The Impact of COVID-19 on Infant Maltreatment Emergency Department and Inpatient Medical Encounters.

OBJECTIVE: To assess the counts of infant maltreatment-related medical encounters at a large medical system during a 21-month span of the COVID-19 pandemic. METHODS: Retrospective data for this study came from all inpatient and emergency department medical encounters for infants from January 1, 2016, through November 30, 2021, at a single children's hospital system in California. Distributions of medical encounters were tabulated and plotted over time. Interrupted time series models were used to evaluate changes in child maltreatment medical encounters. RESULTS: Medical encounters for infants with child maltreatment diagnoses increased following the onset of COVID-19. Monthly counts of encounters with indicated maltreatment trended upward following the start of the pandemic. Interrupted time series models showed that the count of maltreatment encounters increased 64% with the onset of COVID-19. CONCLUSIONS: We found an increase in infant maltreatment medical encounters during a 21-month period following the onset of COVID-19. These findings suggest that the pandemic may have adversely affected the safety of infants and ongoing work is needed to understand better the pandemic impacts on child maltreatment.

A Population-Based Study of Mental Health Diagnoses and Child Protection System Involvement Among Medicaid-Insured Children.

OBJECTIVE: To determine the population prevalence of diagnosed mental health disorders among Medicaid-insured children <18 years old in California based on levels of current and past child protection system (CPS) involvement. STUDY DESIGN: In this retrospective, population-based study, we examined the full population of children enrolled in California's Medicaid program for at least 1 month between 2014 and 2015 and who had at least 1 claim during that period (n = 3 352 886). Records for Medicaid-insured children were probabilistically linked to statewide CPS records of maltreatment and foster care placements since 1998. A primary or secondary mental health diagnosis was classified using International Classification of Diseases codes. RESULTS: Overall, 14% (n = 470 513) of all children insured through Medicaid in 2014-2015 had a documented mental health diagnosis. Among children with a diagnosis, the percentage with CPS involvement (ie, any report for maltreatment) was nearly twice that of the Medicaid population overall (50.4% vs 26.9%). This finding held across all diagnostic groups but with notable variations in magnitude. A graded relationship emerged between the level of CPS involvement and the likelihood of a mental health diagnosis. Diagnoses among children reported for maltreatment were common, regardless of placement in foster care. CONCLUSIONS: Findings document high rates of both mental health diagnoses and past child protection involvement in a population of Medicaid-insured children. Most children reported for maltreatment will never be placed in foster care, underscoring the importance of ensuring that the children who remain at home receive the proper array and coordination of services.

Three-Year Custody Outcomes Among Infants Investigated by Child Protection Systems for Prenatal Substance Exposure in California.

OBJECTIVE: Infants affected by prenatal alcohol and drug use are more likely to be removed from parental custody than those in the general population, although it is unclear whether their custody outcomes differ from infants investigated by child protection systems (CPS) for other reasons. This analysis seeks to compare trajectories of involvement and custody outcomes among infants investigated by CPS with and without documentation of prenatal substance exposure (PSE). METHOD: We used vital birth records linked to administrative CPS records to examine the timing of system involvement and 3-year custodial outcomes among investigated infants with and without identified PSE. We defined PSE according to documentation on the state's standardized hotline screening form, which CPS completes upon referral for alleged maltreatment. We estimated the likelihood a child was in nonparental custody at age 3 by specifying multivariable generalized linear models, adjusted for covariates available in the birth record. RESULTS: In our sample of 22,855 infants investigated by CPS in 2017 in California, more than 26% had documentation of PSE. These infants experienced an accelerated timeline of system penetration and were 2.2 times as likely to be in nonparental placement at age 3. DISCUSSION: PSE confers an independent risk of custody interruption among infants investigated by CPS. The younger age of these infants, complexity of parental substance use, and potential misalignment of administrative permanency timelines with parental recovery all suggest the need for increased research, policy, and programmatic interventions to serve this vulnerable population.

