Child Abuse & Neglect 44 (2015) 184–193
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Child Abuse & Neglect
Child maltreatment and risk patterns among participants in a child abuse prevention program夽 Jennifer Y. Duffy a , Marcia Hughes b , Andrea G. Asnes a , John M. Leventhal a,∗ a b
Yale School of Medicine, 333 Cedar Street, New Haven, CT 06520, USA Center for Social Research, University of Hartford, 260 Girard Ave, Hartford, CT 06105, USA
a r t i c l e
i n f o
Article history: Received 12 February 2014 Received in revised form 29 October 2014 Accepted 5 November 2014 Available online 4 December 2014 Keywords: Child abuse and neglect Prevention Substantiation CPS report
a b s t r a c t The relationship between risk factors and Child Protective Services (CPS) outcomes in families who participate in home visiting programs to prevent abuse and neglect and who are reported to CPS is largely unknown. We examined the relationship between parental risk factors and the substantiation status and number of CPS reports in families in a statewide prevention program. We reviewed CPS reports from 2006 to 2008 for families in Connecticut’s child abuse prevention program. Six risk factors (histories of CPS, domestic violence [DV], mental health, sexual abuse, substance abuse, and criminal involvement) and the number of caregivers were abstracted to create risk scores for each family member. Maltreatment type, substantiation, and number of reports were recorded. Odds ratios were calculated. Of 1,125 families, 171 (15.6%) had at least one CPS report, and reports of 131 families were available for review. Families with a substantiated (25.2%) versus unsubstantiated (74.8%) ﬁrst report had a high number of paternal risk factors (OR = 6.13, 95% CI [1.89, 20.00]) and were more likely to have a history of maternal DV (OR = 8.47, 95% CI [2.96, 24.39]), paternal DV (OR = 11.23, 95% CI [3.33, 38.46]), and maternal criminal history (OR = 4.55; 95% CI [1.32, 15.60]). Families with >1 report (34.4%) versus 1 report (65.6%) were more likely to have >3 caregivers, but this was not statistically signiﬁcant (OR = 2.53, 95% CI [0.98, 6.54]). In a prevention program for ﬁrst-time families, DV, paternal risk, maternal criminal history, and an increased number of caregivers were associated with maltreatment outcomes. Targeting parental violence may impact child abuse prevention. © 2014 Elsevier Ltd. All rights reserved.
Introduction Home visiting programs have been developed in an attempt to prevent child abuse and neglect through home-based parenting programs, parenting curricula, emotional support, and linking families to community services (Avellar & Supplee, 2013; Donelan-McCall, Eckenrode, & Olds, 2009; MacMillan et al., 2005). These programs have traditionally targeted families that are at high-risk of perpetrating child maltreatment. These high-risk families are generally identiﬁed by the presence of certain sociodemographic characteristics, such as poverty or young maternal age, which have been shown to be associated with an increased risk of child maltreatment (Brown, Cohen, Johnson, & Salzinger, 1998). Several outcome measures have been used to assess program efﬁcacy including parental reports of behaviors toward the child (DuMont et al., 2008), the
夽 This study was supported by the Child Abuse funds of the Department of Pediatrics and by a grant from the Doris Duke Foundation to Yale Medical School. ∗ Corresponding author. http://dx.doi.org/10.1016/j.chiabu.2014.11.005 0145-2134/© 2014 Elsevier Ltd. All rights reserved.
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occurrence of injuries resulting in visits to the emergency department or hospitalizations (Kitzman et al., 1997; Matone, O’Reilly, Luan, Localio, & Rubin, 2012), and reports to Child Protective Services (CPS) (Duggan et al., 2004, 2007; Gonzalez & MacMillan, 2008; Olds, Henderson, Kitzman, & Cole, 1995). In this article, we focus on a different aspect of home visiting programs by examining families that were enrolled in a state-wide home visiting program to prevent abuse and neglect and that were reported to CPS. Speciﬁcally, we examined the risk factors in those reported to CPS and the associations between risk factors and substantiation and between risk factors and more than one report to CPS.
