Public Benefit Programs and Differential Associations With Child Maltreatment by Race and Ethnicity

Importance

Public benefit programs, including state spending on local, state, and federal-state partnership programs, have consistently been associated with overall reductions in child protective services (CPS) involvement. Inequities in eligibility and access to benefit programs may contribute to varying associations by race and ethnicity.

Objective

To determine whether associations between state spending on benefit programs and rates of CPS investigations differ by race and ethnicity.

Design, Setting, and Participants

This cross-sectional ecological study used repeated state-level measures of child maltreatment from the National Child Abuse and Neglect Data System and population estimates from the US Census Bureau for all Black, Hispanic, and White children. All 50 US states from October 1, 2009, through September 30, 2019 (fiscal years 2010-2019), were included. Data were collected and analyzed from May 13, 2022, to March 2, 2023.

Exposures

Annual state spending on benefit programs per person living below the federal poverty limit, total and by the following subcategories: (1) cash, housing, and in-kind; (2) housing infrastructure; (3) child care assistance; (4) refundable earned income tax credit; and (5) medical assistance programs.

Main Outcomes and Measures

Race- and ethnicity-specific rates of CPS investigations. Generalized estimating equations, with repeated measures of states, an interaction between race and spending, and estimated incidence rate ratios (IRRs) and 95% CIs for incremental changes in spending of US $1000 per person living below the federal poverty limit were calculated after adjustment for federal spending, race- and ethnicity-specific child poverty rate, and year.

Results

A total of 493 state-year observations were included in the analysis. The association between total spending and CPS investigations differed significantly by race and ethnicity: there was an inverse association between total state spending and CPS investigations for White children (IRR, 0.94 [95% CI, 0.91-0.98]) but not for Black children (IRR, 0.98 [95% CI, 0.94-1.02]) or Hispanic children (IRR, 0.99 [95% CI, 0.95-1.03]) (P = .02 for interaction). Likewise, inverse associations were present for only White children with respect to all subcategories of state spending and differed significantly from Black and Hispanic children for all subcategories except the refundable earned income tax credit (eg, IRR for medical assistance programs for White children, 0.89 [95% CI, 0.82-0.96]; P = .005 for race and spending interaction term).

Conclusions and Relevance

These results raise concerns that benefit programs may add relative advantages for White children compared with Black and Hispanic children and contribute to racial and ethnic disparities in CPS investigations. States' eligibility criteria and distribution practices should be examined to promote equitable effects on adverse child outcomes.

Physical health and emotional and behavioral problems in maltreated children according to family economic status: Health problems of maltreated children in Korea

Low family income is a risk factor for child maltreatment. However, there has been no comparative study on the association between child maltreatment and family income. The objective of this study was to investigate the physical health and emotional and behavioral problems of maltreated children according to the economic status of their family.Cross-sectional nationwide studyData from 2012 to 2014 was extracted from the Korean National Child Abuse Registry (age <18 years) operated by the National Child Protection Agency (NCPA). Demographic characteristics and 34 physical health and emotional/behavioral problems of maltreated children were compared by family economic status. Family economic status was classified into 2 groups: families receiving the National Basic Livelihood Guarantee (NBLG) and those not receiving the guarantee (non-NBLG group).A total of 17,128 children were registered in the system. Mean age was 9.3 years (SD 4.8 years), 44.4% were females, and 29.2% were in the NBLG group. Poor hygiene, anxiety, and attention deficit were frequently reported physical and emotional health problems. Common behavioral problems included running away, rebelliousness/impulsivity/aggressiveness, maladjustment in school, learning problems at school, and frequent unauthorized absenteeism and truancy. Physical health problems (7 of 8 items) occurred more often in the NBLG group, and behavioral problems (6 of 17 items) occurred more often in the non-NBLG group.Children in Korea who are maltreated have different physical health, emotional, and behavioral problems depending on their family income level. These results can be useful in approaching the recognition of and interventions for child maltreatment.

Cost effectiveness of SEEK: A primary care-based child maltreatment prevention model

BACKGROUND

Funding for prevention interventions is often quite limited. Cost-related assessments are important to best allocate prevention funds.

OBJECTIVES

To determine the (1) overall cost for implementing the Safe Environment for Every Kid (SEEK) model, (2) cost of implementation per child, and (3) cost per case of maltreatment averted.

DESIGN

Cost-effective analysis of a randomized controlled trial.

PARTICIPANTS AND SETTING

102 pediatric providers at 18 pediatric primary care practices. 924 families with children < 6 years receiving care by those providers.

METHODS

Practices and their providers were randomized to either SEEK training and implementation or usual care. Families in SEEK and control practices were recruited for evaluation. Rates of psychological and physical abuse were calculated by parent self-report 12 months following recruitment. Model costs were calculated including salaries for team members, provider time for training and booster sessions, and development and distribution of materials.

RESULTS

Implementing SEEK in all 18 practices would have cost approximately $265,892 over 2.5 years; $3.59 per child per year; or $305.58 ($229.18-$381.97) to prevent one incident. Based on a very conservative cost estimate of $2779 per maltreatment incident, SEEK would save an estimated $2,151,878 in health care costs for 29,610 children.

CONCLUSIONS

The SEEK model is cost saving. Cost per case of psychological and physical abuse averted were significantly lower than the short-term costs of medical and mental health care for maltreated children. SEEK model expansion has the potential to significantly decrease medical, mental health, and other related costs associated with maltreatment.

Reducing the Number of Children Entering Foster Care: Effects of State Earned Income Tax Credits

Foster care caseloads, an indicator of child maltreatment, are increasing. Children living in poverty are significantly more likely to be reported to the child welfare system and are overrepresented in foster care. Thus, it is critical to identify prevention strategies that can stem the flow of foster care entries, particularly among populations at higher risk. We used variations in the adoption and refund status of state-level Earned Income Tax Credit (EITC), a socioeconomic policy intended to reduce poverty, to examine their effect on foster care entry rates. Fixed-effects models, accounting for year- and state-fixed effects, demonstrated that a refundable EITC was associated with an 11% decrease in foster care entries compared to states without a state-level EITC after controlling for child poverty rate, racial/ethnic composition, education, and unemployment. Policies that strengthen economic supports for families may prevent child maltreatment and reduce foster care entries and associated costs.

