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.

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.

Child protective services involvement and exclusionary school discipline.

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

Contact with Child Protective Services is pervasive but unequally distributed by race and ethnicity in large US counties.

This article provides county-level estimates of the cumulative prevalence of four levels of Child Protective Services (CPS) contact using administrative data from the 20 most populous counties in the United States. Rates of CPS investigation are extremely high in almost every county. Racial and ethnic inequality in case outcomes is large in some counties. The total median investigation rate was 41.3%; the risk for Black, Hispanic, and White children exceeded 20% in all counties. Risks of having a CPS investigation were highest for Black children (43.2 to 72.0%). Black children also experienced high rates of later-stage CPS contact, with rates often above 20% for confirmed maltreatment, 10% for foster care placement, and 2% for termination of parental rights (TPR). The only other children who experienced such extreme rates of later-stage CPS interventions were American Indian/Alaska Native children in Middlesex, MA; Hispanic children in Bexar, TX; and all children except Asian/Pacific Islander children in Maricopa, AZ. The latter has uniquely high rates of late-stage CPS interventions. In some jurisdictions, such as New York, NY, (0.2%) and Cook, IL (0.2%), very few children experienced TPR. These results show that early CPS interventions are ubiquitous in large counties but with marked variation in how CPS systems respond to these investigations.

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.

Major findings from the Ontario Incidence Study of Reported Child Abuse and Neglect 2018.

BACKGROUND: The Ontario Incidence Study of Reported Child Abuse and Neglect (OIS) is the only source of province-wide statistics on families investigated by child welfare. OBJECTIVE: This paper presents key findings from the 2018 cycle of the OIS (OIS-2018) and highlights select policy and practice implications of these findings. PARTICIPANTS AND SETTINGS: The OIS-2018 captured information directly from investigating child protection workers about children and families who were the subject of a child protection investigation sampled for inclusion in the study. METHODS: The OIS-2018 sample was drawn in three stages: first, a representative sample of child welfare agencies in Ontario was selected, then cases were sampled over a three-month period within selected agencies, and, finally, investigations that met the study criteria were identified from the sampled cases. The data collected for the OIS-2018 were weighted in order to derive provincial, annual incidence estimates. RESULTS: An estimated 158,476 child maltreatment-related investigations were conducted in Ontario in 2018. In the majority of investigations, there was no documented physical or emotional harm to the child. The overall incidence of investigations remains unchanged between 2008 and 2018. The only statistically significant difference during this time period is an increase in risk investigations between 2013 and 2018. CONCLUSIONS: Data from the OIS gives Ontario child welfare policymakers and practitioners an empirical basis for making evidence-informed decisions. Findings are compared to the United States and Australia.

Incidence and neighborhood-level determinants of child welfare involvement.

BACKGROUND: Child maltreatment is a global public health issue that has been linked with multiple negative health and life outcomes. OBJECTIVE: This study evaluates the association between children placed in out-of-home care and neighborhood-level factors using eight years of administrative data. PARTICIPANTS AND SETTING: Between 2011-2018, 33,890 unique instances of child welfare involvement were captured in a department of child and family services database in a southern state in the United States. METHODS: Removal addresses were geocoded and linked to the U.S. Census Bureau's American Community Survey to obtain census tract socioeconomic factors. Incidence overall and stratified by individual and neighborhood-level factors was computed. Rate ratios, relative indexes of inequality, and concentration curves quantified disparities in incidence of child welfare involvement by neighborhood-level factors. RESULTS: Incidence of children less than 19 years old placed into out-of-home care was 255 per 100,000 person-years (95 % CI: 252, 258). At the individual level, incidence was highest among children <5 and 15-17 years old, comparable between male and female children, and higher among Black children. At the neighborhood level, incidence was highest in census tracts with lower median household incomes, higher percentages of households below poverty or of female-headed or single-parent households, higher unemployment rates, and fewer residents with some college education or health insurance. CONCLUSIONS: Incidence of children placed into out-of-home care is disproportionally higher for those who live in disadvantaged communities. Understanding neighborhood-level risk factors that may be linked to child welfare involvement can help inform policy and target prevention efforts.

