Transcript Paternity Establishment Among Children reported to Child

RISK OF INJURY DEATH
FOLLOWING A REPORT
OF PHYSICAL ABUSE:
January 13, 2012
EVIDENCE FROM A PROSPECTIVE,
POPULATION-BASED STUDY
Washingto n, DC
Emily Putnam -Hornstein, PhD
Society for
Social Work
Research
ACKNOWLEDGEMENTS
 Thank you to my colleagues at the Center for Social
Services Research and the California Department of
Social Services
 Funding received from the HF Guggenheim
Foundation, the Fahs-Beck Foundation, and the Center
for Child and Youth Policy
 Additional support for this and other research arising
from the California Performance Indicators Project
generously provided by the California Department of
Social Services, the Stuart Foundation, & Casey Family
Programs
OVERVIEW
A mortality-based standard for evaluating parental
behavior may be the closest we can get to “culture free” definitions of neglect and abuse (S.R. Johannson , 1987)
 first prospective birth cohort analysis of injury
mortality among children reported to child protective
services
 captures all children reported for maltreatment
(including those screened out over the phone)
 examines both unintentional and intentional injury
fatalities
 controls for sociodemographic and health
characteristics present at birth
LINKED DATASET
cps records
514,000
birth records
death records
LINKED
DATA
birth
no cps
no death
birth
cps
no death
birth
no cps
death
birth
cps
death
4.3 million
25,000
1,900
all deaths
injury
deaths
QUESTIONS
1. Are children reported for non-fatal
maltreatment at greater risk of preventable
injury death before age five compared with
sociodemographically similar children not
reported?
2. Among children reported for non-fatal
maltreatment, does subsequent risk of injury
death vary by allegation type?
VARIABLES
baseline birth variables
 sex
 health risk
 public insurance
 maternal age
 maternal education
 established paternity
 race / ethnicity
 birth order
child welfare variables
 allegation
 type
death variables

icd-10 e-codes
unintentional
 intentional

METHOD
Extended Cox Regression Models
 censored data for more recent birth cohorts
 first report to CPS inherently time-varying
 results nearly identical to those obtained using Competing Risk Models
1999
2000
2001
2002
2003
2004
2005
2006
5th
birthday
INJURY DEATHS
QUESTION 1:
ARE CHILDREN REPORTED FOR NONFATAL MALTREATMENT AT GREATER
RISK OF PREVENTABLE INJURY
DEATH BEFORE AGE OF FIVE
COMPARED WITH
SOCIODEMOGRAPHICALLY SIMILAR
CHILDREN NOT REPORTED?
ANSWER?
Yes.
after adjusting for other risk factors at birth, a
prior report to CPS emerged as the strongest
predictor of injury death during a child’s first
five years of life
a prior report to CPS was significantly
associated with a child’s risk of both
unintentional and intentional injury death
A DJ US TE D R ATE OF IN J U RY DE ATH F OR CH IL DR E N
W IT H A P R IOR A L L E GAT IO N O F M A LT REAT ME NT, B Y
C A U S E O F D EAT H
all injury deaths
HR: 2.59
unintentional injury deaths
HR: 2.00
intentional injury deaths
HR: 5.86
0.5
1.0
2.0
3.0
plotted on log scale
Hazard Ratio
95% CI
4.0
8.0
QUESTION 2:
AMONG CHILDREN REPORTED
FOR NON-FATAL
MALTREATMENT, DOES
SUBSEQUENT RISK OF INJURY
DEATH VARY BY ALLEGATION
TYPE?
ANSWER?
Yes.
 children with a prior allegation of physical abuse
were found to have intentional injury death rates
that were dramatically higher than not only
unreported children, but also children reported for
neglect
 rates of unintentional injury death were statistically
indistinguishable
INJURY DEATH RATES BY PRIOR
MALTREATMENT ALLEGATION TYPE
(UNADJUSTED)
all injury
deaths
(1,917*)
HR
inflicted injury
deaths
(381)
95% CI
HR
unintentional injury
deaths
(1,438)
95% CI
HR
95% CI
β1(t):
physical abuse
2.47***
(1.97, 3.09)
9.84***
(6.73, 14.38)
0.65
(0.41, 1.01)
β2(t):
sexual abuse
0.60
(0.30, 1.22)
0.83
(0.20, 3.43)
0.50
(0.20, 1.21)
β3(t):
other abuse
0.35***
(0.25, 0.48)
0.27**
(0.11, 0.64)
0.38***
(0.27, 0.54)
β4(t):
neglect
ref
--
ref
--
ref
--
* Includes injury deaths of undetermined intent.
INJURY DEATH RATES BY PRIOR
MALTREATMENT ALLEGATION TYPE
(ADJUSTED)
all injury
Deaths
(1,917*)
HR
inflicted injury
Deaths
(381)
95% CI
HR
unintentional injury
deaths
(1,438)
95% CI
HR
95% CI
β1(t):
physical abuse
2.48***
(1.94, 3.17)
9.23***
(6.15, 13.87)
0.66
(0.41, 1.05)
β2(t):
sexual abuse
0.74
(0.36, 1.52)
0.97
(0.23, 4.12)
0.61
(0.25, 1.53)
β3(t):
other abuse
0.39***
(0.28, 0.54)
0.26**
(0.11, 0.68)
0.42***
(0.29, 0.60)
β4(t):
neglect
ref
--
ref
--
ref
--
* Includes injury deaths of undetermined intent.
SUMMARY AND IMPLICATIONS
 Population-level linked birth-CPS-death data indicate that a
report to CPS is not a random event. Reports of
maltreatment, including those evaluated out without
investigation, reflect more than just poverty and serve as a
signal of unmeasured family dysfunction and child risk not
otherwise captured in sociodemographic markers
 These data indicate that an allegation of physical abuse
signals a consistently greater level of physical risk in the
form of death than neglect or other forms of maltreatment.
From a public health control and prevention stand -point,
unique protocols for investigating and intervening in cases
in which physical abuse is alleged for a child under the age
of five may be justified .
QUESTIONS?
[email protected]