We Have All Been Working in Our Own Little Silos Forever: Exploring a Cross-Sector Response to Child Maltreatment

ObjectiveA child protective services (CPS) investigation for maltreatment signals risk for childhood toxic stress and poor health outcomes. Despite this, communication between child welfare and health care professionals is rare. We present a qualitative exploration of experiences with, barriers to, and hopes for cross-sector collaboration for children with suspected maltreatment.MethodsWe conducted focus groups with child welfare and health care professionals participating in a cross-sector learning collaborative to improve care for children at high risk for toxic stress. Participants were asked to describe 2 phenomena: identifying and responding to childhood adversities in their professional settings and cross-sector collaboration in cases of suspected maltreatment. Analysis included an iterative process of reading, coding and comparing themes across groups.ResultsHealth care professionals shared positive experiences in screening for social risks in clinic, while child welfare professionals expressed mixed attitudes toward social risk screening during CPS investigations. Consistent with prior research, health care professionals reported limited communication with CPS caseworkers about patients but suggested that relationships with child welfare professionals might reduce these barriers. Child welfare professionals described the poor quality of information provided in referrals from medical settings. Caseworkers also recognized that improved communication could support better understanding of maltreatment concerns and sharing of outcomes of CPS investigation.ConclusionsOur project extends previously published research by describing potential benefits of child welfare and child health care collaboration in cases of suspected maltreatment. Lack of effective cross-sector communication and concerns about confidentiality present significant barriers to uptake of these collaborative practices.     

Child Neglect: Assessment and Intervention

Neglect is often a neglected form of child maltreatment even though it is the most common and deadliest form of child maltreatment. Pediatric nurse practitioners (PNPs) will most likely encounter neglected children in their practice. It is crucial that PNPs recognize child neglect in a timely manner and intervene appropriately. This continuing education article will help PNPs understand and respond to child neglect. Neglect will be defined and risk factors will be discussed. Children who are neglected can experience serious and lifelong consequences. The medical assessment and plan of care for children with concerns of suspected neglect will be discussed.     

Measuring the risk of physical neglect in a population-based sample

Child neglect accounts for the majority of officially substantiated cases of child maltreatment in this country, although population-based data are lacking. This study estimates the number of children at risk for specific subtypes of physical neglect, using results of an anonymous telephone survey administered to 1,435 mothers of children ages 0 to 17 years in North and South Carolina. Children were considered "at risk for neglect" from lack of enough food, lack of access to medical care when needed, and inadequate supervision. Demographic factors were significantly related to the outcomes of interest, including lower family income with lack of enough food and access to medical care. There was little overlap in children at risk for the different subtypes of neglect. Maternal self-report data can be used to improve researchers' understanding of children at risk for neglect and to explore gaps in knowledge that might be amenable to intervention and prevention efforts.     

Child abuse consultations initiated by child protective services: the role of expert opinions

ObjectiveTo describe consultations provided by child abuse pediatricians for cases referred by child protective services (CPS); compare the opinions of the likelihood of child maltreatment of the initial physician, CPS, and the child abuse pediatrician; and examine predictors of the experts’ opinions.MethodsCases were referred by CPS for consultations between March 1, 1998, and June 30, 2005, to 2 child abuse pediatricians at Yale–New Haven Children’s Hospital. We abstracted demographic and clinical information and the opinions of the initial physician, CPS, and the child abuse expert, each coded using a 5-point scale from definite maltreatment to definite benign cause (eg, accident).ResultsOf 187 cases, 50.3% occurred in children younger than 1 year of age. Children’s most serious injuries were fractures (50.8%), burns (16.6%), and bruises/abrasions (15.0%). The child abuse experts’ opinions were 47.6% definite or probable maltreatment, 8.6% uncertain, and 43.9% definite or probable benign. Of the 119 cases with opinions from all 3 assessors, the expert agreed with the physician in 57.1% of cases (κ = 0.34) and with CPS in 64.7% (κ = 0.42). The best predictor of the expert’s opinion that the injury was due to maltreatment was agreement between the physician and CPS that maltreatment had occurred.ConclusionsLevels of agreement were fair to poor between the child abuse expert and either the physician or CPS. Child abuse experts’ opinions have important value in selected cases to confirm previous assessments by the physician and/or CPS, or to change the opinion of the case.     

Risk factors for recurrence of maltreatment: a systematic review

Background

Children who have been maltreated are at increased risk of further maltreatment. Competent identification of those at highest risk of further maltreatment is an important part of safe and effective practice, but is a complex and demanding task.

Aim

To systematically review the research base predicting those children at highest risk of recurrent maltreatment.

Methods

Systematic review of cohort studies investigating factors associated with substantiated maltreatment recurrence in children.

