Child Protective Services Data Research Articles

Mental and neurodevelopmental health needs of Aboriginal children with experience of out-of-home care: a Western Australian data-linkage study

ObjectiveTo identify additional mental and neurodevelopmental health needs of Aboriginal children born in Western Australia, who are placed in out-of-home care (OOHC), relative to Aboriginal children born in Western Australia who were not placed. MethodsData-linkage of hospitalisations, health registries and child protective services data for all Aboriginal children born in WA between 2000 and 2013 was used. Children placed in out-of-home care between 2000 and 2019 were matched to children never placed and prevalence and cumulative incidence estimates of mental and neurodevelopmental health conditions were compared. ResultsChildren placed in out-of-home care had a three times greater prevalence of mental and neurodevelopmental health conditions generally. The prevalence of foetal alcohol spectrum disorder was ten times higher, and post-traumatic stress disorder was seven times higher for those placed in out-of-home care. Cumulative incidence plots highlighted for different conditions the ages at which the rate of diagnosis diverges between the two groups. ConclusionsChildren placed in out-of-home care had greater mental and neurodevelopmental health needs generally when compared to children never placed in out-of-home care . Implications for Public HealthChild protective services must ensure culturally safe, comprehensive, wrap-around services for Aboriginal children and their families are provided. Approaches should build on the strength of children, families and culture and avoid stigmatising children and their parents.

Prevalence of Mental Health Diagnoses Among Early Adolescents Before and During Foster Care.

This study aimed to characterize the rates and types of diagnosed mental health (MH) disorders among children and adolescents before and during foster care (FC) overall and by race and ethnicity. We used population-based linked administrative data of medical assistance (public insurance) claims records and child protective services data from a cohort of early adolescents who entered FC at 10 to 14 years old. MH diagnoses were coded according to the International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification (ICD-9 and ICD-10) and included adjustment disorders, disruptive disorders, attention-deficit/hyperactivity disorder (ADHD), anxiety disorders, mood disorders, attachment disorders, autism, and other disorders. Before FC entry, 41% of children and adolescents had at least 1 MH diagnosis. Attention-deficit/hyperactivity disorder (25%), mood disorders (18%), and disruptive disorders (15%) were the most common pre-entry diagnoses. Among early adolescents entering FC with no previous diagnosis, 52% were later diagnosed with adjustment disorder (accounting for 73% of all youth with a new diagnosis during FC). White early adolescents had higher rates of diagnosed MH disorders before FC, whereas racial/ethnic minority early adolescents were more likely to receive a MH diagnosis during FC. Black early adolescents were more likely than White and Hispanic early adolescents to be diagnosed with disruptive disorders and less likely to be diagnosed with anxiety or adjustment disorders during FC. Results highlight the high rates of MH needs among early adolescents before entry into FC, whether detected before or during FC. Results also illustrate disparities in pre-entry MH care between racial/ethnic minority and White early adolescents, with minority youth less likely to be receiving services before entry.

CHILD WELFARE INTERVENTIONS AND SYSTEM TRANSFORMATION TO IMPROVE THE LIVES OF CHILDREN AND FAMILIES WHO EXPERIENCE TRAUMA

Approximately two-thirds of the children in the United States have experienced at least one traumatic event by the age of 16 years. Based on Child Protective Services data, the national rate of abuse and neglect is approximately 8.9 per 1000 children. Trauma is associated with high risk of complex negative psychological and behavioral effects that require specialized evidence-based trauma treatments that can be difficult to access. This Clinical Perspectives presents initiatives and programs to increase capacity and access to evidence-based trauma-specific treatments at local, state, and national levels.

Are Home Evictions Associated with Child Welfare System Involvement? Empirical Evidence from National Eviction Records and Child Protective Services Data.

This study aimed to understand the relationship between home eviction and child welfare system involvement at the county level. Using administrative data, we examined associations of home eviction and eviction filing rates with child abuse and neglect (CAN) reports and foster care entries. We found one additional eviction per 100 renter-occupied homes in a county was associated with a 1.3% increase in the rate of CAN reports and a 1.6% increase in foster care entries. The association between eviction and foster care entries was strongest among Hispanic children with an 8.1% increase. Assisting parents in providing stable housing may reduce the risk of child welfare system involvement, including out-of-home child placement. Primary and secondary prevention strategies could include housing assistance, increasing access to affordable and safe housing, as well as providing economic support for families (e.g., tax credits, childcare subsidies) that reduce parental financial burden to access stable housing.

