HHS Public Access Author manuscript Author Manuscript
JAMA. Author manuscript; available in PMC 2017 January 05. Published in final edited form as: JAMA. 2016 January 5; 315(1): 85–87. doi:10.1001/jama.2015.12912.
Subsequent Maltreatment in Children With Disabilities After an Unsubstantiated Report for Neglect
Author Manuscript
Caroline J. Kistin, MD, MSc, Martha C. Tompson, PhD, Howard J. Cabral, PhD, Robert D. Sege, MD, PhD, Michael R. Winter, MPH, and Michael Silverstein, MD, MPH Department of Pediatrics, Boston Medical Center, Boston, Massachusetts (Kistin, Silverstein); Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts (Tompson); Department of Epidemiology and Biostatistics, Boston University School of Public Health, Boston, Massachusetts (Cabral); Center for the Study of Social Policy, Washington, DC (Sege); Data Coordinating Center, Boston University School of Public Health, Boston, Massachusetts (Winter) Children with disabilities are at increased risk for maltreatment,1,2 and neglect accounts for the majority of such cases.3 Although most cases of suspected neglect are unsubstantiated at the time of the initial report to child protective services (CPS),4 meaning there is insufficient legal evidence of maltreatment, these children are at risk for subsequent maltreatment.5
Methods Author Manuscript
We conducted a retrospective cohort study to examine the incidence and timing of re-referral to CPS, substantiated maltreatment, and foster care placement for any type of maltreatment after an initial unsubstantiated referral for neglect. We compared outcomes between children with and without disabilities.
Author Manuscript
Corresponding Author: Caroline J. Kistin, MD, MSc, Department of Pediatrics, Boston Medical Center, 89 E Newton St, Vose 3, Boston, MA 02118 ([email protected]). Author Contributions: Dr Kistin had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Kistin, Tompson, Sege. Acquisition, analysis, or interpretation of data: Kistin, Tompson, Cabral, Winter, Silverstein. Drafting of the manuscript: Kistin, Silverstein. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Kistin, Cabral. Obtained funding: Kistin. Administrative, technical, or material support: Sege. Study supervision: Kistin, Sege, Silverstein.
We analyzed data from the National Child Abuse and Neglect Data System (NCANDS),4 which collects data annually on all children reported to state-level CPS agencies in the 50 states, the District of Columbia, and Puerto Rico. The Boston University Medical Campus institutional review board qualified the study as exempt. We included data from states that
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Additional Contributions: The data used in this report were made available by the National Data Archive on Child Abuse and Neglect at Cornell University in Ithaca, New York.
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contributed child-level data to NCANDS for fiscal years 2008 through 2012 and retained unique child identification numbers. Children were included if they had first-time unsubstantiated referrals for neglect in 2008; they were followed up for 4 years. We excluded reports that occurred within 24 hours of initial referral because these likely represented the index incident. Children were excluded if the initial report included maltreatment other than neglect or listed prior maltreatment, or if they had previously been reported to CPS, as determined by a search of all available years of NCANDS records (range, 1–10 years). Children were classified as having disabilities if they had conditions included in the Individuals with Disabilities Education Act, and were excluded if his or her disability status was missing.
Author Manuscript
We conducted the statistical analysis using SAS version 9.3 (SAS Institute Inc). All statistical tests used a 2-sided α level of .05. We evaluated the proportion of children who experienced each outcome, comparing children with and without disabilities. We used Kaplan-Meier statistics to estimate time to event and regression models to estimate adjusted hazard ratios, accounting for clustering by household and adjusting for state, child age, race, ethnicity, and initial referral source.
Results
Author Manuscript
A total of 489 176 children from 33 states, Puerto Rico, and the District of Columbia were included (12 610 children with disabilities and 476 566 children without disabilities; Table). Children with vs without disabilities were more likely to be re-referred (45% vs 36%, respectively; adjusted risk difference [ARD], 14% [95% CI, 13%–15%]; P < .001), experience substantiated maltreatment (16% vs 10%; ARD, 9% [95% CI, 8%–10%]; P < . 001), and be placed in foster care (7% vs 3%; ARD, 4% [95% CI, 4%–5%]; P < .001). The median time to each outcome was shorter for children with disabilities (Figure). For children with disabilities compared with those without, the adjusted hazard ratio was 1.41 (95% CI, 1.35–1.46) for re-referral, 1.82 (95% CI, 1.72–1.94) for substantiated maltreatment, and 2.71 (95% CI, 2.48–2.96) for foster care placement.
Discussion Our data demonstrate that children with disabilities and unsubstantiated referrals for neglect experienced future maltreatment sooner and more often than other children.
Author Manuscript
Our study has some limitations. Substantiated maltreatment may represent prior or ongoing maltreatment.5 Even though we adjusted for referral source, existing data on surveillance bias for child maltreatment are mixed,1,6 and the observed higher incidence in maltreatment of children with disabilities may have resulted in part from increased interactions with mandated reporters. Although we included all available data from geographically diverse states (including 65% of 2008 US population), such data may not be nationally representative. In addition, we
JAMA. Author manuscript; available in PMC 2017 January 05.
