Association of Housing Stress With Child Maltreatment: A Systematic Review

Child Maltreatment Evaluations Following Out-of-Hospital Cardiac Arrests

OBJECTIVES

In children admitted after an out-of-hospital cardiac arrest (OHCA), this study 1) determines the proportion that undergo: physical abuse and toxin exposure evaluation, child protection team (CPT) consultation, and child protective services (CPS) referral, and 2) evaluates the association between demographic, social, clinical characteristics with CPT consultation and CPS referral.

METHODS

Retrospective chart review was conducted of children < 4 years old admitted following an OHCA between November 2012 and February 2023. Associations between demographics, caregiver social risk factors, and clinical characteristics with CPT consultation and CPS referral were examined using logistic regression.

RESULT

Among 157 cases, 70 (45%) had skeletal surveys; eight (11%) identified an occult fracture. Seventy-five (48%) children had toxicology testing; Sixteen of the 75 (21%) revealed a toxic ingestion. Sixteen of the 49 (33%) patients receiving ophthalmologic evaluations had significant retinal hemorrhages. Seventy-seven (49%) patients had a CPT consultation, while 74 (47%) were referred to CPS. A history concerning for ingestion perfectly predicted CPT consultation. History of ingestion, injury on exam, positive skeletal survey, and positive toxicology testing perfectly predicted CPS referral. In multivariate analyses, unsafe sleep history (84% versus 41%, p<0.001) and caregiver social risk factors (82% versus 31%, p<0.001) were associated with CPT consultation, while caregiver social risk factors (70% versus 34%, p<0.001) and normal medical work-up (53% versus 38%, p=0.050) were associated with CPS referral.

CONCLUSIONS

Following OHCA, a child maltreatment evaluation may be underutilized with medical decision-making around CPT consultation and CPS referral driven by knowledge of caregiver social risk factors.

Navigating the services maze: Assessing service needs, referrals, receipts, and child protective services re-report and foster care entry outcomes

BACKGROUND

Research shows that families involved with Child Protective Services (CPS) have diverse needs not fully met by service referrals and provision. Furthermore, it is still unknown whether the service provision gaps are linked to child safety and permanency outcomes.

OBJECTIVE

This study aims to address this research gap by evaluating the rereport and foster care entry outcomes of child welfare services based on the needs, referrals, and receipt of services for families involved with CPS.

PARTICIPANT AND SETTING

The National Survey on Child and Adolescent Well-being II (NSCAW II) was used for this study, excluding children with prior reports and those in foster care to focus on re-report and foster care entry outcomes, reducing the sample from 5872 to 2580 children.

METHODS

Logistic Regression analyses were performed to investigate the relationship between services needed, referred, and receipts and child welfare outcomes. The analyses were structured into three sets of models to explore different aspects of service engagement and its impact on child welfare outcomes.

RESULTS

Our study shows that specific CPS services, particularly caregivers' needs for mental health and substance misuse services, significantly impact the likelihood of re-reporting and foster care placements.

CONCLUSION

Most families contacting the child welfare system receive only case management services if their report moves beyond investigation. Such an approach requires that services are available, acceptable, and of sufficient quality to meet needs. This paper highlights crucial disparities in service needs, referrals, and receipts among families engaged with CPS.

Understanding the Mediation Effect of Social Cohesion on the Relationship Between Material Hardship and Child Maltreatment by Poverty Spells

The purpose of this study is to explore the association between material hardship and child maltreatment, mediated by social cohesion. We used three waves (age three, age five, and age nine) from Future of Families and Child Wellbeing Study (FFCW), a longitudinal cohort study of approximately 5000 families in 20 U.S. cities. The sample size was 2402. The independent variable was material hardship, and the dependent variable was child maltreatment (physical/psychological abuse and neglect). Using a multiple regression analysis, the current study found a positive association between material hardship and frequency of physical/psychological abuse. Social cohesion was found to mediate the relationship between material hardship and physical/psychological abuse among financially secure mothers in the Sobel test, which assesses the presence of indirect effects of the independent variable on the dependent variable. These findings suggest that material hardship mitigation and social cohesion enhancement are potential strategies to prevent physical/psychological abuse.