Measuring the Incidence of Child Maltreatment Using Linked Data: A Two-State Comparison

Measuring and comparing the incidence of child maltreatment is challenging. Linkage of statewide birth cohorts with Child Protective Services reports to study incident child maltreatment over the life course are becoming more common. This study compares the reported incidence between 2 states derived from population-based administrative data linkages. Linked births (2009-2011) with Child Protective Services records (2009-2015) and deaths in each state were used to compare the cumulative incidence of a Child Protective Services report before age 7 years. Given differences in population race structure and documented disparities of race groups in Child Protective Services data, variation was adjusted for using direct standardization. Unadjusted cumulative incidence, race cumulative incidence, and race-adjusted cumulative incidence were compared. Analyses were completed in 2018. Before age 7 years, 26.0% of Alaskan children and 19.0% of Californian children were reported to Child Protective Services (RR=1.37, p<0.001). Aside from Asian/Pacific Islanders, the cumulative incidence between states was similar for each race. The race-adjusted cumulative incidence indicated that children born in Alaska were 1.10 times as likely to experience a report before age 7 years compared with children in California. Much of the difference in risk for child maltreatment observed between Alaska and California is most likely due to variation in the population structure by race as opposed to modifiable factors. Standardization is a simple method to adjust for population structure differences. This study contributes to the growing body of knowledge regarding the use of linked administrative data to study maltreatment and provides insights into considerations for making comparisons or conducting cross-jurisdictional analyses based on commonly aligned data sets.

Predictors of placement disruptions in foster care

BackgroundMany children who are removed from a dangerous or neglectful home and placed in state custody subsequently experience additional disruptions while in custody, which can compound the effects of ongoing stress and instability. As such, placement stability has been identified as a critical objective and a key indicator of success for children residing in substitutive care. ObjectiveTo examine the utility of child protective services data in identifying predictors of placement disruption. Participants and settingThe current study examined data from youth in Tennessee state custody who had been assessed using the Child and Adolescent Needs and Strengths (CANS) assessment within 30-days of their first, out-of-home placement. The sample included 8,853 youth ages 5–19 years old (M = 13.1; SD = 4.0; 44.8 % female). MethodsDemographics, placement information, and the CANS assessment were collected by the Tennessee Department of Children’s Services for all child welfare episodes for children as part of the system’s usual standard of care. Bivariate correlation and linear regression models were conducted. ResultsMultiple risk indices from the CANS appeared to significantly increase risk of placement disruption, including child internalizing and externalizing symptoms, school difficulties, youth affect dysregulation, and child age. ConclusionsThe current findings suggest that data collected as part of standard practice by child welfare workers such as the CANS is both feasible and has utility for identifying sources of risk for placement disruptions and to inform possible targets of intervention to enhance placement stability.

Child Maltreatment Surveillance Improvement Opportunities: A Wake County, North Carolina Pilot Project.

BACKGROUND As child maltreatment often occurs in private, child welfare numbers underestimate its true prevalence. Child maltreatment surveillance systems have been used to ascertain more accurate counts of children who experience maltreatment. This manuscript describes the results from a pilot child maltreatment surveillance system in Wake County, North Carolina.METHODS We linked 2010 and 2011 data from 3 sources (Child Protective Services, Raleigh Police Department, and Office of the Chief Medical Examiner) to obtain rates of definite and possible child maltreatment. We separately analyzed emergency department visits from 2010 and 2011 to obtain counts of definite and possible child maltreatment. We then compared the results from the surveillance systems to those obtained from Child Protective Services (CPS) data alone.RESULTS In 2010 and 2011, rates of definite child maltreatment were 11.7 and 11.3 per 1,000 children, respectively, when using the linked data, compared to 10.0 and 9.5 per 1,000 children using CPS data alone. The rates of possible maltreatment were 25.3 and 23.8 per 1,000, respectively. In the 2010 and 2011 emergency department data, there were 68 visits and 84 visits, respectively, that met the case definition for maltreatment.LIMITATIONS While 4 data sources were analyzed, only 3 were linked in the current surveillance system. It is likely that we would have identified more cases of maltreatment had more sources been included.CONCLUSION While the surveillance system identified more children who met the case definition of maltreatment than CPS data alone, the rates of definite child maltreatment were not considerably higher than official reports. Rates of possible child maltreatment were much higher than both the definite case definition and child welfare records. Tracking both definite and possible case definitions and using a variety of data sources provides a more complete picture of child maltreatment in North Carolina.

