Risk and Protective Factors for Parental Involvement and Early Indicators of School Achievement in Alaska.

OBJECTIVES: Parental involvement can affect child school readiness, which in turn influences subsequent child learning outcomes. While social support, stress, caregiver psychological distress, and drinking could affect parental involvement, it is unknown whether and how these factors influence downstream child learning outcomes through parental involvement and child school readiness. This study tests those associations. METHODS: Using de-identified data provided by the Alaska Longitudinal Child Abuse and Neglect Linkage project (N = 683), we use Structural Equation Modeling to assess direct and indirect effects of paths embedded in the proposed model. RESULTS: This study found statistically significant indirect effects: (1) path linking stress faced by caregivers to child reading proficiency through caregiver psychological distress, parental involvement, and child school readiness, (2) path linking stress faced by caregivers to child reading proficiency through caregiver drinking, parental involvement, and child school readiness, and (3) path linking social support for caregivers to child reading proficiency through caregiver psychological distress, parental involvement, and child school readiness. Post-estimation showed that the sum of the magnitude of total effects of stress and the magnitude of total effects of support is significantly larger than either alone. CONCLUSIONS FOR PRACTICE: Findings suggest that reducing caregiver stress and offering social support could not only benefit caregivers but learning outcomes of their children as well. For child learning outcomes, simultaneously reducing stress and offering social support for caregivers, rather than just one of them alone, is suggested. These results are important for children, particularly for those raised by caregivers experiencing psychological distress or drinking issues.

Replication and validation of a statewide linkage method to estimate incidence proportion of child maltreatment.

PURPOSE: To study familial factors associated with child maltreatment in a birth population, Alaska piloted a mixed-design method that linked child welfare data with the Pregnancy Risk Assessment Monitoring System (PRAMS). We replicated this approach in Oregon and validated it in both states. METHODS: We linked vital records, child welfare, and PRAMS data to create two 2009 birth cohorts for each state: one based on vital records (full birth cohort) and one on PRAMS (stratified random sample). For each cohort, we estimated the incidence proportions (IP) of child maltreatment before age 9 years and compared those estimated using PRAMS with those observed using the full birth cohort. RESULTS: The Oregon PRAMS cohort estimated that 28.7% (95% CI: 24.0, 33.4), 20.9% (17.1, 24.7), and 8.3% (6.0, 10.5) of children experienced an alleged, investigated, and substantiated maltreatment, respectively, versus 32.0%, 25.0%, and 9.9% from the birth cohort. The corresponding Alaska estimates were 29.1% (26.1, 32.0), 22.6% (19.9, 25.2), and 8.3% (6.7, 9.9) of children from the PRAMS cohort versus 29.1%, 23.5%, and 9.1% in the birth cohort. CONCLUSIONS: The IP of child maltreatment in two states was accurately estimated with PRAMS cohorts. Researchers can study a comprehensive set of factors that may influence child maltreatment by incorporating PRAMS into birth cohort linkages.

Changes in Household Challenges and Subsequent Child Welfare Report.

INTRODUCTION: Preventing child maltreatment and reducing adverse childhood experiences is critical for improving adult health. To inform prevention efforts, it is necessary to move beyond static risk models and instead model the dynamic changes in household challenges during the prebirth and early childhood periods. This study examined the effect of changes in the number of household challenges from prebirth (12 months before birth of a child) to early childhood (3 years after birth) period on the risk of a child maltreatment report by age 3 years. METHODS: This retrospective cohort study linked data from the Alaska 2009-2011 Pregnancy Risk Assessment Monitoring System, its 3-year follow-up survey, and administrative records through 2019. Participants were 1,699 birthing parents. Latent class analyses identified prebirth and early childhood low- and high-challenge respondent groups on the basis of the level of reported household challenges. The authors then modeled the relationships between group transition membership and the risk of maltreatment using latent transition analysis. Analyses were conducted in 2021. RESULTS: Households transitioning from a high-challenge-prebirth status to a low-challenge-early-childhood status had a lower predicted risk for child services report than households remaining in the high-challenges group. Transitioning from low- to high-challenges status predicted the highest risk for child services report than that of all other groups. CONCLUSIONS: To reduce the risk of child maltreatment and subsequent adverse childhood experiences, healthcare providers should screen parents for the presence of household challenges during both pregnancy and early childhood and connect patients to resources targeted at reducing those challenges and providing continuous familial support.

