Emily Putnam-Hornstein

The Prevalence of Confirmed Maltreatment Among US Children, 2004 to 2011

IMPORTANCEnChild maltreatment is a risk factor for poor health throughout the life course. Existing estimates of the proportion of the US population maltreated during childhood are based on retrospective self-reports. Records of officially confirmed maltreatment have been used to produce annual rather than cumulative counts of maltreated individuals.nnnOBJECTIVEnTo estimate the proportion of US children with a report of maltreatment (abuse or neglect) that was indicated or substantiated by Child Protective Services (referred to as confirmed maltreatment) by 18 years of age.nnnDESIGN, SETTING, AND PARTICIPANTSnThe National Child Abuse and Neglect Data System (NCANDS) Child File includes information on all US children with a confirmed report of maltreatment, totaling 5,689,900 children (2004-2011). We developed synthetic cohort life tables to estimate the cumulative prevalence of confirmed childhood maltreatment by 18 years of age.nnnMAIN OUTCOMES AND MEASURESnThe cumulative prevalence of confirmed child maltreatment by race/ethnicity, sex, and year.nnnRESULTSnAt 2011 rates, 12.5% (95% CI, 12.5%-12.6%) of US children will experience a confirmed case of maltreatment by 18 years of age. Girls have a higher cumulative prevalence (13.0% [95% CI, 12.9%-13.0%]) than boys (12.0% [12.0%-12.1%]). Black (20.9% [95% CI, 20.8%-21.1%]), Native American (14.5% [14.2%-14.9%]), and Hispanic (13.0% [12.9%-13.1%]) children have higher prevalences than white (10.7% [10.6%-10.8%]) or Asian/Pacific Islander (3.8% [3.7%-3.8%]) children. The risk for maltreatment is highest in the first few years of life; 2.1% (95% CI, 2.1%-2.1%) of children have confirmed maltreatment by 1 year of age, and 5.8% (5.8%-5.9%), by 5 years of age. Estimates from 2011 were consistent with those from 2004 through 2010.nnnCONCLUSIONS AND RELEVANCEnAnnual rates of confirmed child maltreatment dramatically understate the cumulative number of children confirmed to be maltreated during childhood. Our findings indicate that maltreatment will be confirmed for 1 in 8 US children by 18 years of age, far greater than the 1 in 100 children whose maltreatment is confirmed annually. For black children, the cumulative prevalence is 1 in 5; for Native American children, 1 in 7.

Racial and ethnic disparities: A population-based examination of risk factors for involvement with child protective services

OBJECTIVEnData from the United States indicate pronounced and persistent racial/ethnic differences in the rates at which children are referred and substantiated as victims of child abuse and neglect. In this study, we examined the extent to which aggregate racial differences are attributable to variations in the distribution of individual and family-level risk factors.nnnMETHODSnThis study was based on the full population of children born in California in 2002. Birth records were linked to child protective service (CPS) records to identify all children referred for maltreatment by age 5. Generalized linear models were used to compute crude and adjusted racial/ethnic differences in childrens risk of referral, substantiation, and entry to foster care.nnnRESULTSnAs expected, stark differences between Black and White children emerged in the rates of contact with CPS. Black children were more than twice as likely as White children to be referred for maltreatment, substantiated as victims, and enter foster care before age 5. Yet, there were also significant differences across racial/ethnic groups in the distribution of socioeconomic and health factors strongly correlated with child maltreatment and CPS involvement. After adjusting for these differences, low socioeconomic Black children had a lower risk of referral, substantiation, and entry to foster care than their socioeconomically similar White counterparts. Among Latinos, before adjusting for other factors, children of U.S.-born mothers were significantly more likely than White children to experience system contact, while children of foreign-born mothers were less likely to be involved with CPS. After adjusting for socioeconomic and health indicators, the relative risk of referral, substantiation, and foster care entry was significantly lower for Latino children (regardless of maternal nativity) compared to White children.nnnCONCLUSIONSnRace and ethnicity is a marker for a complex interaction of economic, social, political, and environmental factors that influence the health of individuals and communities. This analysis indicates that adjusting for child and family-level risk factors is necessary to distinguish race-specific effects (which may reflect system, worker, or resource biases) from socioeconomic and health indicators associated with maltreatment risk. Identifying the independent effects of these factors is critical to developing effective strategies for reducing racial disparities.

