Predictors of re-referral to child protective services: a longitudinal follow-up of an urban cohort maltreated as infants

Decades of research has identified several psychosocial risk factors for child maltreatment, only some of which are modifiable. The relative importance of the most modifiable psychosocial variables, as compared to more static variables such as demographic characteristics, is not well understood, particularly among children maltreated at a very young age. This study examined predictors of re-referral among 149 urban children originally referred for maltreatment as infants. Of these children, 42.3% were re-referred over a period of 11 to 15 years. Cox regression analyses with time-varying covariates revealed that modifiable psychosocial risk factors failed to predict risk for re-referral in a multivariate model. Demographic characteristics and characteristics of the index incident of maltreatment were the strongest predictors of re-referral. Existing services may not be addressing the underlying reasons for maltreatment, particularly in families with young children. A clearer understanding of the underlying causes of maltreatment is needed.     

Suicidal ideation among urban nine and ten year olds

Little is known about rates and correlates of suicidal ideation among nonclinical samples of preadolescents from low-income urban backgrounds. Using the Children's Depression Inventory, we measured suicidal ideation in 131 preadolescent urban children (49% female, 90% African American/Caribbean) participating in an ongoing prospective longitudinal study of prenatal cocaine exposure and children's outcome. Suicidal ideation was reported by 14.5% of the children in this sample at 9 to 10 years of age. Children's reports of depressive symptoms, exposure to violence, and distress symptoms in response to witnessing violence were associated with suicidal ideation, but prenatal cocaine exposure, parent-rated child behavior, and caregivers' psychological distress symptoms were not. Suicidal ideation may be more prevalent among preadolescents from urban, low-income backgrounds than clinicians suspect, particularly among children exposed to violence.     

Intergenerational continuity of child abuse among adolescent mothers: authoritarian parenting, community violence, and race

Among the negative sequelae of child maltreatment is increased risk for continuity of maltreatment into subsequent generations. Despite acknowledgment in the literature that the pathways toward breaking the cycle of maltreatment are likely the result of dynamic interactions of risk and protective factors across multiple ecological levels, few studies have followed high-risk samples of maltreated and nonmaltreated parents over time to evaluate such processes. In the current investigation, exposure to community violence and authoritarian parenting attitudes were evaluated as predictors of the intergenerational continuity of abuse, and the moderating effect of African American race was examined. The sample included 70 mothers and their 18-year-old children, who have been followed longitudinally since the third trimester of the adolescent mothers' pregnancy. Results revealed that among mothers with a child abuse history, higher exposure to community violence and lower authoritarian parenting attitudes were associated with increased risk for intergenerational continuity of abuse. The relation of authoritarian parenting attitudes to intergenerational continuity was moderated by race; the protective effects of authoritarian parenting were limited to the African American families only. The salience of multiple ecological levels in interrupting the intergenerational continuity of child abuse is discussed, and implications for preventive programs are highlighted.     

Adverse behavioral and emotional outcomes from child abuse and witnessed violence

This article examines mental health outcomes of children who have witnessed violence in their social environment and/or have been physically abused. Participants (n = 167) come from a longitudinal study on child maltreatment. Outcomes-including depression, anger, and anxiety--are measured by the Child Behavior Checklist and the Trauma Symptom Checklist for Children. The authors used adjusted multivariate analyses to test the statistical significance of associations. The majority of children were female (57%) and non-White (64%). One third had been physically victimized; 46% had witnessed moderate-high levels of violence. Results confirm that children are negatively affected by victimization and violence they witness in their homes and neighborhoods. Victimization was a significant predictor of child aggression and depression; witnessed violence was found to be a significant predictor of aggression, depression, anger, and anxiety. Implications will be discussed.     

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.     

