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Study Objective: Emergency department (ED) screening for child physical abuse has been widely implemented, with uncertain effects on child abuse identification. Our goal was to determine the effect of screening on referrals to child protective services (CPS) identifying abuse., Methods: We performed a retrospective cohort study of children younger than 6 years old with an ED encounter at 1 of 2 large health care systems, one of which implemented routine child abuse screening. The main outcome was initial (<2 days) or subsequent (3 to 180 days) referral to CPS identifying child abuse using linked records. We compared outcomes for the 2-year period after screening was implemented to the preperiod and nonscreening EDs using generalized estimating equations to adjust for sex, age, race/ethnicity, payor and prior ED encounters and clustered by center., Results: Of the 331,120 ED encounters, 41,589 (12.6%) occurred at screening EDs during the screening period. Screening was completed in 34,272 (82%) and was positive in 188 (0.45%). Overall, 7,623 encounters (2.3%) had a subsequent referral, of which 589 (0.2%) identified moderate or severe abuse. ED screening did not change initial (adjusted odds ratio [aOR]=1.01, 95% confidence interval [CI] 0.89 to 1.15) or subsequent referral to CPS when compared to the prescreening period (aOR=1.05, 95% CI 0.9 to 1.18) or to the nonscreening EDs (aOR=1.06, 95% CI 0.92 to 1.21)., Conclusion: Routine screening did not affect initial or subsequent referrals to CPS., (Copyright © 2024 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Aims: Most information about the association between childhood maltreatment (CM) and subsequent psychiatric morbidity is based on retrospective self-reports. Findings from longitudinal studies using prospective reports to statutory agencies may be subject to attrition. We therefore compared the prevalence to age 30 of inpatient psychiatric diagnoses in those who experienced agency-reported CM with those of the rest of the cohort using administrative data to minimise loss to follow-up., Methods: We used linked administrative data for two birth cohorts of all individuals born in Queensland, Australia in 1983 and 1984 ( N = 83,050) and followed to age 30 years. This was the entire cohort aside from 312 people who died. Information on CM came from statewide child protection data and psychiatric diagnoses from all public and private hospital admissions in Queensland., Results: On adjusted analyses, the 4,703 participants (5.7%) who had been notified to the statewide child protection authority had three to eight times the odds of being admitted for any of the following psychiatric diagnoses by age 30 years old: schizophrenia-spectrum disorders, bipolar affective disorders, depression, anxiety and post-traumatic stress disorders (PTSD). There were similar findings for all the CM subtypes. Associations were especially strong for PTSD with between a seven - and nine-fold increase in the odds of admission., Conclusions: This is one of the largest studies of the long-term effects of CM, covering an entire jurisdiction. All types of maltreatment are significantly related to a range of psychiatric disorders requiring hospitalisation. Early identification, intervention and providing appropriate support to individuals who have experienced CM may help mitigate the long-term consequences and reduce the risk of subsequent mental health problems.

Background: During the COVID-19 pandemic, the life of families all over the world changed unprecedentedly, risks and vulnerabilities for child maltreatment might have altered. While several studies and reviews look at altered reports to child protective services and other organizations in the child protection system, particularly during the first lockdown in spring 2020, there is a gap in research on trends of reported child maltreatment incidents over time., Objective: To bridge the gap on mid- to long-term developments and trends of changes over time, we aimed at summarizing findings on monthly breakdowns of CM reports over time during the pandemic., Methods: In systematic searches of academic literature databases, we have identified 11 articles that adhere to the inclusion criteria of monthly breakdown data from child protective services during the COVID-19 pandemic with a pre-pandemic comparison period. Three additional grey literature reports haven been identified. Both studies and reports had to be published in either English, Arabic, French, German, Portuguese, or Spanish., Results: Notably, overall, the level of reported incidents has decreased compared to the years before the COVID-19 pandemic. Overall, no clear and reliable picture emerges in developments by different types of reporters. If the number of reports decreases overall, consequently, the overall number or responses to reports does. Some studies, however, report an altered proportion of responses that increased., Conclusion: There is still a lot to be investigated and understood when it comes to the impact of the COVID-19 pandemic on CM. Policy-makers are called to not only invest into more research on the topic, but, first and foremost, to anticipate a potentially surging need in improved responses to a vulnerable group., (Copyright © 2024. Published by Elsevier Ltd.)