Pre-Birth Household Challenges Predict Future Child's School Readiness and Academic Achievement.

Early developmental success and school readiness strongly influence future skill development, occupational opportunities, and health. Therefore, it is critical to identify and address early determinants of school readiness for supporting children's overall well-being and success. In this retrospective cohort study, we examined the effects of pre-birth household challenges, such as homelessness or experiences of intimate partner violence, on children's early school readiness. We linked data from the Alaska 2009-2011 Pregnancy Risk Assessment Monitoring System (PRAMS) to administrative and education records through 2019. Education records included kindergarten developmental scores, third grade reading assessments, and attendance records. Generalized linear models with Quasi-Poisson distributions for each outcome of interest examined the predictive value of pre-birth household challenges on the risks of not meeting school readiness expectations. We found that experiencing higher numbers of pre-birth household challenges was related to higher risk of the child not meeting developmental and reading proficiency and having chronic absenteeism. These results suggest that it is imperative support systems for pregnant persons and their families be introduced as soon as possible in pre-natal care routines to address current pre-birth household stressors and prevent future challenges. Such early prevention efforts are needed to ensure the best possible developmental start for children.

Measuring the Incidence of Child Maltreatment Using Linked Data: A Two-State Comparison.

INTRODUCTION: Measuring and comparing the incidence of child maltreatment is challenging. Linkage of statewide birth cohorts with Child Protective Services reports to study incident child maltreatment over the life course are becoming more common. This study compares the reported incidence between 2 states derived from population-based administrative data linkages. METHODS: Linked births (2009-2011) with Child Protective Services records (2009-2015) and deaths in each state were used to compare the cumulative incidence of a Child Protective Services report before age 7 years. Given differences in population race structure and documented disparities of race groups in Child Protective Services data, variation was adjusted for using direct standardization. Unadjusted cumulative incidence, race cumulative incidence, and race-adjusted cumulative incidence were compared. Analyses were completed in 2018. RESULTS: Before age 7 years, 26.0% of Alaskan children and 19.0% of Californian children were reported to Child Protective Services (RR=1.37, p<0.001). Aside from Asian/Pacific Islanders, the cumulative incidence between states was similar for each race. The race-adjusted cumulative incidence indicated that children born in Alaska were 1.10 times as likely to experience a report before age 7 years compared with children in California. CONCLUSIONS: Much of the difference in risk for child maltreatment observed between Alaska and California is most likely due to variation in the population structure by race as opposed to modifiable factors. Standardization is a simple method to adjust for population structure differences. This study contributes to the growing body of knowledge regarding the use of linked administrative data to study maltreatment and provides insights into considerations for making comparisons or conducting cross-jurisdictional analyses based on commonly aligned data sets.

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

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

Preconception and Prenatal Predictors of Early Experiences of Risk and Protection Among Alaska Children.

OBJECTIVES: Our objective was to identify preconception and prenatal predictors of early experiences of co-occurring risk and protective factors to help target prevention efforts to the highest-need families prior to the birth of the child. METHODS: Data were from the Alaska Longitudinal Child Abuse and Neglect Linkage project and the 2012-2014 Alaska Child Understanding Behaviors Survey. We used latent class analysis and Vermunt's three-step approach to examine predictors of latent classes of risk and protective factors among Alaska children. RESULTS: Among children of Alaska Native/American Indian mothers, financial (OR 2.02, 95% CI 1.04, 3.90) and partner stress (OR 2.06, 95% CI 1.02, 4.10) prior to childbirth, maternal education < 12 years (OR 2.29, 95% CI 1.05, 4.96), and maternal substance use (OR 2.52, 95% CI 1.30, 4.89) were associated with a higher likelihood of membership in a high risk/moderate protection class as compared to a low socioeconomic status/high protection class. Among children of non-Native mothers, partner stress prior to childbirth (OR 3.92, 95% CI 1.08, 14.19), maternal education < 12 years (OR 2.69, 95% CI 1.24, 5.81), maternal substance use (OR 2.69, 95% CI 1.24, 5.81), younger maternal age (OR 0.87, 95% CI 0.80, 0.95), and a greater number of children (OR 1.62, 95% CI 1.09, 2.41) were associated with a higher likelihood of membership in a moderate risk/high protection class as compared to a low risk/moderate protection class. CONCLUSIONS: Results can inform eligibility criteria for prenatal home visiting programs and prenatal screening in Alaska to ensure prevention programming and referrals are directed to families most in need of additional support.

