Interrater reliability of the violence risk assessment checklist for youth: a case vignette study.

BACKGROUND: Facilities providing health- and social services for youth are commonly faced with the need for assessment and management of violent behavior. These providers often experience shortage of resources, compromising the feasibility of conducting comprehensive violence risk assessments. The Violence Risk Assessment Checklist for Youth aged 12-18 (V-RISK-Y) is a 12-item violence risk screening instrument developed to rapidly identify youth at high risk for violent behavior in situations requiring expedient evaluation of violence risk. The V-RISK-Y instrument was piloted in acute psychiatric units for youth, yielding positive results of predictive validity. The aim of the present study was to assess the interrater reliability of V-RISK-Y in child and adolescent psychiatric units and acute child protective services institutions. METHODS: A case vignette study design was utilized to assess interrater reliability of V-RISK-Y. Staff at youth facilities (N = 163) in Norway and Sweden scored V-RISK-Y for three vignettes, and interrater reliability was assessed with the intraclass correlation coefficient (ICC). RESULTS: Results indicate good interrater reliability for the sum score and Low-Moderate-High risk level appraisal across staff from the different facilities and professions. For single items, interrater reliability ranged from poor to excellent. CONCLUSIONS: This study is an important step in establishing the psychometric properties of V-RISK-Y. Findings support the structured professional judgment tradition the instrument is based on, with high agreement on the overall risk assessment. This study had a case vignette design, and the next step is to assess the reliability and validity of V-RISK-Y in naturalistic settings.

Primary Care Interventions to Prevent Child Maltreatment: Evidence Report and Systematic Review for the US Preventive Services Task Force.

Importance: Child maltreatment is associated with serious negative physical, psychological, and behavioral consequences. Objective: To review the evidence on primary care-feasible or referable interventions to prevent child maltreatment to inform the US Preventive Services Task Force. Data Sources: PubMed, Cochrane Library, and trial registries through February 2, 2023; references, experts, and surveillance through December 6, 2023. Study Selection: English-language, randomized clinical trials of youth through age 18 years (or their caregivers) with no known exposure or signs or symptoms of current or past maltreatment. Data Extraction and Synthesis: Two reviewers assessed titles/abstracts, full-text articles, and study quality, and extracted data; when at least 3 similar studies were available, meta-analyses were conducted. Main Outcomes and Measures: Directly measured reports of child abuse or neglect (reports to Child Protective Services or removal of the child from the home); proxy measures of abuse or neglect (injury, visits to the emergency department, hospitalization); behavioral, developmental, emotional, mental, or physical health and well-being; mortality; harms. Results: Twenty-five trials (N = 14 355 participants) were included; 23 included home visits. Evidence from 11 studies (5311 participants) indicated no differences in likelihood of reports to Child Protective Services within 1 year of intervention completion (pooled odds ratio, 1.03 [95% CI, 0.84-1.27]). Five studies (3336 participants) found no differences in removal of the child from the home within 1 to 3 years of follow-up (pooled risk ratio, 1.06 [95% CI, 0.37-2.99]). The evidence suggested no benefit for emergency department visits in the short term (<2 years) and hospitalizations. The evidence was inconclusive for all other outcomes because of the limited number of trials on each outcome and imprecise results. Among 2 trials reporting harms, neither reported statistically significant differences. Contextual evidence indicated (1) widely varying practices when screening, identifying, and reporting child maltreatment to Child Protective Services, including variations by race or ethnicity; (2) widely varying accuracy of screening instruments; and (3) evidence that child maltreatment interventions may be associated with improvements in some social determinants of health. Conclusion and Relevance: The evidence base on interventions feasible in or referable from primary care settings to prevent child maltreatment suggested no benefit or insufficient evidence for direct or proxy measures of child maltreatment. Little information was available about possible harms. Contextual evidence pointed to the potential for bias or inaccuracy in screening, identification, and reporting of child maltreatment but also highlighted the importance of addressing social determinants when intervening to prevent child maltreatment.

Identifying newborn discharge to child protective services: Comparing discharge codes from birth hospitalization records and child protection case files.