Benefit-cost analysis of Promoting First Relationships®: Implications of victim benefits assumptions for return on investment

BACKGROUND

Child abuse and neglect (CAN) cost United States society $136 billion to $428 billion annually. Preventive interventions that reduce CAN may improve people's lives and generate economic benefits to society, but their magnitude is likely to vary greatly with assumptions about victim costs avoided through intervention.

OBJECTIVE

We examined the implications of different assumptions about avoided victim costs in a benefit-cost analysis of Promoting First Relationships® (PFR), a 10-session attachment and strengths-based home visiting intervention.

PARTICIPANTS AND SETTING

Participants were 247 child protection-involved but intact families in Washington State randomized to receive PFR (n = 124) or resource and referral (n = 123).

METHODS

We monetized intervention effects on out-of-home placements and implicit effects on CAN and calculated net present values under three scenarios: (1) benefits from avoided system costs, (2) additional benefits from avoided tangible victim costs, and (3) additional benefits from avoided tangible and intangible quality-of-life victim costs. For scenarios 2 and 3, we varied the CAN effect size and estimated the effect size at which PFR was reliably cost beneficial.

RESULTS

PFR's societal net benefit ranged from $1 (scenario 1) to $5514 - $25,562 (scenario 2) and $7004 - $32,072 (scenario 3) (2014 USD). In scenarios 2 and 3, PFR was reliably cost beneficial at a CAN effect size of approximately -0.25.

CONCLUSIONS

PFR is cost beneficial assuming tangible victim costs are avoided by PFR. Research into the long-term health and economic consequences of reducing CAN in at-risk populations would contribute to comprehensive, accurate benefits models.

The lifetime costs of pediatric abusive head trauma and a cost-effectiveness analysis of the Period of Purple crying program in British Columbia, Canada

BACKGROUND

Abusive head trauma (AHT) is a severe form of child abuse causing devastating outcomes for children and families, but its economic costs in Canada has yet to be determined. The Period of PURPLE crying program (PURPLE) is an AHT prevention program implemented in British Columbia for which success in reducing AHT events was recently reported.

OBJECTIVE

This study estimated the lifetime costs to society of incidental AHT events and compared the benefits and associated costs of AHT before and after the implementation of the PURPLE program.

PARTICIPANTS AND SETTING

Children aged 0-24 months old with a definite diagnosis of AHT between 2002 and 2014 in British Columbia were included in this study.

METHODS

An incidence-based cost-of-illness analysis, using the human capital approach was used to quantify the lifetime costs of AHT events according to their severity (least severe, severe and fatal). A cost-effectiveness analysis of the PURPLE program was conducted from both a societal and a health services' perspectives using decision tree models.

RESULTS

There were sixty-four AHT events between 2002-2014, resulting in a total cost of $354,359,080 to society. The costs associated with fatal, severe and least severe AHT averaged $7,147,548, $6,057,761 and $1,675,099, respectively. The investment of $5 per newborn through the PURPLE program resulted in a $273.52 and $14.49 per child cost avoidance by society and by the healthcare system.

CONCLUSIONS

This study provides evidence to policymakers and health practitioners that investing upstream in well-developed AHT prevention programs, such as PURPLE, not only promote child safety and health, but also translates into avoided costs to society.

Considering the child welfare system burden from opioid misuse: research priorities for estimating public costs

The negative impact of opioids on those who misuse them has been widely documented. Despite significant spillover effects in the form of elevated rates of child maltreatment and child welfare system (CWS) involvement for children affected by parental opioid misuse, the public costs of opioid misuse to the CWS remain largely undocumented. This work seeks to understand the value and limitations of public data in estimating the costs of the opioid epidemic on the CWS. National data from federal sources are combined with best estimates of the association between opioid misuse and child services system utilization. The limitations of this work are explored, and future research priorities are outlined. Ultimately, this work illustrates the need to (1) improve data quality related to parental opioid misuse and CWS linkages; (2) better estimate the number of children and families coming into contact with the CWS as a result of parental opioid misuse; (3) improve predictions of CWS trajectories, including investigation, service provision, and foster care entry among this population; and (4) better estimate the CWS costs associated with patterns of system involvement resulting from parental opioid misuse. This information is crucial to ensuring the production of high-quality system involvement and cost projections related to the opioid crisis.

The economic burden of child maltreatment in the United States, 2015

Child maltreatment incurs a high lifetime cost per victim and creates a substantial US population economic burden. This study aimed to use the most recent data and recommended methods to update previous (2008) estimates of 1) the per-victim lifetime cost, and 2) the annual US population economic burden of child maltreatment. Three ways to update the previous estimates were identified: 1) apply value per statistical life methodology to value child maltreatment mortality, 2) apply monetized quality-adjusted life years methodology to value child maltreatment morbidity, and 3) apply updated estimates of the exposed population. As with the previous estimates, the updated estimates used the societal cost perspective and lifetime horizon, but also accounted for victim and community intangible costs. Updated methods increased the estimated nonfatal child maltreatment per-victim lifetime cost from $210,012 (2010 USD) to $830,928 (2015 USD) and increased the fatal per-victim cost from $1.3 to $16.6 million. The estimated US population economic burden of child maltreatment based on 2015 substantiated incident cases (482,000 nonfatal and 1670 fatal victims) was $428 billion, representing lifetime costs incurred annually. Using estimated incidence of investigated annual incident cases (2,368,000 nonfatal and 1670 fatal victims), the estimated economic burden was $2 trillion. Accounting for victim and community intangible costs increased the estimated cost of child maltreatment considerably compared to previous estimates. The economic burden of child maltreatment is substantial and might off-set the cost of evidence-based interventions that reduce child maltreatment incidence.

Familial financial stress and child internalizing behaviors: The roles of caregivers' maltreating behaviors and social services

Based on the family stress model and the stress-buffering model, the present study examines the relationship between caregivers' financial stress and child internalizing problem behaviors, the mediating role of caregiver maltreating behaviors, and whether social services for caregivers buffer this relationship. The current study is based on data from wave two of the National Survey of Child and Adolescent Well-Being dataset (N = 2670). Results indicated increased high familial financial stress was associated with child internalizing problems. Caregivers' psychological aggression, physical assault, child neglect, and sexual maltreatment emerged as mechanisms mediating this relationship. Tangible service and social network service were found to mitigate the deleterious effect of financial stress on child internalizing behaviors, but primarily for those whom financial stress was high. These findings highlight the role perceived financial stress has on potential maltreatment and child outcomes, rather than relying on objective measures of economic status. Implications for social services focused interventions for children and caregivers coping with high levels of perceived financial stress are discussed.

