Transcript Slide 1

Risks of Serious Maltreatment Without
Additional Child Welfare Services
Race & Child Welfare--Disproportionality, Disparity, Discrimination:
Re-Assessing the Facts, Re-Thinking the Policy Options
Harvard Law School
January 28-29, 2011
Richard P. Barth
School of Social Work
University of Maryland
[email protected]
3 Main Ideas
1.
2.
3.
African American (AA) children are at least as likely to
be underserved as overserved—an adequate discussion
of child protection reform requires serious consideration
of underservice to AA children
The current analysis of disproportionality leads to the
conclusion that there is a problem that can be solved,
primarily, by better decision making —we need to
expand the discussion to include the need for better
services
Child welfare services are not well designed or
sufficiently available to children and families of any race
or ethnicity and require continuous improvement
3 Further Conclusions

Available evidence indicates that African American
children may be more likely than white or Hispanic
children to experience maltreatment, to experience
severe maltreatment, and to experience serious
consequences from the maltreatment

There is currently not substantial scientific evidence that
cultural competency training is an important path to
CWS improvements, no matter how laudable it sounds

Reducing disproportionality is not a primary goal of
CWS, per se—our goal is to improve the quality of child
and family services for all children
Versions of the Central Question in Lay Terms

Should we be so worried that the child welfare
system is unfair or racist that we allow minority
children to be underserved and unprotected?

Are our interventions failing to mitigate the
greater risk and needs of minority children and
their families?
CWS Need and Service Use Grid
NEEDS NO CWS
Actual Need
NEEDS CWS
True Positive False Negative
False Positive True Negative
NEEDS THIS CWS
NEEDS NO CWS
CWS Decision
CWS Need and Service Use Grid
NEEDS CWS
NEEDS NO CWS
Actual Need
Only One
Type of
Disparity is
Now
Discussed
True Positive False Negative
(Child needs CWS
& is determined to
need them)
(Child is thought
not to need this
level of CWS but
needs this or more)
False Positive True Negative
(Child is thought to
need this level of
CWS but does not)
(Child does not
need CWS & is
determined not to
need them)
NEEDS THIS CWS
NEEDS LESS CWS
CWS Decision
CWS Service Need and Use Grid
NEEDS LESS CWS
Actual Need
NEEDS CWS
True Positive False Negative
(Child needs CWS
& is determined to
need them)
(Child is thought
not to need this
level of CWS but
needs this or more)
False Positive True Negative
(Child is thought to
need this level of
CWS but does not)
(Child does not
need CWS & is
determined not to
need them )
NEEDS THIS CWS
NEEDS LESS CWS
CWS Decision
CWS Service Need and Use Grid
NEEDS LESS CWS
Actual Need
NEEDS CWS
False Negative
UNDERSERVED
False Positive
OVERSERVED
NEEDS THIS CWS
NEEDS LESS CWS
CWS Decision
Broaden Focus to Risk of Underservice

FOCUS ON FALSE POSITIVES, ONLY
[OVERSERVICE]


The disproportionality argument shifts the child welfare
field from one that has had a lower level of acceptability
for false positives to one that has a high level of
UNacceptability for false positives (i.e., treating an African
American family as if child abuse has occurred when it has
not is the major concern).
FOCUS ON FALSE NEGATIVES, TOO
[UNDERSERVICE]

The remainder of my comments will be an argument for
refocusing on the seriousness of rejecting true positives
(i.e., not serving children who need protection)
4 Reasons to Refocus on Underservice
1.
African American children are maltreated more often
2.
African American children are not overserved
3.
African American children are maltreated more severely
4.
African American children are more likely to experience
poor outcomes following maltreatment
AA Children More Likely to be Maltreated
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NIS 1- 4 (Brett Drake has made this case)
Maternal arrest is a predictor of child abuse
reports and placement into foster care and 3.5Xs
as many black women as white women are
incarcerated (Albert, et al., 1996; Pew, 2008;
Phillips et al., 2004)
Higher rate of traumatic brain injury (TBI) for
African American (AA) children (Martin & Falcone,
2008), typically occurring while with family
members
Probably Not Overserved
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Misdiagnosis of abusive head trauma (AHT) was higher for white
children indicating that they may be more often underreported and
the accuracy of reporting for African American children is greater
(Jenny, et al., 1999) [Suggests underservice for whites which later
cost them their lives]
Higher rates of injury death for young (0-5) AA children in California
when they were reported to CWS and screened out (PutnamHornstein, 2010)
African American children remaining in foster care had lower
mortality than those that left and the general population of African
American children in California (Blackwell & Barth, 1998).
African American children have less access to quality emergency
health care (Riera & Walker, 2010); and mental health care (Burns
et al., 2006) .
Abused More Severely

NSCAW: By parent’s self-report, twice as many AA caregivers
(18.1%) investigated for maltreatment reported (on the CTS) used
severe violence than white caregivers (5.6% at intake and during
the next 36 months (19% v. 9%, OR = 2.3Xs) (Kohl, 2007).