PURPOSE: Newborn removal by North America's child protective services (CPS) disproportionately impacts Indigenous and Black families, yet its implications for population health inequities are not well understood. To guide this as a domain for future research, we measured validity of birth hospitalization discharge codes categorizing newborns discharged to CPS. METHODS: Using data from 309,260 births in Manitoba, Canada, we compared data on newborns discharged to CPS from hospital discharge codes with the presumed gold standard of custody status from CPS case reports in overall population and separately by First Nations status (categorization used in Canada for Indigenous peoples who are members of a First Nation). RESULTS: Of 309,260 newborns, 4562 (1.48%) were in CPS custody at hospital discharge according to CPS case reports and 2678 (0.87%) were coded by hospitals as discharged to CPS. Sensitivity of discharge codes was low (47.8%), however codes were highly specific (99.8%) with a positive predictive value (PPV) of 81.4%, and a negative predictive value (NPV) of 99.2%. Sensitivity, PPV and specificity were equal for all newborns but NPV was lower for First Nations newborns. CONCLUSIONS: Canadian hospital discharge records underestimate newborn discharge to CPS, with no difference in misclassication based on First Nations status.

Disparities in Child Welfare Referrals for Patients Seen in a Pediatric Emergency Department for Unintentional Ingestions.

OBJECTIVE: To examine the characteristics of patients visiting the pediatric emergency department (PED) for unintentional ingestions and associations between patient race and ethnicity in referrals to Child Protective Services (CPS) for supervisory neglect. METHODS: We conducted a cross-sectional analysis of children <12 years old who presented to the PED between October 2015 and December 2020 for an unintentional ingestion. Patients were identified by searching the electronic health record for diagnosis codes corresponding to unintentional ingestions. Patient demographics, ingestion type, disposition, and referrals to CPS were abstracted by manual chart review. Logistic regression models were used to evaluate associations between patient demographics and visit characteristics with referral to CPS. RESULTS: We identified 129 PED encounters for unintentional ingestions that were included for analysis. Overall, 22 patients (17.1%) were referred to CPS for neglect. In the univariate analysis, both ingestion of an illicit drug and arrival to the PED by ambulance were associated with a higher odds of referral to CPS. In the multivariable model adjusted for parent language, ingestion type, and mode of arrival to the PED, Hispanic patients had higher odds of referral to CPS than White patients (adjusted odds ratio (aOR) = 17.2, 95% confidence intervals [1.8-162.3], P = .03). There was not a statistically significant association between Black race and referral to CPS. CONCLUSIONS: Referrals to CPS from the PED after unintentional ingestions are common and disproportionally involve Hispanic patients. More research is needed to promote equitable child maltreatment reporting for children presenting to the PED following unintentional ingestions.

Predictors of Making a Referral to Child Protective Services Prior to Expert Consultation.

OBJECTIVE: Suspicion for child abuse is influenced by implicit biases. Evaluation by a Child Abuse Pediatrician (CAP) may reduce avoidable child protective services (CPS) referrals. Our objective was to investigate the association of patient demographic, social and clinical characteristics with CPS referral before consultation by a CAP (preconsultation referral). METHODS: Children<5years-old undergoing in-person CAP consultation for suspected physical abuse from February 2021 through April 2022 were identified in CAPNET, a multicenter child abuse research network. Marginal standardization implemented with logistic regression analysis examined hospital-level variation and identified demographic, social, and clinical factors associated with preconsultation referral adjusting for CAP's final assessment of abuse likelihood. RESULTS: Among the 61% (1005/1657) of cases with preconsultation referral, the CAP consultant had low concern for abuse in 38% (384/1005). Preconsultation referrals ranged from 25% to 78% of cases across 10 hospitals (P < .001). In multivariable analyses, preconsultation referral was associated with public insurance, caregiver history of CPS involvement, history of intimate partner violence, higher CAP level of concern for abuse, hospital transfer, and near-fatality (all P < .05). The difference in preconsultation referral prevalence for children with public versus private insurance was significant for children with low CAP concern for abuse (52% vs 38%) but not those with higher concern for abuse (73% vs 73%), (P = .023 for interaction of insurance and abuse likelihood category). There were no differences in preconsultation referral based on race or ethnicity. CONCLUSIONS: Biases based on socioeconomic status and social factors may impact decisions to refer to CPS before CAP consultation.