Children with PSE face environmental risks in the early developmental period. Often in the United States, CPS is relied on to assess and mitigate these risks. Amid calls for a public health response to PSE, it is essential to understand how children with PSE interact with CPS. We describe the incidence and timing of custody interruptions in a large U.S. state, comparing infants with PSE to those investigated by CPS for other reasons. This study extends current understanding by demonstrating the independent risk of custody interruption conferred by PSE status.

Family Care Plans for Infants with Prenatal Substance Exposure.

The federal Child Abuse Prevention and Treatment Act (CAPTA) requires that a plan of safe care, called a family care plan (FCP) in Connecticut, be developed for all newborns identified as being affected by substance abuse and their caregivers. In Connecticut, FCPs are developed in treatment or hospital settings, not by child protective services. Analyzing data from Connecticut from 2019-2021, we found robust yet uneven implementation of FCPs that may have resulted in inadequate support for some affected caregiver-infant dyads. Additional implementation strategies may be needed to ensure that all dyads receive comprehensive FCPs.

A Population-Level Examination of Incarcerated Women and Mothers Before and After the California Public Safety Realignment Act.

BACKGROUND: In 2011, California enacted its public safety realignment initiative (realignment) motivated by a U.S. Supreme Court ruling to reduce state prison overcrowding and in effort to reduce recidivism. Realignment transferred authority for lower-level felony offenders from the state to the counties, leading to a rapid reduction in state prison incarceration levels. OBJECTIVE: This study drew on a unique dataset to assess the effects of California's efforts to downsize the prison system on maternal incarceration levels and to better understand the characteristics of incarcerated mothers and their children. METHODS: Incarceration records concerning all women in California state prisons between 2010 and 2012 (N = 16,917) were linked to 7.5 million vital birth records dating to 1999 to identify incarcerated women who had given birth. Multinomial logistic regression models were specified to better understand offense type differences among incarcerated mothers versus nonmothers. RESULTS: Findings indicate that realignment disproportionately affected women. The number of men entering prison decreased 67.8% between 2010 and 2012. In comparison, the number of women entering prison decreased 78.5%. Further, more than half of incarcerated women had given birth. Mothers were more likely than nonmothers to be convicted of nonviolent crimes. DISCUSSION: This study underscores how prison downsizing can disproportionately reduce incarceration levels for women. Given that such large proportion of incarcerated women were mothers, this policy change may have potential spillover next-generation benefits. Finally, this work reinforces the potential to use linked administrative records to study incarcerated populations.

Cumulative Rates of Child Protection Involvement and Terminations of Parental Rights in a California Birth Cohort, 1999-2017.

Objectives. To document the cumulative childhood risk of different levels of involvement with the child protection system (CPS), including terminations of parental rights (TPRs).Methods. We linked vital records for California's 1999 birth cohort (n = 519 248) to CPS records from 1999 to 2017. We used sociodemographic information captured at birth to estimate differences in the cumulative percentage of children investigated, substantiated, placed in foster care, and with a TPR.Results. Overall, 26.3% of children were investigated for maltreatment, 10.5% were substantiated, 4.3% were placed in foster care, and 1.1% experienced a TPR. Roughly 1 in 2 Black and Native American children were investigated during childhood. Children receiving public insurance experienced CPS involvement at more than twice the rate of children with private insurance.Conclusions. Findings provide a lower-bound estimate of CPS involvement and extend previous research by documenting demographic differences, including in TPRs.Public Health Implications. Conservatively, CPS investigates more than a quarter of children born in California for abuse or neglect. These data reinforce policy questions about the current scope and reach of our modern CPS.

Engaging Families in Voluntary Prevention Services to Reduce Future Child Abuse and Neglect: a Randomized Controlled Trial.