Intentional injury deaths for CWS-involved children (0-5) 5.5Xs as
high for Black children than white in CA (Putnam-Hornstein, 2010)

Nationally, a 3Xs higher rate of homicide victimization among AA
children (CDC, 2006-2009); most of these murders are by family
members

In study using the National Pediatric Trauma Registry, AA children
had significantly increased indication of penetrating trauma and
violent intent (Haider et al., 2007)
Experience Worse Outcomes
Marginally higher rates of death for AA children following
child abuse in MO (Jonson-Reid, Drake, & Chance, 2007),
Higher mortality for African Americans even when
controlling for severity of TBI (Haider et al., 2007) and insurance
(Falcone, Brown, Garcia, 2007; Mushkudiani, et al., 2007);
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For infant deaths from TBI, AA race has bivariate association (p
< .14) but is not an independent factor (income and insurance
matter) (Rangel, Burd, & Falcone, 2010)
Higher rates of mortality among children who have
experienced referral to child welfare services in California
(Putnam-Hornstein, 2010).
Caveat: Underservice is not Proven

Research is not definitive and may never be:
These are dense issues with many confounding factors
 Little independently funded research exists with models
that are adequately specified
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Understanding human behavior without any self-report ed
data about maltreatment is extraordinarily difficult
Underservice in CWS is likely because we see so
much of it in human services—basically, poorer
people live in communities with poorer services
Explanations Matter
CWWs
Decision
Making
Service
CW Agencies
Outside Factors
Cultural Competence
Training, FGDM, and
Administrative Review
Crisis Nursery
Shared Family Care
Re-Engineered Parenting
Programs
Cultural Competence Training
And Agency Audits
Targeted Community Partnerships
with Housing, Police, Mental
Health, Substance Abuse
Closing Caveats

Underservice of African American children is not proven

Nothing in this presentation should be interpreted to
suggest that AA children receive CWS that are meeting
their needs as well, are as comprehensive as, or are as
helpful as those provided for other children.

Nothing in these data should be taken to indicate that the
disproportionately high (per population) involvement in
CWS for African Americans cannot be reduced with
service improvements.
Partial References
Anderson, L. M., Scrimshaw, S. C., Fullilove, M. T., Fielding, J. E., & Normand, J. (2003).
Culturally competent healthcare systems: A systematic review. American Journal of
Preventive Medicine, 24(3, Supplement 1), 68-79.
Barth, R. P., & Blackwell, D. L. (1998). Death rates among California's foster care and former
foster care populations. Children and Youth Services Review, 20, 577-604.
Brown, R. L. (2010). Epidemiology of injury and the impact of health disparities. [Review]. Current
Opinion in Pediatrics, 22(3), 321-325. doi: 10.1097/MOP.0b013e3283395f13
Burns, B. J., Phillips, S. D., Wagner, H. R., Barth, R. P., Kolko, D. J., Campbell, Y., & Landsverk,
J. (2004). Mental health need and access to mental health services by youth involved with
child welfare. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 960970.
Center for Disease Control. (2009). Deaths, percent of total deaths, and death rates for 15
leading causes of death in 10 year age groups, by race and sex: US, 2003. Atlanta, GA:
Author, http://www.cdc.gov/nchs/data/dvs/lcwk2_2003.pdf.
Chipps, J. A., Simpson, B., & Brysiewicz, P. (2008). The effectiveness of cultural-competence
training for health professionals in community-based rehabilitation: A systematic review of
literature. Worldviews on Evidence-Based Nursing, 5(2), 85-94.
Partial References
Falcone, R.A., Jr, Brown, R.L., & Garcia, V.F., (2007) Disparities in child abuse mortality are
not explained by injury severity. Journal of Pediatric Surgery 42(6),1031–1037.
Haider, A.H., Efron, D. T., Haut E.R., Dirusso, S. M., Sullivan, T., Cornwell, E.E., & Stallion,
A. (2007). Black children experience worse clinical and functional outcomes after
traumatic brain injury: An analysis of the National Pediatric Trauma Registry. Journal of
Trauma, 62, 1259–1262; discussion 62–3.
Jenny, C., Hymel, K., Ritzen, A., Reinert, S., & Hay, T. (1999). Analysis of missed cases of
abusive head trauma. The Journal of the American Medical Association, 621-626.
Jonson-Reid, M., Chance, T., & Drake, B. (2007). Risk of death among children reported for
nonfatal maltreatment.(vol 12, pg 86, 2007). Child Maltreatment, 12(2), 199-199.
Kohl, P. L. (2007). Unsuccessful in-home child welfare service plans following a
maltreatment investigation: Racial and ethnic differences. Seattle, WA: Casey Family
Programs.
Martin, C.A., & Falcone, R. A. Jr. (2008). Pediatric traumatic brain injury: An update of
research to understand and improve outcomes. Current Opinion in Pediatrics. 20(3), 294299.
Partial References
Mushkudiani, N.A., Engel, D.C, Steyerberg, E.W., Butcher, I., Lu, J., Marmarou, A., Slieker, F. et
al. (2007). Prognostic value of demographic characteristics in traumatic brain injury: results
from the IMPACT study. Journal of Neurotrauma, 24(2), 259-269.
Phillips, S., Burns, B. J., Wagner, H. R., & Barth, R. P. (2004). Parental arrest and children
involved with child welfare services. American Journal of Orthopsychiatry, 74, 174-186.
Putnam-Hornstein, E. (2010).. Do “Accidents” Happen? An Examination of Injury Mortality
Among Maltreated Children. Berkeley, CA:: University of Caliifornia, School of Social Welfare.
Unpublished Dissertation..
Rangel, E. L., Burd, R. S., Falcone, R. A., & Multictr Child Abuse Disparity, G. (2010).
Socioeconomic Disparities in Infant Mortality After Nonaccidental Trauma: A Multicenter
Study. [Proceedings Paper]. Journal of Trauma-Injury Infection and Critical Care, 69(1), 2025. doi: 10.1097/TA.0b013e3181bbd7c3.
Riera, A., & Walker, D. M. (2010). The impact of race and ethnicity on care in the pediatric
emergency department. [Review]. Current Opinion in Pediatrics, 22(3), 284-289. doi:
10.1097/MOP.0b013e32833973a5
U.S. Department of Health and Human Services Administration for Children and Families. (2005).
National Survey of Child and Adolescent Well-Being: Children involved with the child welfare
sservices (Baseline Report). Washington, DC: Author.