Risk Factors for Abuse and Neglect There is a comprehensive literature on the risk factors for abuse and neglect, and four major domains of risk have been identiﬁed: (a) child characteristics (e.g., prematurity, disability), (b) parental characteristics (e.g., mental health problems, substance use, maltreatment during childhood), (c) family characteristics (e.g., DV, absent father), and (d) social characteristics (e.g., poverty, violent neighborhoods; Belsky, 1980). Studies in the United States and the United Kingdom have examined these risk factors by following families longitudinally. For example, in the United States, Brown et al. (1998) examined the outcomes of abuse and neglect of children who were enrolled in a longitudinal study at ages 1–10 years in 1975 and were followed with periodic interviews. In 1991–1993, data about child maltreatment were obtained from interviews of those over 18 years of age and records from the state’s CPS agency. Many risk factors were associated with the occurrence of abuse or neglect, and children with at least four risk factors were 8 times more likely to have experienced maltreatment compared to those with no risk factors. Risk factors with an odds ratio of greater than 2.5 included parental characteristics: maternal sociopathy, which included drug, alcohol, or police involvement (OR = 4.91), maternal dissatisfaction (3.15), and low maternal education (3.09); family characteristics: early separation from mother (2.80), low father involvement (3.14), and low father warmth (2.57); and social characteristics: being on welfare (5.14) and low income (3.02) (Brown et al., 1998). In a more recent study from the United Kingdom, Sidebotham, Heron, and ALSPAC Study Team (2006) used data from the Avon Longitudinal Study of Parents and Children (ALSPAC) to examine risk factors for children who were reported for suspected maltreatment or placed on the local CPS registry by 6 years of age. Data were obtained on 14,256 children whose mothers were enrolled prenatally; 259 children were reported for suspected maltreatment, and 115 of these were placed on the local registry. Risk factors for being placed on the registry included child characteristics: low birth weight (OR = 2.23) and few positive attributes reported (1.97); parental characteristics: low educational achievement (4.96), young age (3.41), history of psychiatric illness (2.82), and history of childhood abuse (1.86); family characteristics: single mother (2.64) and reordered family (2.58); and social characteristics: social deprivation (11.02) and poor social network (1.93). The odds ratio for the risk factor of DV was elevated at 1.60, but this result was not statistically signiﬁcant. The risk factors for reporting suspected maltreatment were similar to those for being listed on the child abuse registry (Sidebotham et al., 2006). Based on these studies of risk factors, concerns about the links among family violence, substance abuse, and maltreatment (Connelly et al., 2006; Dubowitz et al., 2011; Laslett, Room, Dietze, & Ferris, 2012; U.S. Department of Health and Human Services, 2013), and data that were available in our study about parental characteristics, we focused on six risk factors: (a) parent’s CPS history as a child, (b) DV history, (c) mental health history, (d) sexual abuse history, (e) substance abuse history, and (f) criminal history.
Reports to CPS as the Outcome of Child Maltreatment The accuracy of using CPS reports to approximate abuse and neglect has been debated for several reasons. First, CPS reports may underestimate and overestimate the actual rates of abuse and neglect. Underestimation may occur if levels of maltreatment exist that do not lead to a CPS report, but, in fact, may cause harm to the child. Overestimation can result from the fact that the families in prevention programs may have greater contact with mandated reporters than non-participating families, thus leading to surveillance bias in the reporting of maltreatment in the families with home visitors (Chafﬁn & Bard, 2006). Second, it is unknown whether the severity of child maltreatment is more accurately measured by the frequency with which maltreatment occurs (estimated by the number of maltreatment reports) or by whether a report is substantiated (meaning that there is sufﬁcient evidence to indicate that abuse has occurred; Drake, Jonson-Reid, Way, & Chung, 2013; Hussey et al., 2005). This debate arises, in part, from the fact that both substantiated and unsubstantiated maltreatment can result in negative consequences for the child (Jonson-Reid, Kohl, & Drake, 2012; Smith, Ireland, & Thornberry, 2005). Although substantiation is meant to reﬂect that maltreatment has occurred, substantiation of a CPS report may be more reﬂective of the process and biases inherent in the CPS investigation rather than the severity of the maltreatment (Drake, 1996). Therefore, it has been suggested that the recidivism of maltreatment (represented by the presence of multiple CPS reports) may be a more appropriate way to risk stratify families involved with CPS (Hussey et al., 2005; Jonson-Reid et al., 2012).
