Introduction

1. Household, Family, and Child Risk Factors After an Investigation for Suspected Child Maltreatment: A Missed Opportunity for Prevention Campbell KA, Cook LJ, LaFleur BJ, Keenan HT. Household, family, and child risk factors after an investigation for suspected child maltreatment: a missed opportunity for prevention. Arch Pediatr Adolesc Med. 2010;164(10):943-949.

2. Introduction • Families that have had a Child Protective Services (CPS) investigation are at increased risk for poor child health, family violence, and repeat maltreatment. • CPS investigation grants unique access to households to provide services that may reduce repeat maltreatment and improve outcomes. • This study describes the association between a CPS investigation for suspected child maltreatment and subsequent change in household, family, and child risk factors for repeat maltreatment.

3. CPS Investigation: Possible Outcomes • Under ideal conditions, a CPS investigation would be associated with subsequent improvements in modifiable risk factors. • Alternately, a CPS investigation may disrupt a household and be associated with subsequent worsening in modifiable risk factors. • We hypothesized that a CPS investigation would be independent of subsequent changes in modifiable risk factors.

4. Methods • Retrospective cohort design. • Eligible subjects: Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) data set. • 5 geographically distinct study sites with common study protocols. • Face-to-face surveys conducted every 2 years beginning at age 4 years. • Manual review of CPS records every 2 years. • Study cohort: 595 LONGSCAN participants. • Same maternal caregiver responding to the interviews at the child’s ages of 4 and 8 years. • Complete outcome and covariate data.

5. Methods • Exposure: CPS investigation between ages 4 and 8 years. • Investigated group: Children with ≥1 CPS investigation. • Comparison group: Children with no CPS investigation. • Outcomes: Modifiable risk factors for child maltreatment, measured by LONGSCAN at age 8 years. • Household risks: Social support, family functioning, poverty level. • Caregiver risks: Education level and depressive symptoms. • Child risks: Anxious or depressive behaviors, aggressive or destructive behaviors. • Covariates: Variables potentially associated with either the exposure or the outcomes modeled (confounders). • Baseline risks: Modifiable risks measured at age 4 years. • Baseline characteristics: Child sex and race, caregiver age and relationship, household size, CPS investigation prior to age 4 years. • LONGSCAN study site.

6. Analyses • Univariate analyses identified potential confounders. • Association between CPS investigation (exposure) and covariates. • Association between risks (outcomes) and covariates at age 8 years. • Covariates significantly associated (P<.05) with exposure or outcomes in univariate analyses retained for multivariable analysis as potential confounders. • Multivariable linear model described the difference in modifiable risks between investigated and comparison groups. • Secondary multivariable models examined. • Effect of CPS substantiation on difference in modifiable risks. • Effect of time since CPS investigation on difference in modifiable risks.

7. Interpreting the Analysis • Is there an association between modifiable risk factors for child maltreatment and a prior CPS investigation for child maltreatment? • The β coefficient for CPS investigation reflects the adjusted difference in modifiable risk between investigated and comparison children. • Is there an association between modifiable risk factors and a CPS substantiated case of child maltreatment? • The β coefficient for substantiated CPS investigation reflects the adjusted difference in modifiable risk between substantiated and comparison children. • Are reductions in modifiable risks observed as time from CPS involvement increases? • The β coefficient for the number of months since the last CPS investigation reflects the effect of increasing time on modifiable risks.

8. Limitations • Secondary analysis of existing database. • Cannot assess causality of changes in modifiable risk. • Cannot examine risk factors not captured by LONGSCAN. • Intimate partner violence. • Drug and alcohol dependence. • Postinvestigation services received. • LONGSCAN data may not reflect current practices. • Surveys at age 4 years were collected between 1991 and 2000. • Clinical significance of changes in modifiable risk factors is unknown. • Further research is needed to determine whether changes in risk factors reduce repeat maltreatment and improve child outcomes.

9. Results • Multivariable models. • Are modifiable risks associated with CPS investigation? • CPS investigation between ages 4 and 8 years was associated with • increased maternal depressive symptoms at age 8 years (P<.05) • (see next slide for comparison with other available measures). • Does CPS substantiation of maltreatment alter these findings? • CPS substantiation of maltreatment did not alter primary results. • Are modifiable risks reduced with time since CPS investigation? • Increased time from CPS investigation was associated with increasing household, caregiver, and child risk.

10. Results Adjusted Differences in Modifiable Household, Caregiver, and Child Risk Factors at Age 8 Years in LONGSCAN Subjects With and Without a Child Protective Services Investigation Between Ages 4 and 8 Yearsa

11. Comment • We found an association between CPS investigation and subsequent increased depressive symptoms in maternal caregivers. • We found no association between CPS investigation and subsequent social support, family function, poverty, maternal education, and child behavior problems. • Our results suggest that a CPS investigation represents a missed opportunity to reduce risks in these high-risk households.

12. Implications • For physicians: • A CPS referral should be viewed as a beginning rather than an end. • Physicians may have a role in preventing repeat maltreatment and improving outcomes after a CPS investigation. • For policymakers: • Traditional CPS role of investigation is needed to assess immediate safety. • Strengthening CPS prevention efforts may improve long-term outcomes. • Funding for evidence-based prevention efforts would be needed. • For researchers: • Need to define success for children and caregivers after maltreatment. • Need to identify modifiable risks that predict success after maltreatment. • Need to develop and investigate effective interventions that will reduce risks and improve outcomes for families with a history of maltreatment.

13. Contact Information • If you have questions, please contact the corresponding author: • Kristine A. Campbell, MD, MSc (kristine.campbell@hsc.utah.edu). Funding/Support • Funding was provided by Public Health Services research grant UL1-RR025764 from the National Center for Research Resources.