Characterizing newborn and older infant entries into care in England between 2006 and 2014.

BACKGROUND: The risk of entry to state care during infancy is increasing, both here in England and abroad, with most entering within a week of birth ('newborns'). However, little is known about these infants or of their pathways through care over early childhood. OBJECTIVE: To characterize infant entries to care in England. PARTICIPANTS AND SETTING: All children in England who first entered care during infancy, between April 2006 and March 2014 (n = 42,000). METHODS: We compared sociodemographic and care characteristics for infants entering care over the study period by age at first entry (newborn: <1wks, older infant 1-51wks). Among those who entered before April 2010, we further characterized care over follow-up (i.e. 4 years from first entry) and employed latent class analysis to uncover any common pathways through care. RESULTS: Almost 40 % of infants first entered care as a newborn. Most infants first entered care under s 20 arrangements (i.e. out-of-court, 60 % of newborns vs 47 % of older infants). Among infants entering before April 2010, most were adopted over follow-up (60 % vs 37 %), though many were restored to parental care (20 % vs 32 %) or exited care to live with extended family (13 % vs 19 %). One in six infants (17.7 %) had particularly unstable care trajectories over early childhood, typified by three or more placements or failed reunification. CONCLUSIONS: Evidence-based strengthening of pre-birth social work support is needed to improve preventive interventions before birth, to more effectively target infant placement into care. Linkages between child protection records and information on parents are needed to inform preventive strategies.

Data-informed recommendations for services providers working with vulnerable children and families during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic and associated response measures have led to unprecedented challenges for service providers working with vulnerable children and families around the world. OBJECTIVE: The goal of the present study was to better understand the impact of the pandemic and associated response measures on vulnerable children and families and provide data-informed recommendations for public and private service providers working with this population. PARTICIPANTS AND SETTING: Representatives from 87 non-government organizations (NGOs) providing a variety of direct services (i.e. residential care, family preservation, foster care, etc.) to 454,637 vulnerable children and families in 43 countries completed a brief online survey. METHODS: Using a mixed methods design, results examined 1) ways in which children and families have been directly impacted by COVID-19, 2) the impact of the pandemic on services provided by NGOs, 3) government responses and gaps in services for this population during the pandemic, and 4) strategies that have been effective in filling these gaps. RESULTS: Data revealed that the pandemic and restrictive measures were associated with increased risk factors for vulnerable children and families, including not having access to vital services. The NGOs experienced government restrictions, decreased financial support, and inability to adequately provide services. Increased communication and supportive activities had a positive impact on both NGO staff and the families they serve. CONCLUSIONS: Based on the findings, ten recommendations were made for service providers working with vulnerable children and families during the COVID-19 pandemic.

Inequalities in educational outcomes in individuals with childhood experience of out-of-home care: What are driving the differences?

BACKGROUND: Prior research has shown that individuals with experience of out-of-home care (foster family care or residential care) in childhood are educationally disadvantaged compared to their peers. In order to be better equipped to design interventions aimed at improving the educational outcomes of children for whom society has assumed responsibility, this study seeks to further our understanding about which factors that contribute to the educational disparities throughout the life course. METHODS: Using longitudinal data from a cohort of more than 13,000 Swedes, of which around 7% have childhood experience of out-of-home care, Peters-Belson decomposition is utilized to quantify the extent to which the gap in educational achievement in school (age 16) and midlife educational attainment (age 50) captures differences in the prevalence of factors influencing educational outcomes, and differences in the impacts between these factors. RESULTS: We find that the achievement and the attainment gap was around 13% and 9% respectively. These gaps were to a large extent explained by differences in the distribution of predictors. The major explanatory factor for placed children's lower achievement was a lower average cognitive ability. Yet there were some evidence that the rewards of cognitive ability in these children differed across the life course. While the lower returns of cognitive ability suggest that they were underperforming in compulsory school, the higher returns of cognitive ability on midlife attainment indicate that-given previous underperformance-their attainment at age 50 reflects their cognitive capacity more accurately than their achievement at age 16 do. CONCLUSION: The large influence of the unequal distribution of predictors suggests that policy efforts are needed to promote equity in the distribution of factors contributing to educational achievement and attainment. Since cognitive ability was found to be an important contributory factor, such efforts may include promoting cognitive and intellectual development among children in out-of-home care, preferably starting at a young age.

