Correlates of problem recognition and intentions to change among caregivers of abused and neglected children

OBJECTIVE: To identify individual, family, and caseworker characteristics associated with problem recognition (PR) and intentions to change (ITC) in a sample of caregivers who received in-home child welfare services following substantiated reports of child abuse or neglect. METHODS: Caregivers were interviewed at 4 weeks, 16 weeks, and 1 year after referral for in-home services. In these interviews, the University of Rhode Island Change Assessment scale assessed PR and ITC in relation to caregiving practices. Additional data were obtained from administrative records and surveys of in-home services caseworkers. We used growth models to identify caregiver, family, and caseworker characteristics associated with initial levels of PR and ITC, and with changes in PR and ITC over time. RESULTS: Contrary to expectations, there were no overall increases in PR and ITC during the first 4 months of in-home services. PR and ITC scores fluctuated over time, in relation to some external events, case characteristics, and caseworker characteristics; however, we were able to account for small portions of the variance in PR and ITC. Controlling for social desirability bias and other variables in the analysis, negative life events, lack of network support, and the severity of caregiver depression were associated with greater PR; housing problems were associated with lower PR. Caregiver depression and age were associated with ITC. Caregivers whose children had been removed from their homes showed significant increases in ITC in the first few months of in-home services. The duration of caseworkers' child welfare experience predicted increases in their clients' PR in the first 4 months and more frequent contacts with an experienced caseworker predicted small, but significant increases in ITC over time. CONCLUSIONS: PR and ITC are associated with somewhat different case characteristics and may be affected by caseworkers' experience.     

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

OBJECTIVE: This study uses administrative data to track the first re-reports of maltreatment in a low-income, urban child welfare population (n=4957) while controlling for other public service involvement. Service system involvement is explored across the following sectors: Child Welfare, Income Maintenance, Special Education, Juvenile Court, and various forms of Medicaid-reimbursed medical or mental health care. This study builds knowledge by adding the services dimension to an ecological framework for analyses and by following recurrence for a longer period of time than prior investigations (7.5 years). METHOD: We model the re-reporting of a child for maltreatment as a function of child, caregiver, service, and neighborhood characteristics using data from birth records, child welfare, income maintenance, Medicaid, adult corrections, juvenile court, special education, law enforcement, and census sources. Bivariate and multivariate analyses are presented, the latter using Cox regression with a robust sandwich covariance matrix estimate to account for the intracluster dependence within tracts. RESULTS: Key results across bivariate and multivariate analyses included a lower rate of re-reporting among children with parents who were high school graduates and/or permanently exited from the first spell on AFDC (p<.0001); and for children in families that received less intensive in-home services compared to those not receiving services, receiving intensive in-home, or foster care services (p<.0001). Higher rates of re-reporting were found for children with Medicaid mental health/substance abuse treatment records (p<.0001) and special education eligibility for emotional disturbance (p<.005). CONCLUSIONS: Caretaker characteristics and non-child welfare service use patterns had a strong association with the likelihood of a child being re-reported to the child welfare agency and should be more heavily attended to by child welfare workers. High rates of service sector overlap suggest that interagency ties and cooperation should be strengthened. The lower risk associated with less intensive in-home services compared to un-served cases may indicate under-identification of in-home service eligibility following a first report of maltreatment.     

Intimate partner violence among female caregivers of children reported for child maltreatment

OBJECTIVE: The purpose of this study was to determine the prevalence and correlates of intimate partner violence among female caregivers of children reported to child protective services. METHOD: Data were derived from the National Survey of Child and Adolescent Well-Being, a national probability study of children investigated for child abuse and neglect in the United States. Caregivers were interviewed about demographic characteristics, mental health, substance use, and physical violence by a partner. RESULTS: The lifetime and past year prevalence of intimate partner violence was 44.8 and 29.0%, respectively. Caregiver major depression and history of prior reports of child maltreatment were strongly associated with violence against women. CONCLUSIONS: The findings highlight the need for effective screening and identification of intimate partner violence in families in which child maltreatment has occurred.     

Child maltreatment rates assessed in a national household survey of caregivers and youth

This paper reports on national estimates for past year child maltreatment from a national household survey conducted in 2011. It also discusses the validity of such estimates in light of other available epidemiology. The Second National Survey of Children Exposed to Violence obtained rates based on 4,503 children and youth from interviews with caregivers about the children ages 0–9 and with the youth themselves for ages 10–17. The past year rates for physical abuse by caregivers were 4.0% for all sample children, emotional abuse by caregivers 5.6%, sexual abuse by caregivers 0.1%, sexual abuse by caregivers and non-caregivers 2.2%, neglect 4.7% and custodial interference 1.2%. Overall, 12.1% of the sample experienced at least one of these forms of maltreatment. Twenty-three percent of the maltreated children or 2.8% of the full sample experienced 2 or more forms of maltreatment. Some authority (teacher, police, medical personnel or counselor) was aware of considerable portions of most maltreatment, which suggests the potential for intervention. Many of the study's estimates were reasonable in light of other child maltreatment epidemiological studies, but comparisons about emotional abuse and neglect were problematic because of ambiguity about definitions.     

