Child Protective Services Referrals Research Articles

Repetitive mild traumatic brain injuries in children of abuse

Repetitive mild traumatic brain injuries in children of abuse

Structural Racism Operationalized via Adverse Social Events in a Single-Center Neonatal Intensive Care Unit

To evaluate structural racism in the neonatal intensive care unit (NICU) by determining if differences in adverse social events occur by racialized groups. Retrospective cohort study of 3290 infants hospitalized in a single center NICU between 2017 and 2019 in the Racial and Ethnic Justice in Outcomes in Neonatal Intensive Care (REJOICE) study. Demographics and adverse social events including infant urine toxicology screening, child protective services (CPS) referrals, behavioral contracts, and security emergency response calls were collected from electronic medical records. Logistic regression models were fit to test the association of race/ethnicity and adverse social events, adjusting for length of stay. Racial/ethnic groups were compared with a White referent group. There were 205 families (6.2%) that experienced an adverse social event. Black families were more likely to have experienced a CPS referral and a urine toxicology screen (OR, 3.6; 95% CI, 2.2-6.1 and OR, 2.2; 95% CI, 1.4-3.5). American Indian and Alaskan Native families were also more likely to experience CPS referrals and urine toxicology screens (OR, 15.8; 95% CI, 6.9-36.0 an OR, 7.6; 95% CI, 3.4-17.2). Black families were more likely to experience behavioral contracts and security emergency response calls. Latinx families had a similar risk of adverse events, and Asian families were less likely to experience adverse events. We found racial inequities in adverse social events in a single-center NICU. Investigation of generalizability is necessary to develop widespread strategies to address institutional and societal structural racism and to prevent adverse social events.

Predictors of Making a Referral to Child Protective Services Prior to Expert Consultation

ObjectiveSuspicion for child abuse is influenced by implicit biases. Evaluation by a Child Abuse Pediatrician (CAP) may reduce avoidable child protective services (CPS) referrals. Our objective was to investigate the association of patient demographic, social and clinical characteristics with CPS referral before consultation by a CAP (preconsultation referral). MethodsChildren<5years-old undergoing in-person CAP consultation for suspected physical abuse from February 2021 through April 2022 were identified in CAPNET, a multicenter child abuse research network. Marginal standardization implemented with logistic regression analysis examined hospital-level variation and identified demographic, social, and clinical factors associated with preconsultation referral adjusting for CAP’s final assessment of abuse likelihood. ResultsAmong the 61% (1005/1657) of cases with preconsultation referral, the CAP consultant had low concern for abuse in 38% (384/1005). Preconsultation referrals ranged from 25% to 78% of cases across 10 hospitals (P < .001). In multivariable analyses, preconsultation referral was associated with public insurance, caregiver history of CPS involvement, history of intimate partner violence, higher CAP level of concern for abuse, hospital transfer, and near-fatality (all P < .05).The difference in preconsultation referral prevalence for children with public versus private insurance was significant for children with low CAP concern for abuse (52% vs 38%) but not those with higher concern for abuse (73% vs 73%), (P = .023 for interaction of insurance and abuse likelihood category). There were no differences in preconsultation referral based on race or ethnicity. ConclusionsBiases based on socioeconomic status and social factors may impact decisions to refer to CPS before CAP consultation.

Lifetime rates and types of subsequent child protection system contact following a first report of neglect: An age-stratified analysis.

An estimated 1 in 3 U.S. children will be the subject of a child protective services (CPS) investigation during their lifetime, typically for allegations of neglect. Whether and how an initial report of neglect is addressed may place children on divergent trajectories for safety and stability throughout childhood. The purpose of this study is to track subsequent CPS contact among children born in California in 2000 who were first investigated by CPS for neglect allegations alone (no co-occurring abuse) and not permanently separated from their families of origin (i.e., not removed or reunified if removed). We estimated the rates of subsequent CPS referrals, substantiated maltreatment, placement in foster care, and allegations of physical and sexual abuse by age 18. We assessed how rates of subsequent contact varied by initial CPS response and age at first investigation. Supplemental analyses disaggregated data by race and ethnicity. Results indicate that 64% of children initially investigated for neglect alone were re-referred to CPS by age 18 and 16% experienced a subsequent removal; however, these estimates varied greatly by age. Four out of five (79% to 83%) of children initially investigated as infants had one or more subsequent CPS referrals during childhood. Children were not only re-referred for allegations of neglect; more than half of children re-referred were reported for allegations of physical or sexual abuse, indicating that abuse risk was either missed during the initial CPS investigation or escalated afterward. The failure to address maltreatment risks when children first present to the system is a complex problem with no easy solution. Our findings document that a majority of children initially referred for neglect experience future CPS involvement, often for allegations of physical or sexual abuse.