Follow-up protocol was useful for children whose parents attended emergency departments after partner violence, substance abuse or a suicide attempt.

This was a one-year follow-up of families referred to support services after the parents visited the emergency department due to intimate partner violence, substance abuse or a suicide attempt. Its aim was to evaluate the well-being of any children. Data on families identified a year earlier by the Amsterdam protocol were gathered from child protective services and parent and child self-reports in two Dutch regions from 2012-2015. We included 399 children (52%) boys with a median age of eight years (range 1-18) in the study using child protective services data. Of the 101 families who participated in the first measurement, 67 responded one year after the parent's emergency department visit. The results showed that 20% of the children had no or minor problems, voluntary support services were involved in 60% of cases and child protective services were involved in 20%. Compared to their first assessment a year earlier, the children's psychosocial problems had not increased, but this could have been an underestimation due to selective responses. The Amsterdam protocol was valuable in referring families to voluntary support services, but given the ongoing problems in some families, professionals need to carefully monitor whether support services are sufficiently effective.

Experiences of Somali and Oromo youth in the child protection system

BackgroundLittle is known about the experiences or proportion of refugees involved with child protective services (CPS) in the United States, because they are not an identifiable group in CPS data systems. This study utilized an innovative data matching project to identify refugees in CPS data systems and explored the experiences of Somali and Oromo youth in Minnesota's child protection system. MethodsA sample of 629 Somali and 62 Oromo youth who were involved with CPS between 2000 and 2013 were identified by linking datasets from the Minnesota Departments of Education and Human Services. Descriptive statistics, chi-square analysis, and t-tests were used to explore the proportion and characteristics of children involved with CPS, placement experiences, and child protection professionals' documentation of families' strengths and needs. ResultsSomali and Oromo youth were involved with CPS at low rates (3.7%). Residential treatment facilities were the most common out-of-home (OHP) placement settings for Somali youth (41%), and almost a third of placements for Oromo youth were in a correctional facility (31.6%). Strengths identified for both groups included low alcohol and other drug use and few health issues. Needs included social support, mental health/coping support, and parenting skills. ConclusionsOHP settings for Somali and Oromo youth were highly restrictive. More research is needed to determine what is driving the high utilization of restrictive placements for Somali and Oromo youth, how accurately the Structured Decision Making tool assesses strengths and needs for families with refugee backgrounds, and how CPS professionals' assessments of strengths and needs compare to the refugee families' perceptions of their own strengths and needs.

Physical family violence and externalizing and internalizing behaviors among children and adolescents.

Family violence has been associated with various negative outcomes among children and adolescents. Yet, less is known about how unique forms of physical family violence contribute to externalizing and internalizing behaviors based on a child's developmental stage. Using data from the Illinois Families Study and administrative Child Protective Services data, we explored the relation between 3 types of physical family violence victimization and externalizing and internalizing behaviors among a sample of 2,402 children and adolescents. After including parent and family level covariates in Poisson regressions, we found that a unique form of family violence victimization was associated with increased externalizing behaviors among children at each age group: exposure to physical intimate partner violence (IPV) among children ages 3-5, exposure to the physical abuse of a sibling among children ages 6-12, and child physical abuse among adolescents ages 13-18. No form of physical family violence was significantly associated with internalizing behaviors for children in any age group. Including exposure to the child maltreatment of a sibling is crucial when attempting to contextualize children's responses to family violence and providing comprehensive services in an effort to enhance the well-being of all children in a family. (PsycINFO Database Record