Students' Risks for Out-of-School Suspensions: Indigenous Heritage and Child Protective Services Involvement.

Disproportionality in out-of-school suspensions (OSS) is a persistent social and racial justice issue. Available research indicates that Indigenous children are disproportionately represented in both OSS and the child protective services (CPS) system. This secondary data analysis followed a cohort of 3rd grade students (n = 60,025) in Minnesota public schools from 2008- 2014. It examined the relationship between CPS involvement, Indigenous heritage, and OSS. Results from a zero-inflated negative binomial regression indicated that Indigenous students had two times the odds of suspension compared to white students (OR = 2.06, p < .001). Furthermore, there was a significant interaction between CPS involvement and Indigeneity on frequency of OSS (OR = 0.88, p < .05). Indigenous students showed a much higher odds ratio of OSS compared to white students, but the distance between the odds ratios of the two groups decreased as the number of child maltreatment allegations increased. Indigenous students may experience relatively high levels of both CPS and OSS due to systematic racism. We discussed implications for practice and policy to reduce discipline disparities.

Poverty and Health Inequities in Children Investigated by Child Protective Services.

The objective of our study was to examine the association between poverty and child health outcomes in school-age children referred to child protective services. We conducted a secondary analysis of children aged 5 to 9 years in the Second National Survey of Child and Adolescent Well-Being, a nationally representative longitudinal observational data set of children referred to protective services for maltreatment (2008-2012). We analyzed the association of poverty, defined as family income below the federal poverty level (FPL), with caregiver report of the child's overall health, primary care, and emergency department visits using Pearson's chi-squared test. Children below FPL compared with children above it had poorer overall health (29.8% vs 18.0%, P = .03). We also conducted a longitudinal multivariable logistic regression analysis and found poverty was associated with the child's poorer overall health at 36 months (odds ratios 2.78, 95% confidence interval 1.55-5.01). Future studies and interventions to improve health in this at-risk population should target poverty.

Association of State Expansion of Supplemental Nutrition Assistance Program Eligibility With Rates of Child Protective Services-Investigated Reports.

Importance: States in the US have the option to eliminate the asset test and/or increase the income limit for Supplemental Nutrition Assistance Program (SNAP) eligibility under a policy called broad-based categorical eligibility (BBCE). Given associations of economic hardships, including food insecurity, with child protective services (CPS) involvement, state adoption of these policies may be associated with changes in rates of CPS-investigated reports. Objective: To examine the association of state elimination of the asset test and increases in the income limit for SNAP eligibility under BBCE with rates of CPS-investigated reports. Design, Setting, and Participants: This cross-sectional ecologic study used data from 2006 to 2019 obtained from the SNAP Policy Database and the National Child Abuse and Neglect Data System Child Files and difference-in-differences analyses. The data were analyzed from March to September 2022. The study used CPS-investigated reports for suspected child abuse and neglect from 37 US states to examine elimination of the asset test, from 36 states to examine increases in the income limit, and from 26 states to examine adoption of both policies. Exposures: State elimination of the asset test, increases in the income limit, and adoption of both policies to expand SNAP eligibility. Main Outcomes and Measures: Number of CPS-investigated reports, overall and specifically for neglect and physical abuse, per 1000 child population. Results: From 2006 to 2019 for all 50 states and the District of Columbia, there were a total of 29 213 245 CPS-investigated reports. By race and ethnicity, 19.8% of CPS-investigated reports were among non-Hispanic Black children and 45.7% among non-Hispanic White children (hereafter referred to as Black and White children). On average, there were 8.2 fewer CPS-investigated reports (95% CI, -12.6 to -4.0) per 1000 child population per year in states that eliminated the asset test, 5.0 fewer CPS-investigated reports (95% CI, -10.8 to 0.7) per 1000 child population per year in states that increased the income limit, and 9.3 fewer CPS-investigated reports (95% CI, -15.6 to -3.1) per 1000 child population per year in states that adopted both SNAP policies than there would have been if these states had not adopted these policies. There were decreases in CPS-investigated reports for neglect in states that adopted either or both policies, and small decreases in CPS-investigated reports for physical abuse in states that increased the income limit or adopted both policies. There were decreases in CPS-investigated reports among both Black and White children. For example, there were 6.5 fewer CPS-investigated reports among Black children (95% CI, -14.6 to 1.6) and 8.7 fewer CPS-investigated reports among White children (95% CI, -15.8 to -1.6) in states that adopted both SNAP policies than there would have been if these states had not adopted these policies. Conclusions and Relevance: Results from this cross-sectional study suggest that state expansion of SNAP eligibility through elimination of the asset test and increases in the income limit may contribute to decreases in rates of CPS-investigated reports. These results can inform ongoing debates regarding SNAP policy options, specifically BBCE, and prevention efforts for child abuse and neglect.