Screening for Child Abuse in Children With Isolated Skull Fractures.

Head trauma is the most common cause of death from child abuse, and each encounter for recurrent abuse is associated with greater morbidity. Isolated skull fractures (ISF) are often treated conservatively in the emergency department (ED). We determined patterns of physical abuse screening in a children's hospital ED for children with ISF. A retrospective review was performed for children aged 3 years and younger who presented to the ED with ISF from January 1, 2015 to December 31, 2019. Children were stratified by age (<12 mo, ≥12 mo) and witnessed versus unwitnessed injury. Primary outcome was social work (SW) assessment to prescreen for abuse. Secondary outcomes were suspicion for abuse based on Child Protective Services (CPS) referral and subsequent ED encounters within 1 year. Sixty-six ISF patients were identified. Of unwitnessed injury patients aged younger than 12 months (n = 17/22), 88.2% (n = 15/17) underwent SW assessment and 47.1% (n = 8/17) required CPS referral. Of witnessed injury patients aged younger than 12 months (n = 23/44), 60.9% (n = 14/23) underwent SW assessment, with no CPS referrals. Overall, 18.2% (n = 4/22) unwitnessed and 20.5% (n = 9/44) witnessed injury patients returned to our ED: 2 were aged younger than 12 months and had recurrent trauma. To decrease risk of missed physical abuse, SW consultation should be considered for all ISF patients.

Trends from 2005 to 2018 in child maltreatment outcomes with caregivers' substance use

BackgroundCaregivers' substance use is associated with child maltreatment. ObjectiveExamine trends from 2005 to 2018 in percentages of three outcomes with caregivers' drug or alcohol use: child protective services (CPS) referrals, substantiated maltreatment reports, and foster care placements. Participants and setting22 U.S. states that contributed child-level maltreatment outcomes and caregivers' substance use data to the National Child Abuse and Neglect Data System from 2005 to 2018. MethodsJoinpoint regression was used to examine the average annual percent change (AAPC) in outcomes with caregivers' drug or alcohol use and to identify temporal changes. ResultsFrom 2005 to 2018, CPS referrals with caregivers' drug use increased (AAPC 2.33, p < .001), while referrals with alcohol use remained unchanged (AAPC -0.11, p = .92) (trend difference p = .04). Substantiated reports with caregivers' drug and alcohol use increased (AAPC drug use 3.63, p < .001, AAPC alcohol use 1.28, p = .03), with a greater increase observed with drug use (difference p = .03). Foster care placements with caregivers' drug use increased (AAPC 2.54, p < .001), while placements with alcohol use did not change (AAPC -1.22, p = .29), (difference p = .005).Within the study period, changes in trends with caregivers' drug use included increased substantiated reports from 2010 to 2018 (p < .001) and increased foster care placements from 2009 to 2018 (p < .001). With caregivers' alcohol use, CPS referrals and foster care placements decreased from 2007 to 2018 (all p < .001). ConclusionsTrends differed for outcomes with caregivers' drug versus alcohol use. Findings can inform policies to improve care for families affected by substance use.

Racism in child welfare: Ethical considerations of harm.