Factors associated with mental health services referrals for children investigated by child welfare

Although child welfare caseworkers are responsible for facilitating mental health services access for maltreated children, little is known about caseworkers’ decisions to refer children to services. We aimed to identify factors associated with caseworker referral of children to mental health services after a maltreatment investigation. We analyzed data from 1956 children 2–17 years old from the Second National Survey of Child and Adolescent Well-being. We examined associations of children’s predisposing, enabling, and need-related factors and caseworkers’ work environment characteristics with referral to mental health services. Caseworkers referred 21.0% of children to mental health services. In multivariable analyses controlling for potential covariates, factors associated with increased odds of caseworker referral included: older child age; child sexual abuse (versus neglect); child out-of-home placement; caregiver mental health problems; prior maltreatment reports; clinically significant child behavioral problems; and child welfare agency collaborative ties with mental health providers (all p < .05). Factors associated with decreased odds of caseworker referral included child Black race (versus White race) and lack of insurance (versus Private insurance) (all p < .05). In summary, children’s need for mental health services was positively associated with caseworker referral to services but certain predisposing and enabling factors and caseworker work environment characteristics also correlated with services referral. Interventions to reduce disparities in services referral by race and insurance type are critically needed. These may include child welfare agency implementation of policies for mental health screening, assessment, and services referral based on clinical need and establishment of child welfare-mental health agency collaborative ties.     

Families in need of domestic violence services reported to the child welfare system: Changes in the National Survey of Child and Adolescent Well-Being between 1999–2000 and 2008–2009

This study aimed to determine if identification of intimate partner violence (IPV) has improved by caseworkers that investigate reports of child maltreatment and if mothers who are victims of IPV are more likely to report receipt of services. The study data were drawn from the two cohorts of the National Survey of Child and Adolescent Well-Being (NSCAW I and II), the first in 1999–2000 with a sample of 5,501 children reported for maltreatment and the second in 2008–2009 with a sample of 5,872 children reported for maltreatment. The analyses focused on IPV victimization of 3,625 mothers in NSCAW I and 3,351 mothers in NSCAW II whose children remained in home after the maltreatment investigation. Multiple group logistic regression was used to compare NSCAW I and II. A significant decrease in mother-reported IPV victimization (28.9–24.7%) was observed, representing a 15% decline. There were no significant changes in caseworker identification of history of domestic violence or active domestic violence. In both cohorts, substance abuse by the secondary caregiver was associated with a lower likelihood for the caseworker to miss a history of active domestic violence, while substantiation reduced the likelihood that the caseworker will miss active domestic violence. There were no changes in caseworkers’ service referral, or service receipt among victims. The next decade of efforts to reduce IPV and child maltreatment should focus simultaneously on increasing caseworkers’ ability to identify IPV and on funding needed services for families impacted by IPV and child maltreatment.     

The assessment of the readiness of five countries to implement child maltreatment prevention programs on a large scale

This study aimed to systematically assess the readiness of five countries – Brazil, the Former Yugoslav Republic of Macedonia, Malaysia, Saudi Arabia, and South Africa – to implement evidence-based child maltreatment prevention programs on a large scale. To this end, it applied a recently developed method called Readiness Assessment for the Prevention of Child Maltreatment based on two parallel 100-item instruments. The first measures the knowledge, attitudes, and beliefs concerning child maltreatment prevention of key informants; the second, completed by child maltreatment prevention experts using all available data in the country, produces a more objective assessment readiness. The instruments cover all of the main aspects of readiness including, for instance, availability of scientific data on the problem, legislation and policies, will to address the problem, and material resources. Key informant scores ranged from 31.2 (Brazil) to 45.8/100 (the Former Yugoslav Republic of Macedonia) and expert scores, from 35.2 (Brazil) to 56/100 (Malaysia). Major gaps identified in almost all countries included a lack of professionals with the skills, knowledge, and expertise to implement evidence-based child maltreatment programs and of institutions to train them; inadequate funding, infrastructure, and equipment; extreme rarity of outcome evaluations of prevention programs; and lack of national prevalence surveys of child maltreatment. In sum, the five countries are in a low to moderate state of readiness to implement evidence-based child maltreatment prevention programs on a large scale. Such an assessment of readiness – the first of its kind – allows gaps to be identified and then addressed to increase the likelihood of program success.     