Residential instability, running away, and juvenile detention characterizes commercially sexually exploited youth involved in Washington State's child welfare system.

BACKGROUND: Federal policy in 2015 expanded the definition of "child abuse" to include human trafficking. As a result, child welfare agencies are newly responsible for identifying and providing services for youth in state care who are or at-risk of commercial sexual exploitation. OBJECTIVE: To describe the demographics, state-dependent living situations, and juvenile detention usage of state-dependent commercially sexually exploited youth. PARTICIPANTS AND SETTING: Eighty-three state-dependent youth (89.2 % female, mean age at identification = 15.5 years, SD = 1.5, Range = 11.7-19.1 years) who were confirmed or strongly suspected of commercial sexual exploitation. METHODS: Secondary analysis of lifetime administrative record data from child welfare and juvenile justice systems using descriptive statistics. RESULTS: Youth experienced early and frequent contact with the child welfare system. Youth experienced an average of 27 living situation disruptions while in the care of child welfare, with a disruption an average of every 71 days, primarily due to running away. Nearly 9 out of 10 youth had at least one runaway episode, and for these youth, there were an average of 8.6 runaway episodes. Three out of four youth had at least one juvenile detention episode, and for these youth, the average number of detention episodes was 9.2. CONCLUSIONS: We provide the context of a cycle of multisystem entanglement, whereby running away may be both a response to and cause of further system involvement and commercial sexual exploitation, and call for evidence-based interventions focused on reducing running away for these youth.

It's not "Just poverty": Educational, social, and economic functioning among young adults exposed to childhood neglect, abuse, and poverty.

BACKGROUND: Neglect is the most common allegation in Child Protective Services (CPS) investigations. Researchers and media have questioned whether and how CPS-investigated neglect differs from poverty. Prior studies are limited by self-reported or cross-sectional measures, small samples, and short observation periods. OBJECTIVE: (1) To estimate the "added harm" of CPS-investigated neglect, net of poverty exposure (depth and duration), on high school completion, employment and earnings, incarceration, and teen parenthood; (2) To assess whether abuse is a stronger risk factor for adverse outcomes than neglect. PARTICIPANTS AND SETTING: 29,154 individuals born in 1993-1996 from Milwaukee County, WI, who either received food assistance or were reported to CPS before age 16. METHOD: Using logistic regression with a rich set of social and demographic controls, we compared individuals with CPS-investigated neglect, abuse, or both abuse and neglect in early childhood or adolescence to those who experienced poverty but not CPS involvement. We calculated cumulative measures of poverty duration and poverty depth between ages 0 and 16 for the full sample using public benefit records. RESULTS: Outcomes among children with alleged or confirmed neglect were statistically significantly worse in all domains than impoverished children without maltreatment allegations, and similar to children with alleged or confirmed abuse. Effect sizes varied by outcome. CONCLUSIONS: Overall, this study suggests that CPS allegations of neglect are distinct from poverty and an important risk factor for adverse outcomes in adulthood.

The Cumulative Prevalence of Termination of Parental Rights for U.S. Children, 2000-2016.

Recent research has used synthetic cohort life tables to show that having a Child Protective Services investigation, experiencing confirmed maltreatment, and being placed in foster care are more common for American children than would be expected based on daily or annual rates for these events. In this article, we extend this literature by using synthetic cohort life tables and data from the Adoption and Foster Care Analysis and Reporting System to generate the first cumulative prevalence estimates of termination of parental rights. The results provide support for four conclusions. First, according to the 2016 estimate, 1 in 100 U.S. children will experience the termination of parental rights by age 18. Second, the risk of experiencing this event is highest in the first few years of life. Third, risks are highest for Native American and African American children. Nearly 3.0% of Native American children and around 1.5% of African American children will ever experience this event. Finally, there is dramatic variation across states in the risk of experiencing this event and in racial/ethnic inequality in this risk. Taken together, these findings suggest that parental rights termination, which involves the permanent loss of access to children for parents, is far more common than often thought.