Economic Impact of Multisystemic Therapy for Child Abuse and Neglect

This study evaluated the economics of Multisystemic Therapy for Child Abuse and Neglect (MST-CAN) by applying the Washington State Institute for Public Policy (WSIPP) cost-benefit model to data from a randomized effectiveness trial with 86 families (Swenson et al. in JFP 24:497-507, 2010b). The net benefit of MST-CAN, versus enhanced outpatient treatment, was $26,655 per family at 16 months post-baseline. Stated differently, every dollar spent on MST-CAN recovered $3.31 in savings to participants, taxpayers, and society at large. Policymakers and public service agencies should consider these findings when making investments into interventions for high-need families involved with child protective services.

Understanding trends in neighborhood child maltreatment rates: A three-wave panel study 1990-2010

This study examines how changes in the social and economic structure of neighborhoods relate to changes in child maltreatment report rates over an extended period. The panel study design allows us to partition the changes in child maltreatment report rates into a portion associated with how the levels of socio-economic risk factors have changed over time, and a portion related to how the relative importance of those factors in explaining maltreatment report rates has changed over time. Through the application of fixed effects panel models, the analysis is also able to control for unmeasured time-invariant characteristics of neighborhoods that may be a source of bias in cross-sectional studies. The study finds that increases in vacant housing, single parent families and unemployment rates are strongly associated with increases in child maltreatment report rates. Changes in racial/ethnic composition did not produce changes in maltreatment report rates except when they reached extreme levels of segregation. Although poverty rates were predictive of cross-sectional variation in child maltreatment, increases in neighborhood poverty became less associated with increases in child maltreatment report rates over time.

Homelessness in the child welfare system: A randomized controlled trial to assess the impact of housing subsidies on foster care placements and costs

Inadequate housing and homelessness among families represent a substantial challenge for child and adolescent well-being. Child welfare services confront housing that threatens placement into foster care with little resources and evidence to guide practice. The present study provides the first rigorous test of the Family Unification Program (FUP) - a federal program that offers housing subsidies for inadequately housed families under investigation for child maltreatment. A randomized controlled trial assesses program impact on foster care placement and costs. The experiment referred intact child welfare-involved families whose inadequate housing threatened foster placement in Chicago, IL to FUP plus housing advocacy (n = 89 families with 257 children) or housing advocacy alone (n = 89 families with 257 children). Families were referred from 2011 to 2013, and administrative data recorded dates and costs of foster placements over a 3-year follow-up. Intent-to-treat analyses suggested families randomly assigned for FUP exhibited slower increases in rates of foster placement following housing intervention compared with families referred for housing advocacy alone. The program generates average savings of nearly $500 per family per year to the foster care system. Housing subsidies provide the foster care system small but significant benefits for keeping homeless families together. Findings inform the design of a coordinated child welfare response to housing insecurity.

Lifetime Cost of Abusive Head Trauma at Ages 0-4, USA

This paper aims to estimate lifetime costs resulting from abusive head trauma (AHT) in the USA and the break-even effectiveness for prevention. A mathematical model incorporated data from Vital Statistics, the Healthcare Cost and Utilization Project Kids' Inpatient Database, and previous studies. Unit costs were derived from published sources. From society's perspective, discounted lifetime cost of an AHT averages $5.7 million (95% CI $3.2-9.2 million) for a death. It averages $2.6 million (95% CI $1.0-2.9 million) for a surviving AHT victim including $224,500 for medical care and related direct costs (2010 USD). The estimated 4824 incident AHT cases in 2010 had an estimated lifetime cost of $13.5 billion (95% CI $5.5-16.2 billion) including $257 million for medical care, $552 million for special education, $322 million for child protective services/criminal justice, $2.0 billion for lost work, and $10.3 billion for lost quality of life. Government sources paid an estimated $1.3 billion. Out-of-pocket benefits of existing prevention programming would exceed its costs if it prevents 2% of cases. When a child survives AHT, providers and caregivers can anticipate a lifetime of potentially costly and life-threatening care needs. Better effectiveness estimates are needed for both broad prevention messaging and intensive prevention targeting high-risk caregivers.

Child maltreatment in rural southern counties: Another perspective on race, poverty and child welfare

Building on research that has identified community characteristics associated with child maltreatment, this study investigates the adequacy and equity of the child welfare response at the county level. The study focuses on states in the U.S. south with demographic characteristics that make it possible to disentangle county racial composition from county rurality. County-level child maltreatment data were merged with data from the U.S. Census and other publicly-available sources for the 354 counties in four southern states. Results from multiple regression models indicated that, despite a greater preponderance of risk factors typically associated with child maltreatment, rural, majority African-American counties had lower rates of reported and substantiated child maltreatment compared to other southern counties. Cross-sectional results were consistent across three years: 2012, 2013, and 2014. The findings suggest that children and families in rural, majority African-American counties in the South may not be receiving adequate or equitable responses from the formal child welfare system.

The Economic Burden of Violence against Children in South Africa

The purpose of this study was to estimate the economic burden of violence against children in South Africa. We assembled summative estimates of lifetime prevalence, calculated the magnitude of associations with negative outcomes, and thereby estimated the economic burden of violence against children. According to our calculations, 2.3 million and 84,287 disability-adjusted life-years (DALYs) lost in South Africa in 2015 were attributable to nonfatal and fatal violence against children, respectively. The estimated economic value of DALYs lost to violence against children (including both fatal and nonfatal) in South Africa in 2015 totalled ZAR173 billion (US $13.5 billion)—or 4.3% of South Africa’s gross domestic product (GDP) in 2015. In addition, the reduced earnings attributable to childhood physical violence and emotional violence in South Africa in 2015 were ZAR25.2 billion (US $2.0 billion) and ZAR9.6 billion (US $750 million), respectively. In addition, South Africa spent ZAR1.6 billion (US $124 million) on child care and protection in fiscal year 2015/2016, many of which costs are directly related to violence against children. This study confirms the importance of prioritising violence against children as a key social and economic concern for South Africa’s future.