Inequities in Child Protective Services Contact Between Black and White Children.

Child protective services (CPS) contact occurs at substantially higher rates among Black than White families. The present study considers systemic racism as a central driver of this disparity and emphasizes racialized poverty as a possible mechanism. We used data from the Fragile Families and Child Wellbeing Study and logistic regression analyses to assess the associations between income poverty, a racialized experience, and CPS contact, separately among Black and White families. Results indicated that income poverty was a significant predictor of CPS contact among White families, who were protected by higher income. In contrast, income per se was not a significant predictor of CPS contact among Black families, who were instead impacted by racialized family regulation and consequences of poverty, such as poor health and depression. Refundable state Earned Income Tax Credit (EITC) policies were protective for Black families, and more expansive Temporary Assistance for Needy Families (TANF) programs decreased CPS contact for Black and White families. Implications include centering systemic racism and specifically racialized poverty as causes of racial inequities in CPS contact and rethinking the role of CPS in protecting children.

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.

Associations Between State TANF Policies, Child Protective Services Involvement, And Foster Care Placement.

The Temporary Assistance for Needy Families (TANF) program, which was established in 1996 and renewed in 2005, constituted a major reform of the US welfare system. Since its renewal, few studies have examined its effects on children. We used instrumental variables, two-way fixed effects, and event studies to examine the associations between state-level TANF policies, Child Protective Services involvement, and foster care placement during the period 2004-16. We found that each additional TANF policy that restricted access to benefits was associated with a 13 percent reduction in TANF caseloads. Using TANF policies as an instrument, we found that increases in TANF caseloads were associated with significant reductions in numbers of neglect victims and foster care placements. In two-way fixed effects models, restrictions on TANF access were associated with more than forty-four additional neglect victims per 100,000 child population and between nineteen and twenty-two additional children per 100,000 placed in foster care. Our findings suggest that additional research using data that capture the nuances of maltreatment should be used to investigate the relationships among TANF policies, child maltreatment, and foster care placement.

Social Determinants of Health and Child Maltreatment Prevention: The Family Success Network Pilot.

Child maltreatment is a highly prevalent public health concern that contributes to morbidity and mortality in childhood and short- and long-term health consequences that persist into adulthood. Past research suggests that social determinants of health such as socioeconomic status and intergenerational trauma are highly correlated with child maltreatment. With support from the U.S. Children's Bureau, the Ohio Children's Trust Fund is currently piloting the Family Success Network, a primary child maltreatment prevention strategy in Northeast Ohio that seeks to address these social determinants through pillars of service that include family coaching, financial assistance, financial education, parenting education, and basic life skills training. This study highlights the initial development phase of a pilot study. Plans for in-depth process and outcome evaluations are discussed. The project seeks to improve family functioning and reduce child protective services involvement and foster care entry in an economically disadvantaged region.

The evidence base for risk assessment tools used in U.S. child protection investigations: A systematic scoping review.