Emergency Department Utilization in Children

Early childhood high-frequency use (HFU) of the emergency department (ED) has been endorsed as a marker for increased risk of child maltreatment. In a prior analysis of pediatric ED (PED) visits by 16,664 children, 0-36months old, we defined early childhood HFU (the 90th percentile) as five or more visits. The purpose of this study was to follow HFU patients to determine if they had a higher likelihood of reported maltreatment. This is a single-center, cross-sectional, observational study of the association between PED use in early life and subsequent intervention by child protective services (CPS). CPS data were obtained from a Department of Social Services database for subjects meeting criteria for PED HFU as well as sex, race, and ethnicity-matched controls. Multivariable analyses were performed to assess if HFU was independently associated with child maltreatment. While CPS involvement was more highly represented in the group with PED HFU, so were many confounding variables such as African American race, history of hospital admissions, and social work consultations in the PED for any reason. HFU, by itself, is not a risk factor for a major intervention by CPS. In efforts to identify children at risk for maltreatment, objective assessments such as PED utilization are potential markers to utilize to aid in recognition. Unfortunately, there are many risk factors for increased PED utilization that act as confounders for this marker. Future work is necessary to identify children at risk for maltreatment in the ED.

Maternal Intimate Partner Violence Victimization Before and During Pregnancy and Postbirth Child Welfare Contact: A Population-Based Assessment.

We conducted a population-based prospective cohort study to help elucidate the predictive relationship between a maternal prebirth self-reported history of intimate partner violence (IPV) and any postbirth reported allegation to Child Protective Services (CPS) by age 2. We linked data from the 2009-2010 Alaska Pregnancy Risk Assessment Monitoring System with CPS data through 2012. Among this cohort, we found that 8.0%w self-reported experiencing IPV 12 months prior or during pregnancy, and 8.0%w of the offspring experienced at least one CPS report of alleged maltreatment during the study period. The predictive relationship varied by maternal educational attainment. Among mothers with 12+ years education completed, the odds of a CPS report were 3.9 times compared to those with no IPV, while among mothers with <12 years education completed, no association was noted. These results suggest that for a subset of Alaskan families, maternal history of IPV is a strong independent predictor of future CPS contact.

Disparities in reported and substantiated infant maltreatment by maternal Hispanic origin and nativity: a birth cohort study.

We followed Latino infants prospectively through age 1 to determine whether maternal foreign-born status conferred a protective advantage against reported and substantiated maltreatment across Hispanic-origin groups, and whether the likelihood an infant was reported or substantiated for maltreatment varied by Hispanic origin. We drew data for all Latino infants born in California between 2000 and 2006 (N = 1,909,155) from population-based birth records linked to child protective services data. We used χ(2) tests to assess distributional differences in covariates and utilized generalized linear models to estimate the adjusted relative risk of report and substantiation in models stratified by nativity. We observed significant health advantages in reported and substantiated maltreatment for infants of foreign-born mothers within every Hispanic-origin group. Risks of report and substantiation among infants of Mexican and Central/South American mothers were consistently lower than Puerto Rican and Cuban mothers despite socioeconomic disadvantage. The presence of disparities among Hispanic-origin groups in child maltreatment report and substantiation during infancy has implications for the health of Latinos across the life course. Further research is warranted to unravel the complex processes underlying observed relationships.

Intergenerational Continuity in Maltreatment

Identification of the causes of child maltreatment perpetration is prerequisite for developing efficacious prevention initiatives to reduce its occurrence. Earlier maltreatment victimization is often suggested as an important cause of subsequent maltreatment perpetration. This study investigates a) whether maltreatment victimization causes subsequent perpetration and b) whether the timing of maltreatment victimization--childhood versus adolescence--alters this relationship. We use data from the Rochester Youth Development Study, a longitudinal study begun in Rochester, New York in 1988, based on a stratified random sample of 1000 seventh and eighth graders. At the most recent followup, 80 % were reinterviewed. Child Protective Services data were collected on substantiated incidents of maltreatment victimization from birth to age 17 and on maltreatment perpetration through average age 33, n = 816. Using propensity score models to control selection effects, we find that a history of maltreatment victimization significantly increases the odds of becoming a perpetrator of maltreatment. Although childhood-limited maltreatment does not significantly increase the odds of maltreatment perpetration, maltreatment that occurs in adolescence or that begins in childhood and persists into adolescence does. Adolescent maltreatment was found to be more serious in terms of type, chronicity, and severity than childhood-limited maltreatment, offering a possible explanation for this finding. Therefore, maltreatment victimization, especially during adolescence, is a likely cause of subsequent perpetration. Clinical services to interrupt the cycle of maltreatment are needed to protect subsequent generations from experiencing maltreatment and from experiencing the health-risking behaviors that often flow from maltreatment.