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Author Manuscript
were not able to identify whether children crossed state lines and were referred in a different state. Despite these limitations, our findings highlight the significant incidence of maltreatment experienced by children with unsubstantiated referrals for neglect, particularly children with disabilities. Such children may benefit from targeted interventions to prevent subsequent maltreatment.
Acknowledgments Funding/Support: The study was funded by National Institutes of Health grant K23 HD078503-02 (awarded to Dr Kistin). Funding support for preparing the data for public distribution was provided by contract 90-CA-1370 between the National Center on Child Abuse and Neglect and Cornell University.
Author Manuscript
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
References
Author Manuscript
1. Fluke JD, Shusterman GR, Hollinshead DM, Yuan YY. Longitudinal analysis of repeated child abuse reporting and victimization: multistate analysis of associated factors. Child Maltreat. 2008; 13(1):76–88. [PubMed: 18174350] 2. Dubowitz H, Kim J, Black MM, Weisbart C, Semiatin J, Magder LS. Identifying children at high risk for a child maltreatment report. Child Abuse Negl. 2011; 35(2):96–104. [PubMed: 21376396] 3. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998; 14(4):245–258. [PubMed: 9635069] 4. US Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families. Child maltreatment. 2013. http://www.acf.hhs.gov/ sites/default/files/cb/cm2013.pdf. Accessed September 24, 2015 5. Kohl PL, Jonson-Reid M, Drake B. Time to leave substantiation behind: findings from a national probability study. Child Maltreat. 2009; 14(1):17–26. [PubMed: 18971346] 6. Chaffin M, Bard D. Impact of intervention surveillance bias on analyses of child welfare report outcomes. Child Maltreat. 2006; 11(4):301–312. [PubMed: 17043315]
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Figure. Time to Re-referral, Substantiated Maltreatment, and Foster Care Placement for Children With and Without Disabilities After an Initial Unsubstantiated Report of Neglect
Shaded areas represent 95% Hall-Wellner bands.
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Table
Author Manuscript
Demographics at Time of Index Referral for Unsubstantiated Neglect No. (%) of Childrena With Disabilities (n = 12 610)
Without Disabilities (n = 476 566)
8.90 (5.60)
6.74 (5.04)
7478 (59)
Non-Hispanic white Non-Hispanic black
Age, mean (SD), y
Risk Difference (95% CI)
P Value
2.33 (2.24 to 2.43)
JAMA. Author manuscript; available in PMC 2017 January 05. Published in final edited form as: JAMA. 2016 January 5; 315(1): 85–87. doi:10.1001/jama.2015.12912.
Subsequent Maltreatment in Children With Disabilities After an Unsubstantiated Report for Neglect
Author Manuscript
Caroline J. Kistin, MD, MSc, Martha C. Tompson, PhD, Howard J. Cabral, PhD, Robert D. Sege, MD, PhD, Michael R. Winter, MPH, and Michael Silverstein, MD, MPH Department of Pediatrics, Boston Medical Center, Boston, Massachusetts (Kistin, Silverstein); Department of Psychological and Brain Sciences, Boston University, Boston, Massachusetts (Tompson); Department of Epidemiology and Biostatistics, Boston University School of Public Health, Boston, Massachusetts (Cabral); Center for the Study of Social Policy, Washington, DC (Sege); Data Coordinating Center, Boston University School of Public Health, Boston, Massachusetts (Winter) Children with disabilities are at increased risk for maltreatment,1,2 and neglect accounts for the majority of such cases.3 Although most cases of suspected neglect are unsubstantiated at the time of the initial report to child protective services (CPS),4 meaning there is insufficient legal evidence of maltreatment, these children are at risk for subsequent maltreatment.5
Methods Author Manuscript
We conducted a retrospective cohort study to examine the incidence and timing of re-referral to CPS, substantiated maltreatment, and foster care placement for any type of maltreatment after an initial unsubstantiated referral for neglect. We compared outcomes between children with and without disabilities.
Author Manuscript
Corresponding Author: Caroline J. Kistin, MD, MSc, Department of Pediatrics, Boston Medical Center, 89 E Newton St, Vose 3, Boston, MA 02118 ([email protected]). Author Contributions: Dr Kistin had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Kistin, Tompson, Sege. Acquisition, analysis, or interpretation of data: Kistin, Tompson, Cabral, Winter, Silverstein. Drafting of the manuscript: Kistin, Silverstein. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: Kistin, Cabral. Obtained funding: Kistin. Administrative, technical, or material support: Sege. Study supervision: Kistin, Sege, Silverstein.
We analyzed data from the National Child Abuse and Neglect Data System (NCANDS),4 which collects data annually on all children reported to state-level CPS agencies in the 50 states, the District of Columbia, and Puerto Rico. The Boston University Medical Campus institutional review board qualified the study as exempt. We included data from states that
Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. Additional Contributions: The data used in this report were made available by the National Data Archive on Child Abuse and Neglect at Cornell University in Ithaca, New York.
Kistin et al.