BACKGROUND: Child protective services (CPS) agencies use risk assessment tools to augment decision making about alleged child maltreatment. Under the Family First Prevention Services Act, states and tribes are permitted to claim federal reimbursement for prevention services for children at imminent risk of entering foster care based on assessment tools and protocols. In this context, existing tools are being repurposed. It is critical to reassess the evidence supporting their use. OBJECTIVE: We aimed to synthesize the evidence pertaining to validity and reliability of specific risk assessment tools designed for CPS agencies, summarize how this work has been carried out, and review the conceptual dimensions of risk included in each tool. PARTICIPANTS AND SETTING: We included United States-based, quantitative evaluations of risk assessment tools published between 1990 and May 2021. METHODS: We carried out a scoping review using a protocol in alignment with PRISMA-ScR. We used a multiphase selective screening approach with at least two screeners. RESULTS: In total, 25 studies met inclusion criteria. Overall, research about the validity and reliability of risk assessment tools is dated and heterogeneous in methodology. The conceptualizations of risk assessment and the operationalization of risk also varied widely. There was a general dearth of evidence that supported the use of tools across demographic subgroups. CONCLUSIONS: Heterogeneity of studies assessing tool validity and reliability suggests a lack of agreement about how to assess tools and makes it difficult to interpret findings across studies. Agencies should be cautious about overreliance on tools for which evidence is limited.

Collective value of Abiriwatia and protective informal social control of child neglect: Findings from a Nationally Representative Survey in Ghana.

Evidence of the protective role of informal social control by community members (family members, friends, and neighbours) in child neglect has received considerable attention. Likewise, the protective effects of informal social control interventions in neglect are theorised to be common and highly efficacious in communities that have sanctioned informal interventions through collective social values and norms. Yet, no research has examined this theoretical postulation within the field of community/neighbourhood research in child maltreatment. We tested the theory-driven hypothesis by examining the interaction effects of protective informal social control of neglect and the collective value of Abiriwatia (a collective value based on lineage with norms on collective childcare duties) against the frequency of child neglect. Data consist of 616 caregivers' self-report of child neglect in the past year, from the Ghana Families and Neighbourhood Study. Hypotheses were tested using random effects regression models with standard errors corrected for settlement/community clusters. Protective informal social control of child neglect was significantly associated with fewer neglect in the past year (B = -0.79, p < 0.05). The interaction between protective informal social control of child neglect and the collective value of Abiriwatia was negative (B = -0.07, p < 0.05). The findings suggest that strengthening the collective normative commitment to childcare would promote family members' intervention to protect against neglect situations, and their intervention can deter further acts of neglect. Community neglect prevention programmes should take advantage of the findings to strengthen community norms that sanction collective childcare duties. Community child protection committees of the Department of Social Welfare should develop social groups and informal associations to strengthen Abiriwatia in Ghana.

Association Between State Supplemental Nutrition Assistance Program Policies, Child Protective Services Involvement, and Foster Care in the US, 2004-2016.

Importance: Public assistance policies may play a role in preventing child maltreatment by improving household resources among families of low incomes. The Supplemental Nutrition Assistance Program (SNAP) is one of the largest public assistance programs in the US. However, the association of state SNAP policy options to Child Protective Services (CPS) outcomes has not been rigorously examined. Objective: To model the association of state SNAP policies with changes in CPS and foster care outcomes in the US over time. Design, Setting, and Participants: This cohort study used panel data to examine the association between SNAP policy options and study outcomes from 2004 to 2016 for 50 US states and the District of Columbia in 2-way fixed-effects regression models. The count of SNAP policies was used as an instrument for SNAP caseloads in instrumental variables models. Data analysis was conducted in November 2021. Exposures: The adoption of 1 or more state SNAP income generosity policies that improves or stabilizes household resources for SNAP participants. Main Outcomes and Measures: Reports of child maltreatment accepted for CPS investigation, children in substantiated reports, and children receiving foster care services for all forms of maltreatment, and specifically for child neglect per 100 000 child population. Results: The mean (SD) number of SNAP income generosity policies increased from 1.47 (0.95) in 2004 to 2.37 (0.94) in 2010, to 2.49 (0.86) in 2016 across states; the median increased from 1 to 3 (range, 0-4) over the same period. A count of state income generosity policies was associated with large reductions in reports accepted for CPS investigation (-352.6 per 100 000 children; 95% CI, -557.1 to -148.2). Income generosity policy was associated with -94.8 (95% CI, -155.6 to -34.0) fewer substantiated reports and -77.0 (95% CI, -125.4 to -28.6) fewer reports substantiated for neglect per 100 000. Each additional income generosity policy adopted by a state was associated with -45.1 (95% CI, -71.6 to -18.5) to -42.3 (95% CI, -64.8 to -19.8) fewer total foster care placements per 100 000 children. Conclusions and Relevance: State SNAP policies that improve and stabilize household resources appear to be associated with reductions in CPS involvement and use of foster care. The number of policies implemented had cumulative outcomes beyond individual policy outcomes.