Report of Maltreatment as a Risk Factor for Injury Death: A Prospective Birth Cohort Study

This article presents a population-based study of early childhood injury mortality following a nonfatal allegation of maltreatment. Findings are based on a unique data set constructed by establishing child-level linkages between vital birth records, administrative child protective services records, and vital death records. These linked data reflect over 4.3 million children born in California between 1999 and 2006 and provide a longitudinal record of maltreatment allegations and death. Of interest was whether children reported for nonfatal maltreatment subsequently faced a heightened risk of unintentional and intentional injury mortality during the first 5 years of life. Findings indicate that after adjusting for risk factors at birth, children with a prior allegation of maltreatment died from intentional injuries at a rate that was 5.9 times greater than unreported children (95% CI [4.39, 7.81]) and died from unintentional injuries at twice the rate of unreported children (95% CI [1.71, 2.36]). A prior allegation to CPS proved to be the strongest independent risk factor for injury mortality before the age of five.

Understanding risk and protective factors for child maltreatment: the value of integrated, population-based data

In this article, we argue for expanded efforts to integrate administrative data systems as a practical strategy for developing a richer understanding of child abuse and neglect. Although the study of child maltreatment is often critiqued for being atheoretical, we believe that a more pressing concern is the absence of population-based and prospective epidemiological data that can be used to better understand the distribution and interacting nature of risk and protective factors for maltreatment. We begin by briefly addressing the relevance of empirical observations to etiological theories of child maltreatment. Although the latter is widely cited as critical to the development of effective prevention and intervention responses, less attention has been paid to the role of population-based data in the development of theories relevant to highly applied research questions such as those pertaining to child abuse and neglect. We then discuss how child protection data, in isolation, translates into a relatively narrow range of questions that can be asked and answered, with an inherently pathology-focused construction of risks and little attention paid to strengths or protective factors. We next turn to examples of recent findings--spanning multiple countries--emerging from information integrated across data systems, concluding by calling for expanded administrative data linkages in an effort to better understand and prevent child maltreatment.

Children in the public benefit system at risk of maltreatment: Identification via predictive modeling

A growing body of research links child abuse and neglect to a range of negative short- and long-term health outcomes. Determining a childs risk of maltreatment at or shortly after birth provides an opportunity for the delivery of targeted prevention services. This study presents findings from a predictive risk model (PRM) developed to estimate the likelihood of substantiated maltreatment among children enrolled in New Zealands public benefit system. The objective was to explore the potential use of administrative data for targeting prevention and early intervention services to children and families. A data set of integrated public benefit and child protection records for children born in New Zealand between January 1, 2003, and June 1, 2006, was used to develop a risk algorithm using stepwise probit modeling. Data were analyzed in 2012. The final model included 132 variables and produced an area under the receiver operating characteristic curve of 76%. Among children in the top decile of risk, 47.8% had been substantiated for maltreatment by age 5 years. Of all children substantiated for maltreatment by age 5 years, 83% had been enrolled in the public benefit system before age 2 years. This analysis demonstrates that PRMs can be used to generate risk scores for substantiated maltreatment. Although a PRM cannot replace more-comprehensive clinical assessments of abuse and neglect risk, this approach provides a simple and cost-effective method of targeting early prevention services.

Risk of Re-Reporting Among Infants Who Remain at Home Following Alleged Maltreatment

Maltreatment that begins during infancy is likely to be chronic in duration and developmentally consequential if the appropriate intervention is not delivered. Repeated reports of maltreatment may signal unmet service needs. This study prospectively followed infants who remained at home following an initial report of maltreatment to determine the rate of re-reporting within 5 years. Birth records for all children born in California in 2006 were linked to statewide child protection records through 2012; 5.2% (n = 29,135) of children were reported for abuse or neglect prior to age 1. Following an initial report, 81.9% of infants remained in the home, the majority (60.7%) of whom were re-reported within 5 years. The highest rate of re-reporting was observed among infants whose initial allegation was substantiated and who had a case opened for family maintenance services (69.1%). Infants whose initial allegation was not investigated had re-reporting rates that were equal to or higher than other infants remaining in the home without services. Findings highlight that most families with infants reported for maltreatment are not formally served through the child protection system. High rates of re-reporting underscore the challenge of delivering services that remedy conditions necessitating child protection follow-up and call attention to the importance of accessing data from community service providers.

