Exploring policies for the reduction of child physical abuse and neglect

Policies can be powerful tools for prevention given their potential to affect conditions that can improve population-level health. Given the dearth of empirical research on policies’ impacts on child maltreatment, this article (a) identifies 37 state policies that might have impacts on the social determinants of child maltreatment; (b) identifies available data sources documenting the implementation of 31 policies; and (c) utilizes the available data to explore effects of 11 policies (selected because they had little missing data) on child maltreatment rates. These include two policies aimed at reducing poverty, two temporary assistance to needy families policies, two policies aimed at increasing access to child care, three policies aimed at increasing access to high quality pre-K, and three policies aimed at increasing access to health care. Multi-level regression analyses between within-state trends of child maltreatment investigation rates and these 11 policies, controlling for states’ childhood poverty, adults without a high school diploma, unemployment, child burden, and race/ethnicity, identified two that were significantly associated with decreased child maltreatment rates: lack of waitlists to access subsidized child care and policies that facilitate continuity of child health care. These findings are correlational and are limited by the quality and availability of the data. Future research might focus on a reduced number of states that have good quality administrative data or population-based survey data on child maltreatment or reasonable proxies for child maltreatment and where data on the actual implementation of specific policies of interest can be documented.     

The potential use of social media and other internet-related data and communications for child maltreatment surveillance and epidemiological research: Scoping review and recommendations

Collecting child maltreatment data is a complicated undertaking for many reasons. As a result, there is an interest by child maltreatment researchers to develop methodologies that allow for the triangulation of data sources. To better understand how social media and internet-based technologies could contribute to these approaches, we conducted a scoping review to provide an overview of social media and internet-based methodologies for health research, to report results of evaluation and validation research on these methods, and to highlight studies with potential relevance to child maltreatment research and surveillance. Many approaches were identified in the broad health literature; however, there has been limited application of these approaches to child maltreatment. The most common use was recruiting participants or engaging existing participants using online methods. From the broad health literature, social media and internet-based approaches to surveillance and epidemiologic research appear promising. Many of the approaches are relatively low cost and easy to implement without extensive infrastructure, but there are also a range of limitations for each method. Several methods have a mixed record of validation and sources of error in estimation are not yet understood or predictable. In addition to the problems relevant to other health outcomes, child maltreatment researchers face additional challenges, including the complex ethical issues associated with both internet-based and child maltreatment research. If these issues are adequately addressed, social media and internet-based technologies may be a promising approach to reducing some of the limitations in existing child maltreatment data.     

The utility and challenges of using ICD codes in child maltreatment research: A review of existing literature

ObjectiveThe objectives of this article are to explore the extent to which the International Statistical Classification of Diseases and Related Health Problems (ICD) has been used in child abuse research, to describe how the ICD system has been applied, and to assess factors affecting the reliability of ICD coded data in child abuse research.MethodsPubMed, CINAHL, PsychInfo and Google Scholar were searched for peer reviewed articles written since 1989 that used ICD as the classification system to identify cases and research child abuse using health databases. Snowballing strategies were also employed by searching the bibliographies of retrieved references to identify relevant associated articles. The papers identified through the search were independently screened by two authors for inclusion, resulting in 47 studies selected for the review. Due to heterogeneity of studies meta-analysis was not performed.ResultsThis paper highlights both utility and limitations of ICD coded data. ICD codes have been widely used to conduct research into child maltreatment in health data systems. The codes appear to be used primarily to determine child maltreatment patterns within identified diagnoses or to identify child maltreatment cases for research.ConclusionsA significant impediment to the use of ICD codes in child maltreatment research is the under ascertainment of child maltreatment by using coded data alone. This is most clearly identified and, to some degree, quantified, in research where data linkage is used.Practice implicationsThe importance of improved child maltreatment identification will assist in identifying risk factors and creating programs that can prevent and treat child maltreatment and assist in meeting reporting obligations under the CRC.     