Research on secondary prevention is mixed as to whether referrals to evidence-based practices and other community interventions reduce maltreatment recidivism. This evaluation sought to rigorously assess whether a community service-linkage model to evidence-based programs decreased subsequent reports of abuse and neglect among families reported to the child protection system (CPS). Between 2016 and 2018, administrative CPS records were used to identify families with at least one child under 5 years of age recently reported for maltreatment in Orange County, California, but where no follow-up services were mandated. Families were randomized to one of two community outreach and engagement conditions (i.e., targeted provider outreach vs. treatment-as-usual). Re-reporting outcomes were tracked in administrative records for a period of 12 months. A total of 4873 families met eligibility criteria, with 2231 (45.0%) randomized to the intervention arm and 2642 (54.0%) families to the control group. Among families in the intervention group, 811 (36.4%) were successfully contacted by a community provider. Of those families contacted, 145 (18.0%) agreed to participate in voluntary services. Overall, we did not detect any significant difference in re-reporting between our treatment and control groups (P = .433). Likewise, no significant differences in re-reporting were observed when we stratified the treatment group by levels of outreach and service engagement. Findings indicate low levels of successful engagement of families in voluntary services. Notwithstanding the absence of significant findings, this study demonstrates the potential for using community-based RCTs and administrative records to rigorously evaluate secondary prevention programs in the child protection system.

Ethnic Disparities in Childhood Prevalence of Maltreatment: Evidence From a New Zealand Birth Cohort.

Objectives. To document ethnic disparities in childhood abuse and neglect among New Zealand children.Methods. We followed the 1998 New Zealand birth cohort of 56 904 children through 2016. We determined the cumulative childhood prevalence of reports to child protective services (CPS), substantiated maltreatment (by subtype), and out-of-home placements, from birth to age 18 years, by ethnic group. We also developed estimates stratified by maternal age and community deprivation levels.Results. We identified substantial ethnic differences in child maltreatment and child protection involvement. Both Maori and Pacific Islander children had a far greater likelihood of being reported to CPS, being substantiated as victims, and experiencing an out-of-home placement than other children. Across all levels of CPS interactions, rates of Maori involvement were more than twice those of Pacific Islander children and more than 3 times those of European children.Conclusions. Despite long-standing child support policies and reparation for breaches of Indigenous people's rights, significant child maltreatment disparities persist. More work is needed to understand how New Zealand's public benefit services can be more responsive to the needs of Indigenous families and their children.

Black-White Differences in Child Maltreatment Reports and Foster Care Placements: A Statistical Decomposition Using Linked Administrative Data.

Introduction Official statistics have confirmed that relative to their presence in the population and relative to white children, black children have consistently higher rates of contact with child protective services (CPS). We used linked administrative data and statistical decomposition techniques to generate new insights into black and white differences in child maltreatment reports and foster care placements. Methods Birth records for all children born in Allegheny County, Pennsylvania, between 2008 and 2010 were linked to administrative service records originating in multiple county data systems. Differences in rates of involvement with child protective services between black and white children by age 4 were decomposed using nonlinear regression techniques. Results Black children had rates of CPS involvement that were 3 times higher than white children. Racial differences were explained solely by parental marital status (i.e., being unmarried) and age at birth (i.e., predominantly teenage mothers). Adding other covariates did not capture any further racial differences in maltreatment reporting or foster care placement rates, they simply shifted differences already explained by marital status and age to these other variables. Discussion Racial differences in rates of maltreatment reports and foster care placements can be explained by a basic model that adjusts only for parental marital status and age at the time of birth. Increasing access to early prevention services for vulnerable families may reduce disparities in child protective service involvement. Using birth records linked to other administrative data sources provides an important means to developing population-based research.

A Retrospective Examination of Child Protection Involvement Among Young Adults Accessing Homelessness Services.

