Contextual and individual-level predictors of abused children's reentry into out-of-home care: a multilevel mixture survival analysis

Objectives

This study examined the effects of individual and contextual factors on reentry into out-of-home care among children who were discharged from child protective services in fiscal year 2004-2005. The objectives were to: (1) examine individual and contextual factors associated with reentry, (2) explore whether there are meaningful groups of youth who differ in terms of risk for reentry, and (3) determine whether relatively homogeneous clusters of child welfare agencies, based on contextual characteristics, differ significantly in terms of the reentry rates of the children whom they serve.

Method

The study design involved a multilevel longitudinal analysis of administrative data based on an exit cohort. Two Cox proportional hazards multilevel mixture models were tested. The first model included multiple individual level predictors and no agency level predictors. The second model included both levels of predictors.

Results

The results of multilevel Cox regression mixture modeling indicated that at the individual level, younger age, being placed in out-of-home care because of neglect and having physical, health problems corresponded to a decreased likelihood for reentry. At the agency level, lower average expenditures per child and contracting out case management services were associated with faster reentry into out-of-home care.

Conclusions

This study demonstrates that children who reenter out-of-home care appear to be a homogeneous population and that reentry is associated with both contextual factors and individual characteristics.

Practice implications

The most important implication that can be drawn from the study findings is that reentry may be most effectively prevented by focusing on such factors at the organizational level as contracting out case management services and funding allocation. Child welfare agencies that are responsible for an array of services and decide to contract out case management should consider the use of performance-based contracts and emphasize and strengthen quality assurance approaches for contracted services. In addition, to compensate for lower funding allocated for children served in out-of-home care, child welfare workers should become more familiar with community resources and help connect families to these supports.     

Children with behavioral, non-behavioral, and multiple disabilities, and the risk of out-of-home placement disruption

Objective

This study examined the relative risk of placement disruption for 3-10 year-old children placed in out-of-home care based on the biological relatedness of the placement caregiver and child disability status: no disability, a non-behavioral disability only, a behavioral disability only, or both a non-behavioral and behavioral disability.

Methods

Data were used from the baseline and 36 month follow-up of 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. Disability status was derived using several different nationally-normed measures of language development, daily-living skills, social skills, and behavioral problems.

Results

Around 1 in 4 children placed in out-of-home care experienced a disruption. Placement with kin decreased the likelihood of disruption for a majority of children, and children with different types of disabilities were no more or less likely to disrupt in kinship care compared to children with no disability. Older children with a behavioral disability only or both a non-behavioral and behavioral disability were more likely to disrupt compared to younger regardless of placement.

Conclusion

The study findings suggest that maltreated children placed with kin will be afforded the same stability provided to children without a disability.     

Pediatric health assessments of young children in child welfare by placement type

Objectives

To describe health-related problems across placement types (unrelated foster, kin foster, in-home with birth parent); to examine the association of placement and demographic/child welfare variables (child gender, age, race/ethnicity; caregiver language; type of maltreatment, and length of time receiving services from child welfare) with health-related problems.

Methods

This study utilized a retrospective medical chart review of children less than 6 years old (n = 449) seen at an outpatient child welfare pediatric clinic. Logistic regression modeling was used to estimate odds of having a weight, medical, or provisional developmental delay problem by placement and demographic/child welfare characteristics.

Results

Almost 13% of children in the sample were obese (≥95% age-gender specific percentile) and more than a quarter were overweight/obese (≥85%) while only 7% were underweight (≤5%). Most children (78%) had a physical health diagnosis and 25% were provisionally identified with a developmental delay. No differences between weight diagnoses, type of medical diagnoses, and provisional developmental delay by placement type were found, although children with 3 or more medical diagnoses were more likely to be with kin (p < .05). Children 2 years old or older were more likely to be overweight/obese than children under 2 years old (p < .05) and Hispanic children were more likely to be overweight/obese than non-Hispanic children (p < .01). Length of stay in child welfare was positively related with a medical diagnosis or provisional developmental delay (p < .01).

Conclusions

Results argue for careful assessment of weight, medical, and developmental problems in children active to child welfare, whether residing in their home of origin, with kin, or with unrelated foster parents. The increasing problem of obesity among young children in child welfare warrants further investigation and intervention.

