Using time-to-event analysis to identify preconception and prenatal predictors of child protective services contact

We examined preconception and prenatal predictors of time to first child protective services (CPS) contact among Alaska children. Data were from the Alaska Longitudinal Child Abuse and Neglect Linkage (ALCANLink) project, a population-representative data source linking 2009–2011 Alaska Pregnancy Risk Assessment Monitoring System (PRAMS) data with administrative data sources through 2015. We examined the incidence CPS contact using the Kaplan-Meier method and predictors of CPS contact using Cox proportional hazards regression. Using data from the Alaska Permanent Fund Dividend and Child Death Review, we censored children who emigrated out-of-state or died during the study period. Significant predictors included low socioeconomic status (HR = 2.23, 95% CI 1.68, 2.96), maternal smoking during pregnancy (HR = 1.87, 95% CI 1.55, 2.24), unmarried maternal marital status (HR = 1.62, 95% CI 1.31, 1.99), urban residence (HR = 1.59, 95% CI 1.32, 1.92), lower maternal education (HR = 1.54, 95% CI 1.24, 1.92), maternal experience of intimate partner violence in the 12 months before childbirth(HR = 1.32, 95% CI 1.01, 1.74), Alaska Native/American Indian race (HR = 1.40, 95% CI 1.15, 1.71), a greater number of living children (HR = 1.20, 95% CI 1.13, 1.29), a greater number of stressful life eventsin the 12 months before childbirth (HR = 1.16, 95% CI 1.11, 1.21), and younger maternal age at childbirth (HR = 0.95, 95% CI 0.93, 0.97). Use of multiple linked data sources and time-to-event analysis methods adds to the growing literature regarding predictors of CPS contact. Results suggest that assessing for and addressing clinical, social, and environmental indicators during the prenatal period may aid prevention efforts in mitigating family need for involvement with CPS.     

Patterns of Risk and Protective Factors Among Alaska Children: Association With Maternal and Child Well-Being

This study used population-representative data to examine associations of risk and protective factor patterns among Alaska Native/American Indian (AN/AI; N = 592) and non-Native (N = 1,018) children with maternal and child outcomes at age 3 years. Among AN/AI children, a high risk/moderate protection class was associated with child developmental risk and mothers being less likely to feel comfortable asking for help or knowing where to go for parenting information compared to a low socioeconomic status/high protection class. Among non-Native children, a moderate risk/high protection class was associated with child developmental risk and mothers being less likely to feel comfortable asking for help compared to a low risk/high protection class. Results provide insight on the intersection of risk and protective factors among Alaska families.     

An examination of child protective service involvement among children born to mothers in foster care

ObjectiveThis study identified children born to mothers in foster care and documented Child Protective Service (CPS) involvement among children.MethodsProbabilistically linked birth and CPS records from California (2009–2012) were used to identify all mothers in foster care on or after conception. Children were followed prospectively using linked records to identify CPS involvement occurring during the first three years of life. Differences between reported and unreported children were examined using χ2 tests. The Latent Class Analysis (LCA) identified classes of children born to mothers in care who were at increased risk of CPS involvement. Model fit was assessed using the Bayesian Information Criterion, entropy, and likelihood ratio tests. For each of the classes, the relationship to the distal outcome (i.e., a maltreatment report by age three), was examined.ResultsFindings indicate that 53% of children born to mothers in care were reported. The proportion of children reported to CPS for maltreatment declined over time, from 63% of children born to mothers in foster care in 2009, to 46% in 2012. The LCA documented three distinct classes of mother-child dyads with varying risk of report. More than one third of children in Class 1 and nearly 70% of children in Class 3 were reported.ConclusionsThis study was the first to develop multi-dimensional class profiles of two-generation CPS involvement among mother-child dyads. This study documents that mothers’ experiences in care and mental health conditions vary widely, underscoring the importance of providing services that fit the needs of dyads.     