Medical social work practice in child protection in China: A multiple case study in Shanghai hospitals

With the rapid development of the child welfare system in China over recent years, medical social work has been increasingly involved in providing child protection services in several hospitals in Shanghai. Focusing on five cases in this paper, the exploratory study aims to present a critical overview of current practices and effects of medical social work for child protection, based on a critical analysis of the multidimensional role of social work practitioners engaged in the provision of child protection services as well as potential challenges. Implications and suggestions for future improvements of China's child protection system are also discussed.

Less money, more problems: How changes in disposable income affect child maltreatment

A number of research studies have documented an association between child maltreatment and family income. Yet, little is known about the specific types of economic shocks that affect child maltreatment rates. The paucity of information is troubling given that more than six million children are reported for maltreatment annually in the U.S. alone. This study examines whether an exogenous shock to families' disposable income, a change in the price of gasoline, predicts changes in child maltreatment. The findings of a fixed-effects regression show that increases in state-level gas prices are associated with increases in state-level child maltreatment referral rates, even after controlling for demographic and other economic variables. The results are robust to the manner of estimation; random-effects and mixed-effects regressions produce similar estimates. The findings suggest that fluctuations in the price of gas may have important consequences for children.

Duration in Poverty-Related Programs and Number of Child Maltreatment Reports

This study examined the relationship of a family's duration in poverty-related programs (i.e., Aid to Families with Dependent Children/Temporary Assistance for Needy Families and Medicaid) to the subject child's number of maltreatment reports while considering race and baseline neighborhood poverty. Children from a large Midwestern metropolitan area were followed through a linked cross-sector administrative database from birth to age 15. Generalized multilevel models were employed to account for the multilevel structure of the data (i.e., nesting of families within neighborhoods). The data showed a unique and significant contribution of duration in poverty-related programs to the number of maltreatment reports. The predicted number of maltreatment reports increased by between 2.5 and 3.7 times, as duration in poverty-related programs increased from 0 to 9 years. This relationship was consistent between Whites and non-Whites (over 98% Black), but non-Whites showed a significantly lower number of total maltreatment reports while controlling for duration in poverty-related programs. We were unable to find a significant association between child maltreatment reports and baseline neighborhood poverty.

The influence of geographical and economic factors in estimates of childhood abuse and neglect using the Childhood Trauma Questionnaire: A worldwide meta-regression analysis

This multilevel meta-analysis examined the effects of geographical and economic factors on worldwide childhood maltreatment estimates measured by the Childhood Trauma Questionnaire (CTQ) short-form. The primary outcome extracted was continuous scores on the CTQ subscales - emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect - and total score. Geographical, economical and methodological variables were extracted for use as covariates in meta-regression models. A literature search identified 288 studies suitable for the CTQ total score analysis (N=59,692) and 189 studies suitable for maltreatment subtype analysis (N=44,832). We found that Europe and Asia were associated with lower CTQ estimates while South America presented the highest estimates among continents. Specifically, studies from China, Netherlands and United Kingdom presented the lowest maltreatment estimates. Furthermore, high-income countries presented lower CTQ physical neglect estimates in comparison to low- or middle-income countries, while per-capita gross domestic product of countries was negatively associated with childhood physical neglect estimates. Despite the influence of methodological covariates, these findings indicate that geographical and economic factors could influence variations of childhood maltreatment estimates around the world, particularly when assessed by a structured standardized questionnaire.

[Child maltreatment: long-term economic consequences and implications]

Child maltreatment occurs frequently. This has detrimental effects later in life on mental health and is linked to considerable costs due to health care use and sick leave. Self-mastery, however, is a factor that may well mitigated the effects of child maltreatment . <br/> AIM: To quantify the long-term costs of child abuse and to test the hypothesis that self-mastery can modify the after-effects of maltreatment .<br/> METHOD: Data were obtained from a psychiatric cohort study (n=5618). The risk factors were emotional neglect and mental, physical and sexual abuse before the age of 16.<br/> RESULTS: When individuals are about 39 years old, the various forms of maltreatment to which they were subjected as children are associated with substantially higher health care costs and frequent absenteeism. Higher levels of self-mastery achieved in childhood were indeed associated with lower costs in adulthood. <br/> CONCLUSION: Child maltreatment costs the Netherlands millions of euros annually because it leads to higher health care costs and more frequent sick leave. Active steps to curb child abuse are of both financial and economic significance. More training in self-mastery could perhaps be helpful, but further research is needed in this area.

"I never expected that it would happen, coming to ask me such questions":Ethical aspects of asking children about violence in resource poor settings

BACKGROUND

International epidemiological research into violence against children is increasing in scope and frequency, but little has been written about practical management of the ethical aspects of conducting such research in low and middle-income countries. In this paper, we describe our study procedures and reflect on our experiences conducting a survey of more than 3,700 primary school children in Uganda as part of the Good Schools Study, a cluster randomised controlled trial of a school-based violence prevention intervention. Children were questioned extensively about their experiences of physical, sexual, and emotional violence from a range of different perpetrators. We describe our sensitisation and consent procedures, developed based on our previous research experience and requirements for our study setting. To respond to disclosures of abuse that occurred during our survey, we describe a referral algorithm developed in conjunction with local services. We then describe our experience of actually implementing these procedures in our 2012 survey, based on reflections of the research team. Drawing on 40 qualitative interviews, we describe children's experiences of participating in the survey and of being referred to local child protection services.

RESULTS

Although we were able to implement much of our protocol in a straightforward manner, we also encountered major challenges in relation to the response of local services to children's disclosures of violence. The research team had to intervene to ensure that children were provided with appropriate support and that our ethical obligations were met.

CONCLUSIONS

In resource poor settings, finding local services that can provide appropriate support for children may be challenging, and researchers need to have concrete plans and back-up plans in place to ensure that obligations can be met. The merits of mandatory reporting of children's disclosures to local services need to be considered on a case by case basis-in some places this has the potential to do harm. Research teams also must agree on what level of ancillary care will be provided, and budget accordingly. Further practical examples of how to address the challenges encountered in this work are needed, in order to build a consensus on best practices.

TRIAL REGISTRATION

NCT01678846 (clinicaltrials.gov), August 24, 2012.