Leveraging group model building to operationalize implementation strategies across implementation phases: an exemplar related to child maltreatment intervention selection

BACKGROUND

Implementation strategies can help support the adoption and implementation of health interventions that are appropriate for a local context and acceptable to decision makers and community members. Implementation strategies should be designed to handle the complexity of the multi-level, dynamic contexts in which interventions are implemented. Systems science theories and methods explicitly attend to complexity and can be valuable for specifying implementation strategies. Group Model Building (GMB) combines research partner engagement strategies with systems science to support researchers' and partners' learning about complex problems and to identify solutions through consensus. This paper specifies how GMB can operationalize implementation strategies - methods for supporting evidence implementation in real-world practice - and describes how GMB can aid in selecting and tailoring both health interventions and implementation strategies. A case study in child maltreatment prevention planning is provided to illustrate how GMB was used to specify the "actions" - strategy activities - for three implementation strategies (conduct local consensus discussions; build a coalition; model and simulate change) during the earliest implementation phases, with the goal of supporting intervention selection decisions. Examples are provided of generalizable research products that can be produced concurrently through GMB, in addition to contextually-driven implementation support.

METHODS

Participants (n = 8) were engaged over four sessions using tailored GMB activities. Participants generated a qualitative system dynamics model that described their theory of change for how to prevent child maltreatment in their communities. This theory of change reflected a dynamic understanding of the interconnected determinants of child maltreatment.

RESULTS

GMB was acceptable to participants and resulted in products that could be used for implementation planning (e.g., to model and simulate change) and future research. GMB fostered trust and idea sharing between participants.

CONCLUSION

GMB can facilitate learning about which outcomes are (or are not) impacted by interventions, which resources and approaches are required for quality implementation (e.g., implementation strategies), and tradeoffs in outcomes and resources between interventions. GMB also provides a structured, effective process to generate a shared implementation vision amongst participants. Lessons learned include methods for developing trust with and between participants, and the need for researchers to tailor GMB actions for participant and project needs.

Psychiatric crises among youth with a history of trauma during COVID-19: A retrospective study of psychiatrically hospitalized children and adolescents

BACKGROUND

Youth hospitalized in inpatient child psychiatry units have a high prevalence of trauma and this population may have been especially affected by the pandemic.

OBJECTIVE

This study examined the clinical and sociodemographic characteristics of hospitalized youth with a history of trauma prior to, during, and after the pandemic. Additionally, youth who reported a trauma history were compared to those who denied having a trauma history.

PARTICIPANTS AND SETTING

This retrospective study utilized data gathered from (n = 1101) first admissions to a child and adolescent inpatient psychiatry unit of a New York City hospital during the pandemic.

METHODS

Hospital admission records were reviewed for clinical and sociodemographic variables. Statistical analyses evaluated whether there were significant differences in these variables throughout the pandemic.

RESULTS

The clinical severity of inpatient youth with trauma increased during the quarantine period compared to pre-pandemic. The percentage of youth admitted for psychosis increased by 3 % (φc = 0.15, p = 0.03), suicide attempt by 14.8 % (φc = 0.15, p = 0.03), and suicidal ideation without suicide attempt decreased by 9.6 % (φc = 0.15, p = 0.03). Clinically, patients with a history of trauma were more likely to have greater comorbidity and clinical severity. Demographically, patients with a history of trauma were more likely to be female or transgender/non-binary (φc = 0.11, p < 0.01), Black or Latinx (φc = 0.14, p < 0.01), and on public insurance (φc = 0.11, p < 0.01).