Incidence of Serious Injuries Due to Physical Abuse in the United States: 1997 to 2009

Although US child protective services data showed a 55% decrease in the national incidence of substantiated physical abuse from 1992 to 2009, no study has tracked the occurrence of serious injuries due to physical abuse. This study examined changes in the incidence of serious injuries due to physical abuse in hospitalized children from 1997 to 2009. The Kids' Inpatient Database, a sample of discharges from hospitals in the United States, includes International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis and external cause of injury codes; it was prepared every 3 years from 1997 to 2009. Cases of serious physical abuse (eg, abusive head injury) were identified by using injury codes (800-959) and codes for abuse (995.50, 0.54, 0.55, and 0.59), selected assault codes (E960-966, 968), or perpetrator of abuse (E967). The weighted number of hospitalizations due to serious physical abuse was used to calculate the national incidence, and χ(2) for linear trend compared over time the incidence for children <18 years and <1 year of age. The incidence per 100,000 children <18 years of age increased 4.9%: 6.1 (95% confidence interval = 5.4-6.8) for 1997, 6.0 (5.2-6.7) for 2000, 6.0 (5.3-6.7) for 2003, 6.1 (5.3-6.8) for 2006, and 6.4 (5.7-7.2) for 2009 (P < .01). The incidence for children <1 year of age increased 10.9% (P < .05). Over 12 years, when substantiated physical abuse was declining, there was a small increase in the incidence of serious physical abuse in children <18 and <1 year of age.

The SEEK Model of Pediatric Primary Care: Can Child Maltreatment Be Prevented in a Low-Risk Population?

ObjectiveTo examine the effectiveness of the Safe Environment for Every Kid (SEEK) model of enhanced pediatric primary care to help reduce child maltreatment in a relatively low-risk population. MethodsA total of 18 pediatric practices were assigned to intervention or control groups, and 1119 mothers of children ages 0 to 5 years were recruited to help evaluate SEEK by completing assessments initially and after 6 and 12 months. Children’s medical records and Child Protective Services data were reviewed. The SEEK model included training health professionals to address targeted risk factors (eg, maternal depression), the Parent Screening Questionnaire, parent handouts, and a social worker. Maltreatment was assessed 3 ways: 1) maternal self-report, 2) children’s medical records, and 3) Child Protective Services reports. ResultsIn the initial and 12-month assessments, SEEK mothers reported less Psychological Aggression than controls (initial effect size = −0.16, 95% confidence interval [95% CI] −0.27, −0.05, P = .006; 12-month effect size = −0.12, 95% CI −0.24, −0.002, P = .047). Similarly, SEEK mothers reported fewer Minor Physical Assaults than controls (initial effect size = −0.16, 95% CI −0.29, −0.03, P = .019; 12-month effect size = −0.14, 95% CI −0.28, −0.005, P = .043). There were trends in the same positive direction at 6 months, albeit not statistically significant. There were few instances of maltreatment documented in the medical records and few Child Protective Services reports. ConclusionsThe SEEK model was associated with reduced maternal Psychological Aggression and Minor Physical Assaults. Although such experiences may not be reported to protective services, ample evidence indicates their potential harm. SEEK offers a promising and practical enhancement of pediatric primary care.

Child Protective Services Referrals in Cases of Sudden Infant Death: A 10-Year, Population-Based Analysis in San Diego County, California

The potential diagnostic significance of prior family referral to Child Protective Services (CPS) in cases of sudden infant death is unknown. Therefore, the authors retrospectively searched for CPS data for the 5-year referral history on all 533 families whose infants died suddenly from Sudden Infant Death Syndrome (SIDS), other natural diseases, accidents, or inflicted injuries and underwent postmortem examination by the medical examiner during a 10-year period. No family had more than one infant death. At least 27% of the families in each group had at least one CPS referral. The data suggest that a family's referral to CPS prior to their sudden death of their infant does not increase the likelihood that it was caused by inflicted injuries, and prior referral should not preclude a diagnosis of SIDS. The authors recommend future prospective studies that include refined exposure histories and that are large enough to have sufficient statistical power to compare family CPS referrals and outcomes in groups of infants who died suddenly with a matched group of living infants.

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.