Racism has resulted in significant disproportionality and disparity in the US child welfare system. Being Black is not an inherent risk factor for child abuse and neglect yet Black children are almost twice as likely to be victims of substantiated abuse and neglect claims compared to other racial groups. Addressing the disproportionality within the child welfare system due to systemic racism falls squarely under the purview of bioethics. In this paper, we briefly review the impact of racism on child welfare. We then discuss some ethical considerations that mandatory healthcare reporters should think through when determining whether to report potential abuse and neglect. Specifically, we discuss the need for a broader consideration of what constitutes harm. We then present a hypothetical composite case to illuminate where and how bias can enter the process of referral to child protective services (CPS). We encourage thoughtful reporting with consideration of social and historical context and alternative explanations for worrisome findings. We recommend using evidence, avoiding assumptions by seeking clarification from families and ensuring internal consistency. When contemplating CPS referral, medical providers should feel empowered to ask questions if there is concern for potential bias. The ultimate goal is to protect children from harm. If there are clear safety concerns-they must be addressed. However, in the many cases where the safety concern is less tangible, we need to expand our considerations of the harms that can befall children, especially children of color.

Narrative Abilities and Episodic Memory in School-Aged Children Followed by Child Protective Services.

The ability to narrate routine familiar events develops gradually during middle childhood, in increasingly higher levels of coherence and temporal cohesion. Improvements in episodic memory are also observed, reflecting children’s increasing ability to recall specific circumstances of past events and personal experiences. Even though several studies have evaluated children’s narrative abilities and episodic memory, little information is available regarding the children exposed to risks that justify their referral to Child Protective Services (CPS). The current study analysed children’s narrative abilities and episodic memory performance, according to the circumstances related to the referral to CPS. Event schema representation, narrative coherence, narrative temporal cohesion, and episodic memory concerning routine and specific personal events in family context were analysed in a sample of 56 school-aged children followed by the CPS in Portugal. Children referred to CPS due to disruptive behaviour presented higher episodic memory performance, compared to those exposed to domestic violence, neglect, and abuse. No significant differences were found between groups regarding narrative abilities related to familiar routine events. Results highlight the relevance of evaluating the adverse circumstances that lead to CPS referral, considering the levels of risk and danger involved, given its differential effects on children’s episodic memory development.

Child Protective Services Referral in a Cleft Lip and/or Palate Population: Assessment of Prevalence, Indications, and Outcomes.

To determine the prevalence of, reasons for, and outcomes related to Child Protective Services (CPS) referral in an isolated and syndromic cleft lip/palate population. Retrospective cohort study. Tertiary Children's Hospital. Any patient <18 years of age attending the multidisciplinary cleft team for care at our institution with a history of referral to CPS by the cleft team during the study period 2009 to 2014. The number of children with CPS referrals, reasons for CPS referrals, outcomes of CPS referrals, associated psychosocial risk factors potentially predictive of CPS referral; demographics and cleft-related surgical history was also reviewed for each patient. Of 1392 patients, 25 (1.8%) were identified with a history of referral to CPS. Average age at referral was 11 months; 76.0% of patients were <1 year of age. Most referrals (64.0%) were directly associated with issues related to cleft care. Identified psychosocial risk factors included financial strain, mental illness/cognitive disability, transportation issues, and inadequate social support. Nine families ultimately lost custody of their children temporarily (n = 5) or permanently (n = 4). Cleft team family referral to CPS involves long-term patient care challenges requiring maximal medical and social support. Families are most commonly referred for issues related to medical neglect, which can lead to failure to thrive, delays in care, and ultimate removal from the home. Identifying families with known psychosocial risk factors and providing increased support may potentially help avoid referrals to CPS.

Mandated Reporters: The Ethical Education of Medical Students on Pediatrics Clerkship