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Limitations of Previous Studies and Purpose of Current Study Studies of home visiting programs have usually focused on the frequency of the outcomes in the families in the prevention program compared to the same outcomes in a comparison group who have not received the intervention. For example, several studies have examined the outcome of reports to CPS, and some of these studies have used a randomized clinical trial to examine this outcome. Duggan et al. have conducted two randomized trials – in Hawaii and Alaska – of home visiting programs and have found no statistically signiﬁcant differences in the percentages of children reported to CPS in the treatment versus the control groups (Duggan et al., 2004, 2007). Such studies, however, have not gone further to examine two important aspects of the children and families who have received services in the prevention program and who have experienced the outcome. First, what is the risk proﬁle of these children and families, and how does this proﬁle differ from the children and families who have not experienced the outcome? Second, of the children reported to CPS, are there differences in the risk proﬁle for those cases that are substantiated versus those that are not, and are there differences in those children who experienced a single report versus those who went on to experience subsequent CPS reports? In the current study, we propose to close this gap by examining the detailed risk-proﬁles of ﬁrst-time families who participated in a state-wide home visiting program aimed at preventing child abuse and neglect and who were reported to CPS for suspected maltreatment. We used the data collected from the structured CPS investigation to examine three speciﬁc questions: (a) What are the risk proﬁles of the reported cases? (b) Are the risk proﬁles different for those cases that were substantiated versus those that were not? (c) Are the risk proﬁles different for those with a single report to CPS versus those with at least two reports? To answer questions 2 and 3, we conducted two case control studies where cases were families with the outcome of interest and controls were families without that outcome. Methods Study Sample The sample was drawn from a group of families who participated in Connecticut’s child abuse and neglect prevention program, the Nurturing Families Network (NFN), and who were reported to Connecticut’s CPS agency. NFN is a program that screens all ﬁrst-time births in Connecticut using a 17-item questionnaire (Revised Early Identiﬁcation – REID screen) that solicits information about a mother’s level of risk based on the presence or absence of 17 factors (e.g., young age, single, and history of psychiatric care). The identiﬁed high-risk group is predominately single mothers living in poverty. Eligible families are offered weekly home visits by a paraprofessional visitor until the child’s ﬁfth birthday. Services offered through the home visiting program include an evidence-based parenting curriculum (Zigler, Pfannenstiel, & Seitz, 2008), advice about common parenting problems, modeling effective parenting, screening for developmental problems, and linkage to community resources. Since NFN’s inception in 1997, over 50,000 ﬁrst-time mothers have been screened. Of these, 15,300 families have been identiﬁed as high-risk, and approximately 5,300 individuals ultimately accepted home visiting services. The average length of program participation is 22 months. To determine whether a child has been reported to the state’s Child Protective Service agency for suspected abuse or neglect, NFN obtains annual written consent from participating families to access their records from Child Protective Services. Roughly 50–70% of these families grant this permission each year. This study, therefore, focused on a group of 1,125 families who were involved in NFN between 2006 and 2008 and gave NFN consent to access their CPS reports. This study was granted exemption status by Yale Medical School’s IRB because all data were de-identiﬁed prior to review by the investigators. Demographic Questionnaires We collected basic demographic information, including date of birth, race, and gender of the ﬁrst-born child and date of birth and race for each parent. We also recorded each family’s primary language and town or region of the state. This information was obtained from the CPS reports or from the intake questionnaire that each family completed upon enrolling in NFN’s home visiting program. CPS Reports Full-length narrative CPS reports were reviewed. Each report was written by the CPS investigative social worker and was based on interviews of family members, collateral reports, criminal background checks, medical checks, and a search of CPS’s electronic records. The full-length report consisted of a multi-page narrative that chronicled the circumstances surrounding a report to CPS of suspected maltreatment, the subsequent CPS investigation, and the ﬁnal result of the investigation