Defining child neglect based on child protective services data

Objectives: To compare neglect defined by Child Protective Services official codes with neglect defined by a review of CPS narrative data, and to examine the validity of the different neglect measures using children's functioning at age 8 years. Methods: Data are from 740 children participating in a consortium of longitudinal studies on child abuse and neglect; 481 had at least one CPS report prior to age 8. CPS records were reviewed to ascertain both broad CPS types of neglect as well as specific subtypes of neglect using a modified version of the Maltreatment Classification System (MMCS). Frequencies of, and correlations among, the types and subtypes of neglect were examined. The validity of the neglect measures was evaluated by examining their relationships with children's functioning at age 8. Results: The CPS neglect types and MMCS subtypes were moderately correlated, as were the MMCS subtypes of neglect. In general, neglect was only modestly associated with children's functioning at age 8 ( r 2 = 1–4%), with few differences between the CPS neglect types and the MMCS subtypes. There were significant associations with children's total and externalizing behavior problems, impaired socialization, and impaired daily living skills. Among the specific subtypes, neglect of children's medical needs was related to externalizing behavior problems, impaired socialization, and impaired daily living skills. Neglect of children's hygiene needs was related to impaired socialization. Conclusion: The moderate correlations among CPS and MMCS types and subtypes of neglect and their similar associations with children's functioning suggest that the considerable effort involved in coding neglect subtypes from CPS narrative data may yield limited incremental knowledge regarding the types of neglect children experience and their sequelae. However, the MMCS does offer useful descriptive information on the nature of neglect children experience, and may guide future research and practice on optimal ways to conceptualize neglect.

Child maltreatment in MissouriCombining data for public health surveillance

Background Public health surveillance was established for nonfatal child maltreatment in Missouri using two data sources. This paper describes the epidemiology of nonfatal child maltreatment using this surveillance system, and assesses the usefulness of combining medical data with child protective services (CPS) reports for child maltreatment surveillance. Methods Child abuse and neglect reports for children aged <10 years for 2000 were obtained from the Missouri Division of Family Services (DFS) and linked to hospital discharge and emergency department (ED) data for 2000. Children were classified as maltreated if they had an International Classification of Disease (ICD) maltreatment code for a hospital or ED visit, or a substantiated report to DFS. Validity of the ICD maltreatment codes was assessed in a 10% random sample of the hospital/ED visits. Medical records were reviewed to determine the accuracy of the maltreatment code assigned. The data analyses reported here were conducted in 2002 and 2003. Results In the linked data, 5657 children met the case definition of maltreatment, providing a nonfatal maltreatment rate of 7.4/1000 children. Rates were higher among children aged <1 year (8.4/1000), females (7.7/1000), African Americans (11.8/1000), and children residing in rural counties (8.7/1000). The hospital/ED data identified proportionately more children who were African American, urban, physically abused, or infants, and uniquely identified only 10% of the total cases. In the validation sample, maltreatment was documented in 110 (87%) of the 127 records reviewed. Conclusions CPS and medical data can be linked for surveillance. However, the medical data add few unique cases and identify only a subset of maltreated children. Public health surveillance was established for nonfatal child maltreatment in Missouri using two data sources. This paper describes the epidemiology of nonfatal child maltreatment using this surveillance system, and assesses the usefulness of combining medical data with child protective services (CPS) reports for child maltreatment surveillance. Child abuse and neglect reports for children aged <10 years for 2000 were obtained from the Missouri Division of Family Services (DFS) and linked to hospital discharge and emergency department (ED) data for 2000. Children were classified as maltreated if they had an International Classification of Disease (ICD) maltreatment code for a hospital or ED visit, or a substantiated report to DFS. Validity of the ICD maltreatment codes was assessed in a 10% random sample of the hospital/ED visits. Medical records were reviewed to determine the accuracy of the maltreatment code assigned. The data analyses reported here were conducted in 2002 and 2003. In the linked data, 5657 children met the case definition of maltreatment, providing a nonfatal maltreatment rate of 7.4/1000 children. Rates were higher among children aged <1 year (8.4/1000), females (7.7/1000), African Americans (11.8/1000), and children residing in rural counties (8.7/1000). The hospital/ED data identified proportionately more children who were African American, urban, physically abused, or infants, and uniquely identified only 10% of the total cases. In the validation sample, maltreatment was documented in 110 (87%) of the 127 records reviewed. CPS and medical data can be linked for surveillance. However, the medical data add few unique cases and identify only a subset of maltreated children.