1. Maltreated Infants: Identifying Factors Associated with Poorer Outcomes The research for this presentation was funded by the Administration on Children, Youth, and Families of the U.S. Department of Health and Human Services, Award 90PH0014. Anita Scarborough, Ph.D. Frank Porter Graham Child Development Institute University of North Carolina Julie McCrae, MSW, Ph.D. University of Pittsburgh, School of Social Work Child Welfare Education and Research Programs 2007 OSEP National Early Childhood Conference Marriott Crystal Gateway Hotel

2. 2 Organization of Presentation 1.Data Source 2.Research Questions 3.Findings 4.Discussion Implications for Service Provision

3. 3 Source of Information The Administration for Children and Families (ACF), funded the National Survey of Child and Adolescent Well-Being, the first national probability study of children and adolescents investigated by Child Welfare Services. Baseline data was collected in 1999 and 2000. This session will present the developmental characteristics of a nationally representative sub-sample of 1,196 infants, representing 149,398 maltreated infants shortly after investigation and again, 3 and 4½ years later.

4. 4 Long-term Outcomes of Abused and Neglected Children More likely to be arrested as juveniles, to become pregnant during adolescence, use drugs, have lower grade point averages, and experience mental health problems. 16% of males and 57% of females in State prisons experienced childhood physical or sexual abuse. Research has become quite conclusive regarding the negative impact of the experience of child maltreatment on adult outcomes in cognitive, economic and mental health domains.

5. 5 Growing Public Awareness and Policy Change Amendment of the Child Abuse and Prevention Treatment Act (CAPTA, 2003) “requires referral of a child under the age of 3 who is involved in a substantiated case of child abuse or neglect to early intervention services funded under Part C” (section 106(b)(2)(A)(xxi)). The Individuals with Disability Education Act (IDEA, 2004), requires state Part C programs to have a description of their policy and procedures that require the referral for early intervention services for children under the age of 3 who are involved in a substantiated case of child abuse or neglect. Eligibility requirements for Part C are determined by individual states.

6. 6 Definition of Substantiation Where the allegation of maltreatment was supported or founded by state law or state policy (US Department of Health and Human Services, 2006). Each state requires a specific standard of proof to substantiate maltreatment.

7. 7 Part C Services The goal of Part C is to provide services to children from birth through two years of age with disabilities. Children in this age range experiencing developmental delays, as defined by the individual states, are entitled to services. States vary according to the agency serving as the lead agency, the eligibility definition for delay, if services are provided to children “at risk” for developmental delays (currently 5 states), and in the percentage of children served. Part C services are provided to 2.4% of children between birth and 2 years of age nationally. The percentage of children and families served among the individual states varies, ranging from 1.34 to 6.71% (U.S. Department of Education, 2006).

8. 8 Basis for the Research An under utilization of Part C services among maltreated infants and toddlers, based on scores on developmental measure shortly after investigation by child welfare, has been reported (Rosenberg et al., 2004; Stahmer et al., 2005; Zimmer & Panko, 2006), Clearly it difficult to determine developmental delay as an eligibility criteria among infants who do not have established risk conditions. This study is looking at the developmental characteristics of maltreated infants over time to stress the need for intervention services, and to determine factors present in infancy associated with poorer developmental outcomes.

9. 9 Research Questions What are the characteristics of infants, their caregivers and type of maltreatment shortly after the time of investigation by Child Welfare Services? Are there discernible developmental profiles for maltreated infants, 3 and 4½ years after investigation? What proportion of maltreated infants were reported to have an IFSP 12 months after investigation and what proportion had an IEP 4½ years later? Are characteristics of maltreated infants, their caregivers, or maltreatment type related to developmental outcomes 4½ years later? What do those findings suggest about the need for Part C early intervention services?

10. 10 Characteristics of Maltreated Infants Age Gender Race Health Status Neurodevelopmental risk status as assessed by the Bayley Neurodevelopmental Screener Cognitive development as indicated by scores in the cognitive domain of the Battelle Developmental Inventory

11. 11 Caregiver Characteristics Age Education Cognitive impairment Mental illness/depression Substance abuse Domestic violence Poverty Poor quality home environment as measured by the HOME

12. 12 Maltreatment Characteristics Prior reports of maltreatment Maltreatment type –Physical abuse –Sexual abuse –Physical neglect –Supervisory neglect –Other Maltreatment case substantiated Reported level of harm to the child Child placed out of home

13. 13 Developmental Characteristics Examined 3 and 4 ½ Years after Investigation Cognitive development Language skill Adaptive behavior Behavioral concerns Loneliness & social dissatisfaction