Annual Cost of U.S. Hospital Visits for Pediatric Abusive Head Trauma

We estimated the frequency and direct medical cost from the provider perspective of U.S. hospital visits for pediatric abusive head trauma (AHT). We identified treat-and-release hospital emergency department (ED) visits and admissions for AHT among patients aged 0-4 years in the Nationwide Emergency Department Sample and Nationwide Inpatient Sample (NIS), 2006-2011. We applied cost-to-charge ratios and estimated professional fee ratios from Truven Health MarketScan(®) to estimate per-visit and total population costs of AHT ED visits and admissions. Regression models assessed cost differences associated with selected patient and hospital characteristics. AHT was diagnosed during 6,827 (95% confidence interval [CI] [6,072, 7,582]) ED visits and 12,533 (95% CI [10,395, 14,671]) admissions (28% originating in the same hospital's ED) nationwide over the study period. The average medical cost per ED visit and admission were US$2,612 (error bound: 1,644-3,581) and US$31,901 (error bound: 29,266-34,536), respectively (2012 USD). The average total annual nationwide medical cost of AHT hospital visits was US$69.6 million (error bound: 56.9-82.3 million) over the study period. Factors associated with higher per-visit costs included patient age <1 year, males, coexisting chronic conditions, discharge to another facility, death, higher household income, public insurance payer, hospital trauma level, and teaching hospitals in urban locations. Study findings emphasize the importance of focused interventions to reduce this type of high-cost child abuse.

The burden of child maltreatment in the East Asia and Pacific region

This study estimated the health and economic burden of child maltreatment in the East Asia and Pacific region, addressing a significant gap in the current evidence base. Systematic reviews and meta-analyses were conducted to estimate the prevalence of child physical abuse, sexual abuse, emotional abuse, neglect, and witnessing parental violence. Population Attributable Fractions were calculated and Disability-Adjusted Life Years (DALYs) lost from physical and mental health outcomes and health risk behaviors attributable to child maltreatment were estimated using the most recent comparable Global Burden of Disease data. DALY losses were converted into monetary value by assuming that one DALY is equal to the sub-region's per capita GDP. The estimated economic value of DALYs lost to violence against children as a percentage of GDP ranged from 1.24% to 3.46% across sub-regions defined by the World Health Organization. The estimated economic value of DALYs (in constant 2000 US$) lost to child maltreatment in the EAP region totaled US $151 billion, accounting for 1.88% of the region's GDP. Updated to 2012 dollars, the estimated economic burden totaled US $194 billion. In sensitivity analysis, the aggregate costs as a percentage of GDP range from 1.36% to 2.52%. The economic burden of child maltreatment in the East Asia and Pacific region is substantial, indicating the importance of preventing and responding to child maltreatment in this region. More comprehensive research into the impact of multiple types of childhood adversity on a wider range of putative health outcomes is needed to guide policy and programs for child protection in the region, and globally.

The continuing role of material factors in child maltreatment and placement

This article constitutes a 20-year update to a previous publication (Pelton, 1994), which showed that there is overwhelming evidence that poverty and low income are strongly related to child abuse and neglect. Subsequent evidence shows that the relationship continues to be strong. In addition, there is further evidence since the 1994 publication that this relation is not substantially due to class bias. Yet it is suggested that class bias does exist within the system. There is also further evidence that decreases in child maltreatment follow increases in material supports, and that job loss bears a complex relationship to child maltreatment. Findings pertaining to racial bias within the child welfare system continue to be mixed, but leave no doubt that racial disproportionalities within the system are overwhelmingly related to racial disproportionalities in the poverty population. There is continuing evidence that children placed in foster care are predominantly from impoverished families, and that changes in the level of material supports are related to risk of placement. It is suggested that the fact that there are nearly one million children in out-of-home placement (foster care and child-welfare involved adoption, combined) is indicative of the continuing dysfunction of the child welfare system, and that the differential response paradigm has not altered this dysfunction. A proposal for a fundamental restructuring of the child welfare system is recommended and restated here. Prospects for such change are briefly discussed. Also, to reduce poverty, a previously proposed universal social dividend and taxation system is briefly discussed and recommended.

Examining the feasibility of an economic analysis of dyadic developmental psychotherapy for children with maltreatment associated psychiatric problems in the United Kingdom

BACKGROUND

Children with maltreatment associated psychiatric problems are at increased risk of developing behavioural or mental health disorders. Dyadic Developmental Psychotherapy (DDP) was proposed as treatment for children with maltreatment histories in the USA, however, being new to the UK little is known of its effectiveness or cost-effectiveness. As part of an exploratory study, this paper explores the feasibility of undertaking economic analysis of DDP in the UK.

METHODS

Feasibility for economic analysis was determined by ensuring such analysis could meet key criteria for economic evaluation. Phone interviews were conducted with professionals (therapists trained and accredited or in the process of becoming accredited DDP practitioners). Three models were developed to represent alternative methods of DDP service delivery. Once appropriate comparators were determined, economic scenarios were constructed. Cost analyses were undertaken from a societal perspective. Finally, appropriate outcome measurement was explored through clinical opinion, literature and further discussions with clinical experts.

RESULTS

Three DDP models were constructed: DDP Full-Basic, DDP Home-Based and DDP Long-Term. Two potential comparator interventions were identified and defined as Consultation with Carers and Individual Psychotherapy. Costs of intervention completion per case were estimated to be: £6,700 (DDP Full-Basic), £7,100 (Consultations with Carers), £7,200 (DDP Home-Based), £11,400 (Individual Psychotherapy) and £14,500 (DDP Long-Term). None of the models of service delivery were found to currently measure effectiveness consistently. The Strengths and Difficulties Questionnaire (SDQ) was deemed an appropriate primary outcome measure, however, it does not cover all disorders DDP intends to treat and the SDQ is not a direct measure of health gain. Inclusion of quality of life measurement is required for comprehensive economic analysis.

CONCLUSIONS

Economic analysis of DDP in the UK is feasible if vital next steps are taken to measure intervention outcomes consistently, ideally with a quality of life measurement. An economic analysis using the models constructed could determine the potential cost-effectiveness of DDP in the UK and identify the most efficient mode of service delivery.

The medical cost of abusive head trauma in the United States

OBJECTIVES

Health consequences of shaken baby syndrome, or pediatric abusive head trauma (AHT), can be severe and long-lasting. We aimed to estimate the multiyear medical cost attributable to AHT.