Risk of fatal injury in young children following abuse allegations: Evidence from a prospective, population-based study

OBJECTIVESnWe examined variations in childrens risk of an unintentional or intentional fatal injury following an allegation of physical abuse, neglect, or other maltreatment.nnnMETHODSnWe linked records of 514 232 children born in California from 1999 to 2006 and referred to child protective services for maltreatment to vital birth and death data. We used multivariable Cox regression models to estimate variations in risk of fatal injury before age 5 years and modeled maltreatment allegations as time-varying covariates.nnnRESULTSnChildren with a previous allegation of physical abuse sustained fatal injuries at 1.7 times the rate of children referred for neglect. Stratification by manner of injury showed that children with an allegation of physical abuse died from intentional injuries at a rate 5 times as high as that for children with an allegation of neglect, yet faced a significantly lower risk of unintentional fatal injury.nnnCONCLUSIONSnThese data suggest conceptual differences between physical abuse and neglect. Findings indicate that interventions consistent with the form of alleged maltreatment may be appropriate, and heightened monitoring of young children referred for physical abuse may advance child protection.

Cumulative teen birth rates among girls in foster care at age 17: An analysis of linked birth and child protection records from California

This study used linked foster care and birth records to provide a longitudinal, population-level examination of the incidence of first and repeat births among girls who were in foster care at age 17. Girls in a foster care placement in California at the age of 17 between 2003 and 2007 were identified from statewide child protection records. These records were probabilistically matched to vital birth records spanning the period from 2001 to 2010. Linked data were used to estimate the cumulative percentage of girls who had given birth before age 20. Birth rates and unadjusted risk ratios were generated to characterize foster care experiences correlated with heightened teen birth rates. Between 2003 and 2007 in California, there were 20,222 girls in foster care at age 17. Overall, 11.4% had a first birth before age 18. The cumulative percentage who gave birth before age 20 was 28.1%. Among girls who had a first birth before age 18, 41.2% had a repeat teen birth. Significant variations by race/ethnicity and placement-related characteristics emerged. Expanded data and rigorous research are needed to evaluate prevention efforts and ensure parenting teens are provided with the needed services and supports.

A Population-Based Examination of Maltreatment History Among Adolescent Mothers in California

PURPOSEnTo document the abuse and neglect histories of adolescent mothers using official child protection records.nnnMETHODSnVital birth records were used to identify adolescents 12-19 years of age who were born in California and gave birth in 2009. These records were linked to statewide child protective service data to determine maternal history of alleged and substantiated maltreatment victimization, as well as placement in foster care.nnnRESULTSnA total of 35,098 adolescents gave birth in 2009. Before conception, 44.9% had been reported for maltreatment, 20.8% had been substantiated as victims, and 9.7% had spent time in foster care.nnnCONCLUSIONSnThese population-based data indicate that many adolescent mothers have had contact with child protective services as alleged or substantiated victims of abuse or neglect. Understanding the impact of childhood and adolescent maternal maltreatment on both early childbearing risk and subsequent parenting capacity is critical to the development of responsive service interventions.

Examining the Evidence Reporter Identity, Allegation Type, and Sociodemographic Characteristics as Predictors of Maltreatment Substantiation

Using linked administrative data from child protection and birth records in California, this study examined whether the mandated status and type of reporter are independent predictors of substantiation among infants and young children across maltreatment types and after adjusting for characteristics of the child and family. Of the 59,413 children born in 2002 who were reported and investigated for maltreatment before the age of 5 years, 26% were substantiated. Reports originating from mandated sources were 2.5 times as likely (95% confidence interval, CI [2.40, 2.60]) to be substantiated as those from nonmandated reporters. Findings demonstrated that children whose allegations were reported by law enforcement, medical professionals, and workers in public agencies were consistently substantiated at higher rates than allegations from other mandated reporters. Results also indicated that the relationship between reporter type and the likelihood of substantiation varied by maltreatment type. Children reported by law enforcement for physical abuse were 6.3 times as likely (95% CI [4.86, 8.04]) to be substantiated as those reported by nonmandated sources.