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

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

Multidimensional model to assess the readiness of Saudi Arabia to implement evidence based child maltreatment prevention programs at a large scale

There has been increased awareness of child maltreatment in Saudi Arabia recently. This study assessed the readiness for implementing large-scale evidence-based child maltreatment prevention programs in Saudi Arabia. Key informants, who were key decision makers and senior managers in the field of child maltreatment, were invited to participate in the study. A multidimensional tool, developed by WHO and collaborators from several middle and low income countries, was used to assess 10 dimensions of readiness. A group of experts also gave an objective assessment of the 10 dimensions and key informants’ and experts’ scores were compared. On a scale of 100, the key informants gave a readiness score of 43% for Saudi Arabia to implement large-scale, evidence-based CM prevention programs, and experts gave an overall readiness score of 40%. Both the key informants and experts agreed that 4 of the dimensions (attitudes toward child maltreatment prevention, institutional links and resources, material resources, and human and technical resources) had low readiness scores (<5) each and three dimensions (knowledge of child maltreatment prevention, scientific data on child maltreatment prevention, and will to address child maltreatment problem) had high readiness scores (≥5) each. There was significant disagreement between key informants and experts on the remaining 3 dimensions. Overall, Saudi Arabia has a moderate/fair readiness to implement large-scale child maltreatment prevention programs. Capacity building; strengthening of material resources; and improving institutional links, collaborations, and attitudes toward the child maltreatment problem are required to improve the country's readiness to implement such programs.     

Unintended pregnancy as a predictor of child maltreatment

Whereas child maltreatment research has developed considerable evidence on post-natal risk-factors, pre-natal circumstances have been largely overlooked. The circumstances surrounding a pregnancy may considerably impact the environment in which later parenting behaviors occur. This study examines one of the earliest potentially identifiable risk-factors for child maltreatment: the intentions of a pregnancy. Utilizing both mother and father reports, this study focuses on maltreatment risk, as it relates with both parents’ perspectives of the pregnancy's intention. Drawing upon data from the Fragile Families and Child Well Being study, a longitudinal, birth cohort study, survey questions were used that asked parents, at the time of the birth, whether they considered abortion for the child. Unintended pregnancy demonstrates predictive value as one of the earliest identifiable risk-factors for child maltreatment. Regardless of whether the mother or father reported the unintended pregnancy, the relationship with maltreating behavior is largely the same, although for different maltreatment types. Mothers’ reports of unintended pregnancy are associated with psychological aggression, and neglect. Fathers’ reports of unintended pregnancy are associated with physical aggression. Fathers’ perspectives regarding pregnancy intentions matter just as much as mothers,’ and accounting for their perspectives could be important in understanding the maltreating behaviors of both parents. Identifiable in the earliest stages of caregiving, unintended pregnancy may be an important risk-factor in predicting and understanding child maltreatment.     

Pediatricians' knowledge, attitudes and experience regarding child maltreatment in Kuwait

OBJECTIVES: This cross-sectional survey was conducted to evaluate the awareness and actual professional experience of pediatricians in Kuwait regarding child maltreatment, a topic rarely explored in this part of the world. METHODS: Data were obtained from all pediatricians in public hospitals with pediatric emergency services using a structured detailed self-completed questionnaire. RESULTS: The experience of child neglect was more common than that of child abuse in the clinical practice of surveyed pediatricians. Fifty percent of 117 pediatricians (69% of all eligible) reported having encountered at least 1 case of abuse and up to 3 cases of neglect in the past year. Women and younger doctors more commonly recognized hypothetical situations as maltreatment, and believed child abuse and neglect as being common or very common in Kuwait. Other demographic or professional variables did not affect recognition of maltreatment. Participants would most likely alert social workers about suspected maltreatment cases. More than 80% did not know whether there is a legal obligation to report or which legal authorities should receive reports of suspected cases. DISCUSSION AND CONCLUSIONS: National ethical guidelines regarding reporting suspected cases of maltreatment must be established. Laws protecting maltreated children and reporting physicians must be immediately enacted. Additional training is required to help pediatricians, especially expatriates from other cultures, to diagnose with certainty cases of child maltreatment in their practice in Kuwait.     

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.     

Why are suspected cases of child maltreatment referred by educators so often unsubstantiated?