A descriptive survey of Swedish child health nurses' awareness of abuse and neglect. II. Characteristics of the children

AIM: To determine whether children considered by child health nurses to be at risk of abuse or neglect differed from the general population in gender, age and health status, and whether such child characteristics were related to nurses' perceptions of case seriousness, or to reporting to the child protection services (CPS). METHODS: Questionnaires were sent to nurses in the preventive Child Health Services, 951 of whom identified a total of 6044 children aged 0 to 6 y as suspected of risk of maltreatment. RESULTS: Boys and older children were over-represented among the identified children, possibly because the attention of the nurses was attracted by salient symptoms in older boys. Children with health problems and boys exposed to disturbed parenting/neglect were perceived as more serious cases than other children. Children aged 4-6 y were more likely to be reported to the CPS than children under 3 y of age. CONCLUSION: The findings raise the question whether possibly maltreated children who are very young, female or in good health run a particularly high risk of non-detection, of being considered non-serious cases and of not being reported to the CPS. The risk of going unnoticed may be higher for some children at risk of maltreatment than for others.     

Suicide risk following child sexual abuse.

OBJECTIVE: To determine the suicide rate and prevalence of suicide attempts and suicidal ideation in 183 young people who had experienced child sexual abuse and to examine variables related to the abuse, which may correlate with suicide attempts or suicidal ideation. METHODS: Adolescents and young adults who had experienced child sexual abuse and individuals from a nonabused comparison group were asked about suicide attempts and suicidal ideation 5 and 9 years after intake to the study. Nine years after the abuse, a national death search was carried out to ascertain the number and causes of death in the 2 groups. Logistic regression was used to assess information on demographic and family functioning variables, the sexual abuse, notifications for other child abuse, criminal convictions, and out-of-home placements that were related to the outcome variables. RESULTS: Young people who had experienced child sexual abuse had a suicide rate that was 10.7 to 13.0 times the national Australian rates. There were no suicides in the control group. Thirty-two percent of the abused children had attempted suicide, and 43% had thought about suicide since they were sexually abused. CONCLUSIONS: Little information seems to be available to clinicians at the time of investigations for child sexual abuse in children that may identify those who are at increased risk of suicide. Abuse by an acquaintance, parental denial, or being angry with the child and not the abuser may predispose to suicide attempts but not necessarily to a completed suicide.     

Exposure to violence and associated health-risk behaviors among adolescent girls.

OBJECTIVE: To examine the relationship between exposure to violence and health-risk behaviors. DESIGN: Cross-sectional survey. SETTING: University-based outpatient family planning clinic. PATIENTS: Sexually active adolescent girls younger than 18 years (N = 517) who presented for contraceptive care. MAIN OUTCOME MEASURES: Prevalence of witnessing or experiencing violence and the associations with health-risk behaviors, including high-risk sexual behaviors, substance use, and self-injury. RESULTS: Compared with adolescents who had not been exposed to violence, those who had only witnessed violence were 2 to 3 times more likely to report using tobacco and marijuana, drinking alcohol or using drugs before sex, and having intercourse with a partner who had multiple partners. Those who had experienced, but not witnessed violence were at increased risk of these same behaviors and were 2 to 4 times more likely than those who had neither witnessed nor experienced violence to report early initiation of intercourse, intercourse with strangers, multiple partners, or partners with multiple partners, tobacco, alcohol and drug use, or to have positive test results for a sexually transmitted disease. Individuals who had both witnessed and experienced violence demonstrated the greatest risk of adverse health behaviors. These adolescents demonstrated 3 to 6 times greater risk of suicidal ideation (odds ratio [OR], 3.1; 95% confidence interval [CI], 2.2-4.0) or suicide attempts (OR, 4.5; 95% CI, 2.2-9.4), self-injury (OR, 5.8; 95% CI, 2.6-12.9), and use of drugs before intercourse (OR, 6.2; 95% CI, 3.0-12.9) than those who had neither witnessed nor experienced violence. CONCLUSIONS: Adolescents exposed to violence are at increased risk of multiple adverse health behaviors. Programs designed to improve health outcomes should target this high-risk group.     