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Author Manuscript
contributed child-level data to NCANDS for fiscal years 2008 through 2012 and retained unique child identification numbers. Children were included if they had first-time unsubstantiated referrals for neglect in 2008; they were followed up for 4 years. We excluded reports that occurred within 24 hours of initial referral because these likely represented the index incident. Children were excluded if the initial report included maltreatment other than neglect or listed prior maltreatment, or if they had previously been reported to CPS, as determined by a search of all available years of NCANDS records (range, 1–10 years). Children were classified as having disabilities if they had conditions included in the Individuals with Disabilities Education Act, and were excluded if his or her disability status was missing.
Author Manuscript
We conducted the statistical analysis using SAS version 9.3 (SAS Institute Inc). All statistical tests used a 2-sided α level of .05. We evaluated the proportion of children who experienced each outcome, comparing children with and without disabilities. We used Kaplan-Meier statistics to estimate time to event and regression models to estimate adjusted hazard ratios, accounting for clustering by household and adjusting for state, child age, race, ethnicity, and initial referral source.
Results
Author Manuscript
A total of 489 176 children from 33 states, Puerto Rico, and the District of Columbia were included (12 610 children with disabilities and 476 566 children without disabilities; Table). Children with vs without disabilities were more likely to be re-referred (45% vs 36%, respectively; adjusted risk difference [ARD], 14% [95% CI, 13%–15%]; P < .001), experience substantiated maltreatment (16% vs 10%; ARD, 9% [95% CI, 8%–10%]; P < . 001), and be placed in foster care (7% vs 3%; ARD, 4% [95% CI, 4%–5%]; P < .001). The median time to each outcome was shorter for children with disabilities (Figure). For children with disabilities compared with those without, the adjusted hazard ratio was 1.41 (95% CI, 1.35–1.46) for re-referral, 1.82 (95% CI, 1.72–1.94) for substantiated maltreatment, and 2.71 (95% CI, 2.48–2.96) for foster care placement.
Discussion Our data demonstrate that children with disabilities and unsubstantiated referrals for neglect experienced future maltreatment sooner and more often than other children.
Author Manuscript
Our study has some limitations. Substantiated maltreatment may represent prior or ongoing maltreatment.5 Even though we adjusted for referral source, existing data on surveillance bias for child maltreatment are mixed,1,6 and the observed higher incidence in maltreatment of children with disabilities may have resulted in part from increased interactions with mandated reporters. Although we included all available data from geographically diverse states (including 65% of 2008 US population), such data may not be nationally representative. In addition, we
JAMA. Author manuscript; available in PMC 2017 January 05.
Kistin et al.
Page 3
Author Manuscript
were not able to identify whether children crossed state lines and were referred in a different state. Despite these limitations, our findings highlight the significant incidence of maltreatment experienced by children with unsubstantiated referrals for neglect, particularly children with disabilities. Such children may benefit from targeted interventions to prevent subsequent maltreatment.
Acknowledgments Funding/Support: The study was funded by National Institutes of Health grant K23 HD078503-02 (awarded to Dr Kistin). Funding support for preparing the data for public distribution was provided by contract 90-CA-1370 between the National Center on Child Abuse and Neglect and Cornell University.
Author Manuscript
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
References
Author Manuscript
1. Fluke JD, Shusterman GR, Hollinshead DM, Yuan YY. Longitudinal analysis of repeated child abuse reporting and victimization: multistate analysis of associated factors. Child Maltreat. 2008; 13(1):76–88. [PubMed: 18174350] 2. Dubowitz H, Kim J, Black MM, Weisbart C, Semiatin J, Magder LS. Identifying children at high risk for a child maltreatment report. Child Abuse Negl. 2011; 35(2):96–104. [PubMed: 21376396] 3. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998; 14(4):245–258. [PubMed: 9635069] 4. US Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families. Child maltreatment. 2013. http://www.acf.hhs.gov/ sites/default/files/cb/cm2013.pdf. Accessed September 24, 2015 5. Kohl PL, Jonson-Reid M, Drake B. Time to leave substantiation behind: findings from a national probability study. Child Maltreat. 2009; 14(1):17–26. [PubMed: 18971346] 6. Chaffin M, Bard D. Impact of intervention surveillance bias on analyses of child welfare report outcomes. Child Maltreat. 2006; 11(4):301–312. [PubMed: 17043315]
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Figure. Time to Re-referral, Substantiated Maltreatment, and Foster Care Placement for Children With and Without Disabilities After an Initial Unsubstantiated Report of Neglect
Shaded areas represent 95% Hall-Wellner bands.
Author Manuscript JAMA. Author manuscript; available in PMC 2017 January 05.
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Table
Author Manuscript
Demographics at Time of Index Referral for Unsubstantiated Neglect No. (%) of Childrena With Disabilities (n = 12 610)
Without Disabilities (n = 476 566)
8.90 (5.60)
6.74 (5.04)
7478 (59)
Non-Hispanic white Non-Hispanic black
Age, mean (SD), y
Risk Difference (95% CI)
P Value
2.33 (2.24 to 2.43)