Heterogeneity in Risk and Protection Among Alaska Native/American Indian and Non-Native Children.

Currently, little is known about patterns of co-occurring risk and protective factors among young children. Understanding variations in co-occurring risk and protective factors among children in Alaska is important as experiences of collective trauma may contribute to differences in the intersection of risk and protective factors between Alaska Native/American Indian (AN/AI) and non-Native children. Using data from the Alaska Longitudinal Child Abuse and Neglect Linkage (ALCANLink) project, a linkage of the 2009-2011 Alaska Pregnancy Risk Assessment Monitoring System survey and administrative data sources, and the 2012-2014 Childhood Understanding Behaviors Survey, we conducted latent class analysis to identify classes of AN/AI (N = 593) and non-Native (N = 1018) children in terms of seven risk factors (poverty, maternal depression, maternal binge drinking, parental incarceration, intimate partner violence exposure, other violence exposure, child maltreatment) and four protective factors (father figure involvement, reading by adults, family meals, peer interactions) experienced prior to age 3 years. We identified two classes among AN/AI children: (1) high risk-moderate protection (29.1%) and (2) low socioeconomic status-high protection (70.9%). We identified two classes among non-Native children: (1) moderate risk-high protection (32.9%) and (2) low risk-high protection (67.1%). A test of invariance revealed that risk and protective factor probabilities differed significantly for corresponding classes of AN/AI and non-Native children. Overall, results demonstrate heterogeneity within and between AN/AI and non-Native children in early experiences of risk and protection and suggest that interventions will be more effective if tailored to the experiences and developmental needs of specific groups of Alaska children.

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

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

Quantifying sources of bias in longitudinal data linkage studies of child abuse and neglect: measuring impact of outcome specification, linkage error, and partial cohort follow-up.

BACKGROUND: Health informatics projects combining statewide birth populations with child welfare records have emerged as a valuable approach to conducting longitudinal research of child maltreatment. The potential bias resulting from linkage misspecification, partial cohort follow-up, and outcome misclassification in these studies has been largely unexplored. This study integrated epidemiological survey and novel administrative data sources to establish the Alaska Longitudinal Child Abuse and Neglect Linkage (ALCANLink) project. Using these data we evaluated and quantified the impact of non-linkage misspecification and single source maltreatment ascertainment use on reported maltreatment risk and effect estimates. METHODS: The ALCANLink project integrates the 2009-2011 Alaska Pregnancy Risk Assessment Monitoring System (PRAMS) sample with multiple administrative databases through 2014, including one novel administrative source to track out-of-state emigration. For this project we limited our analysis to the 2009 PRAMS sample. We report on the impact of linkage quality, cohort follow-up, and multisource outcome ascertainment on the incidence proportion of reported maltreatment before age 6 and hazard ratios of selected characteristics that are often available in birth cohort linkage studies of maltreatment. RESULTS: Failure to account for out-of-state emigration biased the incidence proportion by 12% (from 28.3%w to 25.2%w), and the hazard ratio (HR) by as much as 33% for some risk factors. Overly restrictive linkage parameters biased the incidence proportion downwards by 43% and the HR by as much as 27% for some factors. Multi-source linkages, on the other hand, were of little benefit for improving reported maltreatment ascertainment. CONCLUSION: Using the ALCANLink data which included a novel administrative data source, we were able to observe and quantify bias to both the incidence proportion and HR in a birth cohort linkage study of reported child maltreatment. Failure to account for out-of-state emigration and low-quality linkage methods may induce bias in longitudinal data linkage studies of child maltreatment which other researchers should be aware of. In this study multi-agency linkage did not lead to substantial increased detection of reported maltreatment. The ALCANLink methodology may be a practical approach for other states interested in developing longitudinal birth cohort linkage studies of maltreatment that requires limited resources to implement, provides comprehensive data elements, and can facilitate comparability between studies.

Classification of maltreatment-related mortality by Child Death Review teams: How reliable are they?