At-risk and maltreated children exposed to intimate partner aggression/violence: what the conflict looks like and its relationship to child outcomes

Despite increasing research on children's exposure to intimate partner aggression/violence (IPAV), and co-occurrence of IPAV and maltreatment, little is known about IPAV in at-risk and maltreating families. We explored the nature of IPAV in 554 homes where children were identified as at risk or reported for maltreatment and examined differences between emotional and behavioral outcomes for children in homes where one or both intimate partners is the alleged perpetrator of IPAV. We found in this sample that IPAV primarily took the form of verbal aggression with differences in perpetrator gender for verbal, minor, and severe violence. There were few child outcomes predicted by perpetrator gender: Significant child behavior problems were found with all types of IPAV and both genders as perpetrators. Results suggest the need for comprehensive assessments of IPAV when assessing risk, safety, and harm issues for children reported as being at risk or victims of maltreatment.     

A prospective analysis of the relationship between reported child maltreatment and special education eligibility among poor children

This study presents data from the first large-scale longitudinal study to track the involvement of children reported for maltreatment in both the special education and child welfare systems. A range of state and local administrative databases were combined and cross-sector service histories were established for 7,940 children who had received Aid to Families With Dependent Children between 1993 and 1994. The authors address the following questions: (a) Is maltreatment associated with entry into special education after controlling for other factors? (b) among maltreated children, does maltreatment type or child welfare service use predict special education eligibility? and (c) what is the relationship between maltreatment type and type of educational disability? Results indicate that child maltreatment system involvement generally predates special education entry and is predictive of entry even after controlling for other factors. A range of other associations between factors such as child and maternal characteristics, services received, maltreatment type, and special education classification are detailed.     

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.     

Ecological influences on the sequelae of child maltreatment: a review of the literature

Numerous studies indicate that child maltreatment increases the risk for the development of internalizing and externalizing behavior problems. Great variations in outcome, however, have been noted among victims of maltreatment. From an ecological perspective, this review examines how the effects of maltreatment may be influenced by the contexts in which children develop, including their families, peer groups, schools, and communities. The literature reviewed suggests that contextual factors not only influence the incidence of maltreatment but also may moderate its developmental effects, thereby accounting for some of the heterogeneity in the outcomes associated with abuse and neglect. Closer examination of the influence contextual factors exert on the psychosocial sequelae of maltreatment will better inform the interventions, treatments, and public policies directed toward the maltreated population. Methodological considerations for conducting research in this area are also discussed.     

A novel differential susceptibility gene: CHRNA4 and moderation of the effect of maltreatment on child personality

Background: The differential susceptibility hypothesis states that some genetic variants that confer risk in adverse environments are beneficial in normal or nurturing environments. The cholinergic system is promising as a source of susceptibility genes because of its involvement in learning and neural plasticity. The cholinergic receptor gene CHRNA4 has been linked to characteristics related to the personality traits Neuroticism and Openness/Intellect. Methods: The effects of interaction between CHRNA4 genotype and maltreatment status on child personality were examined in a well matched sample of 339 maltreated and 275 non‐maltreated children (aged 8–13 years). Results: Variation in CHRNA4 interacted with childhood maltreatment to predict personality in a manner indicating differential susceptibility. The interaction of CHRNA4 and maltreatment status predicted Neuroticism and Openness/Intellect. Maltreated children with the rs1044396 T/T genotype scored highest on Neuroticism and showed no effect of genotype on Openness/Intellect. Non‐maltreated children with this genotype scored lowest on Neuroticism and highest on Openness/Intellect. Conclusion: Variation in CHRNA4 appears to contribute to personality by affecting degree of developmental sensitivity to both normal and adverse environments.     

