recurrence after psychological maltreatment confirmed by child protective services

Physical abuse re-reporting during the COVID-19 pandemic: The kids are not okay

BACKGROUND

Child physical abuse (PA) is a significant societal concern with limited research into predictors of re-reports.

OBJECTIVE

Our research explores correlations between sociodemographic variables and re-reported PA. Our aim was to characterize populations at higher risk and identify changes in presentation during the COVID-19 pandemic.

PARTICIPANTS AND SETTING

This retrospective descriptive study focused on 238 patients with re-reports of PA made by a pediatric hospital from January 2019 through April 2021.

METHODS

We analyzed sociodemographic information and details of reports made to child protective services (CPS) obtained from the electronic health record.

RESULTS

Females were 2.5 years older than males (mean 11.0 and 8.5 years, respectively) (p < .001, 95%CI 1.21-3.76). Males were more likely to have observable injuries (OR 2.61, p < .001) and a CPS response (OR = 2.70, p = .003). Patients categorized as "Other" races were less likely to have observable injuries (OR = 0.32, p = .006). Presentation changed during the pandemic: a quadrupling of re-reports by behavioral health clinicians caused the percentage of reports made by them to increase significantly (OR = 3.46, p < .001) and the mean age increased by 2.0 years (8.2 years before, 10.2 years during) (p = .009, 95%CI 0.5-3.5), though females remained approximately 2.2 years older than males (p = .003, 95%CI 0.8-3.7).

CONCLUSIONS

Males experienced higher rates of re-reported PA and were younger at the time of re-report. Changes to presentation during the pandemic suggest an increase in PA among older children. Future research should further explore differences in sex/race, while current prevention efforts should focus on children receiving behavioral health care.

Factors related to medical neglect recurrence and foster care and adoption services

BACKGROUND

Medical neglect is defined as the failure of a caretaker to heed obvious signs of serious illness, to seek medical care in a timely fashion, or to follow instructions once medical advice is obtained. It is reportable as a form of child maltreatment.

OBJECTIVES

(1) identify factors associated with referrals after medical neglect to adoption and foster care services; (2) describe a cohort of children with first-time cases; and (3) assess whether there were factors associated with recurrence.

PARTICIPANTS AND SETTING

Data from the National Child Abuse and Neglect Data System for 36 U.S. states.

METHODS

A cohort of children was constructed with first confirmed reports of medical neglect in 2012 with matched confirmed reports during 2012-2017 to describe child, family, offender, and report factors associated with recurrence. These factors were then used in multivariate models, including logistic regression and Cox proportional hazard models, to assess their effects on recurrence and with referral to foster care and adoption services.

RESULTS

Complex family problems were associated with referral for foster care and adoption services, and 8.1% had recurrence within 5 years. Older children with medical problems, Black race, or who were reported by medical or legal personnel had increased risk for recurrence. Only referral to mental health care services was found to decrease this risk.

CONCLUSIONS

Medical neglect recurs within 5 years despite referrals to most services. Those trying to stop its recurrence should focus on mental health needs and families with children who are older, Black, or have complex medical problems.

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.

Risk Factors and Services to Reduce Child Sexual Abuse Recurrence

Child sexual abuse (CSA) is associated with a range of negative consequences for victims that are compounded when it recurs. We used the National Child Abuse and Neglect Data System to study a cohort of 42,036 children in 45 U.S. states with sexual abuse reports first confirmed by child protective services (CPS) during 2010 in order to identify children with increased risk for recurrence. A small proportion (3.6%) had a second confirmed sexual abuse report through 2015. In multivariate models, female gender, family hearing and vision problems, other child maltreatment, and other family violence were associated with increased risk of recurrence, while younger children, Hispanic families, and those with substance abuse tended to have less risk. One fourth of recurrence involved the same offender, usually a parent or caretaker. One fourth of cases were referred for any CPS services, which were more likely to be provided for families with poverty, drug or alcohol problems, or other violence. Only substance abuse services significantly reduced recurrence in multivariable models. Those trying to reduce CSA recurrence should recognize that certain case characteristics are associated with greater recurrence, and most CPS services do not significantly reduce CSA recurrence.