Medical students are taught to cherish the ethical mandate to “do no harm.” However, the competency to actualize this mandate – or at least theorize how – is not always available to students on pediatrics clerkship when they encounter situations suspicious for child abuse. Mandated reporter training for medical students is largely perfunctory and does not prepare students to identify or document instances of suspected child abuse. Such training approaches students from the threatening angle that they can face punitive measures if they fail to report suspected abuse. In the absence of more thorough, ethics-driven training, students learn informally about their responsibilities as mandated reporters by observing pediatricians communicate about their own interactions with Child Protective Services (CPS), if the topic arises during clerkship. The theoretical premise of child protection is that all involved parties act in accordance with implicitly understood and shared ethical principles to safeguard the wellbeing of children [3]. Despite this assumption of accord, very little standardization exists throughout the process of identifying and reporting suspected child abuse, with the exception of some specific situations that explicitly require CPS referral. Families of color, especially Black families, are disproportionately reported to CPS for child abuse, revealing a major consequence of subjective bias in assessing parental adequacy [2]. A pediatrician may, for example, misattribute a parent’s confusion about a child’s treatment plan to noncompliance and medical neglect [1]. A CPS referral in such an instance draws a line between the medical treatment team – in the role of benevolent advocate of the child’s wellbeing – and the obstructionist, perhaps abusive parent. The medical student, as part of the treatment team, has proximity to the power-holder in the situation, the physician. The student is incentivized to neglect an ethical obligation to explore whether this dynamic is causing harm to the patient. The student does not learn to interrogate the etiology of challenges faced by the parent, or to consider that CPS involvement itself may have deleterious effects on the family [4]. A more intentional and expansive approach to the ethics of mandated reporting throughout medical school would better prepare students to understand and exercise ethical judgment.

Obstetrical and perinatal outcomes of patients with methamphetamine-positive drug screen on labor and delivery

The incidence of methamphetamine use in reproductive-age women across the United States is increasing. The existing literature on methamphetamine use in pregnancy has indicated an elevated risk of adverse maternal and neonatal health outcomes. This study aimed to investigate pregnancy outcomes in patients with recent methamphetamine use compared with patients who received negative test results for methamphetamine at the time of delivery. A single-site retrospective cohort study from January to December 2015 was performed. Patients with a documented urine drug screen during the delivery encounter were identified from the electronic medical records. The outcomes of patients with methamphetamine-positive urine drug screens were compared with controls with urine drug screens negative for methamphetamine. Maternal outcomes of interest included placental abruption, hypertensive disorders, premature preterm rupture of membranes, postpartum hemorrhage, and preterm birth. Utilization of prenatal care, social work consults, and child protective services referrals were also recorded. Neonatal outcomes included birthweight, neonatal intensive care unit length of stay, Apgar scores, and perinatal mortality. The 2 groups had similar demographic characteristics (age, multiparity, ethnicity), with the methamphetamine-positive group more likely to have no or limited prenatal care. Both groups engaged in polysubstance use. A methamphetamine-positive urine drug screen at the time of delivery carries an increased risk of abruption (odds ratio, 5.63; confidence interval, 1.21-26.21) but indicated no increased risk of maternal hypertensive disorders. Additional associated risks include preterm birth (odds ratio, 3.10; confidence interval, 1.44-6.68), lower Apgar scores at 1 and 5 minutes (P=.012 and P=.02, respectively), and increased perinatal mortality (odds ratio, 6.9; confidence interval, 1.01-47.4). Positive urine drug testing for methamphetamines during labor admission confers considerable maternal and perinatal morbidity and mortality including an increased risk of placental abruption, preterm birth, and perinatal demise. Given the limited treatments for methamphetamine addiction, further research is urgently needed.

Factors associated with the decision to investigate child protective services referrals: A systematic review

AbstractLimited resources for child protection create challenging decision situations for child protective services (CPS) workers at the point of intake. A body of research has examined the factors associated with worker decisions and processes using a variety of methodological approaches to gain knowledge on decision‐making. However, few attempts have been made to systematically review this literature. As part of a larger project on decision‐making at intake, this systematic review addressed the question of the factors associated with worker decisions to investigate alleged maltreatment referrals. Quantitative studies that examined factors associated with screening decisions in CPS practice settings were included in the review. Database and other search methods were used to identify research published in English over a 35‐year period (1980–2015). Of 1,147 identified sources, 18 studies were selected for full data extraction. The studies were conducted in the United States, Canada, and Sweden and varied in methodological quality. Most studies examined case factors with few studies examining other domains. To inform CPS policy and practice, additional research is needed to examine the relationships between decision‐making factors and case outcomes. Greater attention needs to be given to the organizational and external factors that influence decision‐making.

The Case for Including Adverse Childhood Experiences in Child Maltreatment Education: A Path Analysis.