Child maltreatment among school children in the Kurdistan Province, Iran

OBJECTIVE: This study examines the determinants of three types of child maltreatment: physical maltreatment, mental maltreatment, and child neglect among school children in the Kurdistan Province of Iran. The analysis examines the impact of socioeconomic, familial, demographic, and household dynamic factors on the three child maltreatment outcomes, and compares the differential impact of these factors across the three types of child maltreatment. A greater understanding of the factors associated with child maltreatment has the potential to inform public health interventions aimed at reducing specific forms of maltreatment and at identifying at risk populations. METHODS: Data were collected from 1,370 school students, age 11-18. Separate logistic models are fitted for six binary outcomes examining self-reported experiences of physical maltreatment in the home or school, mental maltreatment in the home or school, and child neglect in the home or school. RESULTS: Male children were more likely to report experiencing any kind of child maltreatment than girls. Residency in a rural area, poor parental relationships and the use of addictive substances by household members were associated with increased odds of reporting child maltreatment. Poor school performance was associated with the reporting of experiencing maltreatment at school. CONCLUSION: Each of the forms of child maltreatment is highly correlated with socioeconomic, demographic, and living condition factors. The results point to the strong influence that familial factors have in shaping a child's likelihood of reporting maltreatment. Characteristics of the mother were associated with maltreatment, but not characteristics of the father. The results highlight a number of mechanisms through which public health interventions may seek to reduce the prevalence of child maltreatment in Kurdistan; different approaches are needed to reduce child maltreatment in the home and school environments.     

Providing medical evaluations for possible child maltreatment to children with special health care needs

OBJECTIVE: Children with special health care needs are known to be at increased risk of all forms of child maltreatment when compared to children without such needs. We describe a health care team's experience providing medical evaluations for suspected child maltreatment to children with special health care needs. METHOD: Consecutive cases seen as outpatients in the Abuse Referral Clinic for Children with Disabilities were abstracted and analyzed. Mail and telephone follow-up contact was attempted after the medical evaluation to determine adherence with treatment recommendations. A subsample of cases for which complete financial information was available was reviewed to determine a reimbursement rate. RESULTS: During the study, 49 children received complete outpatient evaluations. Ages ranged from 3 to 16 years old, and 54% were males. Special needs spanned a wide range of physical, developmental/cognitive and behavioral conditions. The largest number of referrals came from child protective services (42%) followed by referrals from physicians (27%). After the team's comprehensive evaluation, 18% of the children were found to have a history or physical examination that was diagnostic for child maltreatment, 13% were thought to be at high risk, 25% were thought to be at low risk and 44% were thought to have non-abusive etiologies. The collection rate was 14% for an average reimbursement of $38 per case. Only 29 caregivers could be found at follow-up and 22 remembered the recommendations made by the team. Of the 25 cases that were referred for outpatient mental health counseling, 12 (48%) complied. CONCLUSION: Children with a wide range of special health care needs were evaluated in an outpatient special health care needs clinic that offered comprehensive medical evaluations for possible child maltreatment. Medical evaluation services for this group of children were poorly reimbursed. Mental health services were frequently recommended but often not accessed. Child maltreatment teams seeking to serve children with special health care needs will need to plan for service delivery to a potentially diverse group of children and families who may experience difficulty in carrying through on the team's treatment recommendations.     