Practice implications

The comprehensive health examination and enhanced health maintenance schedule for children in foster care should be extended to children who remain at home with child welfare services as child welfare involvement rather than placement is related to health-related problems.     

Factors associated with caregiver stability in permanent placements: a classification tree approach

Objective

Identify individual and environmental variables associated with caregiver stability and instability for children in diverse permanent placement types (i.e., reunification, adoption, and long-term foster care/guardianship with relatives or non-relatives), following 5 or more months in out-of-home care prior to age 4 due to substantiated maltreatment.

Methods

Participants were 285 children from the Southwestern site of Longitudinal Studies of Child Abuse and Neglect (LONGSCAN). Caregiver instability was defined as a change in primary caregiver between ages 6 and 8 years. Classification and regression tree (CART) analysis was used to identify the strongest predictors of instability from multiple variables assessed at age 6 with caregiver and child reports within the domains of neighborhood/community characteristics, caregiving environment, caregiver characteristics, and child characteristics.

Results

One out of 7, or 14% of the 285 children experienced caregiver instability in their permanent placement between ages 6 and 8. The strongest predictor of stability was whether the child had been placed in adoptive care. However, for children who were not adopted, a number of contextual factors (e.g., father involvement, expressiveness within the family) and child characteristics (e.g., intellectual functioning, externalizing problem behaviors) predicted stability and instability of permanent placements.

Conclusions

Current findings suggest that a number of factors should be considered, in addition to placement type, if we are to understand what predicts caregiver stability and find stable permanent placements for children who have entered foster care. These factors include involvement of a father figure, family functioning, and child functioning.

Practice implications

Adoption was supported as a desired permanent placement in terms of stability, but results suggest that other placement types can also lead to stability. In fact, with attention to providing biological parents, relative, and non-relative caregivers with support and resources (e.g., emotional, financial, and optimizing father involvement or providing a stable adult figure) the likelihood that a child will have a stable caregiver may be increased.     

The validity and utility of the California Family Risk Assessment under practice conditions in the field: A prospective study

Objective

Analysis of the validity and implementation of a child maltreatment actuarial risk assessment model, the California Family Risk Assessment (CFRA).

Questions addressed

(1) Is there evidence of the validity of the CFRA under field operating conditions? (2) Do actuarial risk assessment results influence child welfare workers’ service delivery decisions? (3) How frequently are CFRA risk scores overridden by child welfare workers? (4) Is there any difference in the predictive validity of CFRA risk assessments and clinical risk assessments by child welfare workers?

Method

The study analyzes 7,685 child abuse/neglect reports originating in 5 California counties followed prospectively for 2 years to identify further substantiated child abuse/neglect. Measures of model calibration and discrimination were used to assess CFRA validity and compare its accuracy with the accuracy of clinical predictions made by child welfare workers. The extent of use of an override feature of the CFRA and child welfare worker reliance on CFRA risk scores for making service decisions were analyzed.

Results

Imperfect but better-than-chance predictive validity was found for the CFRA on a range of measures in a large temporal validation sample (n = 6,543). For 114 cases where both CFRA risk assessments and child welfare worker clinical risk assessments were available, the CFRA exhibited evidence of imperfect but better-than-chance predictive validity, while child welfare worker risk assessments were found to be invalid. Child welfare workers overrode CFRA risk assessments in only 114 (1.5%) of 7,685 cases and provided in-home services in statistically significantly larger proportions of higher- versus lower-risk cases, consistent with heavy reliance on the CFRA.

Conclusions/practice implications

Until research identifies actuarial models exhibiting superior predictive validity when applied in every-day practice, the CFRA is, and will be a valuable tool for assessing risk in order to make in-home service-provision decisions.     

Maternal mental illness and the safety and stability of maltreated children

Objective

Children of mothers with mental illness are at risk for multiple untoward outcomes, including child maltreatment and foster care placement. The purpose of this analysis was to determine the association between maternal mental illness and children's long term safety and stability.

Methods

A multi-sector administrative dataset from the Department of Social Services (DSS) and Department of Mental Health (DMH) was analyzed. The sample was 4,895 low income families (mother and child dyads) first reported to child welfare in 1993 or 1994. Families were followed until March of 2009. Dates of new report and foster care placement were obtained from DSS data. ICD-09 or ICD-10 diagnostic codes were obtained from Department of Mental Health data. Schizophrenic disorders, episodic mood disorders, anxiety disorders and personality disorders were examined.