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(whether the case was substantiated). The report also contained information about family dynamics, risk factors present in all individuals involved in the child’s life, and the number of caregivers (full-time and partial caregivers). For each family, we recorded the number of reports made to CPS for suspected maltreatment over a two-year period. Although each report pertained to a single alleged maltreatment event, a report may have contained multiple allegations, either because there were multiple alleged perpetrators or a single alleged perpetrator was accused of committing multiple types of maltreatment. Therefore, we recorded information on each allegation contained within each report, including: the alleged perpetrator, the alleged victim, the ﬁnal CPS classiﬁcation of maltreatment (physical abuse, sexual abuse, emotional maltreatment, physical neglect, medical neglect, educational neglect), and whether the allegation was substantiated. Risk Factor Assessment We abstracted risk information from the full-length CPS reports using a coding scheme to classify the types and extent of risk factors in household members. The abstraction of all data was done by the ﬁrst author (JYD); a random selection of 15 cases was also abstracted by a second reviewer to ensure that there was agreement between the abstractors. The full-length reports provided systematic information on six risk factors that we used as our variables of interest based on a literature review of factors known to increase the risk of child maltreatment: (a) parent’s CPS history as a child, (b) DV history, (c) mental health history, (d) sexual abuse history, (e) substance abuse history, and (f) criminal history. This information was recorded on each individual listed in the CPS report, including immediate family members, non-immediate family members, and non-related individuals living in the child’s home. In addition, for each individual mentioned in each CPS report, we recorded the extent of the person’s involvement as a caregiver to the index child (full-time caregiver, part-time caregiver, non-caregiver living in the home with child, or not involved). Development of Risk Scores Based on the six risk factors, each individual (e.g., mother, father, grandparent) was given a risk score of 0–6. Using these individual risk scores, an additional risk score was derived. The Environmental Risk Score was the sum of the risk scores of all individuals involved in the child’s life, excluding the mother and father. In the analyses, the risk scores were initially utilized as continuous variables. To conserve power and protect against the impact of outliers in the small sample, risk indices were then used to create risk groups based on a median split of the continuous variable. For example, the maternal risk score was used to create a high risk group (>2 risk factors) and low risk group (0–2 risk factors). These risk groups were created for maternal, paternal, and environmental risk scores and were separately considered in the analyses. Data about risk factors were based on information contained in the ﬁrst CPS report, as we felt that this information was most relevant to the question of maltreatment prevention. Additionally, because families with multiple reports may have had a greater amount of available information, we did not want to bias the results by including risk information obtained from subsequent CPS reports. Deﬁnitions of Outcome Measures For the families with CPS reports, we used two outcomes: the result of the CPS investigation and the number of CPS reports. We deﬁned the result of the CPS investigation according to the substantiation status, meaning that at the end of the CPS investigation there was sufﬁcient evidence for CPS to conclude that maltreatment had occurred. Our second outcome was maltreatment recidivism, based on whether the family had a single or multiple CPS reports. Our study period reviewed all reports generated for a two-year period. Case–Control Analyses Using the risk factor and caregiver data, we conducted two case–control studies involving the families with CPS reports. In this standard epidemiological methodology, we divided the sample based on the occurrence of the outcome: cases were those with the outcome present and controls were those who did not have the outcome of interest (Schlesselman, 1982). The ﬁrst case–control study compared families with substantiated versus not substantiated reports. The second compared families with multiple versus those with single reports. For each of these studies, we examined differences in risk factors and caregiver information between cases and controls. Univariate logistic regression and multivariate logistic regression analyses controlling for the mother’s age, race, and language and the child’s gender were used to calculate odds ratios. Two sub-analyses were also conducted. First, because of the heterogeneity of paternal involvement in the sample and because the level of paternal involvement may impact the level of information available to prevention programs and CPS investigators, we conducted a sub-analysis in which uninvolved fathers (e.g., non-caregivers) were removed from the sample. This sub-analysis allowed us to examine the relationship between caregiver risk and child maltreatment without consideration of the risk associated with non-caregivers. Second, the sample contained a subset of families who continued to participate in the prevention program beyond our study dates. For these families, we, therefore, could not ascertain whether they truly had a single report during their program
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Table 1 Characteristics of 131 families reported to CPS while involved in NFN home visiting. Characteristic