Results

Sixteen studies met the inclusion criteria. The studies were heterogeneous. A variety of forms of maltreatment were considered. Four factors were most consistently identified as predicting future maltreatment: number of previous episodes of maltreatment; neglect (as opposed to other forms of maltreatment); parental conflict; and parental mental health problems. Children maltreated previously were approximately six times more likely to experience recurrent maltreatment than children who had not previously been maltreated. The risk of recurrence was highest in the period soon after the index episode of maltreatment (within 30 days), and diminished thereafter.

Conclusions

There are factors clearly associated with an increased risk of recurrent maltreatment, and these should be considered in professional assessments of children who have been maltreated. A comprehensive approach to risk assessment, including but not solely based on these factors, is likely to lead to interventions which offer greater protection to children.     

American Academy of Pediatrics: Committee on Child Abuse and Neglect and Committee on Children With Disabilities. Assessment of maltreatment of children with disabilities

Widespread efforts are continuously being made to increase awareness and provide education to pediatricians regarding risk factors of child abuse and neglect. The purpose of this statement is to ensure that children with disabilities are recognized as a population that is also at risk for maltreatment. The need for early recognition and intervention of child abuse and neglect in this population, as well as the ways that a medical home can facilitate the prevention and early detection of child maltreatment, should be acknowledged.     

Maltreatment of children with disabilities

Widespread efforts are being made to increase awareness and provide education to pediatricians regarding risk factors of child abuse and neglect. The purpose of this clinical report is to ensure that children with disabilities are recognized as a population that is also at risk of maltreatment. Some conditions related to a disability can be confused with maltreatment. The need for early recognition and intervention of child abuse and neglect in this population, as well as the ways that a medical home can facilitate the prevention and early detection of child maltreatment, are the subject of this report.     

Child Protection in the United States: An Examination of Mandated Reporting of Child Maltreatment

Child protection is one of the key indicators of a society’s health. In the U.S. all states have enacted laws which require certain professionals who regularly come into contact with children to report suspected maltreatment. Passage of these laws has resulted in an unprecedented increase in the number of reports of child maltreatment made to U.S. child protective services (CPS), yet this increase has not been systematically studied to determine whether this increase in reports is actually reducing the incidence of child maltreatment. This paper describes and compares the reporting practices of four mandated reporting groups in the U.S. over a 3-year period. Data from the National Child Abuse and Neglect Dataset (NCANDS) were analyzed. NCANDS is a national database created by the US Department of Health and Human Services (DHHS) of reports of maltreatment made to child protective services agencies (CPS) in the US. Results indicate that each reporter group has a somewhat unique profile of reports and responses from the child protection agencies to which they report. Significant differences were found related to the type of maltreatment reported and the rate of report substantiation by CPS. While some differences can be easily explained, others require more research and have broad implications for the professional education and training of mandated reporters.     

Effects of child abuse and neglect: does social capital really matter?

OBJECTIVE: To explore whether social capital and social support moderate the relationship between child maltreatment and emotional and behavioral outcomes such as depression-anxiety and aggression in 6-year-old children. DESIGN: Data from Longitudinal Studies of Child Abuse and Neglect were used. Data were collected through interviews and questionnaires at the child's birth and at the age of 6 years. SETTING: General community. PARTICIPANTS: Two hundred fifteen maternal caregivers of children at high risk for child abuse and neglect were included in this study. MAIN OUTCOME MEASURES: Depression-anxiety and aggression were measured through the Child Behavior Checklist. RESULTS: Among 5 potential effect modifiers (3 social capital constructs and 2 measures of social support), only 1 (instrumental support) significantly modified the relationship between maltreatment and child aggression. CONCLUSIONS: Social capital did not modify the relationship between child maltreatment and either aggression or depression-anxiety. This might be related to the fact that many previous studies looked at social capital ecologically, whereas this study uses individuals as the unit of analysis. The results of this study might also indicate that previous studies of social capital and health outcomes might actually be using social capital as a proxy for social support.     

Identification during the postpartum period of infants who are at high risk of child maltreatment

To determine whether clinicians correctly identify newborn infants who are at high risk of child maltreatment, we examined the outcomes of high-risk and non-high-risk children. Infants who were born at Yale-New Haven Hospital from 1979 to 1981 and who were referred by clinicians during the postpartum period to the hospital's child abuse registry because they were considered at high risk of child abuse or neglect became the high-risk group. For each high-risk infant, a comparison infant was selected and matched according to date of birth, gender, race, and method of payment for the hospitalization. For both groups, the occurrence of maltreatment was ascertained by reviewing the medical records until the child's fourth birthday. Each injury for which medical care was sought was classified into one of seven categories (from definite child abuse to accident) by a pediatrician who was unaware of the child's risk status. Information also was recorded about nonorganic failure to thrive and changes in the child's caretaker. Maltreatment (defined as abuse or neglect) occurred more frequently in the high-risk group than the comparison group (adjusted matched odds ratio = 4.3; 95% confidence interval = 1.41, 6.93; p less than 0.001), as did poor weight gain from a nonorganic cause (matched odds ratio = 7.0; 95% confidence interval = 1.59, 30.79; p less than 0.01) and changes in the child's caretaker (matched odds ratio = 9.0; 95% confidence interval = 3.80; 20.55; p less than 0.001). We conclude that as early as the postpartum period, clinicians can identify some families who are at high risk of maltreatment and other major adverse outcomes resulting from poor parenting.     

