Transcript Risk of Re-referral among infants who remain at home

RISK OF RE-REFERRAL AMONG
INFANTS WHO REMAIN AT HOME
FOLLOWING REPORTED
MALTREATMENT
Society for
Social Work
Research
San Diego, CA
Emily Putnam-Hornstein, PhD
James Simon, MSW
Joseph Magruder, PhD
Barbara Needell, PhD
acknowledgements
 Thank you to our colleagues at the Center for Social
Services Research and the California Department of
Social Services
 Data linkages funded by the H.F. Guggenheim
Foundation
 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
background
 In 2011, referrals involving approximately 6.2 million
children were made in the US, yet only 3 million were
included in an investigation
 California is one of the few states that collects data on these
“evaluated out” cases
 Large body of research indicates a limited ability to
accurately and consistently determine if a child has been a
victim, or to accurately discern future risk among
investigated cases – are we better at screening out cases?
 In this study we longitudinally follow a cohort of children
remaining in the home following a referral for maltreatment
during infancy
 We look at the cumulative risk of begin reported again over a
five year window
 We examine differences by CPS disposition/response
epidemiological questions addressed
1. Among infants remaining in the home
following a report of maltreatment, how many
are re-reported within 5 years?

How many infants who were evaluated out are rereported?
2. Do the risk factors observed at birth vary with
the initial CPS response/disposition?
3. Does the likelihood of being re-reported vary
by initial CPS response/disposition, after
adjusting for baseline risk differences?
data
File A
2006
birth records
File B
91.9%
infant cps
records
from birth to re-report…
variables
first referral
disposition
confounders
• First Maltreatment
• Sex
• Birth Weight
• Race/Ethnicity (by birth place)
• Prenatal Care
• Maternal Age
• Birth Order
• Paternity
• Birth Payment Method
outcome
• Re-report
analysis
 χ 2 tests used to assess covariate distributions across
initial CPS response types
 Cox Regression Models used to estimate relative
differences in likelihood of being re -reported within 5
years
Evaluated Out
Risk factors
that may
influence rereporting
risk
Re-Referral
(?)
Unfounded/
Inconclusive
Substantiated,
FM Services
Substantiated,
No FM Services
5 years
Population Characteristics
infants reported for maltreatment
 563,871 children born in California in 2006
 5.2% (29,927) were reported for maltreatment before age 1
 First reported maltreatment type:
 82% = neglect; 9% = emotional abuse (e.g., DV exposure); 8% = at risk,
sibling abused; 6% = physical abuse
 89% of referrals received from a mandated reporter
 29% of reported infants were reported to CPS within three
days of birth
 Not surprisingly, among these 3-day referrals, 98% involved an
allegation of neglect or substantial risk of maltreatment.
 Unfortunately, we do not have data as to how many of these
allegations involved maternal substance abuse
 70% of these infants had older siblings. And among those
with older siblings, 49% had an older sibling who had been
referred for maltreatment prior to the infant’s birth.
stark and consistent differences between overall
birth cohort and infants reported for maltreatment
Among infants remaining in
the home following a report of
maltreatment, how many are
re-reported within 5 years?
Question 1
initial CPS response
47% of substantiated infants placed
in foster care and excluded (5,339)
41% (2,372)
24% (5,774)
563,871
59% (3,402)
5.2% (29,927)
61% (14,647)
15% (3,450)
82% of all referred infants remained at home,
10% received CPS FM services
we will see 6 out of every 10 of these
infants again…
47% of substantiated infants placed
in foster care and excluded (5,339)
69%
41% (2,372)
64%
24% (5,774)
563,871
59% (3,402)
61%
5.2% (29,927)
61% (14,647)
60%
15% (3,578)
82% of all referred infants remained at home,
10% received CPS FM services
within a relatively short period of time.
Kaplan-Meier Failure Estimates
75%
cumulative percentage of children re-reported
52%
54%
56%
58%
60%
50%
49%
44%
39%
33%
0
25%
24%
0
1
2
3
Time from First Report (in Years)
Evaluated Out
Unfounded
4
Substantiated
5
Do the risk factors observed at
birth vary by initial cps
response/disposition?
Question 2
high risk (relative to full cohort) …difficult
to discern a risk pattern
among substantiated infants, suggestion of some
triaging of highest risk infants to formal CPS
services
Does the likelihood of being
re-reported vary by initial cps
response/disposition, after
adjusting for baseline risk
differences?
Question 3
unadjusted and adjusted Cox Regression
models (hazard ratios & 95% confidence intervals)
Any Follow-up
Report
(Unadjusted)
Any Follow-up
Report
(Adjusted)
Follow-up
Substantiation
(Unadjusted)
HR
HR
95% CI
HR
95% CI
Follow-up
Substantiation
(Adjusted)
95% CI
HR
95% CI
Evaluated
Out
1.09**
(1.03, 1.14)
1.04
(0.99, 1.10)
1.19***
(1.07, 1.32)
1.12*
(1.01, 1.24)
Unfounded
Ref
-----
Ref
-----
Ref
-----
Ref
-----
Inconclusive
1.17**
(1.12, 1.22)
1.13***
(1.08, 1.19)
1.47***
(1.34, 1.61)
1.40***
(1.28, 1.54)
Subst., no
services
1.18***
(1.13, 1.24)
1.11***
(1.06, 1.17)
1.82***
(1.66, 2.00)
1.66***
(1.51, 1.83)
Subst.,
services
1.11**
(1.04, 1.19)
1.07*
(1.01, 1.14)
1.01
(0.90, 1.14)
1.00
(0.88, 1.12)
Notes: *<.05, **<.01, ***<.001; adjusted models included sex, birth weight, birth abnormality
race, maternal age, paternity establishment, prenatal care, birth order,
conclusions
 among infants remaining in the home following an initial
report – rates of re-reports are VERY high
 Why wouldn’t they be? Fewer than 10% of these infants were
provided with formal services…not clear if these highly
vulnerable/chaotic families with young infants can be
informally served
 infants initially evaluated out/screened out have a higher
likelihood of being re-reported than infants who
received an investigation in which the CPS worker
deemed the referral to be unfounded
 Are we really able to effectively screen over the phone?
 a story of missed opportunities – only 5% of all infants yet the data indicate we do little by way of formal
interventions…
limitations / next steps
 No counterfactual – it may be that absent whatever
informal/formal services were provided – the rates of
re-reporting would have been even higher (i.e., these
data do not necessarily indicate our services are poor –
although certainly we wish there was evidence they
were better)
 No information concerning informal/community based
services
 More careful modeling of family-level CPS history
 Exploration of first vs. follow -up substantiation timing
and disposition dates – not sure what to make of it
questions?
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