Mother’s race (%) Caucasian African-American/Black Hispanic/Latino Biracial Other Mother’s age at child’s birth (years, median; range) Child’s age at 1st report (months, median; range) Child’s gender (%) Male Female Primary household language (%) English Spanish Bilingual Location (%) Urban Non-urban Number of caregivers 1 2 3 4+
42.0% 14.5% 35.1% 3.1% 5.3% 20; 13–44 5; 0–42 51.2% 48.8% 84.7% 6.9% 8.4% 50.4% 49.6% 6.9% 41.2% 35.1% 16.8%
Table 2 Maltreatment allegations in sample. Type of maltreatment
Total (N = 333)
Neglect Physical neglect Emotional neglect Medical neglect Educational neglect Total neglect
70.0% 15.0% 2.1% 0.6% 87.7%
Abuse Physical abuse Emotional abuse Sexual abuse Total abuse
6.0% 3.9% 2.4% 12.3%
participation or whether additional reports occurred during their time in the prevention program, but after our study period. Therefore, for the analyses in which we used the number of reports as a binary outcome, an additional sub-analysis only included families who had exited the prevention program before the end of the study period. This approach allowed us to conﬁdently place each of these families in the correct group – single or multiple reports. Results Description of Families, Reports, and Risk Between 2006 and 2008, approximately 65% or 1,125 families who were receiving home visiting services gave written consent to have their CPS records reviewed. Of these families, 175 families (15.6%) had one or more CPS reports, and 950 (84.4%) did not have any CPS reports. When compared on the basis of their demographics, the group with CPS reports as compared to those without CPS reports had a larger percentage of Caucasians (39.6% versus 23.3%) and a smaller percentage of Hispanic families (34.0% versus 46.3%) (p < 0.05). Of the 175 families with CPS reports, 131 (76.2%) had a detailed CPS report that could be reviewed; 44 (23.8%) of the reports were not available because they had been misplaced prior to the initiation of our study. The demographic characteristics of these 131 families are shown in Table 1. Of the mothers, 58.0% were non-white, and there were equal numbers of families living in urban and non-urban settings. The median age of the mothers at the time of the child’s birth was 20 years. There were no demographic differences between these 131 families and the other 44 families for whom no CPS report was available for review. Of the 131 families, 45 (34.4%) had more than one CPS report, which yielded a total of 210 CPS reports. The child’s median age at the time of the ﬁrst report was 5 months (range 0–42 months). Each report contained one or more allegations of
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Fig. 1. Risk factors in caregiving mothers and fathers (“father” includes all biological fathers in sample for whom information is available, including both fathers in a caretaking role and fathers not in a caretaking role) in 131 families with CPS reports. White bars represent n individuals with available data; dark bars represent n individuals with each risk factor. Paternal Sexual Abuse risk estimates include 5 fathers (8% of available sample) who were perpetrators of sexual abuse and 3 fathers (5% of available sample) who were victims of sexual abuse.
maltreatment, resulting in 333 allegations of maltreatment. Of these 333 allegations, 291 (87.7%) were because of neglect (Table 2). As shown in Fig. 1, there were high levels of maternal and paternal risk in the 131 families: the highest levels of risk for mothers were prior CPS involvement (46.4%) and mental health problems (47.4%) and for fathers were DV (39.3%) and criminal history (58.9%). Both caregiving and non-caregiving parents are included in this ﬁgure, and the percentages are based on the number of individuals for whom data were available rather than the sample size of 131. For example, prior CPS history was known for 127/131 mothers in the sample (96.9%). Of these 127 mothers, 59 (46.4%) had been involved with CPS as a child. In contrast, prior CPS history was only known for 87/131 fathers (66.4%); of these 87 fathers, 17 (19.5%) had been involved with CPS as a child. Families with a “Substantiated Report” versus “Unsubstantiated Report” The ﬁrst case–control analysis compared the families based on substantiation status of their ﬁrst DCF report. Of the 131 families, 33 (25.2%) had their ﬁrst report to CPS that was substantiated, and 98 (74.8%) had an unsubstantiated ﬁrst report. Table 3 Unadjusted odds ratios for parental and environmental risk predictors of “substantiated” versus “not substantiated” CPS reports. Maternal risk Maternal risk groupa Maternal CPS history Maternal DV history Maternal MH history Maternal sexual abuse history Maternal criminal history Maternal substance abuse history Paternal risk Paternal risk groupb Paternal CPS history Paternal DV history Paternal MH history Paternal sexual abuse history Paternal criminal history Paternal substance abuse history Environmental risk Environmental risk groupb Number of caregivers Caregiver groupc a b c * ** ***
2.19 0.93 5.11*** 0.87 0.84 2.86* 0.71
0.97–5.00 0.41–2.10 2.12–12.32 0.37–2.03 0.30–2.38 1.10–7.42 0.27–1.82
4.16** 1.21 5.71*** 1.89 0.79 1.45 1.84
1.57–11.01 0.29–5.18 2.06–15.80 0.59–5.99 0.19–3.31 0.57–3.71 0.64–5.31
0.67 1.17 1.14
0.16–2.64 0.77–1.77 0.41–3.20
Deﬁned as having 0–2 risk factors versus 3 or more risk factors. Deﬁned as having 0–1 risk factors versus 2 or more risk factors. Deﬁned as having 0–3 caregivers versus 4 or more caregivers. DV, DV; MH, mental health. p < 0.05. p < 0.01. p < 0.001.