A reasonably large review of operationalization in child maltreatment research: Assessment approaches and sources of information in youth samples

Child maltreatment research varies considerably in how maltreatment is measured. Although researchers have advocated for improvements in maltreatment assessment, a first step is a clear understanding of the status on how the field operationalizes maltreatment. The current paper sought to achieve this goal through reviewing research on child maltreatment over a recent 10-year span to identify trends in maltreatment assessment and operationalization. Information on maltreatment measurement was extracted from 338 articles across three major journals devoted to publishing research on child maltreatment. Among the various definitional dimensions of maltreatment, type was the most common way maltreatment was operationalized, followed by severity, frequency, and chronicity, a stable trend across the 10-year span of review. The results indicated that the majority of studies measured maltreatment as consisting of multiple types, although some studies focused on one type of maltreatment as the indicator of child maltreatment. Further, the most common assessment method was the administration of a questionnaire or the combination of two questionnaires with the second most common being summaries from case file review. Recommendations for future research are discussed.

Cumulative risk effect of household dysfunction for child maltreatment after intensive intervention of the child protection system in Japan: a longitudinal analysis

Background

Building an effective casework system for child maltreatment is a global issue. We estimated the effect of household dysfunction (i.e., interparental violence, caregiver mental health problems, and caregiver substance abuse) on child maltreatment to understand how to advance the current framework of child welfare.

Methods

The sample comprised 759 children (1- to 17-year-old; mean age was 10.6; 404 boys and 355 girls) placed in temporary custody units (one of the strongest intervention of the Japanese child protection system). Caseworkers from 180 units across 43 prefectures completed questionnaires on children and their family and were asked whether a child maltreatment report had been made after cancelation of custody in a 15-month follow-up period. The relations of household dysfunction and maltreatment reports were assessed using the Cox proportional hazard model.

Results

About half (48.4%) of the children had been placed in the unit because of maltreatment, and 88.3% had a history of victimization. Seventy-six cases had maltreatment reports after cancelation. We entered household dysfunction variables individually into the model, and each had a significant relationship with maltreatment reports (hazard ratios for interparental violence, caregiver mental health problem, and substance abuse were 1.69, 1.69, and 2.19, respectively) after covariate adjustment. When treating these three variables as cumulative risk score model of household dysfunction, the hazard ratio increased with increasing number of score (1.96 for score two; 2.35 for score three; score 0 as reference).

Conclusions

Greater household dysfunction score is a risk of maltreatment after intensive intervention. It is imperative to construct systems facilitating cooperation between child and adult service sectors and to deliver seamless services to children and families. Our findings provide child protect services with risk-stratified interventions for children at victimization risk and promote adult-focused services to be proactive in prevention or intervention for adults with perpetration risk.

Electronic supplementary material

The online version of this article (10.1186/s12199-018-0703-6) contains supplementary material, which is available to authorized users.

Does parental substance use always engender risk for children? Comparing incidence rate ratios of abusive and neglectful behaviors across substance use behavior patterns

Parental substance use disorder (SUD) is associated with an added risk for child abuse and neglect, but less is understood about how a range of parental use behaviors is associated with differential maltreatment frequencies. This study used the National Survey of Child and Adolescent Well-Being (NSCAW I) to create categories for parental substance use behaviors that are conceptually associated with varying levels of substance-related impairments. The study sample was composed of 2100 parents of children ages 2-17 years from Wave 4 data collection. Weighted negative binomial regression models assessed the relationship between substance use behavior patterns and maltreatment frequencies by type. Behavior patterns defined by some form of past year substance use were associated with a higher frequency of physical or emotional abuse compared to non-users. In contrast, only past year SUD was associated with a higher frequency of neglect compared to other categories. In sum, the relationship between substance use and maltreatment frequencies differed for abuse and neglect, suggesting different pathways may be underlying these observed relationships.