Modelling factors for Aboriginal and Torres Strait Islander child neurodevelopment outcomes: A latent class analysis.

BACKGROUND: The Australian Early Development Census (AEDC) provides a measure of early child development upon school entry. Understanding which combination of factors influences Aboriginal child neurodevelopment is important to inform policy and practice. OBJECTIVE: The primary objective was to use latent class analysis (LCA) to model AEDC profiles and identify the highest need profiles. The secondary objective was to determine the associations of these high need profiles on the likelihood of a child becoming developmentally vulnerable. METHODS: We designed a prospective population-based birth cohort study (n = 2715) using linked data sets with information on Aboriginal cohort children, and their mothers and siblings in Western Australia. Specific developmental indicators in the 2009 and 2012 AEDC were used to assess developmental vulnerability. LCA methods were used to determine need profiles and their association with developmental vulnerability. RESULTS: 49.3% of Aboriginal children were vulnerable on at least one developmental domain, and 37.5% were vulnerable on two or more domains. LCA found six unique profiles. High needs family, High needs young mother, and Preterm infant comprised 42% of the cohort and were considered to have high need configurations. These groups were at least 1.7 times as likely to have children who had at least one or two developmental vulnerabilities compared with the Healthy family group. CONCLUSION: Many Aboriginal children in Western Australia enter school with at least one developmental vulnerability. This study highlights a range of unique profiles that can be used to empower Aboriginal families for change and develop targeted programmes for improving the early development of young Aboriginal children.

Quality of investigations into unexpected deaths of infants and young children in England after implementation of national child death review procedures in 2008: a retrospective assessment.

OBJECTIVES: In 2008, new statutory national procedures for responding to unexpected child deaths were introduced throughout England. There has, to date, been no national audit of these procedures. STUDY DESIGN: Families bereaved by the unexpected death of a child under 4 years of age since 2008 were invited to participate. Factors contributing to the death and investigations after the death were explored. Telephone interviews were conducted, and coroners' documents were obtained. The nature and quality of investigations was compared with the required procedures; information on each case was reviewed by a multiagency panel; and the death was categorised using the Avon clinicopathological classification. RESULTS: Data were obtained from 91 bereaved families (64 infant deaths and 27 children aged 1-3 years); 85 remained unexplained after postmortem examination. Documentation of multiagency assessments was poorly recorded. Most (88%) families received a home visit from the police, but few (37%) received joint visits by police and healthcare professionals. Postmortem examinations closely followed national guidance; 94% involved paediatric pathologists; 61% of families had a final meeting with a paediatrician to explain the investigation outcome. There was no improvement in frequency of home visits by health professionals or final meetings with paediatricians between 2008-2013 and 2014-2017 and no improvement in parental satisfaction with the process. CONCLUSIONS: Statutory procedures need to be followed more closely. The implementation of a national child mortality database from 2019 will allow continuing audit of the quality of investigations after unexpected child deaths. An important area amenable to improvement is increased involvement by paediatricians.

The lifetime costs of pediatric abusive head trauma and a cost-effectiveness analysis of the Period of Purple crying program in British Columbia, Canada.

BACKGROUND: Abusive head trauma (AHT) is a severe form of child abuse causing devastating outcomes for children and families, but its economic costs in Canada has yet to be determined. The Period of PURPLE crying program (PURPLE) is an AHT prevention program implemented in British Columbia for which success in reducing AHT events was recently reported. OBJECTIVE: This study estimated the lifetime costs to society of incidental AHT events and compared the benefits and associated costs of AHT before and after the implementation of the PURPLE program. PARTICIPANTS AND SETTING: Children aged 0-24 months old with a definite diagnosis of AHT between 2002 and 2014 in British Columbia were included in this study. METHODS: An incidence-based cost-of-illness analysis, using the human capital approach was used to quantify the lifetime costs of AHT events according to their severity (least severe, severe and fatal). A cost-effectiveness analysis of the PURPLE program was conducted from both a societal and a health services' perspectives using decision tree models. RESULTS: There were sixty-four AHT events between 2002-2014, resulting in a total cost of $354,359,080 to society. The costs associated with fatal, severe and least severe AHT averaged $7,147,548, $6,057,761 and $1,675,099, respectively. The investment of $5 per newborn through the PURPLE program resulted in a $273.52 and $14.49 per child cost avoidance by society and by the healthcare system. CONCLUSIONS: This study provides evidence to policymakers and health practitioners that investing upstream in well-developed AHT prevention programs, such as PURPLE, not only promote child safety and health, but also translates into avoided costs to society.