Association between U.S. state prenatal drug use laws and child welfare reporting in Alabama, Maryland and Utah.

BACKGROUND: Over the past decade, states have passed several laws on prenatal drug use, including "maltreatment laws" deeming prenatal drug use child maltreatment, "reporting laws" requiring providers to report prenatal drug use to Child Protective Services (CPS) and "criminalization laws" that criminalize prenatal drug use. METHOD: We examined the association between a 2012 Utah maltreatment law, a 2013 Alabama maltreatment and criminalization law, and a 2014 Maryland reporting law on the rate of infant CPS reports using 2010-2017 National Child Abuse and Neglect Data System data. We conducted an event study comparing CPS reporting pre/post law in each treatment state with reporting in a pool of control states over the same period. Regression models included state and year fixed effects and state-level demographics. We triangulated quantitative results with qualitative interviews of 11 state leaders whose professional responsibilities included implementation of the state law. RESULTS: We found no association between Alabama's simultaneous maltreatment and criminalization laws and infant reporting. Maryland's reporting law (28.2 fewer reports per 1000 infants, 95%CI: [-42.9, -13.6], 4-years post-law) and Utah's maltreatment laws (31.0 fewer CPS reports per 1000 infants, 95%CI: [-61.2, -0.8], 6-years post-law) were associated with declines in infant CPS reports. Qualitative results suggest that the reduced reporting associated with Maryland's reporting and Utah's maltreatment laws may be due to increased perceived stigma resulting from the law, and health providers' distrust of CPS and/or confusion about reporting to CPS. CONCLUSION: Future research should characterize differential policy implementation across states and counties and identify policy impacts on treatment seeking behavior.

Racial/ethnic and gender disparities in child protection decision-making: What role do stereotypes play?

BACKGROUND: A wide range of studies have revealed racial/ethnic and gender disparities in child protection decision-making. OBJECTIVE: This study investigated whether disparities are mediated by stereotypes that professionals may hold, by applying the Stereotype Content Model (SCM) which suggests that stereotypes are formed by perceptions of sociability, morality, and competence. PARTICIPANTS AND SETTING: 258 professionals (133 current staff and 125 trainees) from Colorado participated in the study. METHODS: The study applied a 2 × 3 randomized experimental vignette design. Participants read a case in which the gender of the parent responsible for maltreatment (mother or father) and race/ethnicity of the family (white, Black, or Latinx) varied. RESULTS: A SEM model (CFI = .94, RMSEA = .05) with free parameters for trainees and current staff was estimated. No significant association between stereotypes and race/ethnicity and gender appeared. However, evidence for disparities emerged. In the trainee group, scores to decide for a supervision order were higher for white fathers, Black mothers, Latinx mothers, and Latinx fathers (ß = 0.18 to 0.25) compared to white mothers. Current staff provided larger risk scores for Black mothers and both Latinx parents (ß = 0.20 to 0.22) compared to the white mother, resulting in increased inclinations to decide for a supervision order (ß = 0.26). Lastly, negative perceptions of morality increased supervision order scores (ß = -0.55 to -0.36). CONCLUSIONS: Evidence for disparities in decision-making appeared, but the study could not confirm that these disparities were mediated by stereotypes. Furthermore, perceptions of morality seemed to impact decision-making processes.

Public health nurses' perceptions of their interactions with child protection services when supporting socioeconomically disadvantaged young mothers in British Columbia, Canada.