14. NSCAW Sample 6,231 children, birth to 14 years of age, who had contact with the Child Welfare System Over Sampled on the basis of: Children/Families Receiving Child Welfare Services Infants Sexually Abused Children Baseline collection from Nov. 1999 to Apr. 2001 Follow-Ups at 12, 18, 36, and 54 months after baseline 12 month follow-up included only limited data collection 54 months follow-up currently available only on infants at baseline

15. 15 Measures Neurodevelopment Bayley Infant Neurodevelopmental Screener (BINS; 0-2 years) Cognitive Domain Battelle Developmental Inventory – Cognitive Domain (BDI; 0 – 3 years) Kaufman Brief Intelligence Test (K-BIT; 4+ years) Adaptive Behavior Domain Vineland Adaptive Behavior Scale Screener, Daily Living Skills sub-domain (VABS) Communication Domain Preschool Language Scale-3 (PLS-3)

16. 16 Measures Behavior Domain Child Behavior Checklist (CBCL; 2+ years for parent; 5+ years for teacher) Socialization Loneliness and Social Dissatisfaction Questionnaire for Young Children (self report 5+ years) Home environment The Home Observation for Measurement of the Environment (HOME)

17. 17 Definition of Delay Children scoring 1.5 standard deviations or more below the mean on a developmental measure were considered to have a delay. High Risk for subsequent developmental difficulties based on the BINS. Described 3 and 4 ½ years later using: PLS – 3 VABS CBCL- parent and teacher KBIT Loneliness & Social Dissatisfaction

18. 18 Age in months at baseline% 0-645 7-1255 Male49 Race/ethnicity White44 African-American30 Hispanic21 Other5 Fair/poor health8 High risk on the BINS53 Characteristics of Infants Investigated by Child Welfare

19. 19 At baseline% Less than high school education37 Cognitive impairment13 Mental illness/depression34 Active or history of domestic violence56 Poverty45 Low score on HOME12 High number of risk factors34 Caregiver Characteristics

20. 20 Female Caregiver ageEducation-level Caregiver Characteristics

21. 21 Household Characteristics

22. 22 Family Risks

23. 23 At baseline% Prior report of maltreatment41 Maltreatment type Physical abuse20 Sexual abuse2 Physical neglect40 Supervisory neglect33 Other5 Severe level of harm16 Clear evidence of maltreatment41 Worker reports the child has special needs14 Maltreatment substantiated38 Out of home placement22 Characteristics of Maltreatment

24. 24 Low Scores at Baseline by Age in Months

25. 25 High Risk on BINS by Age at Baseline

26. 26 Low Scores 3 Years Later, by Age at Baseline Domain0-6 mos. % 7-12 mos. % Total % Cognitive373234 Language353837 Adaptive Behavior251017 At least 1 Problem score 5957

27. 27 Combinations of Low Score Areas 3 Years After Baseline Developmental areas % No problem scores42 Cognitive12 Language14 Adaptive behavior6 Cognitive & Language15 Adaptive + Cognitive or Language 5 All problems6 Total100

28. 28 Low Scores 3 Years after Baseline by Race/ethnicity p<.10

29. 29 Low Scores 3 Years After Baseline by Gender p<.05

30. 30 Infants with an IFSP, or 4 ½ Years Later an IEP IFSP in the12 months after baseline32% IEP 54 months after baseline20% IFSP 12 months, or IEP 54 months after baseline37% Those with an IEP who also had an IFSP54%

31. 31 Teacher Report of Areas of Concern for Those with an IEP Category% % Learning disability24Speech language delay66 Autism18Traumatic brain injury5 Emotional disturbance22ADHD25 Mental retardation15Developmental disability26 Multiple disabilities11Visual impairment2 Orthopedic6Deafness or hearing impaired 2 Other/unknown13

32. 32 Low Score Areas 4 ½ Years Later, by Age at Baseline Domain0-6 mos. % 7-12 mos. % Total % Cognitive161113 Language272125 Adaptive Behavior422834 At least 1 Problem score 454455

33. 33 Focus on Low Language Scores 4 ½ Years after Baseline (PLS-3) Low language scores associated with: –Severe level of harm reported at baseline (p<.05) –High risk rating on the Bayley scales of infant neurodevelopment at baseline (p<.001) No association with: –Child demographic characteristics –Maltreatment characteristics, including substantiation –Caregiver risks, age, education-level, poverty status –Poor quality home environment –Baseline cognitive delay