Disorganized attachment in infancy: a review of the phenomenon and its implications for clinicians and policy-makers

Disorganized/Disoriented (D) attachment has seen widespread interest from policy makers, practitioners, and clinicians in recent years. However, some of this interest seems to have been based on some false assumptions that (1) attachment measures can be used as definitive assessments of the individual in forensic/child protection settings and that disorganized attachment (2) reliably indicates child maltreatment, (3) is a strong predictor of pathology, and (4) represents a fixed or static "trait" of the child, impervious to development or help. This paper summarizes the evidence showing that these four assumptions are false and misleading. The paper reviews what is known about disorganized infant attachment and clarifies the implications of the classification for clinical and welfare practice with children. In particular, the difference between disorganized attachment and attachment disorder is examined, and a strong case is made for the value of attachment theory for supportive work with families and for the development and evaluation of evidence-based caregiving interventions.

Infants Investigated by the Child Welfare System: Exploring a Distinct Profile of Risks, Service Needs, and Referrals for Support in Ontario

The science of early childhood development underscores that maltreatment and other adversities experienced during infancy heightens the risk for poor developmental and socio-emotional outcomes. Referrals to supportive services by the child welfare system are particularly critical during infancy given the rapidity of brain development and infants' sensitivity to their environment. The main objectives of the current study are to: (1) examine age-specific differences in clinical and case characteristics; (2) determine the factors associated with the service referral decision involving infants; and (3) explore the types of services families have been referred to at the conclusion of a maltreatment-related investigation. Using data from the Ontario Incidence Study of Reported Child Abuse and Neglect for 2013, descriptive analyses were conducted, as was a logistic regression to identify factors associated with the decision to refer families of infants to supportive services. Overall, the findings reveal that the profile of infants and their families differs distinctly from those of older children with respect to risks, service needs, and service referrals, although this is rarely reflected in child welfare practice and policy. Investigations involving infants were most likely to have a referral made to supportive services, least likely to have an infant functioning concern identified; most likely to have a primary caregiver risk factor identified; and, the greatest likelihood of experiencing economic hardship. Multiple risks, identified for the primary caregiver of the infant are correlated to referral decisions for infants. However, the needs of the infant are likely under-identified and require cross-sectorial collaboration.

The Impact of Family Engagement and Child Welfare Services on Maltreatment Re-reports and Substantiated Re-reports

Despite decades of debate about the most effective ways to intervene with families reported to child protective services (CPS), little evidence exists regarding the types of services or approach that reduce children's risk of additional maltreatment. The current study used data collected during a statewide experimental evaluation of CPS to examine the impact of numerous service variables, family engagement, and family characteristics on the risk of maltreatment re-reports and substantiated re-reports among families initially reported for neglect and risk of harm. The sample included 4,868 families with screened-in reports that were randomly assigned to receive either an investigation or an assessment. The results of the Cox regression analyses found that service duration, intensity, and breadth were unrelated to maltreatment re-report or substantiated re-reports, but caseworker ratings of the service-need match were associated with both. The provision of domestic violence services was related to decreased risk of maltreatment re-reports. Increased levels of family engagement were associated with lowered risk of both maltreatment re-reports and substantiated re-reports. Once the effects of services, engagement, and family characteristics were taken into account, CPS response pathway (investigation or assessment) had no relationship to maltreatment re-reports or substantiated re-reports.

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.

Identifying families with complex needs after an initial child abuse investigation: A comparison of demographics and needs related to domestic violence, mental health, and substance use

Families with complex needs related to domestic violence, mental health, and substance use have some of the worst child protective services (CPS) outcomes. Although many of these families are identified during a CPS investigation and subsequently referred to home-based postinvestigation services (HBPS), many are re-reported to CPS, so it is important to understand the postinvestigation experiences of this vulnerable group. Therefore, this study compared families with and without complex needs to understand their uniquedemographics, needs, and postinvestigation outcomes. The sample consisted of 2008 caregivers who received HBPS following an initial CPS investigation. The Family Assessment Form (FAF) was used to measure family functioning in eight domains using a 1-5 scale with higher ratings representing worse functioning. Complex needs were indicated by a mean FAF score of 3 or higher for either domestic violence, mental health, or substance use. Using Pearson chi-square analyses and two-sample t-tests, comparisons were made between families with (n=836) and without (n=1172) complex needs. Half of caregivers with complex needs had a history of abuse, 25% had three to five needs, and nearly half had six to eight needs; 90% of caregivers without complex needs had zero to two needs. Furthermore, caregivers with complex needs had higher mean scores for concrete, educational, and clinical needs. These findings highlight the importance of recognizing variation among families referred to HBPS and accurate screening to ensure that families with complex needs are offered and receive services matched to their unique characteristics and needs.