Antecedents of child neglect in the first two years of life.

To determine the prenatal antecedents of child neglect by low-income women, data from a prospective study of child maltreatment were reviewed. Mothers determined to be at high risk prenatally for maltreatment were more likely to be identified as neglectful within 24 months of the interview. Neglectful mothers were less likely to have completed high school, had more children younger than 6 years of age, and had more aberrant responses on parenting skills and support systems scales. Neglected children were lower in birth weight, were rated more difficult temperamentally, and had poorer mental and motor developmental scores.     

The role of men in chronic supervisory neglect

This study investigates whether parents' child care demand and resources, their capacity to provide adequate supervision, and their understanding of the supervision problem predict chronic supervisory neglect. A case-comparison design was used to compare families who had one isolated incident of supervisory neglect, who were involved with child protective services (CPS) because of a persistent supervision problem (2 years or less), and who were involved with CPS because of a chronic supervision problem (more than 2 years). When the mother's partner was not the father of her children or had a drug, alcohol, or mental health challenge, and when no one understood that there was a supervision problem or took responsibility for it, the problem was more likely to persist or become chronic. Therefore, when predicting whether a family will continue to provide inadequate supervision, it is important to also assess the mother's partner.     

Police involvement in child protective services investigations: literature review and secondary data analysis

This article examines the relationship of police and child protective services (CPS) coinvolvement to the outcomes of child maltreatment investigations. It reviews practice and empirical literature and conducts a secondary analysis of a national CPS data set. Most sources argue that coordination of the two agencies improves investigations and benefits children and families. Yet, sources also report friction between these agencies, interference with each other's job, and concerns that police involvement increases child removal. In the CPS case data, allegations were more likely to be judged credible when police also investigated and families were also more likely to receive various services. For neglect cases, multi-disciplinary decision making, but not police involvement per se, was linked to child removal. Across studies, police do not appear to hinder CPS effectiveness and may actually promote it. Their investigations should be coordinated in every community.     

Associations between voluntary and involuntary forms of perinatal loss and child maltreatment among low-income mothers

AIM: This study explored maternal history of perinatal loss relative to risk of child physical abuse and neglect. METHODS: The 518 study participants included 118 abusive mothers, 119 neglecting mothers, and 281 mothers with no known history of child maltreatment. Interviews and observations were conducted in the participants' homes, and comparisons were made between women without a history of perinatal loss and women with one and multiple losses relative to risk for child maltreatment. RESULTS: Compared to women with no history of perinatal loss, those with one loss (voluntary or involuntary) had a 99% higher risk for child physical abuse, and women with multiple losses were 189% more likely to physically abuse their children. Compared to women with no history of induced abortion, those with one prior abortion had a 144% higher risk for child physical abuse. Finally, maternal history of multiple miscarriages and/or stillbirths compared to no history was associated with a 1237% increased risk of physical abuse and a 605% increased risk of neglect. CONCLUSION: Perinatal loss may be a marker for elevated risk of child physical abuse, and this information is potentially useful to child maltreatment prevention and intervention efforts.     

Effects of chronic maltreatment and maltreatment timing on children’s behavior and cognitive abilities

Background: Chronic maltreatment has been associated with the poorest developmental outcomes, but its effects may depend on the age when the maltreatment began, or be confounded by co‐occurring psychosocial risk factors. Method: We used data from the National Survey of Child and Adolescent Well‐Being (NSCAW) to identify four groups of children who varied in the timing, extent, and continuity of their maltreatment from birth to 9 years. Internalizing and externalizing problems, prosocial behavior, and IQ were assessed 21 months, on average, following the most recent maltreatment report. Results: Children maltreated in multiple developmental periods had more externalizing and internalizing problems and lower IQ scores than children maltreated in only one developmental period. Chronically maltreated children had significantly more family risk factors than children maltreated in one developmental period and these accounted for maltreatment chronicity effects on externalizing and internalizing problems, but not IQ. The timing of maltreatment did not have a unique effect on cognitive or behavioral outcomes, although it did moderate the effect of maltreatment chronicity on prosocial behavior. Conclusion: There is a need for early intervention to prevent maltreatment from emerging and to provide more mental health and substance use services to caregivers involved with child welfare services.     