Programs for the promotion of family wellness and the prevention of child maltreatment: a meta-analytic review

OBJECTIVE: The objectives were to determine the effectiveness of programs in promoting family wellness and preventing child maltreatment and to identify factors that moderate program success. METHOD: Meta-analysis, employing a 3-step model testing procedure, was used to review 56 programs designed to promote family wellness and prevent child maltreatment. RESULTS: The effect sizes for proactive interventions were larger at follow-up than at post-assessment, while the effect sizes for reactive interventions were higher at post-assessment than follow-up. The lowest effect sizes for home visitation programs on child maltreatment were for programs with 12 or fewer visits and less than a 6-month duration. Intensive family preservation programs with high levels of participant involvement, an empowerment/strengths-based approach, and a component of social support had higher effect sizes than programs without those elements. Also, both home visitation and intensive family preservation interventions achieved higher effect sizes with participants of mixed socioeconomic status (SES) than participants with low SES. CONCLUSIONS: The total mean weighted effect size was .41, indicating that outcomes for the intervention group exceed 66% of those in control/comparison groups. The findings from this review demonstrated that child maltreatment can be prevented and that family wellness can be promoted.     

Survivors of institutional abuse in long-term child care in Scotland

BackgroundThe Scottish Child Abuse Inquiry (SCAI) commissioned the research project to document the outcomes of institutional abuse in long-term child care in Scotland.ObjectiveTo profile the experiences of survivors abused in long-term child care in Scotland, and to develop a model which linked maltreatment, risk and protective factors, and outcomes.Participants and Setting225 survivors of historical institutional abuse in Scotland, who made witness statements to SCAI.MethodsData were extracted from witness statements using a coding frame developed through a thematic analysis of a subsample of 52 statements.ResultsSurvivors had been in care in predominantly Catholic and non-religious residential institutions in Scotland for an average of 8 years, having entered at an average age of 6.8 years. They had suffered multiple forms of maltreatment. Maltreatment rates were: physical abuse, 95.6%; emotional abuse, 85.3%; sexual abuse, 60.4%; emotional neglect, 51.1%; and physical neglect, 37.3%. Across the lifespan survivors had negative outcomes in psychosocial adjustment (96%), mental health (84%), and physical health (43%). The effect of maltreatment in care on psychosocial problems was mediated by both risk and protective factors; and on mental health was mediated by risk factors, but not protective factors. Maltreatment in care had a direct effect on physical health which was not mediated by risk or protective factors. The effects of the cumulative number of risk factors on adverse mental health and psychosocial outcomes was greater than that of maltreatment, and protective factors had a limited impact on adverse outcomes.ConclusionsEvidence-based child protection policies and practices should be implemented to prevent institutional abuse and treat child abuse survivors in Scotland.     

The child protection and juvenile justice nexus in Australia: A longitudinal examination of the relationship between maltreatment and offending

There is convincing evidence that many young people who are in the justice system have had contact with child protection services and that victims of childhood maltreatment are at increased risk of subsequent youth justice involvement. In Australia, however, there have been few longitudinal studies that have examined these associations and relatively less is known in this area. This study examines the overlap between the child protection and youth justice involvement in South Australia, and determines how substantiated maltreatment and variations in these experiences (e.g., the type, timing and recurrence of maltreatment) relate to criminal convictions as a youth. The results show that although the majority of child-protection involved youth do not become convicted offenders, the odds of subsequent convictions are significantly greater both for those with notifications and substantiated maltreatment and for those who had been placed in out-of-home care. Multivariate analyses revealed that the strongest predictors for receiving a conviction among maltreated youth were: male gender, Aboriginal and Torres Strait Islander ethnicity, experiences of physical abuse and emotional abuse, a greater number of substantiations (recurrence), experiencing maltreatment that commenced in childhood and continued into adolescence, and placement in out-of-home care. The mechanisms through which maltreatment might be linked with behavior are then considered, along with directions for future research in this area.     

The relationship between cigarette taxes and child maltreatment

Prior research suggests that income and child maltreatment are related, but questions remain about the specific types of economic factors that affect the risk of maltreatment. The need to understand the role of economics in child welfare is critical, given the significant public health costs of child maltreatment. One factor that has been overlooked is regressive taxation. This study addresses this need by examining whether state-level changes in cigarette tax rates predict changes in state-level child maltreatment rates. The results of both a fixed effects (FE) and a fixed effects instrumental variables (FE-IV) estimator show that increases in state cigarette tax rates are followed by increases in child abuse and neglect. An additional test finds that increases in the sales tax (another tax deemed to be regressive) also predict increases in child maltreatment rates. Taken as a whole, the findings suggest that regressive taxes have a significant effect on the risk of child maltreatment.     

