1. LINKING RECORDS TO ADVANCE CHILD PROTECTION: A CALIFORNIA CASE STUDY Emily Putnam-Hornstein, PhD University of Southern California Barbara Needell, PhD University of California at Berkeley 3 rd Annual State of Health Care Conference

2. BACKGROUND California Child Welfare Indicators Project longstanding university/agency partnership longitudinal configuration of states child protective services data technical assistance to California counties & state consultation services to other state child welfare agencies publicly available website for tracking outcomes and performance indicators (interactive queries) data available for research…

3. In 2011, more than 6 million children were referred for possible maltreatment in the United States; nearly 700,000 were substantiated as victims Estimated lifetime cost of child maltreatment is $124 billion each year (Fang, et al., 2012) A growing body of research indicates that children who experience abuse or neglect are at heightened risk of adverse health outcomes, including: Obesity, cancer, strokes (Felitti, et al., 1998) Teen pregnancy (Noll & Shenk, 2013) Self-injurious behaviors (Rhodes, et al., 2013) WHAT WE KNOW (NATIONAL)

4. WHAT WE KNOW (CALIFORNIA)

5. WHAT WE DO Birth Maltreatment ReferralInvestigationServices CPS involvement

6. A SNAPSHOT OF MALTREATED CHILDREN before CPS Data after Children not Reported for Maltreatment

7. MOVING AWAY FROM DATA SILOS… birth data death data population-based information child protective service records before CPS Data after Children not Reported for Maltreatment

8. RECORD LINKAGES 101 File AFile B SSN First Name Middle Name Middle Initial Last Name Date of Birth Address Zip Code deterministic match probabilistic match

9. LINKED DATASET birth records LINKED DATA birth cps contact birth no cps contact 4.3 million 514,000 cps records

10. EXPANDED INFORMATION vital birth records population-based information child protective service records California Birth Cohort Child A Child B Child C Child D Referral by Age 5

11. Risk factor: a term used in epidemiology to define a characteristic that is either directly or indirectly associated with risk of disease or other adverse health outcomes Stable / Fixed at birth (e.g., male gender is a risk factor for injury) Time varying – developing through exposure to adversities in the social or physical environment This information can be used to identify individuals/groups/communities particularly vulnerable to a given adverse outcome in order to strategically target prevention and intervention programs and policies LANGUAGE

12. sex female male birth weight 2500g+ <2500g prenatal care 1 st trimester 2 nd trimester 3rd trimester no care birth abnormality present none maternal birth place US born non-US born race Native American black Hispanic white Asian/Pacific Islander maternal age <=19 20-24 25-29 30+ maternal education <high school high school some college college+ pregnancy termination hx prior termination none reported named father missing named father # of children in the family one two three+ birth payment method public/med-cal other BIRTH RECORD VARIABLES

13. SELECTED FINDINGS… 14% of children in birth cohort were reported to CPS by age 5 Lower bound estimate…could not match 16% of CPS records Cumulative rate of CPS involvement 3x higher than single year estimates suggest 11 of 12 variables were significantly associated with CPS contact Crude risk ratios >2 were observed for 7 variables Contact with CPS is hardly a rare event for certain groups 34% children without paternity established 25% of children born to teen mothers

17. AN EPIDEMIOLOGIC RISK ASSESSMENT TOOL? (BACK OF THE ENVELOPE CALCULATIONS…) We classified as high risk any child with three or more of the following (theoretically modifiable) risk factors at birth: late prenatal care (after the first trimester) missing paternity <=high school degree 3+ children in the family maternal age <=24 years Medi-Cal birth for a US-born mother Think of this as a means of sorting children – looking for proxy indicators that give us additional information about an infants likelihood of referral

18. RISK ASSESSMENT TOOLS

19. ADMINISTERED AT BIRTH? Full Birth CohortChildren Reported to CPS

20. RECOGNIZING THE RISK ASSOCIATED WITH THE PRESENCE OF MULTIPLE RISK FACTORS… High Risk on Every Modifiable Risk Factor: 89% probability of CPS report Low Risk on Every Modifiable Risk Factor: 3% probability of CPS report

21. CONCLUDING THOUGHTS… Data that are universally collected at birth can be used to identify those children that are at greatest risk of later CPS involvement Compared with the demographics of the birth cohort as a whole, these young children are defined by the presence of multiple risk factors A standardized assessment tool can never replace more comprehensive assessments of a familys strengths and risks, but against an invariable backdrop of limited resources, the ability to prioritize investigations and adjust levels of case monitoring in order to meet the greater needs of a targeted swath of at-risk children and families has the potential for cost-savings to be realized, while also improving child well- being

22. Each person in the world creates a Book of Life. This Book starts with birth and ends with death. Its pages are made up of the records of the principal events in life. Record linkage is the name given to the process of assembling the pages of this Book… (Dunn, 1946) RECORD LINKAGES Government University Partners Ongoing Collaboration

23. QUESTIONS? ehornste@usc.edu bneedell@berkeley.edu http://cssr.berkeley.edu/ucb_childwelfare /

24. Thank you to our colleagues at the Center for Social Services Research and the California Department of Social Services Ongoing support for research arising from the California Performance Indicators Project and related activities is generously provided by CDSS, the Stuart Foundation, and Casey Family Programs Record linkages funded by the Harry Frank Guggenheim Foundation, the Conrad N. Hilton Foundation, and First 5 LA ACKNOWLEDGEMENTS