School professionals have a unique vantage point for identifying child maltreatment and they are a frequent source of referral to child protective services. Disturbingly, past studies have found that maltreatment concerns reported by educators go unsubstantiated by child protective services at much higher rates than suspected maltreatment reported by other professionals. This study explores whether there are systematic differences in the characteristics of cases reported by educators as compared to other professionals and examines whether such variation might account for differences in investigation outcome. Analyses were based on 7,725 cases of suspected maltreatment referred by professionals to child protective services from the Canadian Incidence Study of Reported Child Abuse and Neglect – 2003 a national database on the characteristics of children and families investigated by child protective services. School professionals were responsible for 35.8% of professional referrals. Reports by educators were much more likely to be unsubstantiated (45.3%) than those by other professionals (28.4%) in subsequent child protective investigation. Cases reported by educators were found to contain significantly more child risk factors (e.g., child emotional and behavioural problems) and fewer caregiver and family risk factors (e.g., caregiver mental health problem, single parent family) than cases reported by other professionals. Even controlling for these differences, educator-reported concerns were still 1.84, 95% CI [1.41, 2.40] times as likely to be unsubstantiated as reports from other professionals. Contrary to the notion that educators are mostly reporting non-severe cases, suspected/substantiated cases reported by school professionals were more likely to be judged as chronic and more likely to involve families with a previous child protection history. Results are concerning for the capacity of the education and child protection systems to work together to meet their shared goal of promoting healthy child development. Additional research is needed on the way in which child risks and problems influence child protective service, particularly in the context of chronic abuse and neglect and lack of availability of child and family mental health interventions. Potential problems with credibility of school professionals as reporters of child maltreatment concerns also warrant further investigation.     

Exposure to domestic violence as abuse and neglect: Constructions of child maltreatment in daily practice

Research finds that exposure to domestic violence can adversely affect the emotional, behavioral, and physical health of children. These effects have led some child advocates and policymakers in the United States to conclude that child exposure to domestic violence (CEDV) is a type of child maltreatment warranting state intervention. However, few states have defined CEDV as a type of maltreatment in statute and little is known about how child welfare agencies respond to allegations of CEDV in the absence of other safety threats. This study considers that CEDV itself might prompt an initial child welfare referral and may be construed by workers as a type of statutory maltreatment. Using a random sample (n = 295) of case records, this study analyzed one large child welfare agency’s response to referrals alleging CEDV between 2011 and 2012. Findings indicate that CEDV itself did trigger investigation. At time of referral, workers used statutory maltreatment typologies to construe alleged CEDV as a type of maltreatment; however, CEDV was not consistently construed as a safety threat and few allegations were substantiated. Instead most families were referred to community-based domestic violence services. Findings indicate that CEDV was not consistently construed as a type of statutory maltreatment and infrequently resulted in ongoing child welfare services. Findings suggest that training is needed to help workers better assess CEDV-related safety threats. Findings also raise questions about what types of interventions are needed to protect children from domestic violence and which types of agencies are best positioned to deliver those interventions.     

Cumulative stress and substantiated maltreatment: the importance of caregiver vulnerability and adult partner violence

OBJECTIVE: Our goal is to assess the effect of caregiver vulnerabilities, singly and in combination, on the substantiation of child abuse (physical, sexual) and neglect, while controlling for relevant background variables. We test the moderator role of adult partner violence in qualifying the relationship between caregiver vulnerabilities and maltreatment substantiation. METHOD: Secondary analyses of the 1998 Canadian Incidence Study of Reported Child Maltreatment (CIS) are used to predict child protective service investigation substantiation versus non-substantiation from a range of caregiver vulnerability factors. Involvement in partner violence was examined as a moderator in the relation between caregiver vulnerabilities and maltreatment substantiation. The CIS is an epidemiological survey of first-reported cases to child protective services, using a random sample of child welfare agencies across Canada. Child welfare workers completed a research form on the child, primary caregiver, family, perpetrator, severity and type of maltreatment, as well as services and court outcomes. All maltreatment classifications were assigned according to the Canadian legal definition of child abuse and neglect. Hierarchical logistic regression analyses were used, with stepped entry of: (1) demographic factors, socioeconomic disadvantage, and caregiver's own history of maltreatment; (2) caregiver vulnerability factors; (3) involvement in partner violence; (4) the interaction between caregiver vulnerability and partner violence. RESULTS: Caregiver substance abuse was found to be the single most potent kind of caregiver vulnerability in predicting maltreatment substantiation. When the total number of vulnerabilities was used as the predictor, prediction across all types of maltreatment increased, especially for substantiated neglect. Analyses also showed that the presence of partner violence in the home exacerbated the effect of caregiver vulnerability on substantiation. CONCLUSIONS: The total number of caregiver vulnerabilities was the best predictor of the substantiation of child abuse and neglect. This relationship was moderated by the existence of partner violence: high caregiver vulnerability and high partner violence increased the likelihood of substantiation versus non-substantiation. These results suggest that caregiver issues should be considered in tandem with partner relationships. Among child welfare cases, caregiver vulnerability and partner violence are critical targets for child maltreatment prevention and early child protective services intervention.     