CONCLUSIONS

In an urban area inpatient youth psychiatric unit, the clinical severity of inpatient youth with trauma increased during COVID-19 quarantines. The clinical severity of inpatient youth with trauma was greater than those without during and after COVID-19 and youth with certain minority and marginalized identities were particularly impacted.

Systematic Review of the Impacts of U.S. Social Safety Nets on Child Maltreatment

INTRODUCTION

Children living in poverty are at an increased risk for maltreatment. Social safety net (SSN) programs with antipoverty objectives may reduce child maltreatment through pathways such as reduced food insecurity, lessened caregiver stress, and improved caregiving behaviors and ability to meet children's basic needs. The objective of this study is to conduct a systematic review of evidence on the ability of SSN programs to reduce child maltreatment in the United States (U.S.).

METHODS

This systematic review was conducted using PRISMA protocol. Among studies published between 1996-2022, the initial search returned 1,873 articles, and 27 papers were included in the final analysis. Abstracts were identified primarily on June 24th, 2022, and extraction and synthesis of data was conducted in 2022-2023.

RESULTS

Of the 27 papers assessed, 16 studies found that SSN programs were protective against child maltreatment. Three of the reviewed studies found no effect of safety net programs, 4 studies presented mixed findings, and 4 studies found adverse impacts in terms of child maltreatment outcomes. When restricting to high-quality studies only, 10 out of 12 found protective impacts and none found adverse impacts on child maltreatment.

DISCUSSION

SSNs are associated with protective effects against child maltreatment. Expansion of SSN programs would likely have positive benefits beyond poverty-related objectives, including reducing incidence of child maltreatment.

The neighborhood deprivation gradient and child physical abuse and neglect: A Bayesian spatial model

BACKGROUND

Child abuse and neglect is a public health priority due to its long-term maladaptive consequences. No study in the USA has assessed the nature and magnitude of the social deprivation effect on substantiated child maltreatment risk.

OBJECTIVES

To examine linear and non-linear relationships between area level deprivation and the log-risk of both substantiated physical abuse and neglect while accounting for spatial and heterogeneous random effects.

METHODS

Substantiated child maltreatment and population data (2008-2015) were aggregated to neighborhoods in Bernalillo County, New Mexico. The contribution of area level deprivation to the geographical variation in the log-risks of substantiated child physical abuse and neglect was modeled using Bayesian spatial regression.

RESULTS

Forty-three percent and 46.4 % of the 153 neighborhoods recorded greater risk for either substantiated physical abuse or neglect compared to the county average. The most deprived 20 % of neighborhoods had 71 % and 72 % more cases of substantiated physical abuse and neglect, respectively, than would be expected if the substantiations were randomly distributed throughout the county. Area level deprivation explained 47 % of the variation in substantiated physical abuse and 51 % of the variation in substantiated neglect after controlling for both spatial autocorrelation and heterogeneity.

CONCLUSIONS

Implications from this study can be used to quantify disparities in substantiated child maltreatment attributed to regional differences in social deprivation and to identify priority areas for intervention.

Material hardship in the postpartum year: Links to child maltreatment

BACKGROUND

Millions of mothers with young children in the U.S. struggle to afford basic needs. Material hardships such as inadequate food, housing, and medical care increase risk for child maltreatment as mothers face heightened physical and emotional strain.

OBJECTIVE

The present study applied a person-centered approach to understand unique subtypes of material hardship experienced by at-risk mothers in the postpartum year, and links from hardship subtypes to subsequent child maltreatment.

PARTICIPANTS AND SETTING

The sample included at-risk mothers who gave birth in one of 20 large American cities 1998-2000 and retained custody of their children at age 1 and 3 (N = 3966).

METHOD

Latent class analysis (LCA) identified subtypes of material hardship; mean maltreatment scores were estimated across classes.