Accurate estimation of the incidence of maltreatment-related child mortality depends on reliable child fatality review. We examined the inter-rater reliability of maltreatment designation for two Alaskan Child Death Review (CDR) panels. Two different multidisciplinary CDR panels each reviewed a series of 101 infant and child deaths (ages 0-4 years) in Alaska. Both panels independently reviewed identical medical, autopsy, law enforcement, child welfare, and administrative records for each death utilizing the same maltreatment criteria. Percent agreement for maltreatment was 64.7% with a weighted Kappa of 0.61 (95% CI 0.51, 0.70). Across maltreatment subtypes, agreement was highest for abuse (69.3%) and lowest for negligence (60.4%). Discordance was higher if the mother was unmarried or a smoker, if residence was rural, or if there was a family history of child protective services report(s). Incidence estimates did not depend on which panel's data were used. There is substantial room for improvement in the reliability of CDR panel assessment of maltreatment related mortality. Standardized decision guidance for CDR panels may improve the reliability of their data.

Investigating the Decline of Fetal and Infant Mortality Rates in Alaska During 2010 and 2011.

INTRODUCTION: The U.S. infant mortality rate has been steadily declining since 2007. Although the downward trend has been notable in Alaska since 2006 when the rate was 6.9 infant deaths per 1000 live births, a dramatic drop in infant mortality occurred in 2010 and 2011 when the infant mortality rate fell to 3.8 infant deaths per 1000 live births during both years. The purpose of this study was to investigate the sudden decrease in fetal and infant mortality rates (FIMR) using the perinatal periods of risk (PPOR) method, an approach that has not been used previously in Alaska. METHODS: The study was conducted for 251 fetal and infant deaths in 2004-2006, 265 deaths in 2007-2009, and 129 deaths in 2010-2011. Data were stratified by Alaska Native (AN) and White maternal race and urban/rural residence. RESULTS: Among both urban and rural White women, the rate ratios (RR) for FIMRs between the earlier and later time periods were not significantly different. The postneonatal mortality rate (PNMR) among AN infants living in rural areas decreased significantly (RR 0.40; 95 % confidence interval 0.21-0.76) between 2007-2009 and 2010-2011. An unexplained increase in sudden unexplained infant death was noted in 2009, followed by a precipitous decrease in 2010-2011. No other unusual distribution of the cause specific mortality rates was observed. DISCUSSION: The decrease in the Alaska Native FIMR might have been due to focused efforts for preventing postneonatal sleep associated deaths. Education for prevention of sleep related deaths, particularly in rural communities, is necessary to maintain Alaska's low PNMR.

Maternal Intimate Partner Violence Victimization Before and During Pregnancy and Postbirth Child Welfare Contact: A Population-Based Assessment.

We conducted a population-based prospective cohort study to help elucidate the predictive relationship between a maternal prebirth self-reported history of intimate partner violence (IPV) and any postbirth reported allegation to Child Protective Services (CPS) by age 2. We linked data from the 2009-2010 Alaska Pregnancy Risk Assessment Monitoring System with CPS data through 2012. Among this cohort, we found that 8.0%w self-reported experiencing IPV 12 months prior or during pregnancy, and 8.0%w of the offspring experienced at least one CPS report of alleged maltreatment during the study period. The predictive relationship varied by maternal educational attainment. Among mothers with 12+ years education completed, the odds of a CPS report were 3.9 times compared to those with no IPV, while among mothers with <12 years education completed, no association was noted. These results suggest that for a subset of Alaskan families, maternal history of IPV is a strong independent predictor of future CPS contact.

National, regional, and state abusive head trauma: application of the CDC algorithm.

OBJECTIVE: To examine national, regional, and state abusive head trauma (AHT) trends using child hospital discharge data by applying a new coding algorithm developed by the Centers for Disease Control and Prevention (CDC). METHODS: Data from 4 waves of the Kids' Inpatient Database and annual discharge data from North Carolina were used to determine trends in AHT incidence among children <1 year of age between 2000 and 2009. National, regional, and state incidence rates were calculated. Poisson regression analyses were used to examine national, regional, and state AHT trends. RESULTS: The CDC narrow and broad algorithms identified 5437 and 6317 cases, respectively, in the 4 years of KID weighted data. This yielded average annual incidences of 33.4 and 38.8 cases per 100,000 children <1 year of age. There was no statistically significant change in national rates. There were variations by region of the country, with significantly different trends in the Midwest and West. State data for North Carolina showed wide annual variation in rates, with no significant trend. CONCLUSIONS: The new coding algorithm resulted in the highest AHT rates reported to date. At the same time, we found large but statistically insignificant annual variations in AHT rates in 1 large state. This suggests that caution should be used in interpreting AHT trends and attributing changes in rates as being caused by changes in policies, programs, or the economy.