The lifelong, negative consequences of exposure to adverse childhood experiences (ACEs) for individuals and their families are well established. To demonstrate the importance of including ACE information in child maltreatment education curricula using path analysis. Survey data examined the impact of child maltreatment education programs and knowledge about ACEs on medical practitioners' reporting habits and ability to detect maltreatment. A path diagram distinguished between the direct impact of education programs on outcome measures and the indirect effect that is mediated through knowledge of ACEs. Medical practitioners' ability to detect child maltreatment and their number of referrals to Child Protective Services (CPS). The optimized path diagram (χ2SB(3) = 3.9, p = 0.27; RMSEA-SB = 0.017; R2 = 0.21, where SB is Satorra-Bentler coefficient and RMSEA is root-mean-square error of approximation) revealed the mediating variable "knowledge about ACEs" as the strongest structural effect (SB-β = 0.34) on the number of CPS referrals. It was almost twice as high as the second strongest effect of formal education programs (SB-β = 0.19). For workplace training programs, the total effect when including knowledge of ACEs was almost double as strong as the direct effect alone. Even when previous child maltreatment education was controlled for, practitioners familiar with the consequences of ACEs were significantly more likely to recognize and to report abuse to CPS. This study documented the importance of specialized training programs on ACEs, and the essential role ACE knowledge plays in the effectiveness of provider education programs.

Incidence and Outcomes of Child Protective Services Referral in a Cleft Lip and Palate Population

Incidence and Outcomes of Child Protective Services Referral in a Cleft Lip and Palate Population

Incidence and Outcomes of Child Protective Services Referral in a Cleft Lip and Palate Population

Background: Having a child affected by cleft lip and/or palate can create numerous challenges for a family. Some patients have few medical issues while others have significant needs requiring close attention and monitoring to ensure appropriate growth and development. The cleft team occasionally encounters families who are not able to meet these challenges well. When all conservative prompts and supports provided by the team have proved unsuccessful, referring the family to Child Protective Services for intervention may help ensure appropriate care is provided to the patient. …

Intersections of family homelessness, CPS involvement, and race in Alameda County, California

The homelessness and child protective services (CPS) systems are closely linked. This study examines the patterns and sequence of families’ involvement with homeless shelters and CPS, as well as whether involvement in each system predicts involvement in the other using linked administrative records for 258 families recruited in emergency shelters in Alameda County, California. More than half of families were reported to CPS at some point, but less than one-fifth ever had a report substantiated. Reports that were uninvestigated or unfounded increased in the months leading up to shelter entry and spiked immediately afterward, but substantiations and child removals increased only later. Shelter use before study entry was associated with CPS referrals and investigations after study entry, although not with substantiated cases or child removals. However, CPS involvement before study entry was not associated with returns to shelter after study entry. These results imply that an unsubstantiated report of neglect or abuse may serve as an early warning signal for homelessness and that preventive strategies aiming to affect both homeless and child protective systems should focus on reducing homelessness. CPS workers should evaluate families’ housing needs and attempt to link families to appropriate resources. Black families were disproportionately referred to CPS after shelter entry after controlling for other family characteristics, but race was not associated with substantiations of neglect or abuse or with child removals. Findings lend modest support to human decision-making and institutional explanations of racial disproportionalities in CPS involvement, especially for reporters outside of the CPS system.

Outcomes of referrals to Child Protective Services for medical neglect in patients with phenylketonuria: Experiences at a single treatment center.

Phenylketonuria (PKU) results in an accumulation of phenylalanine (phe) in the blood which can lead to multiple health consequences in affected individuals. Treatment for PKU is available; however adherence to medical management recommendations can be difficult. When recommendations are not followed and the health of a child is at risk, one intervention that may be necessary is a referral for medical neglect to the local child protective services (CPS) agency. This study summarizes the cases that were referred from our metabolic clinic at the Children's Hospital of Michigan to CPS, and the outcomes of that intervention. CPS referrals helped to improve adherence to medical management recommendations in the majority of cases, including a lower blood phe level for the child; however, at times that improvement did not occur until after a second referral and/or the child's temporary removal from the home.