RESULTS

LCA identified four hardship subtypes with differential risks for maltreatment. Compared to "Stable" mothers, "Cost-Burdened" mothers - who displayed high levels of missed rent and utility payments - were significantly more likely to psychological abuse (χ2 = 5.04, p < 0.05) or neglect (χ2 = 4.46, p < 0.05) their children. "Severely Housing Insecure Mothers" - characterized by elevated rates of doubling up, eviction, and homelessness - were significantly more likely to engage in physical assault (χ2 = 16.25, p < 0.001), psychological aggression (χ2 = 11.15, p < 0.01), and neglect (χ2 = 17.55, p < 0.001).

CONCLUSIONS

Difficulty maintaining stable and affordable housing is associated with elevated risk of child maltreatment. Efforts to prevent child maltreatment must incorporate access to housing screening and supports, particularly among families with infants.

Housing insecurity and employment stability: An investigation of working mothers

Little evidence informs the relationship between housing insecurity and employment for working mothers. The present study aimed to identify variation in work schedules and supports, as well as the link from housing insecurity to employment experiences in a sample of at-risk mothers. Latent class analysis identified subtypes of employment stability; multinomial logistic regression estimated links from housing insecurity to class membership. Three subtypes of employment stability emerged, "Full-Time and Stable," "Full-Time and Unstable," and "Part-Time Weekend." Housing insecurity increased risk for being in the "Unstable" class relative to the other classes such that these mothers experienced stressful work schedules that offered little support or flexibility for family and child needs. Identifying and intervening on housing insecurity can promote stable employment. Increased workplace supports such as paid leave, flexible schedules, and antidiscrimination training can better enable mothers to juggle the competing demands of motherhood and work.

Homelessness and health-related outcomes: an umbrella review of observational studies and randomized controlled trials

BACKGROUND

Homelessness has been associated with multiple detrimental health outcomes across observational studies. However, relatively few randomized controlled trials (RCTs) have been conducted on people who experience homelessness (PEH). Thus, this umbrella review ranked the credibility of evidence derived from systematic reviews (SRs) and meta-analyses (MAs) of observational studies investigating the associations between homelessness and any health outcome as well as RCTs targeting health needs in this population.

METHODS

Several databases were systematically searched from inception through April 28, 2021. Any SR and/or MA reporting quantitative data and providing a control group were eligible for inclusion. The credibility of the evidence derived from observational studies was appraised by considering the significance level of the association and the largest study, the degree of heterogeneity, the presence of small-study effects as well as excess significance bias. The credibility of evidence was then ranked in five classes. For SRs and/or MAs of RCTs, we considered the level of significance and whether the prediction interval crossed the null. The AMSTAR-2 and AMSTAR-plus instruments were adopted to further assess the methodological quality of SRs and/or MAs. The Newcastle-Ottawa Scale (NOS) was employed to further appraise the methodological quality of prospective cohort studies only; a sensitivity analysis limited to higher quality studies was conducted.

RESULTS

Out of 1549 references, 8 MAs and 2 SRs were included. Among those considering observational studies, 23 unique associations were appraised. Twelve of them were statistically significant at the p≤0.005 level. Included cases had worst health-related outcomes than controls, but only two associations reached a priori-defined criteria for convincing (class I) evidence namely hospitalization due to any cause among PEH diagnosed with HIV infection, and the occurrence of falls within the past year among PEH. According to the AMSTAR-2 instrument, the methodological quality of all included SRs and/or MAs was "critically low." Interventional studies were scant.

CONCLUSION

While homelessness has been repeatedly associated with detrimental health outcomes, only two associations met the criteria for convincing evidence. Furthermore, few RCTs were appraised by SRs and/or MAs. Our umbrella review also highlights the need to standardize definitions of homelessness to be incorporated by forthcoming studies to improve the external validity of the findings in this vulnerable population.

Examining the intersection of child protection and public housing: development, health and justice outcomes using linked administrative data

OBJECTIVE

We described development, health and justice system outcomes for children in contact with child protection and public housing.