Pathway to Hope: an indigenous approach to healing child sexual abuse.

BACKGROUND: The Alaska Native (AN) population has endured multiple historical traumatic events. This population has poorer health outcomes on nearly all factors compared with Alaska non-Natives with more than 75% reportedly being physically assaulted in their lifetime, and child sexual abuse nearly 6 times the national average. OBJECTIVE: This article describes the Pathway to Hope (PTH) program, which is an indigenous approach to ending silence and denial related to child sexual abuse and encourages multigenerational healing. DESIGN: PTH was developed by ANs who believe that each community is unique, thus strategies for ending denial and support for healing must be woven from the historical context, cultural strengths of individual communities. Strengths-based solutions built on truth, honesty, compassion and shared responsibility for healing and protecting today's children have been profound and successful. The PTH curriculum addresses child sexual abuse from a historical perspective; that the higher rates of sexual abuse among certain Tribes, regions and communities is linked in part to years of victimisation, but may also be perpetuated by internalised oppression and lateral violence among Tribal members. RESULTS: Data suggest that community-based dialogue and wisdom of Native elders and spiritual leaders paired with readiness of community service providers are necessary for sustained change. At all levels, this Indigenous model for learning, sharing, helping and healing brings hope for an end to denial and silence about child sexual abuse for Native people. CONCLUSION: The PTH program utilises the wisdom and values that have sustained Native people for generations. Ending silence and denial about child sexual abuse and building upon strengths have assisted many Indigenous communities begin the journey toward wellness. Through the PTH, communities have taken steps to accept the challenges associated with establishing safety for children, supporting child victims in healing and to holding offenders accountable.

Identifying risk factors for child maltreatment in Alaska: a population-based approach.

BACKGROUND: Child maltreatment has been linked to multiple negative health outcomes and many leading causes of death. Statewide population-based evaluations are needed to identify high-risk populations early in life for targeted interventions. PURPOSE: To assess the utility of combining Pregnancy Risk Assessment Monitoring System (PRAMS) data with child protective services (CPS) records to identify risk factors associated with Protective Services Reports (PSR) suggestive of child maltreatment. METHODS: This was a retrospective population-based cohort study conducted in the spring of 2010 using weighted survey data from Alaska PRAMS for birth years 1997-1999. PRAMS responses were linked with CPS records for the sampled child. The outcome of interest was any PSR made to CPS after the survey was returned through 48 months after birth. Validation of the PRAMS data set occurred through direct comparison between the total population and PRAMS weighted sample for birth certificate factors. Multivariate logistic regression models were constructed to identify risk groups. RESULTS: In the final multivariate model among the main effect variables, three of the top five strongest associated factors were derived all or in part from PRAMS. Public aid as a source of income had a significant interaction with Alaska Native status, and among Alaska non-Natives had an AOR of 3.37 (95% CI=2.2, 5.1). Six significant modifiable factors were identified in the multivariate model. Three quarters (75%) of the maltreatment cases occurred among children with two or more of these factors, despite being found in about one third (32%) of the total population. CONCLUSIONS: Although birth certificates remained a valuable source of risk factor information for child maltreatment, PRAMS identified additional risk factors not available from birth certificates.

Characteristics of women who sought emergency contraception at a university-based women's health clinic.

OBJECTIVE: The purpose of this study was to identify unique characteristics for seeking emergency contraception (EC) among sexually active unmarried women who attended a university-based women's health clinic (WHC). STUDY DESIGN: Three hundred nine consecutive women who attended the women's health clinic for 3 months of the 2006 spring semester completed an anonymous self-administered questionnaire. Fisher exact and Student t tests were used to assess bivariate associations, and step-wise regression was used to determine independent associations. RESULTS: Women who requested EC were more likely to have previously used EC (P < .001), to have had unprotected sex in the past 6 months (P < .001), to have experienced an unintended pregnancy in the past year (P = .009), and to perceive the need for EC use in the next 3 months (P < .001) but were less likely to use hormonal contraception or an intrauterine device (P < .001). CONCLUSION: Our findings support the need for increased education that would include the use of and access to effective primary contraceptive methods in conjunction with EC awareness.