Impact of a statewide home visiting program to prevent child abuse

OBJECTIVES: To assess the impact of a voluntary, paraprofessional home visiting program in preventing child maltreatment and reducing the multiple, malleable psychosocial risks for maltreatment for which families had been targeted. METHODS: This collaborative, experimental study focused on 6 Healthy Families Alaska (HFAK) programs; 325 families were enrolled in 2000-2001, randomized to intervention and control groups, and interviewed to measure baseline attributes. Follow-up data were collected when children were 2 years old (85% follow-up rate). Outcomes included maltreatment reports, measures of potential maltreatment and parental risks, for example, poor mental health, substance use, and partner violence. HFAK records were reviewed to measure home visiting services. Home visitors were surveyed to measure perceived effectiveness and training adequacy. RESULTS: Parental risks were common at baseline, and one-sixth of families had a substantiated child protective services report in the child's first 2 years of life. There was no overall program effect on maltreatment reports, and most measures of potential maltreatment. Home visited mothers reported using mild forms of physical discipline less often than control mothers. The groups were similar in their use of more severe forms of physical discipline. There was no program impact on parental risks. There was no impact on outcomes for families with a 'high dose' of home visiting. Home visitors often failed to address parental risks and seldom linked families with community resources. Contradictions in the model compromised effectiveness. CONCLUSIONS: The program did not prevent child maltreatment, nor reduce the parental risks that had made families eligible for service. Research is needed to develop and test strategies to improve the effectiveness of home visiting.     

Child maltreatment as a function of cumulative family risk: Findings from the intensive family preservation program

This study examined child maltreatment as a function of cumulative family risk in a sample of at-risk families (N = 837) who were referred to an intensive family preservation program because of child behavior problems or suspected child abuse and neglect. The goal of this intensive family preservation program is to improve parenting skills and reduce immediate family stressors that may lead to an increased risk of child abuse and neglect. The findings indicate that the most prominent family risks comprising the cumulative risk scale in our sample were socio-economic disadvantage (e.g., income, unemployment, housing instability) and parental characteristics (e.g., mental/physical health, parental use of alcohol, domestic violence). Further, the results demonstrated a strong quadratic trend in the relationship between cumulative family risk and child maltreatment, and identified a risk threshold effect at three cumulative family risks after which the child risk for maltreatment increased exponentially. These findings are interpreted in the light of the current research on differentiative interventions, supporting differentiated services to the families with low vs. higher risk for child maltreatment.     

Involvement with child protective services: Is this a useful question in population-based surveys?

Direct questions on child maltreatment in population-based surveys are often limited by ethical and methodological issues. This restricts the ability of researchers to examine an important aspect of early adversity and its relationship to health and behavior. An alternative to excluding issues of maltreatment entirely in population-based surveys is to include questions on child and family involvement with child protective services (CPS). A school-based adolescent survey that included a question on child and family involvement with CPS yielded results that were generally consistent with other studies relating child maltreatment to health and behavioral outcomes such as psychological distress symptoms, delinquency, aspects of bullying, and health service utilization. Such findings suggest that questions on involvement with CPS may be a reasonable proxy for child maltreatment. Despite the lack of information on the reason for involvement or specific categories of maltreatment, CPS involvement questions highlight the shared familial experience that surrounds CPS involvement and serves as a general reflection of an adverse experience that can be utilized by researchers interested in early experiences.     