DESIGN

Descriptive analysis of outcomes for children known to child protection who also had contact with public housing drawn from the South Australian (SA) Better Evidence Better Outcomes Linked Data (BEBOLD) platform.

SETTING

The BEBOLD platform holds linked administrative records collected by government agencies for whole-population successive birth cohorts in SA beginning in 1999.

PARTICIPANTS

This study included data from birth registrations, perinatal, child protection, public housing, hospital, emergency department, early education and youth justice for all SA children born 1999-2013 and followed until 2016. The base population notified at least once to child protection was n=67 454.

PRIMARY OUTCOME MEASURE

Contact with the public housing system.

SECONDARY OUTCOME MEASURES

Hospitalisations and emergency department presentations before age 5, and early education at age 5, and youth justice contact before age 17.

RESULTS

More than 60% of children with at least one notification to child protection had contact with public housing, and 60.2% of those known to both systems were known to housing first. Children known to both systems experienced more emergency department and hospitalisation contacts, greater developmental vulnerability and were about six times more likely to have youth justice system contact.

CONCLUSIONS

There is substantial overlap between involvement with child protection and public housing in SA. Those children are more likely to face a life trajectory characterised by greater contact with the health system, greater early life developmental vulnerability and greater contact with the criminal justice system. Ensuring the highest quality of supportive early life infrastructure for families in public housing may contribute to prevention of contact with child protection and better life trajectories for children.

What kind of "poverty" predicts CPS contact: Income, material hardship, and differences among racialized groups

•Differences in income explain some racial inequities in child welfare contact. •Differences in hardship do not explain racial inequities in child welfare contact. •Material hardship predicts child welfare contact across racialized groups.

Background and Purpose

Child protective services (CPS) contact is consistently linked with poverty in the US, and empirical evidence is mounting to indicate that disparate exposure to income poverty explains a substantial portion of racial inequities in CPS involvement. Evidence about the different distributions of income poverty and material hardship also suggests that income poverty may not sufficiently capture economic wellbeing among families. This paper assessed whether differences in exposure to income poverty and/or material hardship explain racial inequities in CPS contact and further examined whether income poverty and material hardship predict CPS contact differently within racialized groups.

Methods

We used data from the Fragile Families and Child Wellbeing Study (FFCWS), an urban cohort representative of births in large US cities in 1998–2000. The FFCWS data are ideal for this study in capturing each of the key constructs: racialized group membership, income, material hardship, and CPS contact. We measured income poverty and material hardship when children were age 1 and measured any CPS contact by age five. Our final sample included 3,517 families, including 1,848 Black, 614 white, and 1,055 Latinx families. We employed logistic regression to assess the associations between income poverty and material hardship, independently and jointly, and CPS contact. We conducted analyses in our full analytic sample and among subsamples of the Black, white, and Latinx families.

Results

We found that differences in income-to-poverty ratio account for differences in CPS contact between Black and white families. Differences in CPS contact between Black and Latinx families were not explained by economic wellbeing measures alone but were ameliorated when differences in income poverty, material hardship, and a full set of family characteristics were considered. Additionally, we found that material hardship was a consistent predictor of CPS contact in the full sample and within each of the Black, white, and Latinx subsamples, even accounting for differences in income and other family characteristics.

Conclusions

The clear role of income poverty in explaining inequities in CPS contact between Black and white families and the consistent importance of material hardship in predicting CPS contact across all families underscore the critical importance of reducing income poverty and hardship and of distinguishing material need from maltreatment in the context of CPS. Our findings offer clear implications for policy intervention to reduce income poverty and material hardship. Such interventions might include extending the temporarily expanded Child Tax Credit and expanded food and housing assistance benefits, toward the ends of supporting child and family wellbeing and reducing economic and racial inequities in CPS contact.