Childhood maltreatment is associated with a variety of young adult adversities including homelessness. This study used linked administrative records to develop a population-level, epidemiological characterization of the child protection histories of young adults accessing homelessness services. The records of all 17- to 24-year-olds receiving homeless services between 2011 and 2014 in San Francisco County, California (n = 2241) were probabilistically linked to statewide child protective service (CPS) records. Findings document that 50.0% of young adults had been reported for maltreatment at least once during childhood, yet the prevalence of past CPS involvement varied across demographic and child welfare characteristics. Homeless female youth were significantly more likely to have a CPS history than male youth (58.1% vs. 41.5%). Nearly twice as many Black clients accessing homelessness services had a CPS history as did White clients (59.8% vs. 31.8%). Roughly half (47.3%) of those with a childhood history of reported maltreatment had been last reported for maltreatment in another California county. Targeting services that address past trauma and instability among homeless young adults may be justified given the prevalence of CPS history in this population.

A population-level and longitudinal study of adolescent mothers and intergenerational maltreatment.

For teenage mothers in California, we generated population-level estimates of the relationship between maternal history of maltreatment and next-generation abuse and neglect. California birth records for all infants born to primiparous teen mothers in 2006 or 2007 were linked to statewide child protective services (CPS) records. For each birth, we used CPS records to document 1) whether the teen mother had a history of reported or substantiated maternal maltreatment at or after age 10 years and before the estimated date of conception and 2) whether the teen's child was reported or substantiated for maltreatment before age 5 years. We fitted multivariable survival models to examine the association between a teenage mother's CPS involvement and child maltreatment, after adjusting for a range of sociodemographic variables. Our final data set included 85,084 births to first-time mothers aged 15-19 years. Significantly heightened rates of abuse and neglect were observed for children of mothers who had been reported to CPS as possible victims of maltreatment (P < 0.001). After adjustment for other risk factors, a maternal history of either unsubstantiated (hazard ratio = 2.19, 95% confidence interval: 2.06, 2.33) or substantiated (hazard ratio = 3.19, 95% confidence interval: 3.00, 3.39) maltreatment emerged as a strong predictor of maltreatment and CPS involvement in the next generation.

Disparities in reported and substantiated infant maltreatment by maternal Hispanic origin and nativity: a birth cohort study.

We followed Latino infants prospectively through age 1 to determine whether maternal foreign-born status conferred a protective advantage against reported and substantiated maltreatment across Hispanic-origin groups, and whether the likelihood an infant was reported or substantiated for maltreatment varied by Hispanic origin. We drew data for all Latino infants born in California between 2000 and 2006 (N = 1,909,155) from population-based birth records linked to child protective services data. We used χ(2) tests to assess distributional differences in covariates and utilized generalized linear models to estimate the adjusted relative risk of report and substantiation in models stratified by nativity. We observed significant health advantages in reported and substantiated maltreatment for infants of foreign-born mothers within every Hispanic-origin group. Risks of report and substantiation among infants of Mexican and Central/South American mothers were consistently lower than Puerto Rican and Cuban mothers despite socioeconomic disadvantage. The presence of disparities among Hispanic-origin groups in child maltreatment report and substantiation during infancy has implications for the health of Latinos across the life course. Further research is warranted to unravel the complex processes underlying observed relationships.

A prospective study of sudden unexpected infant death after reported maltreatment.

OBJECTIVE: To examine whether infants reported for maltreatment face a heightened risk of sudden infant death syndrome (SIDS) and other leading causes of sudden unexpected infant death (SUID). STUDY DESIGN: Linked birth and infant death records for all children born in California between 1999 and 2006 were matched to administrative child protection data. Infants were prospectively followed from birth through death or 1 year of age. A report of maltreatment was modeled as a time-varying covariate; risk factors at birth were included as baseline covariates. Multivariable competing risk survival models were used to estimate the adjusted relative hazard of postneonatal SIDS and other SUID. RESULTS: A previous maltreatment report emerged as a significant predictor of SIDS and other SUID. After adjusting for baseline risk factors, the rate of SIDS was more than 3 times as great among infants reported for possible maltreatment (hazard ratio: 3.22; 95% CI: 2.66, 3.89). CONCLUSION: Infants reported to child protective services have a heightened risk of SIDS and other SUID. Targeted services and improved communication between child protective services and the pediatric health care community may enhance infant well-being and reduce risk of death.

What Does Child Protective Services Investigate as Neglect? A Population-Based Study.