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Table 4 Frequencies of maternal risk factors and adjusted odds ratios for “substantiated” versus “not substantiated” CPS reports. Maternal risk Risk groupa CPS history DV history MH history Sexual abuse history Criminal history Substance abuse history Mean total risk score
SUBS (% with risk) – 45.2 66.7 44.8 22.2 32.3 21.9 2.12
NOT SUBS (% with risk) – 46.9 28.1 48.3 25.3 14.3 28.4 1.78
OR 2.45 0.99 8.47*** 2.07 0.64 4.55* 0.64 –
CI 0.90–6.67 0.92–1.06 2.96–24.39 0.68–2.05 0.19–2.17 1.32–15.60 0.20–2.03 –
a Deﬁned as having 0 to 2 risk factors versus 3 or more risk factors. MH, mental health. SUBS, at least one substantiated allegation (case); NOT SUBS, no substantiated allegations. * p < 0.05. *** p < 0.001.
Table 5 Frequencies of paternal risk factors and adjusted odds ratios for “substantiated” versus “not substantiated” CPS reports. Paternal risk Risk groupa CPS history DV history MH history Sexual abuse history Criminal history Substance abuse history Mean total risk score
SUBS (% with risk) – 13.0% 68.0% 35.0% 15.8% 65.4% 34.8% 2.10
NOT SUBS (% with risk) – 10.9% 27.1% 22.2% 19.1% 56.5% 22.4% 1.52
OR 6.13** 0.88 11.23*** 2.22 0.91 1.83 2.58 –
CI 1.89–20.00 0.17–4.65 3.33–38.46 0.56–8.77 0.17–4.90 0.62–5.41 0.69–9.72 –
a Deﬁned as having 0–1 risk factors versus 2 or more risk factors. MH, mental health; SUBS, at least one substantiated allegation (case), NOT SUBS, no substantiated allegations. ** p < 0.01. *** p < 0.001.
Table 3 shows the unadjusted odds ratios for the likelihood of substantiation based on maternal, paternal, and environmental risk factors. Tables 4 and 5 show the results for the maternal and paternal risk factors, respectively; each table shows the percentage of the risk factors and the risk scores in the substantiated versus not substantiated families and the adjusted ORs and 95% CI for the likelihood of substantiation. Maternal DV history (OR = 8.47) and criminal history (OR = 4.55) and paternal DV history (OR = 11.23) were each signiﬁcantly associated with report substantiation. In addition, the paternal risk group score (the presence of at least two or more risk factors) was signiﬁcantly associated with report substantiation (OR = 6.13). To determine if the occurrence of the risk factors for the mothers was affected by whether risk factor information was available for fathers, we stratiﬁed mothers by whether the father data were available. We then compared these two groups of mothers and found that the level of risk was not different between the two groups (data not shown), suggesting that the level of maternal risk was not higher when father data were absent. When paternal risk factors were examined after stratifying by the level of paternal involvement, 55 families (42%) had no paternal involvement and were classiﬁed as non-caregivers. The removal of these non-caregiving fathers resulted in a significant relationship between paternal criminal history and report substantiation (OR = 4.57, 95% CI [1.03, 20.41]). There were no other substantial differences between this sub-analysis and the analysis in which fathers without parental involvement were included in the sample. Families with “Multiple Reports” versus a “Single Report” Of the 131 families, 45 (34.4%) had more than one report, and 86 (65.6%) had a single report. The median time between the ﬁrst two reports was 7 months (range: 1–44). None of the maternal or paternal risk factors or maternal or paternal risk scores was signiﬁcantly associated with the outcome of two or more reports. The variable – number of caregivers (considered as 0–3 caregivers versus >3 caregivers) approached statistical signiﬁcance (p = .05) with an odds ratio of 2.53 (95% CI [0.98, 6.54]). The results were similar in the sub-analysis in which we analyzed only the families who exited the program prior to the study completion. Discussion This study is the ﬁrst to focus on families that were identiﬁed as “high-risk” prior to program entry, participated in a home visiting program intended to prevent child maltreatment, and were reported to CPS. There were two key ﬁndings: ﬁrst, we found very high levels of parental risk in the sample, and second, we found that DV and criminal history (in the mothers’ and fathers’ lives), paternal risk score, and complex caregiver networks were related to maltreatment outcomes.