Neighborhood inequality in the prevalence of reported and substantiated child maltreatment

BackgroundPrior research documents spatial concentration in the incidence of child maltreatment reported to and confirmed by Child Protective Services (CPS), but without estimates of the prevalence of such reports, the extent of CPS contact in different communities is unknown.ObjectiveTo estimate the prevalence of CPS reports during early childhood and substantiated investigations during childhood for children living in different types of neighborhoods.Participants and settingChildren who experienced CPS reports and substantiated investigations in Connecticut.MethodsThis study uses synthetic cohort life tables to estimate the cumulative risk of CPS reports before age five and substantiated CPS investigations before age 18, by neighborhood poverty rate and neighborhood racial composition.ResultsThe analysis reveals substantial stratification in the prevalence of CPS contact by the demographic characteristics of children’s residential neighborhoods. For example, while 7% of children in low-poverty neighborhoods (under 10% poor) experience a substantiated CPS investigation at some point during childhood at 2014 and 2015 rates, this risk more than doubles to 17% for their peers in moderate-poverty neighborhoods (10–20% poor) and more than triples to 26% for their peers in high-poverty neighborhoods (over 20% poor). Similar trends emerge when examining CPS reports in early childhood as well as when comparing neighborhoods with different proportions of White residents.ConclusionsCPS reports and substantiated investigations are a widespread and disproportionately experienced life event for children in poor neighborhoods and children in non-White neighborhoods.     

Risk of re-report: A latent class analysis of infants reported for maltreatment

A key challenge facing child protective services (CPS) is identifying children who are at greatest risk of future maltreatment. This analysis examined a cohort of children with a first report to CPS during infancy, a vulnerable population at high risk of future CPS reports. Birth records of all infants born in California in 2006 were linked to CPS records; 23,871 infants remaining in the home following an initial report were followed for 5 years to determine if another maltreatment report occurred. Latent class analysis (LCA) was used to identify subpopulations of infants based on varying risks of re-report. LCA model fit was examined using the Bayesian information criterion, a likelihood ratio test, and entropy. Statistical indicators and interpretability suggested the four-class model best fit the data. A second LCA included infant re-report as a distal outcome to examine the association between class membership and the likelihood of re-report. In Class 1 and Class 2 (lowest risk), the probability of a re-report was 44%; in contrast, the probability in Class 4 (highest risk) was 78%. Two birth characteristics clustered in the medium- and highest-risk classes: lack of established paternity and delayed or absent prenatal care. Two risk factors from the initial report of maltreatment emerged as predictors of re-report in the highest-risk class: an initial allegation of neglect and a family history of CPS involvement involving older siblings. Findings suggest that statistical techniques can be used to identify families with a heightened risk of experiencing later CPS contact.     

Lifetime risk of child protection system involvement in South Australia for Aboriginal and non-Aboriginal children, 1986–2017 using linked administrative data

BackgroundChild protection services exist to reduce potential harms from child maltreatment. Many jurisdictions produce annual data on child protection system (CPS) involvement, leaving a gap in knowledge of lifetime involvement.ObjectiveTo describe lifetime involvement in CPS, by type of contact.ParticipantsAll 608,547 children born in South Australia (SA), Australia between 1986 and 2017.MethodsA retrospective cohort design using linked administrative data to report cumulative incidence of CPS involvement from birth to age <18 (or June30 2017) by Aboriginal status. CPS involvement was categorised into notifications (3 levels), investigations, substantiations and out-of-home care (OOHC). Cumulative incidence curves were derived for 5 birth cohorts.ResultsAcross childhood (to age <18 years), substantiated maltreatment was experienced by 3.2–3.6% of non-Aboriginal and 19–25% of Aboriginal children, 7 times reported annual substantiation rates. For most CPS categories CPS involvement increased until 2010, and was occurring earlier in life. By age 3, 0.5% of non-Aboriginal and 4.5% of Aboriginal children born 1986–1991 were the subject of a substantiation compared with 1.9% and 15% of non-Aboriginal and Aboriginal children, respectively, born 2010–2017. Incidence rates beyond age 3 were similar. OOHC contact was similar across cohorts, with ˜1.5% of non-Aboriginal and 12.7% of Aboriginal children ever-placed in care.ConclusionsData linkage is an essential tool for understanding life course involvement with the CPS and describing trends not observable from annual snapshots. Such information is critical for burden of disease estimates, informing policy and monitoring CPS performance.     