METHODS

Using Truven Health MarketScan data, 2003-2011, we identified children 0 to 4 years old with commercial or Medicaid insurance and AHT diagnoses. We used exact case-control matching based on demographic and insurance characteristics such as age and health plan type to compare medical care between patients with and without AHT diagnoses. Using regression models, we assessed service use (ie, average annual number of inpatient visits per patient) and inpatient, outpatient (including emergency department), drug, and total medical costs attributable to an AHT diagnosis during the 4-year period after AHT diagnosis.

RESULTS

We assessed 1209 patients with AHT and 5895 matched controls. Approximately 48% of patients with AHT received inpatient care within 2 days of initial diagnosis, and 25% were treated in emergency departments. AHT diagnosis was associated with significantly greater medical service use and higher inpatient, outpatient, drug, and total costs for multiple years after the diagnosis. The estimated total medical cost attributable to AHT in the 4 years after diagnosis was $47,952 (95% confidence interval [CI], $40,219-$55,685) per patient with AHT (2012 US dollars) and differed for commercially insured ($38,231 [95% CI, $29,898-$46,564]) and Medicaid ($56,691 [95% CI, $4290-$69,092]) patients.

CONCLUSIONS

Children continue to have substantial excess medical costs for years after AHT. These estimates exclude related nonmedical costs such as special education and disability that also are attributable to AHT.

Intimate partner violence: associations with low infant birthweight in a South African birth cohort

Violence against women is a global public health problem. Exposure to intimate partner violence (IPV) during pregnancy has been associated with a number of adverse maternal and fetal outcomes, including delivery of a low birthweight (LBW) infant. However, there is a paucity of data from low-middle income countries (LMIC). We examined the association between antenatal IPV and subsequent LBW in a South African birth cohort. This study reports data from the Drakenstein Child Lung Health Study (DCLHS), a multidisciplinary birth cohort investigation of the influence of a number of antecedent risk factors on maternal and infant health outcomes over time. Pregnant women seeking antenatal care were recruited at two different primary care clinics in a low income, semi-rural area outside Cape Town, South Africa. Antenatal trauma exposure was assessed using the Childhood Trauma Questionnaire (CTQ) and an IPV assessment tool specifically designed for the purposes of this study. Potential confounding variables including maternal sociodemographics, pregnancy intention, partner support, biomedical and mental illness, substance use and psychosocial risk were also assessed. Bivariate and multiple regression analyses were performed to determine the association between IPV during pregnancy and delivery of an infant with LBW and/or low weight-for-age z (WAZ) scores. The final study sample comprised 263 mother-infant dyads. In multiple regression analyses, the model run was significant [r2  = 0.14 (adjusted r2  = 0.11, F(8, 212) = 4.16, p = 0.0001]. Exposure to physical IPV occurring during the past year was found to be significantly associated with LBW [t = -2.04, p = 0.0429] when controlling for study site (clinic), maternal height, ethnicity, socioeconomic status, substance use and childhood trauma. A significant association with decreased WAZ scores was not demonstrated. Exposure of pregnant women to IPV may impact newborn health. Further research is needed in this field to assess the relevant underlying mechanisms, to inform public health policies and to develop appropriate trauma IPV interventions for LMIC settings.

Design of a quasi-experiment on the effectiveness and cost-effectiveness of using the child-interview intervention during the investigation following a report of child abuse and/or neglect

BACKGROUND

In the Netherlands, suspected cases of child maltreatment can be reported to an advice and reporting center on child abuse and neglect (Advies- en Meldpunt Kindermishandeling or AMK). AMKs investigate these reports, screen for problems in the family and its surroundings and refer to child welfare. Over the last decades the focus of AMK investigations has changed from an adult-only approach to a more child-oriented approach using a Child-Interview intervention. The effects and cost-effectiveness of AMK involvement in the Netherlands have never been studied. The primary aim of this study is therefore to examine the effect of the participation of maltreated children aged 6-18 years in the Child-Interview intervention on their mental health and quality of life. As a second aim, this study will examine the balance between additional costs and effects of the Child-Interview intervention in comparison with AMK investigation without the Child-Interview intervention (adult-only intervention).

DESIGN/METHODS

A quasi-experiment will be performed consisting of two post-intervention measurements of two nonequivalent groups: an intervention group, in which the Child-Interview intervention has been used during the AMK investigation, and a control group, in which the intervention has not been used (adult-only intervention). Participants from an ongoing prospective study on the mental health and quality of life of maltreated children after a report to an AMK, will be contacted to complete a questionnaire twice. Multivariate regression analyses will be used to determine effectiveness of the Child-Interview intervention. The economic evaluation will involve a cost-effectiveness analysis and a cost-utility analysis.

RESULTS/DISCUSSION

This will be the first study to examine the effect of AMK involvement in the Netherlands. Using the Child-Interview intervention during AMK investigation may prevent or reduce negative outcomes of child maltreatment, which may result in a lower consumption of healthcare and other services. In addition, the importance of economic evaluations is increasingly recognized, and economic evaluations about child maltreatment are scarce. Limitations include the risk of potential recall bias and selection bias.

TRIAL REGISTRATION

NTR3728, funded by ZonMw, project 15700.2012.

Current issues and future directions in evidence-based child protection practices: a view from Romania

The constantly changing nature of social care practice necessitates continuous development of educational programs to prepare current practitioners. Basing social work practice on methodologically sound research evidence is an appealing prospect for the child protection services. However, Romania, once considered an Eastern European model for child welfare policy and practice, is somehow lagging behind. In this article the author gives a short overview of where the Romanian Child Protection System currently stands in terms of evidence-based practice.

Health care costs associated with child maltreatment: impact on medicaid

OBJECTIVE

To estimate the increased Medicaid expenditures associated with child maltreatment.

METHODS

Data on child maltreatment were collected from the National Survey of Child and Adolescent Well-Being, a nationally representative sample of cases investigated or assessed by local Child Protective Services agencies between October 1999 and December 2000. Medicaid claims data for 2000 to 2003 were obtained from the Medicaid Analytic Extract (MAX). Children from the National Survey of Child and Adolescent Well-Being who had Medicaid were matched to the MAX data by Social Security number or birthdate, gender, and zip code. Propensity score matching was used to select a comparison group from the MAX data. Two-part regression models were used to estimate the impact of child maltreatment on expenditures. Data with individual identifiers were obtained under confidentiality agreements with the collecting agencies.