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.

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.

Child maltreatment deaths in the U.S. National Child Death Review Case Reporting System

Comprehensive reviews of child death are increasingly conducted throughout the world, although limited information is available about how this information is systematically used to prevent future deaths. To address this need, we used cases from 2005 to 2009 in the U.S. National Child Death Review Case Reporting System to compare child and offender characteristics and to link that information with actions taken or recommended by review teams. Child, caretaker, and offender characteristics, and outcomes were compared to team responses, and findings were compared to published case series. Among 49,947 child deaths from 23 states entered into the Case Reporting System during the study period, there were 2,285 cases in which child maltreatment caused or contributed to fatality. Over one-half had neglect identified as the maltreatment, and 30% had abusive head trauma. Several child and offender characteristics were associated with specific maltreatment subtypes, and child death review teams recommended and/or planned several activities in their communities. Case characteristics were similar to those published in other reports of child maltreatment deaths. Teams implemented 109 actions or strategies after their review, and we found that aggregating information from child death reviews offers important insights into understanding and preventing future deaths. The National Child Death Review Case Reporting System contains information about a large population which confirms and expands our knowledge about child maltreatment deaths and which can be used by communities for future action.

Predictors of treatment completion in a sample of youth who have experienced physical or sexual trauma

Despite significant advances in knowledge and availability of evidence-based models for child traumatic stress, many children simply do not complete treatment. There remain notable gaps in the services research literature about treatment completion among youth, particularly those who have experienced trauma and related sequelae. This study investigated the linkages among child physical and sexual trauma, posttraumatic stress disorder (PTSD) symptomatology, and treatment completion utilizing a clinical sample drawn from a large database from community treatment centers across the United States specializing in childhood trauma. Results from regression analyses indicated that neither the experience of sexual nor physical trauma directly predicted successful treatment completion. The links between sexual trauma and treatment completion, however, were mediated by PTSD avoidance symptoms. Children and youth experiencing sexual trauma reported higher levels of avoidance symptoms that were, in turn, significantly associated with a lower likelihood of completing trauma-focused mental health treatment. Practice implications are discussed and include strategies for clinicians to intervene during pivotal points of treatment to improve rates of service utilization and treatment completion.

Resilience in the context of child maltreatment: connections to the practice of mandatory reporting

A human rights perspective places the care for children in the obligation sphere. The duty to protect from violence is an outcome of having a declaration confirming inalienable human rights. Nationally, rights may be reflected in constitutions, charters, and criminal codes. Transnationally, the United Nation's (UN) Convention on the Rights of the Child (CRC) prioritizes a child's basic human rights, given their dependent status. UN CRC signatory countries commit to implementing minimal standards of care for minors. Laws requiring professionals to report child maltreatment to authorities is one practical strategy to implement minimal child protection and service standards. Mandatory reporting laws officially affirm the wrong of maltreatment and the right of children. Mandatory reporting can be conceptualized as part of a resilience process, where the law sets the stage for child safety and well-being planning. Although widely enacted law, sizeable research gaps exist in terms of statistics on mandatory reporting compliance in key settings; obstacles and processes in mandatory reporting; the provision of evidence-based training to support the duty to report; and the training-reporting-child outcomes relationship, this latter area being virtually non-existent. The fact that mandatory reporting is not presently evidence-based cannot be separated from this lack of research activity in mandatory reporting. Reporting is an intervention that requires substantial inter-professional investment in research to guide best practices, with methodological expectations of any clinical intervention. Child abuse reporting is consistent with a clinician's other duties to report (i.e., suicidality, homicidality), practice-based skills (e.g., delivering "bad" news, giving assessment feedback), and the pervasive professional principle of best interests of the child. Resilience requires the presence of resources and, mandated reporting, is one such resource to the maltreated child. Practice strategies identified in the literature are discussed.