Child protection reports and removals of infants diagnosed with prenatal substance exposure

BackgroundA frequent response for prenatal substance exposure (PSE) is intervention by child protective services (CPS). Previous research has examined differences in reports to CPS regarding PSE by substance exposure and by maternal race. However, little is known regarding the frequency of immediate removals by CPS relating to PSE and maternal race.MethodsWe investigated hospital reports to CPS and CPS removals of PSE infants by using linked birth, hospital discharge, and CPS records for all children born in Washington State between 2006 and 2013 (N = 760,863). We identified PSE using diagnostic codes, calculated prevalence by substance type and maternal race, and tested for differences by interactions of race and substance using multinomial logistic regression.ResultsPrevalence of PSE births varied by race with 8.1% of Native American, 2.8% of black, 1.9% of white, and 0.8% of Hispanic births diagnosed with PSE. Opioids was the most common type of PSE diagnosis at 48.2%. The majority of PSE infants (86.7%) were not removed by CPS but variations by substance type were observed. Of the interactions in the multinomial logistic regression model, only black infants exposed to alcohol were more likely to result in reports to CPS without removal than the referent group of white infants exposed to opioids.ConclusionsFindings indicate that most infants diagnosed with PSE were not removed by CPS and minority PSE infants were not reported to CPS or removed by CPS more than white infants. Racial differences identified in the prevalence of PSE present opportunities for targeted prevention efforts.     

Child protection cases,one size fits all? Cluster analyses of risk and protective factors

BackgroundTo provide effective tailor made case management in Child Protection Services (CPS) a insight is needed into the specific characteristics of the target group. Using the ecological perspective of maltreatment, this study explored poorly known characteristics of the CPS population.ObjectiveTo distinguish CPS subgroups based on risk and protective factors enables tailor made case management that fits the specific needs of these subgroups.Participants and settingWe studied 250 Dutch CPS cases of family supervision by court order that had completed the LIRIK and Action Plan checklists in August 2014–March 2015.MethodsThis quantitative study analyzed risk and protective factors for children and parents reported in client files. Subgroups were identified by two-step cluster analyses. Chi-square analyses identified relations between parental risk subgroups and other groups.ResultsBuilding on the interplay between risk and protective factors on the levels of child, parent and environment, we found five distinct subgroups in the CPS population. The most vulnerable is parents with multiple problems (31%) or socio-economic problems (13%). Parts of both subgroup have limited protective factors. Parents with major life events (16%) or poor parenting (13%) are characterized by single-level problems. One subgroup (28%), the unaccepted, has no parental risk factors registered.ConclusionsStudying client files can lead to a better understanding of the healthcare needs of the CPS population. To develop and implement more effective case management requires constant dialogue between science, policy, and the experiences of both clients and professional.     

Identifying and predicting problem behavior trajectories among pre-school children investigated for child abuse and neglect

Objective

Young children involved with child welfare services are at high risk for behavior problems. This study aims to identify externalizing behavior paths that preschoolers in this high-risk population follow over a 6 year period, and the predictors of membership in normative and problematic pathways.

Methods

Using data from the National Study of Child and Adolescent Well-being (NSCAW), the sample included 246 4-year-olds who remained home after investigation. Latent class growth analysis (LCGA) was used to estimate the number, size, and shape of subgroups of preschoolers following distinct behavioral pathways. Early predictors of membership in the resulting groups were then examined.

Results

Four groups of preschool children following distinct behavior trajectories over 6 years were identified. Weighted results show that more than half (61%) of the children followed a low/normal problem behavior trajectory while just over one tenth (12%) were on a persistent high trajectory, remaining in the clinical range throughout the study. Improving (23%) and worsening (4%) problem behavior groups were also identified. Internalizing problems, attention problems, child ethnicity, and maltreatment type reported at age 4 predicted membership in the trajectory groups.

Conclusions

Internalizing behavior problems and maltreatment type may distinguish preschool children who are more likely to experience worsening or persistent problematic externalizing behaviors from those likely to follow a normal behavior trajectory.

Practice implications

Identifying early indicators of externalizing behavior problems and addressing them with evidence-based interventions to reduce negative behaviors may avert long-term negative outcomes.     

Prenatal substance exposure diagnosed at birth and infant involvement with child protective services

Infants have the highest rates of maltreatment reporting and entries to foster care. Prenatal substance exposure is thought to contribute to early involvement with child protective services (CPS), yet there have been limited data with which to examine this relationship or variations by substance type. Using linked birth, hospital discharge, and CPS records from California, we estimated the population prevalence of medically diagnosed substance exposure and neonatal withdrawal disorders at birth. We then explored the corresponding rates of CPS involvement during the first year of life by substance type after adjusting for sociodemographic and health factors. Among 551,232 infants born alive in 2006, 1.45% (n = 7994) were diagnosed with prenatal substance exposure at birth; 61.2% of those diagnosed were reported to CPS before age 1 and nearly one third (29.9%) were placed in foster care. Medically diagnosed prenatal substance exposure was strongly associated with an infant’s likelihood of being reported to CPS, yet significant variation in the likelihood and level of CPS involvement was observed by substance type. Although these data undoubtedly understate the prevalence of prenatal illicit drug and alcohol use, this study provides a population-based characterization of a common pathway to CPS involvement during infancy. Future research is needed to explicate the longer-term trajectories of infants diagnosed with prenatal substance exposure, including the role of CPS.     