RESULTS

Children who were identified as maltreated or as being at risk of maltreatment incurred, on average, Medicaid expenditures that were >$2600 higher per year compared with children not so identified. This finding accounted for ~9% of all Medicaid expenditures for children.

CONCLUSIONS

Child maltreatment imposes a substantial financial burden on the Medicaid system. These expenses could be partially offset by increased investment in child maltreatment prevention.

The Good Schools Toolkit to prevent violence against children in Ugandan primary schools: study protocol for a cluster randomised controlled trial

BACKGROUND

We aim to evaluate the effectiveness of the Good School Toolkit, developed by Raising Voices, in preventing violence against children attending school and in improving child mental health and educational outcomes.

METHODS/DESIGN

We are conducting a two-arm cluster randomised controlled trial with parallel assignment in Luwero District, Uganda. We will also conduct a qualitative study, a process evaluation and an economic evaluation. A total of 42 schools, representative of Luwero District, Uganda, were allocated to receive the Toolkit plus implementation support, or were allocated to a wait-list control condition. Our main analysis will involve a cross-sectional comparison of the prevalence of past-week violence from school staff as reported by children in intervention and control primary schools at follow-up.At least 60 children per school and all school staff members will be interviewed at follow-up. Data collection involves a combination of mobile phone-based, interviewer-completed questionnaires and paper-and-pen educational tests. Survey instruments include the ISPCAN Child Abuse Screening Tools to assess experiences of violence; the Strengths and Difficulties Questionnaire to measure symptoms of common childhood mental disorders; and word recognition, reading comprehension, spelling, arithmetic and sustained attention tests adapted from an intervention trial in Kenya.

DISCUSSION

To our knowledge, this is the first study to rigorously investigate the effects of any intervention to prevent violence from school staff to children in primary school in a low-income setting. We hope the results will be informative across the African region and in other settings.

TRIAL REGISTRATION

clinicaltrials.gov NCT01678846.

An evaluation of the parents under pressure programme: a study protocol for an RCT into its clinical and cost effectiveness

BACKGROUND

Many babies in the UK are born to drug-dependent parents, and dependence on psychoactive drugs during the postnatal period is associated with high rates of child maltreatment, with around a quarter of these children being subject to a child protection plan. Parents who are dependent on psychoactive drugs are at risk of a wide range of parenting problems, and studies have found reduced sensitivity and responsiveness to both the infant's physical and emotional needs. The poor outcomes that are associated with such drug dependency appear to be linked to the multiple difficulties experienced by such parents.An increase in understanding about the crucial importance of early relationships for infant well-being has led to a focus on the development and delivery of services that are aimed at supporting parenting and parent-infant interactions. The Parents under Pressure (PuP) programme is aimed at supporting parents who are dependent on psychoactive drugs or alcohol by providing them with methods of managing their emotional regulation, and of supporting their new baby's development. An evaluation of the PuP programme in Australia with parents on methadone maintenance of children aged 3 to 8 years found significant reductions in child abuse potential, rigid parenting attitudes and child behaviour problems.

METHODS/DESIGN

The study comprises a multicentre randomised controlled trial using a mixed-methods approach to data collection and analysis in order to identify which families are most able to benefit from this intervention.The study is being conducted in six family centres across the UK, and targets primary caregivers of children less than 2.5 years of age who are substance dependent. Consenting participants are randomly allocated to either the 20-week PuP programme or to standard care.The primary outcome is child abuse potential, and secondary outcomes include substance use, parental mental health and emotional regulation, parenting stress, and infant/toddler socio-emotional adjustment scale.

DISCUSSION

This is one the first UK studies to examine the effectiveness of a programme targeting the parenting of substance-dependent parents of infants and toddlers, in terms of its effectiveness in improving the parent-infant relationship and reducing the potential for child abuse.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number Register: ISRCTN47282925.

Multi-exposure and clustering of adverse childhood experiences, socioeconomic differences and psychotropic medication in young adults

Purpose

Stressful childhood experiences have negative long-term health consequences. The present study examines the association between adverse childhood experiences, socioeconomic position, and risk of psychotropic medication in young adulthood.

Methods

This register-based cohort study comprises the birth cohorts between 1985 and 1988 in Sweden. We followed 362 663 individuals for use of psychotropic medication from January 2006 until December 2008. Adverse childhood experiences were severe criminality among parents, parental alcohol or drug abuse, social assistance recipiency, parental separation or single household, child welfare intervention before the age of 12, mentally ill or suicidal parents, familial death, and number of changes in place of residency. Estimates of risk of psychotropic medication were calculated as odds ratio (OR) with 95% confidence intervals (CIs) using logistic regression analysis.

Results

Adverse childhood experiences were associated with increased risks of psychotropic medication. The OR for more than three adverse childhood experiences and risk of psychotropic medication was for women 2.4 (95% CI 2.3–2.5) and for men 3.1 (95% CI 2.9–3.2). The risk of psychotropic medication increased with a higher rate of adverse childhood experiences, a relationship similar in all socioeconomic groups.

Conclusions

Accumulation of adverse childhood experiences increases the risk of psychotropic medication in young adults. Parental educational level is of less importance when adjusting for adverse childhood experiences. The higher risk for future mental health problems among children from lower socioeconomic groups, compared to peers from more advantaged backgrounds, seems to be linked to a higher rate of exposure to adverse childhood experiences.

Parental employment status and symptoms of children abused during a recession

Incidences and severity of child abuse have increased since the start of the recession. This study examined the relationship between employment status and severity of symptoms in children abused during a recession year. Participants included 154 females and 65 males between 2 and 17 years old referred to Dallas Children's Advocacy Center after surviving child sexual abuse, physical abuse, and/or neglect. We found that child abuse survivors whose mothers were unemployed showed higher symptom severity. Larger differences were found when participants were broken down by age, ethnicity, and living situation. Father's employment status did not affect symptom severity probably because many children lived with single mothers. We concluded that child abuse survivors whose mothers are unemployed have increased risk for psychological symptoms.

Primary prevention of pediatric abusive head trauma: a cost audit and cost-utility analysis

OBJECTIVES

To obtain comprehensive, reliable data on the direct cost of pediatric abusive head trauma in New Zealand, and to use this data to evaluate the possible cost-benefit of a national primary prevention program.