Results

New reports were more likely for children of mothers with mental illness, regardless of diagnosis. While overall 67% of children had a new report over the course of their childhood, rates ranged from 80 to 90% for children of mothers with mental illness and occurred within a shorter time frame than for other children. In the multivariate models, mood (HR = 1.41, p < .001) and anxiety disorders (HR = 1.32, p < .05) placed children at greater risk for new reports. The proportion of children with foster placements was more than double for children of mothers with mental illness than for other children. In the multivariate model, anxiety disorders were strongly associated with the risk of placement (HR = 1.75, p < .001).

Conclusions and Practice implications

Important differences in safety and stability were found between children of mothers with and without mental illnesses, as well as some variability across diagnoses. Since these mothers had already received services our findings suggest that access is not enough. The services they are receiving or have received may be an ineffective approach to helping them parent safely.     

Traumatic and stressful events in early childhood: can treatment help those at highest risk?

Objective

This study involves a reanalysis of data from a randomized controlled trial to examine whether child-parent psychotherapy (CPP), an empirically based treatment focusing on the parent-child relationship as the vehicle for child improvement, is efficacious for children who experienced multiple traumatic and stressful life events (TSEs).

Methods

Participants comprised 75 preschool-aged children and their mothers referred to treatment following the child's exposure to domestic violence. Dyads were randomly assigned to CPP or to a comparison group that received monthly case management plus referrals to community services and were assessed at intake, posttest, and 6-month follow-up. Treatment effectiveness was examined by level of child TSE risk exposure (<4 risks versus 4+ TSEs).

Results

For children in the 4+ risk group, those who received CPP showed significantly greater improvements in PTSD and depression symptoms, PTSD diagnosis, number of co-occurring diagnoses, and behavior problems compared to those in the comparison group. CPP children with <4 risks showed greater improvements in symptoms of PTSD than those in the comparison group. Mothers of children with 4+ TSEs in the CPP group showed greater reductions in symptoms of PTSD and depression than those randomized to the comparison condition. Analyses of 6-month follow-up data suggest improvements were maintained for the high risk group.

Conclusions

The data provide evidence that CPP is effective in improving outcomes for children who experienced four or more TSEs and had positive effects for their mothers as well.

Practice implications

Numerous studies show that exposure to childhood trauma and adversity has negative consequences for later physical and mental health, but few interventions have been specifically evaluated to determine their effectiveness for children who experienced multiple TSEs. The findings suggest that including the parent as an integral participant in the child's treatment may be particularly effective in the treatment of young children exposed to multiple risks.     

Changes in parental depression symptoms during family preservation services

Objectives

Parental depression symptoms often change over the course of child welfare family preservation and parenting services. This raises the question of whether certain processes in family preservation services might be associated with depression symptom change. This study tests three correlational models of change among family preservation service participants: (a) changes in depression symptoms are one facet of broad general changes in wellbeing; (b) the quality of the home visitor-client relationship is associated depression symptom changes; and (c) linking parents to adjunctive services is associated with symptom changes.

Methods

Participants were 2,175 parents in family preservation services, largely for child neglect, who were surveyed using standard measures at pre-treatment, post-treatment and 6 month follow-up. Change patterns were evaluated using growth models, including bivariate parallel and multivariate second-order models.

Results

Parallel growth was noted among depression symptoms and changes in social, economic, familial, and parenting domains. A second order change model positing a global change pattern fit the data well. Working alliance had a modest association with improvement, but successful linkage to outside mental health services was not associated with improvement.

Conclusions

Changes in diverse indicators of wellbeing follow a global pattern which might support use of less complex rather than more fully comprehensive service plans. Findings about lack of adjunctive usual care mental health service benefit may be related to uncontrolled factors and this is a topic in need of additional study.     

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.     

Identifying children at high risk for a child maltreatment report

Objective

To help professionals identify factors that place families at risk for future child maltreatment, to facilitate necessary services and to potentially help prevent abuse and neglect.

Method

The data are from a prospective, longitudinal study of 332 low-income families recruited from urban pediatric primary care clinics, followed for over 10 years, until the children were approximately 12 years old. Children with prior child protective services involvement (CPS) were excluded. The initial assessment included sociodemographic, child, parent and family level variables. Child maltreatment was assessed via CPS reports. Risk ratios (RRs) and their 95% confidence intervals (CIs) were estimated using Cox regression models.