Inter-agency indicators of out-of-home-care placement by age 13–14 years: A population record linkage study

BackgroundCross-agency administrative data can improve cost-effective triage systems for child protection and other human service delivery.ObjectiveTo determine the minimum set of cross-agency indicators that could accurately classify placement in out-of-home-care (OOHC) before age 13–14 years.Participants and settingParticipants were 72,079 Australian children (mean age = 13.16 years; SD = 0.37; 51.4% male) and their parents, for whom linked administrative records spanning the years 1994–2016 were available for analysis within the ‘New South Wales Child Development Study’.MethodsFirst, a series of logistic regression analyses were conducted to examine associations between cross-agency (health, justice, education) risk indicators and membership of the sub-cohort of 1239 children who had an OOHC placement prior to age 13–14 years, relative to (1) the sub-cohort of 55,473 children who had no previous contact with child protection services, and (2) the sub-cohort of 15,367 children who had been reported to child protection services but had no record of OOHC placement. We then explored the classification characteristics associated with a smaller combination of risk factors, and the utility of specific familial risk factors, for classifying membership of the OOHC subgroup.ResultsA combination of six risk indicators evident before OOHC placement can classify children placed in OOHC with approximately 95% accuracy, and the presence of at least four of these risk indicators provides excellent specificity (99.6%).ConclusionsA combination of risk factors observable in administrative datasets held by multiple government agencies may be used to target support services to prevent entry into OOHC for children from vulnerable families.     

What does effectiveness mean?: A qualitative assessment of two child protection systems

BackgroundChild Protective Services (CPS) systems have not historically conducted system effectiveness research. More information is needed about the long-term outcomes of children and families served by the systems.ObjectiveTo investigate how workers within CPS systems in Colorado and the Netherlands measure and perceive the effectiveness of their CPS system.Participants and settingCPS administrators and workers in Colorado and the Netherlands from August 2015 through May 2016. At both sites, interviewees included front line employees with deep knowledge of daily mechanics and processes, as well as experts and thought leaders who possessed historical memory and perspective about their site’s CPS system.MethodsIn-depth, semi-structured interviews were conducted with 77 participants. In Colorado (n = 36), 8 participants were state experts and 28 held county-level roles. In the Netherlands (n = 41), 17 participants were national experts and 24 worked at Veilig Thuis agencies.ResultsParticipants in both sites reported that they did not know if their system had empirical evidence to support its effectiveness, and had difficulty identifying how they would measure the effectiveness of their system.ConclusionsBoth systems lack the ability to collect data on the quality of their services and the longitudinal outcomes for the children and families they serve. Measures of good outcomes must be developed. Without longitudinal outcome data, CPS systems cannot assess the effectiveness of their practice. CPS systems might partner with the healthcare system, where the infrastructure and culture are already in place to look at quality and longitudinal outcomes.     

Characteristics of effective collaboration: A study of Nurse-Family Partnership and child welfare

BackgroundIn February 2018, President Trump signed into law the Family First Prevention Act, legislation in the United States aimed at providing prevention services for families at risk of entering the child welfare system. The effectiveness of these prevention efforts is dependent on the formation of collaborative relationships between prevention-programs and child welfare.ObjectiveTo identify factors that influence the ability of the Nurse-Family Partnership (NFP) and Child Protective Services (CPS) to collaborate in serving high-risk mothers and their children.Participants123 NFP, CPS workers, and community partners.SettingSeven sites in the U.S. state of Colorado selected to include an array of community sizes, geographies, apparent levels of collaboration, and variations in internal structures and practices.MethodsUsing an adapted grounded theory approach, we conducted semi-structured interviews with frontline NFP and CPS workers and supervisors. Interviews were recorded, transcribed, validated, and coded in NVivo 10.ResultsAlignment of core organizational mission and methods was key in determining collaboration levels between NFP and CPS. Only when workers perceived there to be alignment in organizational mission, did other factors such as program eligibility, communication channels, and risk and safety assessment practices influence the perceived benefits and efforts undertaken to enhance collaboration.ConclusionsHigh-risk families frequently require services that go beyond the scope of any one organization. As programs that serve high-risk families refine their efforts to serve them effectively, collaborative efforts should focus on examining opportunities and challenges involved in creating greater mission alignment.     