Environmental and individual attributes associated with child maltreatment resulting in hospitalization or death

Maltreatment continues to be a leading cause of death for young children. Researchers are beginning to uncover which neighborhood attributes may be associated with maltreatment outcomes. However, few studies have been able to explore these influences while controlling for individual family attributes, and none have been able to parse out the most severe outcomes—injuries resulting in hospitalization or death. This study utilizes a retrospective, case-control design on a dataset containing both individual and environmental level attributes of children who have been hospitalized or died due to maltreatment to explore the relative influence of attributes inside and outside the household walls. Binary conditional logistic regression was used to model the outcome as a function of the individual and environmental level predictors. Separate analyses also separated the outcome by manner of maltreatment: abuse or neglect. Finally, a sub-analysis included protective predictors representing access to supportive resources. Findings indicate that neighborhood attributes were similar for both cases and controls, except in the neglect only model, wherein impoverishment was associated with higher odds of serious maltreatment. Dense housing increased risk in all models except the neglect only model. In a sub-analysis, distance to Family Resource Centers was inversely related to serious maltreatment. In all models, variables representing more extreme intervention and/or removal of the victim and/or perpetrator from the home (foster care or criminal court involvement) were negatively associated with the risk of becoming a case. Medi-Cal insurance eligibility of a child was also negatively associated with becoming a case. Government interventions may be playing a critical role in child protection. More research is needed to ascertain how these interventions assert their influence.     

Social support and child maltreatment: a review of the evidence

Parents who maltreat their children have long been thought to lack support from informal and social networks. Recent writers have taken the position that this relationship is a proven, causal one, with social isolation seen as a necessary antecedent condition for the occurrence of child abuse. Concurrently, initial enthusiasm for social support as a powerful explanatory variable in other areas of psychological and health research is giving way to cautious reevaluation of the evidence. The present review was undertaken to bring into sharper focus what is now known regarding the relationship between child maltreatment and parental isolation from informal helping networks. Existing research is fraught with both conceptual and methodological problems. There is, at present, little research evidence that lack of social support plays a significant role in the etiology of physical abuse. Stronger evidence exists that neglectful parents are socially isolated, but the data are consistent with the hypothesis that this is one manifestation of the character problems of these parents. Future research must give closer attention to clearly defining social support and using reliable and valid instruments to measure it, while exploring multivariate models of child maltreatment.     

Does the gender of parent or child matter in child maltreatment in China?

Child maltreatment is a public health problem worldwide, and China is no exception. However, the pattern of child maltreatment remains unknown, including whether the gender of children and their parents has an impact on the occurrence of maltreatment. This study aims at examining the rates and frequency of child maltreatment, including physical abuse, psychological abuse and neglect perpetrated by mothers and fathers. We also test whether the interaction between parents’ gender and their child's gender affects the occurrence of child maltreatment in China. 997 children from the China Jintan Child Cohort Study participated in the present study and reported their maltreatment experience perpetrated by their mothers and fathers using the questionnaire, Parent–Child Conflict Tactics Scale (CTSPC_CA). Generalized linear model analyses show that boys were more likely than girls to report physical abuse, and, in particular, boys were more likely than girls to be physically abused by their fathers. On the other hand, mothers were more likely than fathers to exhibit psychological aggression and use corporal punishment for both boys and girls. There was no difference based on the child's or parent's gender in the occurrence of neglect. The findings present empirical evidence that enhances the understanding of the pattern of child maltreatment in China, provide implications for social workers and health professionals to identify children at risk of child maltreatment, and shed light on future research studies.     

Developmental effects of child abuse: recent findings

This paper summarizes the pre-1982 research findings on the developmental effects of child abuse and reviews recent contributions to this area. While some of the recent research continues to demonstrate deleterious developmental consequences of child maltreatment, others are pointing to a complex relationship between child maltreatment and development. Mediating variables such as the child's individual characteristics, environmental resources, and the quality of personal interactions the child is exposed to may interact with negative experiences like maltreatment and may be just as important in predicting outcome than maltreatment alone. Recent research has also been concerned with specifying the possible differential effects of different patterns of maltreatment. This has led to a clearer separation between the effects of abuse and neglect, particularly in language development. Despite the methodological improvements in recent research, there is still the need for longitudinal prospective studies on the developmental effects of child abuse, taking into account possible mediating variables.     