Results

Of the 224 children without a prior CPS report and with complete data who were followed for an average of 10 years, 97 (43%) later had a CPS report. In a multivariate survival analysis, 5 risk factors predicted CPS reports: child's low performance on a standardized developmental assessment (RR = 1.23, 95% CI = 1.01-1.49, p = .04), maternal education ≤ high school (RR = 1.55, CI = 1.01-2.38, p = .04), maternal drug use (RR = 1.71, CI = 1.01-2.90, p < .05), maternal depressive symptoms (RR per one standard deviation higher score = 1.28, CI = 1.09-1.51, p < .01), and more children in the family (RR per additional child = 1.26, CI = 1.07-1.47, p < .01).

Conclusions

Five risk factors were associated with an increased risk for later maltreatment. Child health care and other professionals can identify these risk factors and facilitate necessary services to strengthen families, support parents and potentially help prevent child maltreatment.     

Investigating geographic variation in use of psychotropic medications among youth in child welfare

Objectives

Public Law (P.L.) 110-351, the “Fostering Connections to Success Act,” calls for state child welfare agencies to partner with Medicaid and pediatric experts to provide planning and oversight regarding the provision of health and mental health services, including medication, to children in state custody. Recent reports, media cases, and class action lawsuits suggest over-use of psychotropic medications to address the behavioral needs of children in the child welfare system. We examined geographic variability in psychotropic medication use across US child welfare agency catchment areas to determine how rates of psychotropic medication use vary in relation to child, community, child welfare, and health system-level factors.

Methods

Cross-sectional analysis of Wave 1 data for the 92 child welfare catchment areas participating in the National Survey of Child and Adolescent Well-being, a random probability sample of 2,504 children ages 2-15 years undergoing investigation for abuse and neglect. We employed multilevel regression modeling to examine the impact of catchment-level variables on medication use, controlling for child-level variables.

Results

Fifteen percent of children reported taking psychotropic medications. Rates of medication use across catchment areas ranged widely from 0 to 40%, a 40-fold difference. On multi-level logistic regression modeling, older age (p < .001), male gender (p < .001), emotional and behavioral problems (p < .001), and insurance (p = .05) were associated with psychotropic medication use at the child-level. At the catchment-level, stressful environment within the child welfare system was negatively associated with medication use. No other catchment-level variables examined were found to explain use.

Conclusions

Striking disparities in medication use exist across catchment areas in this national sample. Of the catchment variables examined, only stressful environment was related to medication use.

Practice implications

These findings highlight significant geographic variation in medication use that most likely reflect both under-use and over-reliance on psychotropic medication. The link between child welfare environment and medication use suggests the influence of systemic, as opposed to clinical, causes of variation in medication use. This requires greater implementation of organizational processes governing quality of care for this highly vulnerable population.     

Maternal experiences of childhood abuse and intimate partner violence: Psychopathology and functional impairment in clinical children and adolescents

Objectives

The current study examined the independent effects of mothers’ childhood abuse (CA) and intimate partner violence (IPV) on psychopathology and functional impairment in children; and the potential moderating and mediating role of individual and family factors in these relationships. Additionally, this study explored the potential cumulative effects of both maternal CA and IPV on children's outcomes.

Method

The sample included 547 Spanish children and adolescents aged between 8 and 17 years, and their parents, who had accessed mental health services. The assessment was based on structured interviews with the children and their parents. Statistical analyses were carried out through hierarchical multiple, negative-binomial and logistic regressions, and Structural Equation Models.

Results

Children whose mothers experienced CA and those whose mothers suffered physical IPV showed increased DSM-IV disruptive disorders and externalizing behavior problems, respectively. Children who directly observed physical IPV and also suffered physical punishment by parents showed increased internalizing problems. IPV had effects, either direct or indirect by physical punishment, on children's externalizing problems. Cumulative effect analyses indicated that the prevalence of disruptive disorders was highest in children whose mothers had suffered both CA and IPV.

Conclusion

Spanish children whose mothers have suffered CA, IPV or both, are at high risk of serious conduct problems, whereas children exposed to IPV and who were also physically abused are at greater risk of internalizing problems. Physical punishment of children contributes in part to explain externalizing problems of IPV-exposed children. These findings indicate potential targets of assessment and intervention for families seeking help in mental health services.     