Emotion regulation predicts attention bias in maltreated children at-risk for depression

Background: Child maltreatment is associated with heightened risk for depression; however, not all individuals who experience maltreatment develop depression. Previous research indicates that maltreatment contributes to an attention bias for emotional cues, and that depressed individuals show attention bias for sad cues. Method: The present study examined attention patterns for sad, depression‐relevant cues in children with and without experience of maltreatment. We also explored whether individual differences in physiological reactivity and emotion regulation in response to a sad emotional state predict heightened attention to sad cues associated with depression. Results: Children who experienced high levels of maltreatment showed an increase in attention bias for sad faces throughout the course of the study, such that they showed biased attention for sad faces following the initiation of a sad emotional state. Maltreated children who had high levels of trait rumination showed an attention bias toward sad faces across all time points. Conclusions: These data suggest that maltreated children show heightened attention for depression‐relevant cues in certain contexts (e.g. after experience of a sad emotional state). Additionally, maltreated children who tend to engage in rumination show a relatively stable pattern of heightened attention for depression‐relevant cues. These patterns may identify which maltreated children are most likely to exhibit biased attention for sad cues and be at heightened risk for depression.     

Foster care for child maltreatment. II. Impact on school performance

At least 150,000 children currently reside in foster care in the United States because of child maltreatment. Nearly 15% of all confirmed maltreatment reports record foster care as one of the acute interventions. Yet, the impact of foster care has been largely unexamined. We conducted a historical cohort study of the impact of foster care on subsequent school performances for 114 children placed in foster care because of maltreatment. A comparison cohort was constituted of 106 maltreated children who were similar in age, race, sex, and year of diagnosis but who were left in their homes after report. School records were reviewed for 96 of the foster care children and 69 of the home care children. School attendance had improved for both groups at the time of follow-up nearly 8 years later. Children in school at the time of report who were then placed in foster care missed an average of 15.6% of the school year prior to the report compared with missing only 3.48% of the most recent school year. The children from the comparison group missed an average of 8.5% of the school year prior to their index maltreatment report and 7.2% of their most recent year in school. Forty-four percent of the foster care group achieved average or above average grades on follow-up compared with the passing rate for the home care group of 32% (P = .17). The foster care children were more likely to receive special education services. Overall, both groups were doing poor work in school an average of 8 years after maltreatment report. There appears to be no evidence for a significant rehabilitative effect of foster care as measured by subsequent school performance.     

Child maltreatment and foster care: unpacking the effects of prenatal and postnatal parental substance use

Parental substance use is a well-documented risk for children. However, little is known about specific effects of prenatal and postnatal substance use on child maltreatment and foster care placement transitions. In this study, the authors unpacked unique effects of (a) prenatal and postnatal parental alcohol and drug use and (b) maternal and paternal substance use as predictors of child maltreatment and foster care placement transitions in a sample of 117 maltreated foster care children. Models were tested with structural equation path modeling. Results indicated that prenatal maternal alcohol use predicted child maltreatment and that combined prenatal maternal alcohol and drug use predicted foster care placement transitions. Prenatal maternal alcohol and drug use also predicted postnatal paternal alcohol and drug use, which in turn predicted foster care placement transitions. Findings highlight the potential integrative role that maternal and paternal substance use has on the risk for child maltreatment and foster care placement transitions.     

Child protection in Sweden: Are routine assessments reliable?

AIM: To study the validity of the decision not to investigate mandatory reports of suspected child maltreatment. METHODS: Written files of 220 reports indicating possible child maltreatment were analysed and re-evaluated. As a measure of the justification for the decisions, a 5-y follow-up study was done. RESULTS: We determined that 76% of the reports still indicated child maltreatment after the initial assessment was done. In the follow-up study, 45% of the children had been investigated. The social worker used the family as the only source of information in 74% of the cases, in 6% someone outside the family was contacted, and in 11% no further information in addition to the report was collected. In 9%, data on information sources were missing. CONCLUSION: The findings are rather discouraging, as they challenge the belief that a report is a means of ensuring that maltreatment does not continue. The study shows that, depending upon the way in which the initial assessments are made, maltreated children may run a risk of not being identified, even though the maltreatment has been reported. This suggests that there may be a need for national guidelines concerning the reporting of maltreatment.     

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.