The effect of services on the recurrence of child maltreatment

OBJECTIVE: Building on a previous model of recurrence, this study examined the relationship of services on the hazard of child maltreatment recurrence during CPS intervention for families who were provided continuing intervention following a confirmed index report of physical abuse or neglect. METHOD: This nonconcurrent prospective study selected 434 subject families who met study eligibility requirements from 1181 families randomly selected from the 2902 families who had experienced a substantiated report of child abuse or neglect during the sampling year. Data were collected and coded from archival sources for 5 years following the index report. Each record was coded by two research analysts to increase inter-rater reliability. Data were analyzed with the Cox Proportional Regression Model. RESULTS: Case characteristics that predicted recurrence were: child vulnerability, family stress, partner abuse, and social support deficits. After examining the potential effect of nine service-related variables only attendance at services predicted recurrence while controlling for other variables in the model. Families who were noted to attend the services identified in their service plans were 33% less likely to experience a recurrence of child maltreatment while their case was active with CPS. CONCLUSIONS: Implications of this and other research suggests that actively engaging families in a helping alliance and helping them accept and receive services may reduce the likelihood of future maltreatment.     

Comparing policies for children of parents attending hospital emergency departments after intimate partner violence,substance abuse or suicide attempt

To improve identification of child maltreatment, a new policy (‘Hague protocol’) was implemented in hospitals in The Netherlands, stating that adults attending the hospital emergency department after intimate partner violence, substance abuse or a suicide attempt should be asked whether they care for children. If so, these children are referred to the Reporting Center for Child Abuse and Neglect (RCCAN), for assessment and referrals to support services. An adapted, hospital-based version of this protocol (‘Amsterdam protocol’) was implemented in another region. Children are identified in the same manner, but, instead of a RCCAN referral, they are referred to the pediatric outpatient department for an assessment, including a physical examination, and referrals to services. We compared results of both protocols to assess how differences between the protocols affect the outcomes on implementation, detection of child maltreatment and referrals to services. Furthermore, we assessed social validity and results of a screening physical examination. We included 212 families from the Amsterdam protocol (cohort study with reports by pediatric staff and parents) and 565 families from the Hague protocol (study of RCCAN records and telephone interviews with parents). We found that the RCCAN identified more maltreatment than pediatric staff (98% versus at least 51%), but referrals to services were similar (82% versus 80% of the total sample) and parents were positive about both interventions. Physical examination revealed signs of maltreatment in 5%. We conclude that, despite the differences, both procedures can serve as suitable methods to identify and refer children at risk for maltreatment.     

Child maltreatment prevalence and mental disorders outcomes among American Indian women in primary care

OBJECTIVE: To examine (1) the prevalence, types, and severity of child abuse and neglect (CAN) and (2) the relationship between CAN and lifetime psychiatric disorders among American Indian women using primary care services. METHODS: A cross-sectional study was conducted among 234 American Indian women, age 18-45 who presented for outpatient ambulatory services at a community-based Indian Health Service Hospital in Albuquerque, New Mexico. Dependent measures included mood, substance abuse, and anxiety disorders as well as posttraumatic stress disorder (PTSD) as measured by the Composite International Diagnostic Interview. CAN was assessed using the Childhood Trauma Questionnaire. RESULTS: Approximately three-quarters of respondents (76.5%; 95% CI = 70.4, 81.7) reported some type of childhood abuse or neglect; over 40% reported exposure to severe maltreatment. Severity of child maltreatment was associated in a dose response manner with lifetime diagnosis of mental disorders. After adjusting for social and demographic correlates, severe child maltreatment was strongly associated with lifetime PTSD (prevalence ratio [PR] 3.9; 95% CI = 1.9, 8.0); and was moderately associated with lifetime substance use disorders (PR = 2.3; 95% CI = 1.6, 3.3); mood disorders (PR = 2.1; 95% CI 1.4, 3.2); and with two or more disorders (PR = 2.3; 95% CI = 1.6, 3.4). CONCLUSION: CAN was common in our sample of American Indian women in primary care and was positively associated with lifetime psychiatric disorders outcomes. Screening for CAN and psychiatric disorders would enhance the treatment of patients seeking primary care services. Primary prevention of child maltreatment might reduce the high prevalence of mental disorders among American Indian women.