Neglect, Abuse, and Adaptive Functioning: Food Security and Housing Stability as Protective Factors for Adolescents

This study addresses gaps in knowledge of protective factors that support adaptive functioning among maltreated adolescents. The sample included 1003 high-risk youths participating in the Longitudinal Studies of Child Abuse and Neglect (53% female, 56% Black, and 82% living in poverty). Adolescent neglect (Exposure to Risky Situations, Lack of Monitoring, Inattention to Basic Needs, Permitting Misbehavior, Lack of Support) and physical, sexual, and emotional abuse were self-reported at age 16. Age 18 adaptive functioning measures included healthcare receipt (medical, dental, and mental health), self-rated global health, high school graduation or enrollment, prosocial activities, peer relationships (Companionship, Conflict, Satisfaction, and Intimacy), and independent living skills. Previous childhood maltreatment, demographics, and earlier prosocial activities and peer relationships were controls. Structural equation modeling showed that adolescent neglect and abuse were associated with lower adaptive functioning. Multigroup models showed protective effects for food security on the relationships between sexual abuse and self-rated health and between Inadequate Monitoring and Companionship. Housing stability buffered relationships between Inadequate Support and high school graduation or enrollment and between Permitting Misbehavior and independent living skills. Findings imply the need for adolescent-focused prevention, including the promotion of food security and housing stability to support adaptive functioning in maltreated adolescents. However, notable mixed findings show the need for additional research.

"Because the resources aren't there, then we fail. We fail as a society": A Qualitative Analysis of Human Trafficking Provider Perceptions of Child Welfare Involvement among Trafficked Mothers

BACKGROUND

Little is understood about child welfare involvement (CWI) in cases where the birth mother has experienced human trafficking.

OBJECTIVES

The aim of this study was to explore provider perceptions of the impact of CWI for the trafficked mother.

METHODS

Participants were selected among providers caring for trafficked birth mothers. Semi-structured interviews were conducted with providers and qualitative content analysis was conducted.

RESULTS

Interviewees reported reasons for CWI, positive and negative impacts of CWI and provided recommendations for systems improvement.

CONCLUSION FOR PRACTICE

Recommendations from this exploratory study include mechanisms to support trafficked mothers, train hospital social workers, and systems change. During the prenatal period, strategies to support the trafficked mother may include addressing gaps in social determinants of health, ensuring appropriate medical and mental health care, early screening and referral to substance use treatment services, enhancing community support, and working to develop safety plans for survivors and their families. Enhanced engagement of social workers and all providers to improve understanding of the unique complexity of trafficked mothers is needed. Education should include an understanding that judgement of a caretaker's ability to parent should be current and holistic and not reflexive based on history in the electronic medical record. An exploration of the child welfare system itself should also be undertaken to identify and modify discriminatory laws and policies. Finally, efforts to address social determinants of health in the community and enhance the trauma-informed nature of child welfare referrals could improve the lives of trafficked mothers.

"The Propellers of My Life" The Impact of Domestic Violence Transitional Housing on Parents and Children

Housing and homelessness are frequent issues facing domestic violence (DV) survivors and their children. Several DV programs provide transitional housing (DVTH) to address the housing needs of DV survivors and their children. Despite wide use, little is known about the impact of DVTH, especially on child and parenting related needs and outcomes. Multiple structured interviews (82) were conducted with 27 parents with minor children living in DVTH in order to explore housing program experiences. Thematic analysis techniques produced three themes and seven subthemes about DVTH impact on parenting and child wellness. Overarching themes include: (1) DVTH helps to strengthen the parent-child relationship through a focus on family connection and health; (2). Transitional housing provides an opportunity for family stability via housing, material, and economic stability; (3). Time at DVTH allows family to access a diverse range of trauma-informed resources and social support to meet family goals. Barriers to these potential impacts are explored. Implications for practice with youth and parents include the need for extensive mental health and legal advocacy, programmatic models that emphasize resources, safety and the transition to permanent housing, and build on family strengths. Further research is needed to evaluate DVTH program outcomes.