The effects of abuse history on sexually intrusive behavior by children: An analysis of child justice records

Objectives

A commonly cited risk factor for sexually intrusive behavior (SIB) among children and adolescents is a history of abuse. Based on a large and non-clinical nationwide sample of children who were investigated as abuse victims and suspects of SIBs in Israel over a decade, the present study examines the rate of abuse history among child suspects who have admitted SIBs. In addition, this study compares some personal and family characteristics as well as selected aspects of SIBs reported by children with and without a history of abuse. Abuse history is then used to predict the nature of SIBs after controlling for other predictors.

Methods

National data files of the investigation of alleged child victims and child suspects aged 14 or under were electronically merged, allowing the identification of a sub-group of suspects, out of all suspects, who had a record of child abuse. Using only confirmed cases of boys with SIBs, child suspects with a record of abuse were compared to the larger group of child suspects with no record of abuse.

Results

Of 3,554 child suspects of SIBs, 345 or 9.7% had a formal record of abuse. Boys with a record of abuse engaged in SIBs at a younger age; were more likely to display mental disabilities; more often belonged to large size, single-parent, low SES, and immigrant families and were more likely to be removed from home to alternative care than boys with no record of abuse. The nature of SIBs varied across the groups, with victim-suspects more likely than their counterparts to act repeatedly, and to do so alone rather than in the presence of others. Victim-suspects were more likely to involve in SIBs with younger children, with siblings, and with unrelated children. Most aspects of SIBs were predicted by abuse history after controlling for other predictors, with some differences between age groups being evident.

Conclusions

Although abuse history is uncommon among children displaying SIBs in this sample, it seems to affect the involvement of children at a younger age in more severe SIBs, posing a higher risk to other children.

Practical implications

The low rate of abuse history among boys with SIBs suggests that clinical assessors of SIBs in children should not assume that these children have been victims of abuse or that abuse is a necessary component in the development of SIBs. This implies that the exploration of past abuse in the assessment of children with SIBs is not always relevant and that trauma-related components in the treatment of these children should be selective. As past-abuse is less related to SIB's for older children, the clinical focus on abuse is even less relevant for older children. However, when boys with SIBs have been past-victims, they seem to be in greater need for treatment than other boys with SIBs. Moreover, the dynamics of SIBs by past victims should raise more concern for older than for younger children.     

Children exposed to child maltreatment and intimate partner violence: a study of co-occurrence among Hong Kong Chinese families

Objective

This study assessed the co-occurrence of child maltreatment and intimate partner violence (IPV) and examined the association between them.

Method

The cross-sectional study recruited a population-based sample of 1,094 children aged 12-17 years in Hong Kong. Structured questionnaires were used to collect data from the children. The prevalence of occurrence of child abuse and neglect by parents and exposure to IPV in both the past year and lifetime was examined, and their correlates were assessed using univariate and multivariate logistic regression.

Results

The results show that 26% and 14.6% of child participants had been exposed to IPV physical assault, and 44.4% and 22.6% had been subjected to a parent's corporal punishment or to physical maltreatment from a parent in their lifetime and the year preceding the study, respectively. Among those families characterized by IPV, 54.4% and 46.5% were involved in child physical maltreatment over the child's lifetime and in the preceding year, respectively.

Conclusions

Multivariate logistic regression analyses revealed that children exposed to IPV were at higher risk of being victims of neglect, corporal punishment, and physical maltreatment or severe physical maltreatment by their parents than children who were not exposed to IPV, even when child and parent demographic factors were controlled for.

Practical implications

The higher risk of child physical maltreatment associated with IPV highlights the need for an integrated assessment to screen for the presence of multiple forms of family violence within the family, and for intervention to assess effective responses to both IPV and child maltreatment by child protective service workers and domestic violence agencies.     

The relationship between time spent living with kin and adolescent functioning in youth with a history of out-of-home placement

Objective

Many children in the US who are court-ordered to live in out-of-home care are placed with kinship caregivers. Few studies have examined the impact of living with kin on child well-being. This study examined the relationship between length of time living with kin and indices of adolescent well-being in a cohort of children who were initially court-ordered into out-of-home care.