BACKGROUND: Children of girls and young women experiencing socioeconomic disadvantage are at risk of maltreatment and associated health and developmental problems. Nurse-Family Partnership (NFP) is an early intervention program designed to improve child and maternal health outcomes. The effectiveness of NFP is being evaluated in British Columbia (BC) through a randomized controlled trial, augmented by a process evaluation to identify influences on how NFP was implemented. OBJECTIVE: To describe how public health nurses providing NFP perceived their interactions with child protection professionals. PARTICIPANTS AND SETTING: Forty-seven public health nurses across BC. METHODS: The principles of interpretive description informed the qualitative component of the process evaluation. Data from interviews and focus groups were analyzed using the framework analysis approach. A thematic framework was generated through processes of coding, charting and mapping, with a focus on organizational and systems influences. RESULTS: Nurses' practice in supporting families often involved engagement with child protection services. Four themes about the nature of this work were identified: 1) developing a deeper understanding of the disciplinary perspectives of child protection, 2) striving for strengthened collaboration, 3) navigating change and uncertainty, and 4) responding to family and community complexity. CONCLUSIONS: Participants valued the contribution of child protection professionals and expressed willingness to collaborate to support families. However, collaboration was constrained by multiple structural barriers. Collaborative models offer possibilities for integrated practice, although can be difficult to implement within current health and child protection systems and child protection regulatory contexts.

Child Protective Services Referral in a Cleft Lip and/or Palate Population: Assessment of Prevalence, Indications, and Outcomes.

OBJECTIVE: To determine the prevalence of, reasons for, and outcomes related to Child Protective Services (CPS) referral in an isolated and syndromic cleft lip/palate population. DESIGN: Retrospective cohort study. SETTING: Tertiary Children's Hospital. PATIENTS: Any patient <18 years of age attending the multidisciplinary cleft team for care at our institution with a history of referral to CPS by the cleft team during the study period 2009 to 2014. MAIN OUTCOME MEASURES: The number of children with CPS referrals, reasons for CPS referrals, outcomes of CPS referrals, associated psychosocial risk factors potentially predictive of CPS referral; demographics and cleft-related surgical history was also reviewed for each patient. RESULTS: Of 1392 patients, 25 (1.8%) were identified with a history of referral to CPS. Average age at referral was 11 months; 76.0% of patients were <1 year of age. Most referrals (64.0%) were directly associated with issues related to cleft care. Identified psychosocial risk factors included financial strain, mental illness/cognitive disability, transportation issues, and inadequate social support. Nine families ultimately lost custody of their children temporarily (n = 5) or permanently (n = 4). CONCLUSIONS: Cleft team family referral to CPS involves long-term patient care challenges requiring maximal medical and social support. Families are most commonly referred for issues related to medical neglect, which can lead to failure to thrive, delays in care, and ultimate removal from the home. Identifying families with known psychosocial risk factors and providing increased support may potentially help avoid referrals to CPS.

Economic instability and child maltreatment risk: Evidence from state administrative data.

BACKGROUND: The effects of economic instability and the role of economic conditions preceding child protective services (CPS) involvement have not been fully considered in the child welfare literature. OBJECTIVE: This paper investigates the link between earnings instability and CPS involvement. Specifically, it examines whether adequate access to safety net programs mitigates the likelihood of child welfare involvement when families encounter negative earnings shocks. METHODOLOGY: The study used quarterly administrative data from a sample of at-risk families for CPS involvement in Wisconsin. Event history analysis was employed to estimate the relationship between earnings instability and subsequent child maltreatment investigations. RESULT: Experiencing a negative earnings shock of 30% or more increases the likelihood of CPS involvement by approximately 18%. The effect diminishes and becomes nonsignificant when an earnings decline is compensated by benefit receipt. Each additional earnings drop is associated with a 15% greater likelihood of CPS involvement. Each consecutive quarter with stable income is associated with 5% lower probability of a CPS report. The results are more pronounced for abuse than neglect and are marginally significant for neglect reports. CONCLUSION: Unfavorable economic instability is linked to greater CPS-involvement risk, particularly for child abuse. Moreover, accessing sufficient social benefits as supplemental income when negative earnings shocks occur serves to effectively buffer against the risk of child maltreatment, particularly among families with young children (ages 0-4).