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The levels of parental risk in this population were substantial and highlight the challenges of providing preventive services to this group of ﬁst-time mothers and their partners. Almost half of the mothers had a history of mental health problems (47%) and had previous involvement with CPS (46%); when violence was examined, over a third had a criminal history (37%), and 25% had a history of sexual abuse. Data were available for fewer fathers, and the levels of risk were lower than for mothers except for criminal history, which was noted for 59% of the fathers with available data. The percentage of fathers with each risk factor may have been higher if information were available on all fathers since it is likely that CPS workers were not able to collect data from the highest risk fathers. In the case–control study focusing on substantiation, we found that several risk factors were correlated with the substantiation of CPS reports, including paternal risk group score, maternal and paternal DV, and maternal criminal history. These results suggest that substantiation may depend not just on the extent of maltreatment, but also on the levels of risk in the family and, in particular, on the risk factors of DV and criminal history. In terms of paternal risk, prior studies have proposed a relationship between decreased paternal involvement as a caregiver and an increased risk of child maltreatment (Guterman & Lee, 2005). This relationship may be linked to the economic hardship experienced in single-mother households or to the fact that paternal absence increases the likelihood that there will be a surrogate father ﬁgure (e.g., maternal boyfriend), which may be associated with child maltreatment (Radhakrishna, Bou-Saada, Hunter, Catellier, & Kotch, 2001). Although these studies have focused on paternal involvement, few have focused on the impact of paternal risk on child maltreatment. One study by Berger et al., however, used paternal risk as a covariate in the investigation of the relationship between paternal involvement and maltreatment. This study found that the level of paternal risk did not attenuate the relationship between paternal involvement and maltreatment. The authors noted, however, that there was little variance in paternal risk in their sample, so it is possible that their analyses were not able to detect the effect of paternal risk factors on child maltreatment (Berger, Paxson, & Waldfogel, 2009). The strong association between DV (either maternal or paternal) and report substantiation is consistent with the results of previous studies. For example, one study found that DV was implicated in 20% of the cases that were reported to CPS, and that among reports that were classiﬁed as “high-risk” by CPS investigators, reports involving DV were more likely to remain open for services or have a child removed from the home than the reports in which DV was not a factor (English, Edleson, & Herrick, 2005). Another study with ﬁndings similar to ours by Kohl et al. reported a signiﬁcant association between report substantiation and DV: in families with active DV, the substantiation rate was 52% compared to 29% in families with a past history of DV and 22% in families with no DV history (Kohl, Edleson, English, & Barth, 2005). The relationship between parental criminal history and perpetration of child maltreatment is less thoroughly described; the relationship between violence and child maltreatment, however, is well known (Belsky, 1980; Thornberry & Henry, 2013). In our study sample, we did not have the details of the parental criminal records. Thus, it is possible that the crimes in our sample were violent in nature and, therefore, the correlation of criminal history with report substantiation is a reﬂection of the relationship between violence and maltreatment. Additionally, there is evidence for a relationship between childhood maltreatment and a propensity to commit crimes as adults (Nikulina, Widom, & Czaja, 2011; Olds et al., 1998; Reavis, Looman, Franco, & Rojas, 2013; Widom & Maxﬁeld, 1996). Approximately 40% of the parents in our sample had a history of maltreatment during their childhood, and therefore it is possible that the high level of parental criminal activity is reﬂective of this cycle of violence. In our study, we identiﬁed a relationship between the likelihood of substantiation and paternal risk score and DV. In the stratiﬁed sub-analysis when we only considered caregiving fathers, the father’s criminal history was also identiﬁed as a signiﬁcant risk factor. Although the sample size in this sub-analysis was small, this result suggests that paternal risk bears an important relationship to substantiation of child maltreatment, regardless of the level of paternal involvement in these high-risk families. Regarding the outcome of maltreatment recidivism, only a single risk factor approached statistical signiﬁcance, namely an increased number of caregivers. Prior studies have shown several factors to be associated with recidivism, including family poverty, a caregiver’s history of abuse, a caregiver’s