Methods

Prospective cohort design with 148 youth, ages 7-12, who entered out-of-home care between May, 1990, and October, 1991. Seventy-five percent of those interviewed at T1 (6 months following placement) were interviewed at T2 (5 years later).

Results

Bivariate analyses did not demonstrate significant relationships between length of time living with kin and the outcome variables. In multivariate analyses, longer length of time living with kin was related to: (1) greater involvement in risk behaviors including: delinquency (β = .22, p < .05), sexual risk behaviors (β = .31, p < .05), substance use (β = .26, p < .05), and total risk behaviors (β = .27, p < .05), and (2) poorer life-course outcomes including: Tickets/Arrests (OR = 1.4, p < .05) and lower grades (β = −.24, p < .05). Time living with kin was not related to total competence, or self-destructive, internalizing, externalizing, or total behavior problems. There were trends (p < .10) for time living with kin to predict greater trauma symptomatology (β = .17) and suspensions (OR = 1.1).

Conclusions

There were no significant bivariate findings. The multivariate findings suggested a pattern of poorer functioning for youth who spent more time living with kin. No differences were found in current symptomatology.

Practice implications

Although findings from a single study should not dictate changes in practice or policy, the current study's findings do suggest that the field needs to conduct more methodologically sophisticated research on the impact of kinship care.     

Differential effects of psychological maltreatment on children of mothers exposed to intimate partner violence

Objective

Psychological maltreatment (PM) is the most prevalent form of child abuse, and is the core component of most of what is considered as child maltreatment. The aim of this work was to explore differential adverse outcomes of the different types of PM in the mental health and functioning of children living in homes in which they are exposed to intimate partner violence (IPV).

Method

Participants were 168 children, aged between 4 and 17, whose mothers experienced IPV. They were assessed using different measures of psychopathology and functioning: Diagnostic Interview for Children and Adolescents-IV, Child Behavior Checklists and Child and Adolescent Functioning Assessment Scale. Furthermore, IPV was assessed with the Schedule for Assessment of Intimate Partner Violence Exposure in Children and the Index of Spouse Abuse. Statistical analyses were carried out with regression models adjusted by means of Generalized Estimating Equations.

Results

Spurning was the PM subtype with the greatest global effect on the children, as it was significantly associated with internalizing and externalizing problems. Denying emotional responsiveness specifically increased the risk of internalizing psychopathology and impairment in the emotional area. Terrorizing was not significantly associated with a greater number of negative outcomes in children's psychopathology or functioning in this population.

Implications

The results suggest the importance of taking PM types into account in order to fully understand the problems of children exposed to IPV at home, and for the design of effective treatment and prevention programs.     

Should child protection services respond differently to maltreatment, risk of maltreatment, and risk of harm?

Objective

To examine evidence available in large-scale North American datasets on child abuse and neglect that can assist in understanding the complexities of child protection case classifications.

Methods

A review of child abuse and neglect data from large North American epidemiological studies including the Canadian Incidence Study of Reported Child Abuse and Neglect (CIS), the National Child Abuse and Neglect Data System (NCANDS), and the National Incidence Studies of Reported Child Abuse and Neglect (NIS).

Results

The authors of this paper argue that recent evidence from large North American epidemiological studies examining the incidence of child abuse and neglect demonstrate that children and families identified as being at risk of maltreatment present with as many household and caregiver concerns as investigations that are substantiated.

Conclusions

In order to continue to develop appropriate services and policies for vulnerable children the authors urge continue definitional clarity for research in child maltreatment that considers the exemplars or indicators of categories, in tandem with parental and child characteristics which can provide one source of evidence-basis to meaningful child protection case classifications. Continued monitoring, refined by the dilemmas faced in practice, are critical for a continued public health investment in children's well-being, predicated upon upholding children's rights.     

Abusive head trauma: A perpetrator confesses

Objectives

To present a detailed confession from a perpetrator of Shaken Baby syndrome.

Methods

Case study.

Results

We present a confession of Shaken Baby syndrome describing how the perpetrator severely injured a 3 year old with repeated bursts of acceleration-deceleration (shaking). The child sustained retinal and intracranial hemorrhage. Details of the confession and circumstances by which it was obtained lead us to believe its accuracy.

Conclusions

Accurate perpetrator confessions offer useful windows into realities and pathophysiology of abusive head trauma.