34. 34 Low Language Scores 4 ½ Years after Baseline Baseline characteristicOdds of age 5 language delay p-value Age: 0-6 months1.36.47 Male1.41.24 Black.67.42 Hispanic or other.88.71 Poor physical health1.08.80 High risk BINS1.46.28 Cognitive delay1.52.19 Regression using child characteristics, R-square:.03

35. 35 Low Language Scores 4 ½ Years after Baseline Baseline characteristicOdds of age 5 language delayp-value Age: 0-6 months1.12.80 Male1.87.15 Black.41.16 Hispanic or other1.64.36 High risk BINS2.34.11 Poor health3.00.03 Cognitive delay.69.53 Caregiver age: <35 years1.20.80 <HS education.57.29 Caregiver cognitive impairment10.59.01 Mental illness.22.05 Substance abuse1.65.43 Domestic violence2.46.14 Below poverty line.86.80 Poor quality home environment1.08.87 Regression using child & caregiver characteristics, R-square:.17

36. 36 Low Language Scores 4 ½ Years After Baseline Baseline characteristics related to low language scores Odds of age 5 language delay p-value Caregiver cognitive impairment16.12.02 Caregiver mental illness.20.03 Prior reports.27.05 Severe level of harm7.77.02 Regression with child, caregiver & maltreatment characteristics, R-square:.27 Statistical trends (p<.10): High risk BINS, domestic violence, “Other” as the primary type of maltreatment

37. 37 Predictors of IEP 4 ½ After Baseline Baseline characteristics related to Special Education 4 ½ years later Odds of having an IEPp-value Male5.00.01 Child cognitive problem.21.02 Caregiver cognitive impairment 13.21.002 Caregiver mental illness.30.03 Statistical trends (p<.10): Age 0-6 months at baseline, Hispanic, low level of child harm Regression with child, caregiver & maltreatment characteristics, R-square:.26

38. 38 Emotional-behavioral Problems Reported 4 ½ Years Later Problem type % with clinical-level score Teacher reportParent report Total problems921 Internalizing97 Externalizing1320

39. 39 Self-report of Loneliness and Social Dissatisfaction 4 ½ Years Later Age at baseline% 1 SD or greater above the mean 0 – 6 months16% 7 – 12 months11% Total13%

40. 40 Summary More than half of maltreated infants are at high risk for poor developmental outcomes, based on the presence of multiple risk factors such as high family stress (61%), single parent (48%), and domestic violence (56%), coupled with a low score on a measure of cognition, language or neurodevelopmental risk status (BINS). 32% of maltreated infants were reported to have an IFSP in the period of time 12 months after baseline. Three years after baseline more than half are reported to have a delay in at least one of the domains measured, with cognitive (12%) and language delays (14%) being the most common. Three years after baseline 74% of boys were reported to have a low score in at least one domain.

41. 41 Summary Using language as a global marker of development revealed infant & caregiver characteristics associated with low scores 4 ½ years later: –Poor infant health –Caregivers with a cognitive impairment –Caregiver mental illness was associated with reduced likelihood of language delay Likely due to the self-report, laptop computer method used to have caregivers describe their mental health/depression Adding maltreatment characteristics, infant health was no longer predictive, but reported severity of harm was. Prior report of maltreatment was negatively related to language delay.

42. 42 Summary continued When infants were 5 years of age, 1/5 of them were reported to have an IEP, but only about half of those children were reported to have had an IFSP. Factors associated with having an IEP 4 ½ years later: –Male infants –Caregiver cognitive impairment –Infant cognitive problem (-) –Caregiver mental illness (-)

43. 43 Summary continued Maltreated infants at five years of age: –25% low score on a language measure –20% IEP –13-20% reported to have clinical level externalizing problems –7-9% reported to have clinical level internalizing problems –13% of the children report loneliness or social dissatisfaction Factors in infancy found to be associated: –Infant poor health –Caregiver cognitive impairment –Severe level of harm Maltreatment characteristics not found to be associated: –Substantiation –Poverty - though these children are disproportionately poor –Out of home placement

44. 44 Discussion Points Have Part C services been adapted to meet the needs of these children and families? Many maltreated infants have multiple risk factors, recognized as a Part C eligibility in only a few states, yet these findings support the increased likelihood of poor outcomes for these children. –What can be done to help meet the needs of these children and families and to help children get services earlier? Has the CAPTA requirement to refer substantiated infants and toddlers resulted in more children being served? Substantiation is the criteria for referral, yet these findings show that this is not significantly related to outcomes.

45. 45 http://www.fpg.unc.edu/~promise/ Visit Project Website for updates: Anita_Scarborough@unc.edu