METHODS

A 5 year cohort of infants with abusive head trauma admitted to hospital in Auckland, New Zealand was reviewed. We determined the direct costs of hospital care (from hospital and Ministry of Health financial records), community rehabilitation (from the Accident Compensation Corporation), special education (from the Ministry of Education), investigation and child protection (from the Police and Child Protective Services), criminal trials (from the Police, prosecution and defence), punishment of offenders (from the Department of Corrections) and life-time care for moderate or severe disability (from the Accident Compensation Corporation). Analysis of the possible cost-utility of a national primary prevention program was undertaken, using the costs established in our cohort, recent New Zealand national data on the incidence of pediatric abusive head trauma, international data on quality of life after head trauma, and published international literature on prevention programs.

RESULTS

There were 52 cases of abusive head trauma in the sample. Hospital costs totaled $NZ2,433,340, child protection $NZ1,560,123, police investigation $NZ1,842,237, criminal trials $NZ3,214,020, punishment of offenders $NZ4,411,852 and community rehabilitation $NZ2,895,848. Projected education costs for disabled survivors were $NZ2,452,148, and the cost of projected lifetime care was $NZ33,624,297. Total costs were $NZ52,433,864, averaging $NZ1,008,344 per child. Cost-utility analysis resulted in a strongly positive economic argument for primary prevention, with expected case scenarios showing lowered net costs with improved health outcomes.

CONCLUSIONS

Pediatric abusive head trauma is very expensive, and on a conservative estimate the costs of acute hospitalization represent no more than 4% of lifetime direct costs. If shaken baby prevention programs are effective, there is likely to be a strong economic argument for their implementation. This study also provides robust data for future cost-benefit analysis in the field of abusive head trauma prevention.

The economic burden of child maltreatment in the United States and implications for prevention

OBJECTIVES

To present new estimates of the average lifetime costs per child maltreatment victim and aggregate lifetime costs for all new child maltreatment cases incurred in 2008 using an incidence-based approach.

METHODS

This study used the best available secondary data to develop cost per case estimates. For each cost category, the paper used attributable costs whenever possible. For those categories that attributable cost data were not available, costs were estimated as the product of incremental effect of child maltreatment on a specific outcome multiplied by the estimated cost associated with that outcome. The estimate of the aggregate lifetime cost of child maltreatment in 2008 was obtained by multiplying per-victim lifetime cost estimates by the estimated cases of new child maltreatment in 2008.

RESULTS

The estimated average lifetime cost per victim of nonfatal child maltreatment is $210,012 in 2010 dollars, including $32,648 in childhood health care costs; $10,530 in adult medical costs; $144,360 in productivity losses; $7,728 in child welfare costs; $6,747 in criminal justice costs; and $7,999 in special education costs. The estimated average lifetime cost per death is $1,272,900, including $14,100 in medical costs and $1,258,800 in productivity losses. The total lifetime economic burden resulting from new cases of fatal and nonfatal child maltreatment in the United States in 2008 is approximately $124 billion. In sensitivity analysis, the total burden is estimated to be as large as $585 billion.

CONCLUSIONS

Compared with other health problems, the burden of child maltreatment is substantial, indicating the importance of prevention efforts to address the high prevalence of child maltreatment.

The dollars and senselessness in failing to prioritize childhood maltreatment prevention

Childhood maltreatment captured medical attention almost 50 years ago. Reviews considering the evidence for published maltreatment prevention programming emerged about 20 years ago. In the second decade of the 21st century, evidence-based maltreatment prevention is a reality for at-risk groups; however, the research-to-practice and policy gap remains in most countries. This article considers the importance of personal financial health and how that is necessarily the building blocks of national health. It argues for the primacy of the goal of problem prevention-the prevention of childhood maltreatment. A twofold approach is suggested: (1) broad-scale adoption of evidence-based prevention and (2) and on-going commitment to refining the evidence base for effective, promising, and novel intervention.

Long-term consequences of child abuse and neglect on adult economic well-being

Child abuse and neglect represent major threats to child health and well-being; however, little is known about consequences for adult economic outcomes. Using a prospective cohort design, court substantiated cases of childhood physical and sexual abuse and neglect during 1967-1971 were matched with nonabused and nonneglected children and followed into adulthood (mean age 41). Outcome measures of economic status and productivity were assessed in 2003-2004 (N 1/4 807). Results indicate that adults with documented histories of childhood abuse and/or neglect have lower levels of education, employment, earnings, and fewer assets as adults, compared to matched control children. There is a 14% gap between individuals with histories of abuse/neglect and controls in the probability of employment in middle age, controlling for background characteristics. Maltreatment appears to affect men and women differently, with larger effects for women than men. These new findings demonstrate that abused and neglected children experience large and enduring economic consequences.

Total parenting

In this essay, Richard Smith observes that being a parent, like so much else in our late-modern world, is required to become ever more efficient and effective, and is increasingly monitored by the agencies of the state, often with good reason given the many recorded instances of child abuse and cruelty. However, Smith goes on to argue, this begins to cast being a parent as a matter of "parenting," a technological deployment of skills and techniques, with the loss of older, more spontaneous and intuitive relations between parents and children. Smith examines this phenomenon further through a discussion of how it is captured to some extent in Hannah Arendt's notion of "natality" and how it is illuminated by Charles Dickens in his classic novel, Dombey and Son.

Minors in name only: child laborers on the diamond mines of the "Companhia de Diamantes de Angola" (Diamang), 1917-1975

Although African men and women comprised the vast majority of the labor force on Angola's colonial-era diamond mines, child laborers, or "minors," also played important roles, primarily as mineworkers and plantation laborers. While these young male and female laborers' daily tasks were often lighter than those assigned to adult males, they often worked side-by-side with more senior workers and were equally subject to physical abuse, poor rations, and injuries. Similarly, minors also employed many of the same strategies as their more senior coworkers to better their lives. Their experiences suggest that these young laborers were minors in name only.

Socioeconomic correlates of rates of child maltreatment in small communities

This study expands the research on neighborhood effects and child maltreatment by examining the structural conditions, including religion and nationality, in small towns in Israel. The results are compared with those in inner-city and suburban neighborhoods in Western countries. Five community structural variables were statistically correlated with investigated cases of child maltreatment: adults' unemployment rate, rate of new immigrants, rate of children in single-parent families, population gain or loss, and the community's location in relation to a central city. A multivariate regression analysis of these variables explained 44% of the variance.