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

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

Considering the child welfare system burden from opioid misuse: research priorities for estimating public costs.

The negative impact of opioids on those who misuse them has been widely documented. Despite significant spillover effects in the form of elevated rates of child maltreatment and child welfare system (CWS) involvement for children affected by parental opioid misuse, the public costs of opioid misuse to the CWS remain largely undocumented. This work seeks to understand the value and limitations of public data in estimating the costs of the opioid epidemic on the CWS. National data from federal sources are combined with best estimates of the association between opioid misuse and child services system utilization. The limitations of this work are explored, and future research priorities are outlined. Ultimately, this work illustrates the need to (1) improve data quality related to parental opioid misuse and CWS linkages; (2) better estimate the number of children and families coming into contact with the CWS as a result of parental opioid misuse; (3) improve predictions of CWS trajectories, including investigation, service provision, and foster care entry among this population; and (4) better estimate the CWS costs associated with patterns of system involvement resulting from parental opioid misuse. This information is crucial to ensuring the production of high-quality system involvement and cost projections related to the opioid crisis.

Child Protective Service Referrals Involving Exposure to Domestic Violence: Prevalence, Associated Maltreatment Types, and Likelihood of Formal Case Openings.

Childhood exposure to domestic violence (CEDV) is widely understood as potentially harmful to children. Accordingly, many child welfare systems in the United States construe CEDV as maltreatment when the exposure results in harm or threatened harm to the child. The purpose of the current study was to investigate substantiated child welfare referrals directly related to CEDV to better understand the prevalence and patterns of CEDV-related maltreatment and how child welfare workers respond under the "harm or threatened harm" standard. Data were drawn from 23,704 substantiated referrals between 2009 and 2013 in a large Midwestern child welfare system. Approximately 20% of substantiated referrals were CEDV related. A plurality of CEDV-related referrals included both a male caregiver and female caregiver who were co-substantiated for maltreatment. The most common maltreatment types substantiated for these referrals were neglect based rather than abuse based, and just under a quarter (23%) of CEDV-related referrals were formally opened for services. Referrals involving co-occurring substance abuse were most likely to be opened for services based on predicted probabilities derived from multilevel modeling. Implications for policy and practice are considered.

Adverse childhood experiences and their relationship to complex health profiles among child welfare-involved children: A classification and regression tree analysis.

OBJECTIVE: To identify the clustering of adverse childhood experiences (ACEs) that best characterize child welfare-involved children with known complex health concerns. DATA SOURCE: Multi-informant data were obtained from Wave I of the National Survey of Child and Adolescent Well-Being (NSCAW II). STUDY DESIGN: This study used a cross-sectional design and classification and regression tree (CART) analyses. DATA COLLECTION: Data were collected from families with children, aged birth to 17, investigated for child maltreatment and their child protective services caseworkers, including demographic characteristics of the children, their histories of adversity, and a wide range of health concerns. PRINCIPAL FINDINGS: Results indicate that for children between the ages of six and 17, experiences of physical abuse alone, as well as experiences of physical abuse combined with having a caregiver with mental illness, are most strongly associated with complex health concerns. For children aged 2-5 years, results suggest that caregiver mental illness is a key adverse experience associated with complex health concerns. CONCLUSIONS: Identifying specific combinations of ACEs may be a critical next step for child- and youth-serving agencies to allow providers to better calculate risk of health problems among children exposed to adversity.