Ain’t nobody got time for dad? Racial-ethnic disproportionalities in child welfare casework practice with nonresident fathers

BackgroundGiven fathers’ potential role in bringing about desired child welfare case outcomes, researchers have begun to identify factors that impact agency efforts to identify and involve fathers. Racial-ethnic inequality and bias are not among factors studied, despite longstanding evidence that racial-ethnic minority children make up a disproportionate share of the child welfare population.ObjectiveWe set out to identify racial-ethnic patterns in initial casework activity with nonresident fathers and explore whether select factors explain racial-ethnic differentials.Participants and SettingCaseworkers of 1,754 children in foster care in four U.S. states were surveyed.MethodsBivariate and multivariate logistic regression models were used to identify factors associated with whether agencies identified, located, and contacted nonresident fathers.ResultsAgencies were less likely to identify nonresident fathers of Black, Latinx, and Multiracial children, relative to those of White children. Among fathers whom agencies identified, Black and Latinx fathers were less likely to be located. Among fathers whom agencies located, Black and Latinx fathers were less likely to be contacted. Whereas greater rates of international mobility among Latinx fathers explained agencies’ disproportionately low rates of contact, no other factor explained racial-ethnic differentials.ConclusionWe find evidence of historical racial-ethnic disproportionalities across the three initial stages of casework practice with nonresident fathers in U.S. child welfare systems. Though more recent data are needed, this research suggests that racial-ethnic minority foster children are more likely than White foster children to be denied the benefits of agency-father contact, whether due to societal or systemic racial inequalities.     

Prior opportunities to identify abuse in children with abusive head trauma

Infants with minor abusive injuries are at risk for more serious abusive injury, including abusive head trauma (AHT). Our study objective was to determine if children with AHT had prior opportunities to detect abuse and to describe the opportunities. All AHT cases from 7/1/2009 to 12/31/2011 at four tertiary care children's hospitals were included. A prior opportunity was defined as prior evaluation by either a medical or child protective services (CPS) professional when the symptoms and/or referral could be consistent with abuse but the diagnosis was not made and/or an alternate explanation was given and accepted. Two-hundred-thirty-two children with AHT were identified; median age (IQR) was 5.40 (3.30, 14.60) months. Ten percent (22/232) died. Of the 232 patients diagnosed with AHT, 31% (n = 73) had a total of 120 prior opportunities. Fifty-nine children (25%) had at least one prior opportunity to identify abuse in a medical setting, representing 98 prior opportunities. An additional 14 (6%) children had 22 prior opportunities through previous CPS involvement. There were no differences between those with and without a prior opportunity based on age, gender, race, insurance, mortality, or institution. Children with prior opportunities in a medical setting were more likely to have chronic subdural hemorrhage (48 vs. 17%, p < 0.01) and healing fractures (31 vs. 19%, p = 0.05). The most common prior opportunities included vomiting 31.6% (38/120), prior CPS contact 20% (24/120), and bruising 11.7% (14/120). Improvements in earlier recognition of AHT and subsequent intervention might prevent additional injuries and reduce mortality.     

Perceptions of child protective services among pregnant or recently pregnant,opioid-using women in substance abuse treatment

Pregnant, opioid-using women represent a challenge to healthcare providers attempting to engage them in prenatal and substance abuse services. Limited, primarily international research suggests that child welfare clients have mixed feelings about Child Protective Services (CPS) and that fear of CPS may present a barrier to care. Understanding how pregnant opioid-using women in substance abuse treatment perceive CPS may be useful in encouraging substance abuse treatment initiation. Participants were currently or recently (within past 12 months) pregnant women with current or recent (within past 12 months) abuse/dependence of pharmaceutical opioids at a drug treatment facility. Participants were recruited by treatment staff to participate in a comprehensive study across multiple domains. Data for this analysis were collected using semi-structured qualitative interviews. Transcribed data were thematically analyzed using in vivo and interpretive coding by three coders for purposes of inter-rater reliability. Following 2, two-hour meetings, consensus was reached on primary themes and sub-themes. Two major themes and several sub-themes were identified: 1) Participants’ feelings and attitudes about CPS (positive and negative); 2) Interaction-based perceptions of CPS’ function and performance. Participants’ feelings toward CPS were often conditioned by their experiences with individual caseworkers. While many pregnant, opioid-using women identify legitimate, and even useful features of CPS, fear of CPS can be a barrier to care. Making substance abuse treatment accessible to this population requires recognition of their complex feelings toward CPS, and coordination among CPS case workers and substance abuse treatment providers.     