Child maltreatment related injuries: incidence, hospital charges, and correlates of hospitalization

OBJECTIVE: This study was undertaken to determine the incidence, hospital charges, and correlates associated with inpatient treatment of child maltreatment related injuries. METHODS: The data were based on the 1995 Pennsylvania Hospital Discharge Data which included all Pennsylvania acute care hospitals that reported child maltreatment discharges. Per capita hospital discharge rates were computed for children discharged with child maltreatment related injuries according to selected variables. Odds ratios for child maltreatment related injury hospitalizations were also computed. RESULTS: A total of 348 maltreated injured children ages 0-19 years were discharged from Pennsylvania hospitals in 1995, representing an incidence rate of 10.8 per 100,000 persons. The total hospital charges for child maltreatment related injury discharges amounted to over $5.4 million, of which Medicaid alone paid for 45%. Compared to a random sample of non-maltreated injured children (n = 1052), maltreated injured children were found to be significantly younger, more likely to be females, and more likely to be Black. Child maltreatment related injury hospitalizations were more likely to be urgent and via physician referral or transfer from other health care facility. Maltreated injured children were three times as likely to die as other children. CONCLUSIONS: These findings indicate that injury from child maltreatment is a major cause of hospitalization of young children 5 years and younger and represents a significant cost to publicly financed health care. While hospital discharge data can be used for population-based surveillance of child maltreatment related trauma, there is need for improvement in the surveillance of these injuries.     

Disentangling the effect of out-of-home care on child mental health

BackgroundChildren in out-of-home care are consistently found to have poor mental health compared to children in the general population. However, UK research has so far failed to disentangle the impact of the care system on children’s mental health outcomes from the effects of the adverse circumstances that led to their admission to care.ObjectiveThis research investigated the association between care placement and the presence of child mental health problems after controlling for children’s pre-care experiences. It also identified factors associated with mental health problems among children in care.Participants and SettingThe sample comprised three groups of children involved with child welfare services due to maltreatment, including children in out-of-home care (n = 122), reunified children (n = 82) and those who had never been in care (n = 159).MethodsThe mental health of the children in the three groups was compared, using information collected from their parents/foster carers and social workers.ResultsThe odds of a child in out-of-home care having a mental health problem were not significantly higher than those of a child who had never been in care (AOR = 1.24; p = 0.462). However, the odds of a child in out-of-home care having reactive attachment disorder (RAD) were significantly higher than those of a child who had never been in care (AOR=1.92; p = 0.032).ConclusionsThese findings make an important contribution to international debates about whether placing children in care is beneficial or detrimental to their wellbeing, and highlight a range of inter-linking factors associated with the mental health of children in out-of-home care.     

Predicting child maltreatment recurrences during treatment.

The primary purpose of the child protective services system is to protect children from the recurrence of child maltreatment. Understanding more about what predicts recurrence may help us more adequately target interventions to reduce the risk of future maltreatment. OBJECTIVE: The specific objective of this study was to identify correlates of 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 446 subject families who met study eligibility requirements from 1,181 families randomly selected from the 2,902 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 survival analysis methods: (1) Kaplan Meier and (2) the Cox Proportional Regression Model. RESULTS: Predictors of recurrence were child vulnerability, family stress, partner abuse, social support deficits, and an interaction between family stress and social support deficits. CONCLUSIONS: Implications of this and earlier research suggest that increasing social supports may help families cope with life events that increase stress and the risk of continued child maltreatment; that collaborations between CPS and domestic violence agencies are needed; and that screening maltreated children for mental health problems and other disabilities and assuring that children with these needs and their families get effective treatment may reduce the likelihood of continued maltreatment.     

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.