substance abuse, and neglect as the maltreatment type (Connell, Bergeron, Katz, Saunders, & Tebes, 2007; Dakil, Sakai, Lin, & Flores, 2011; Hindley, Ramchandani, & Jones, 2006). In our study that focused on a selected, socially high-risk sample, no parental risk factors were independently associated with having multiple reports. Our results are consistent with Thompson et al. who followed a group of 149 high-risk, racially diverse infants for upwards of eleven years to investigate the possible predictors of maltreatment recidivism. This study found that only non-modiﬁable factors (maltreatment type and substantiation) were associated with maltreatment recidivism; in contrast, modiﬁable risk factors (e.g., substance abuse, DV) were not associated with multiple reports (Thompson & Wiley, 2009). None of the studies cited above has investigated the role of caregiver networks or family dynamics in predicting the likelihood of recidivism, although a recent study did highlight the relationship between caregiver instability and child maltreatment (Casanueva et al., 2014). Our ﬁnding about the number of caretakers needs to be examined in a larger sample. If this ﬁnding is conﬁrmed, we postulate that the number of caregivers may serve as a proxy for instability in the home environment. The presence of multiple caregivers may indicate that the care of the child changes frequently, thus exposing the child to the risk of abuse and neglect. In addition, many of these caregivers were non-parental and, therefore, may not have had an attachment relationship with the child, which has been shown to increase the risk of child maltreatment (Morton & Browne, 1998; Stronach et al., 2011). It is also possible that the more caregivers responsible for the care of a child,
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the greater the points of contact that a child may have with society, and the greater the number of people who may report an incident or concern to CPS. There are several limitations of the study. First, the sample sizes were relatively small, and thus important risk factors may have been missed because the odds ratios were not signiﬁcant. Second, only 65% of the families signed consent to allow the review of CPS records, and those who refused consent may have been at higher risk than those who allowed the review. By not including these higher risk families, we may have underestimated the presence of some of the risk factors and the associations that were found. Third, we had CPS reports on 76.2% of the subjects who were reported to CPS, resulting in missing data, which contributed to the small sample size and potentially introduced bias. There were, however, no statistically signiﬁcant demographic differences between the families whose reports we reviewed and the other 23.8% of families that were reported to CPS, but for whom no CPS reports were available. Fourth, the study relied on the reports of CPS social workers, which resulted in incomplete data regarding the six risk factors. The absence of data occurred more frequently for fathers than mothers and likely reﬂects the approach used by CPS in its investigation of reports of suspected maltreatment. By using CPS data, however, we were able to use information directly from the ﬁeld, and these data were not biased by parental self-reports on questionnaires. Despite these limitations, our study is unique in its ability to investigate both substantiated reports and maltreatment recidivism in the same population, speciﬁcally socially high-risk families who were participating in a prevention program. By doing so, we were able to identify risk factors and social network data related to both types of outcomes and to identify risks that may be targeted for prevention efforts. Although our results do not point to a single risk factor that is common to both outcomes, high levels of paternal risk, maternal and paternal DV and criminal history were associated with the likelihood of substantiation. We cannot, however, determine from these strong associations, the extent to which these risk factors were predictive of more serious maltreatment, thus leading to substantiation or inﬂuenced the actual decision by CPS about substantiation. The only risk factor that was of borderline signiﬁcance for the outcome of recidivism was the presence of many caregivers; this potentially important ﬁnding about the caregiving environment in these high-risk families needs further study. If, as prior studies suggest, the number of reports and report substantiations should both be considered as indicators of the severity of abuse, then, perhaps, it is important to target both the level of risk and the chaotic nature of caregiver networks with future prevention efforts. Recent attention has focused on DV in high-risk families as an important target for prevention efforts (Jack et al., 2012). The results of our study support the idea that because DV may correlate with report substantiation (as a marker of abuse severity), targeting DV may be a promising strategy for preventing child maltreatment. 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