Copyright restrictions may apply 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):

Copyright restrictions may apply 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.

Copyright restrictions may apply 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.

Copyright restrictions may apply 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.

Copyright restrictions may apply 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.

Copyright restrictions may apply 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.

Copyright restrictions may apply 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.

Copyright restrictions may apply 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 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.

Copyright restrictions may apply 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.

Copyright restrictions may apply 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 Years a

Copyright restrictions may apply 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.

Copyright restrictions may apply 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.

Copyright restrictions may apply Contact Information If you have questions, please contact the corresponding author: Kristine A. Campbell, MD, MSc Funding/Support Funding was provided by Public Health Services research grant UL1-RR from the National Center for Research Resources.