Most child protective services (CPS) investigations involve allegations of neglect. Broad and vague definitions have led to concerns that CPS-investigated neglect is driven by poverty-based material hardship. In a representative sample of 295 neglect investigations in California in 2017, structured data and narrative text fields were used to characterize the types of neglect and concurrent parental risk factors investigated by CPS and to assess the rate and nature of investigated physical neglect, defined as inadequate food, housing, or hygiene. The most common types of neglect were inadequate supervision (44%) and failure to protect (29%), followed by physical neglect (14%). Common risk factors identified in neglect investigations were parental substance use (41%), domestic violence (21%), mental illness (18%), and co-reported physical or sexual abuse (29%). Nearly all investigations of physical neglect (99%) included concerns related to substance use, domestic violence, mental illness, co-reported abuse or an additional neglect allegation (i.e., abandonment). Given concerns identified in neglect investigations, economic supports are likely insufficient without an array of behavioral-health supports.

Rates of Emotional Disturbance Among Children in Foster Care: Comparing Federal Child Welfare Data and Medicaid Records in Two States.

The purpose of this study is to estimate the rate of emotional disturbance (ED) among children in foster care and assess the validity of the national foster care census data (AFCARS) measure of ED. This study used linked child protection and Medicaid records from 2014 and 2015, for the states of California and Wisconsin, as well as data from AFCARS, a federal population census of children in foster care which states are mandated to contribute to. ED is defined by AFCARS and includes an array of mental and behavioral health diagnoses. According to AFCARS, 13% of CA children in foster care and 15% of WI children in foster care had an ED, whereas Medicaid claims produce rates of 45% and 48%, respectively. Rates of ED among children in congregate care were underestimated by 43-46 percentage points, with substantial proportions having diagnoses of disruptive behavioral disorders. Despite the AFCARS ED measure being cited in congressional testimonies and its wide use in research, results from this study suggest that the AFCARS ED estimates are an unreliable metric for use in research, policy, or practice.

Child Protection System Removal and Short-Interval Births Among Individuals With Prenatal Substance Use.

Child protection systems often intervene after substance-exposed births but are not designed to address the postpartum needs of the delivering parent. In this retrospective cohort study, we aimed to estimate the association between early child protection system removal and high-risk subsequent birth trajectories among a cohort of mothers with substance-exposed births in California. Of 6,893 births in 2015 with documented prenatal drug and alcohol exposure, 20.4% of mothers experienced child protection system removal within 30 days after birth. First-month child protection system removal was associated with short-interval birth (adjusted hazard ratio [HR] 1.61, 95% CI, 1.09-2.36) and short-interval birth with documentation of substance exposure (adjusted HR 3.17, 95% CI, 1.65-6.08). We found that child separation was associated with an increase, not a reduction, in subsequent substance-exposed births. These findings indicate the need for focused public health and supportive services to address the treatment, health care, family-building, and psychological needs of parents with substance use during pregnancy.

A Longitudinal Study of Health Care Utilization Among Infants Investigated for Maltreatment.

OBJECTIVE: To evaluate whether maltreatment investigated during infancy affects high-acuity health care utilization patterns during early childhood. METHODS: Retrospective case-control study based on linked data between child protection and hospital encounter records conducted to review health records of infants investigated for abuse and/or neglect. Cases and controls were followed longitudinally through the Rady Children's Hospital electronic health records for 4 years starting at the age of 1 year. RESULTS: A total of 3692 children were investigated for maltreatment within the first year of life. When comparisons were made between children reported for maltreatment and matched controls, children with infancy maltreatment reports had significantly more high-acuity health care encounters than matched controls (average treatment effect = 1.53, 95% Confidence Interval 1.08-1.99, P < .001). CONCLUSIONS: Infants investigated for maltreatment have greater high-acuity health care utilization in early childhood. These findings highlight this population's need for well-defined medical homes to ensure appropriate health care. Further understanding of the underlying reasons for this increased health care burden will help inform these efforts.