Psychosocial adjustment in Swedish children with upper-limb reduction deficiency and a myoelectric prosthetic hand

Aim: To study psychosocial adjustment and mental health in children with upper-limb reduction deficiency and a myoelectric prosthetic hand. Methods: Sixty-two parents of children aged 8 to 18 y old answered a questionnaire concerning competence and behaviour/emotional problems in their children. Of the 62 children, 37 adolescents aged 11 to 18 y old answered questionnaires concerning competence, problems and mood state. The results were compared with Swedish normative data. The children were divided into five groups based on degree of myoelectric prosthetic use. Results: Children with upper-limb reduction deficiency and a myoelectric prosthetic hand showed social competence and behaviour/emotional problems similar to Swedish standardized norms. However, withdrawn behaviour was significantly higher in all children, social competence was significantly lower in girls, and social activities were significantly lower in older children with upper-limb reduction deficiency. There was a significant difference between prosthetic use groups. Non-users had significantly more delinquent behaviour problems than full-time users. There was an interaction between gender and prosthetic use in their affect on competence and behaviour/emotional problems, yielding two contrasting patterns.

Conclusion: Children with upper-limb reduction deficiency and a myoelectric prosthetic hand are as well adjusted psychosocially as their able-bodied peers. There are indications, however, of social stigmata related to the deficiency, which have to be considered differently in boys and girls.     

Longitudinal pathways linking child maltreatment,emotion regulation,peer relations,and psychopathology

Background: The aim of this study was to investigate longitudinal relations among child maltreatment, emotion regulation, peer acceptance and rejection, and psychopathology. Methods: Data were collected on 215 maltreated and 206 nonmaltreated children (ages 6–12 years) from low‐income families. Children were evaluated by camp counselors on emotion regulation and internalizing and externalizing symptomatology and were nominated by peers for peer acceptance and rejection. Results: Structural equation modeling analyses revealed that experiencing neglect, physical and/or sexual abuse, multiple maltreatment subtypes, and earlier onset of maltreatment were related to emotion dysregulation. Lower emotion regulation (Time 1) was associated with higher externalizing symptomatology (Time 1) that contributed to later peer rejection (Time 2), which in turn was related to higher externalizing symptomatology (Time 2). Conversely, higher emotion regulation was predictive of higher peer acceptance over time, which was related to lower internalizing symptomatology controlling for initial levels of symptomatology. Conclusions: The findings emphasize the important role of emotion regulation as a risk or a protective mechanism in the link between earlier child maltreatment and later psychopathology through its influences on peer relations.     

Child physical abuse with and without other forms of maltreatment: dysfunctionality versus dysnormality

The fact that most etiological studies of physical abuse have not taken into account co-occurrence of different forms of maltreatment calls into question the validity of our knowledge on the subject. The aim of this study, therefore, is to compare the etiological patterns of cases of physical abuse reported to Quebec child protective services (CPS) according to whether the abuse occurs alone or co-occurs with other forms of maltreatment. The data are taken from the Quebec Incidence Study (QIS), which examined 4,929 reports investigated by Quebec CPS in the fall of 1998. The cases included 514 children who were physically abused: 269 of them were not subjected to any other type of maltreatment and 245 were also victims of one or two other forms of maltreatment. The survey form provided information on more than 30 characteristics of the children reported, their families, and their parental figures. Bivariate and direct logistic regression analyses revealed that the profile of physical abuse cases varies depending on whether the physical abuse occurs alone (what we are calling dysnormality) or in combination with one or two other forms of maltreatment (dysfunctionality). Those results will help deepen our etiological knowledge of physical abuse and may serve to inspire different types of intervention for the two groups of children.     

乌鲁木齐农村3~6岁儿童忽视现状及其危险因素分析

目的 了解新疆乌鲁木齐农村3~6岁儿童忽视现状及其危险因素，为今后开展新疆农村儿童忽视的防治提供理论依据。方法 采用分层随机整群抽样方法抽取乌鲁木齐农村6所幼儿园中1 326名3~6岁儿童，采用自行设计问卷和"儿童忽视状况评价问卷"对儿童家长进行问卷调查。结果 1 326名儿童中，忽视检出率为51.89%（688例），忽视度为49±6。不同年龄组儿童忽视率和忽视度差异有统计学意义（P < 0.01）；单亲家庭、再婚家庭儿童忽视率和忽视度均高于三代同堂家庭和核心家庭（P < 0.01）；留守儿童忽视程度高于非留守儿童（P < 0.01）。多因素logistic回归分析显示，低龄儿童、母亲文化程度较低、母亲外出打工、单亲家庭、再婚家庭、低收入家庭、留守儿童是儿童忽视的危险因素（P < 0.05）。结论 乌鲁木齐农村3~6岁儿童忽视问题较为突出，应加大对低龄儿童、文化程度较低母亲儿童、留守儿童及单亲家庭、再婚家庭、低收入家庭儿童的关注。