Child protective services involvement and exclusionary school discipline

The study examined the impact of child protective services (CPS) contact on out-of-school suspensions for 49,918 Wisconsin students (followed from ages 5–6 to 14–15; [school years 2010–2019; 74% White; 7% Black; 11% Hispanic; 8% other; 49% female]). A quasi-experimental design comparing recent CPS contact to upcoming (future) CPS contact shows that both recent CPS contact without foster care and future CPS contact predict higher odds of suspension compared with no contact. Higher odds of suspension emerged prior to CPS contact and did not substantially increase during or after CPS contact, suggesting that system-induced stress is not a primary driver of behavioral problems leading to suspension. Foster care reduced the odds of suspension among White children and children in special education.     

From care to education and work? Education and employment trajectories in early adulthood by children in out-of-home care

BackgroundTemporal dynamics during the early adulthood transition among children in out-of-home care is a neglected research area, leaving the possibility of coping with childhood adversity over time a poorly understood topic.ObjectiveTo explore early adulthood education and employment trajectories among young adults who experienced out-of-home care during childhood and to examine how various care history factors predict these trajectories.ParticipantsWe use longitudinal birth cohort data comprising individual-level information from national registers of all children born in Finland in 1987 (N = 59,476, of whom 1893 were in care).Setting and methodsWe use trajectory clustering from a previous study on the 1987 birth cohort to compare trajectories between children in care and a propensity score–matched group of peers never in care. We investigated the association between care history factors and trajectories with multinomial logistic regression modeling.ResultsCompared with the matched peer group, children in care were less likely to enter trajectories characterized by education and employment (38%) and more likely to enter trajectories involving early parenthood (14%) or long periods of fragmented social assistance benefit receipt and unemployment (21%). Those on early parenthood trajectories were almost exclusively women, whereas those receiving social assistance benefits and experiencing unemployment for lengthy periods were mostly men. Entering disadvantaged trajectories was associated with, inter alia, placement as an adolescent, residential care, and aging out of care.ConclusionThe study demonstrates the relevance of examining longitudinal trajectories in children in care’s early adulthood. Many young adults with care experience need support in education and employment beyond young adult age.     

Interdisciplinary collaboration needed in obtaining high-quality medical information in child abuse investigations

BackgroundDespite reporting legislation, healthcare providers (HCPs) do not always report and collaborate in cases of suspected child abuse. Recognizing this leaves children at risk, the Wisconsin Child Abuse Network (WI CAN) sought to understand barriers to mandated reporting and collaboration with child abuse investigators.ObjectiveThe purpose of the study was to investigate barriers for professionals in providing and obtaining high-quality medical information in child abuse investigations.Participants and settingParticipants included five discipline-specific focus groups: HCPs, child protective services (CPS), law enforcement, lawyers, and judges. All professionals had been directly involved in Wisconsin child abuse cases.MethodsThis qualitative study consisted of discipline-specific focus groups, directed by open-ended interview questions. Data analysis was completed through the narrative inquiry methodology.ResultsBarriers to providing and obtaining high-quality medical information in child abuse investigations were both discipline-specific and universal amongst all groups. Discipline-specific barriers included: HCPs’ discomfort with uncertainty; CPS’ perception of disrespect and mistrust by HCPs; law enforcement’s concerns with HCPs’ overstepping professional boundaries; lawyers’ concern of HCPs’ discomfort with court proceedings; and judges’ perception of a lack of understanding between all disciplines. Universal barriers included: value of high-quality medical information in child abuse investigations, burden of time and money; unequal resources between counties; a need for protocols, and a need for interdisciplinary collaboration.ConclusionFindings from this study suggest several ways to address identified barriers. Possible interventions include equalizing resources between urban and rural counties (specifically financial resources and access to child abuse experts); protocolizing reporting and investigations; and, increasing interprofessional education.