Predictors of inadequate prenatal care in methamphetamine-using mothers in New Zealand and the United States.

This study compared patterns of prenatal care among mothers who used methamphetamine (MA) during pregnancy and non-using mothers in the US and New Zealand (NZ), and evaluated associations among maternal drug use, child protective services (CPS) referral, and inadequate prenatal care in both countries. The sample consisted of 182 mothers in the MA-Exposed and 196 in the Comparison groups in the US, and 107 mothers in the MA-Exposed and 112 in the Comparison groups in NZ. Positive toxicology results and/or maternal report of MA use during pregnancy were used to identify MA use. Information about sociodemographics, prenatal care and prenatal substance use was collected by maternal interview. MA-use during pregnancy is associated with lower socioeconomic status, single marital status, and CPS referral in both NZ and the US. Compared to their non-using counterparts, MA-using mothers in the US had significantly higher rates of inadequate prenatal care. No association was found between inadequate care and MA-use in NZ. In the US, inadequate prenatal care was associated with CPS referral, but not in NZ. Referral to CPS for drug use only composed 40 % of all referrals in the US, but only 15 % of referrals in NZ. In our study population, prenatal MA-use and CPS referral eclipse maternal sociodemographics in explanatory power for inadequate prenatal care. The predominant effect of CPS referral in the US is especially interesting, and should encourage further research on whether the US policy of mandatory reporting discourages drug-using mothers from seeking antenatal care.

Need for and access to supportive services in the child welfare system

The purpose of this paper is to examine how geographical availability of social services is related to foster care entry rates and referrals for child maltreatment investigations. The primary concerns are to (1) determine locations across Los Angeles County where the availability of social services is low but display a high need for those services and (2) begin to examine how the geographic distribution of social services is related to rates of referrals and foster care entries in child maltreatment. Archival data for all 288 zip codes within Los Angeles County were collected on rates of referrals, foster care entries, location and types of social service agencies, and zip code demographics. Data were analyzed using point process models and spatial regressions. Higher densities of child welfare services in local areas (for referrals) and lagged areas (for referrals and foster care entries) were related to lower rates of child maltreatment. The density of housing and housing-related services was negatively related to referrals in local areas and foster care entry rates in lagged areas. Areas with higher densities of substance abuse and domestic violence service agencies had significantly higher rates of both Child Protective Services (CPS) referrals and entries into foster care in local areas. While the total density of child welfare services within and surrounding zip code areas is related to lower rates of referrals and foster care entries, the findings are less clear about what those specific services are. Living in and around "resource rich" zip codes may reduce rates of child maltreatment.

Assessment of factors resulting in abuse evaluations in young children with minor head trauma

Objective The primary objective was to determine which of the examined factors prompted physicians to initiate a further abuse evaluation in young children with minor head injury. The recording of important historical elements in the charts of these patients was also evaluated. Methods Charts of 349 children less than 3 years of age with minor head injury were retrospectively reviewed. Age, race, sex, insurance status, findings on head CT, mechanism of injury, witnessing of event and delay in seeking care were analyzed for association with performance of skeletal survey and referral to Child Protective Services (CPS). Results Increased odds of CPS referral and increased odds of obtaining a skeletal survey were associated with positive findings on head CT, delay in seeking care, and unknown mechanism of injury. Despite a known association of age/ambulatory status with abuse, the age of the child was not associated with increased odds of abuse evaluation, and younger age was not associated with increased odds of documenting whether the injury was witnessed or when the injury occurred. Documentation of timing of injury was lacking in 29.2% of the charts. Witnessing of the event was undocumented in 48.7% of cases. Conclusion Clinicians may not be using readily available, important information when considering the initiation of an abuse evaluation in young children. Clinicians seeing acutely injured children may need further education regarding developmental status and its effect on mechanisms of injury and the importance of detailed documentation in cases where abuse is a possible cause of injury. Practice implications Historical factors associated with injuries in young children continue to be poorly documented. Increased pediatric training for emergency medicine physicians, clinical protocols for evaluation and documentation of injured children, and regular continuing medical education on child development and its implications on mechanisms of injury for clinicians practicing in acute care settings are needed changes that may bring about improvements.