Background: Recent studies show the high prevalence of child maltreatment in Germany and that assaults by hospital staff also pose a problem. Since 2020, the Joint Federal Committee has been calling for institutional safeguarding measures (ISM) to protect and support those affected in hospitals. The aim of this study is to analyze the level of knowledge and action competencies regarding child maltreatment among hospital staff and the extent to which ISM are implemented in hospitals., Methods: A survey was administered to 1011 participants before they took part in two online courses on child protection and protection measures in hospitals, with questions regarding self-assessed level of knowledge and competence on child protection and the occurrence of cases of maltreatment and protective measures in their own institution. Data were analyzed using descriptive methods., Results: It becomes apparent that the knowledge and competencies of hospital staff regarding child protection are in the middle range. In hospitals, cases of maltreatment that occur outside the institution are particularly common, but violence by staff or other patients of the same age also plays a significant role. Of the respondents, 93.6% stated that their institution had already developed at least one element of an ISM, but only 1.0% of respondents reported that all the elements surveyed had already been fully developed., Discussion: Hospitals in Germany seem to be largely on the path to better protect children and adolescents from maltreatment and to support those affected. However, there are still deficits in the competencies of employees and the implementation of the ISM elements. More resources need to be made available by hospital operators and the public sector for this purpose., (© 2024. The Author(s).)

Limited data are available on cases presenting for triage by child abuse specialists, particularly data combining patient demographics with presenting concerns and outcomes. This study aims to provide a descriptive analysis of cases presenting to one child abuse medical subspecialty team. Data were collected for all referrals triaged by the Child Protection Program, a child abuse team located within an academic children's medical center. The program triaged a total of 928 cases and completed 345 in-person visits with a medical provider. Nearly, half of all provider visits were for evaluation of children aged 3 years and younger (51%) and for a concern of physical abuse (49%). Of these visits, 26% were determined to be consistent with an accident or medical condition. This descriptive analysis highlights the burden of child abuse cases presenting to one small hospital-based child abuse program, as well as the structural and financial challenges faced by these programs., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Success in young adulthood marked by independence and exploration is not universal. Parentification, when young people acquire adult roles before they are developmentally ready, and family support patterns suggest potential differences based on childhood maltreatment history hence widening inequalities., Objective: This study aimed to describe family-of-origin support patterns among young adults with various levels of exposure to child maltreatment and child protective services (CPS)., Participants & Setting: The study leveraged Year 22 data of the Future of Families and Child Wellbeing dataset; a national, longitudinal, birth-cohort study of U.S. children born in 1998-2000., Methods: We used bivariate statistics and logistic regressions to examine maltreatment exposure, socioeconomic conditions, and family-of-origin relationships., Results: Those with out-of-home care and CPS contact without out-of-home care had lower odds of contact and feeling "extra" close to their caregiver compared to those without reported maltreatment, and those with out-of-home care had lower odds of receiving financial support from family for bills (OR = 0.62, 95 % CI [0.42, 0.92]). Those with out-of-home care had higher odds of providing dependent care to family members (OR = 1.67, 95 % CI [1.02, 2.72]); and those with CPS contact only had higher odds of supporting family members financially (OR = 1.79, 95 % CI [1.29, 2.47])., Conclusion: Findings suggest the importance of public support programs to assist those with maltreatment histories susceptible to the absence of parental support and additional demands of support provision. Understanding young adult-parent relationships within the context of childhood maltreatment is critical to promote well-being., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Little is known about dental healthcare workers reported suspected child maltreatment to and received inquiry from the child welfare services (CWS)., Aim: Assess time lag differences in public dental healthcare workers' information sharing with CWS and identify sociodemographic and attitudinal covariates of information sharing with CWS in 2014 and 2019., Design: In 2014 and 2019, a national census of 1542 and 1791 Norwegian dental health care workers, respectively, were invited to participate in an electronic survey. Of them, 1200 (77.8%) and 1270 (70.9%) replied to the questionnaires. Time trends of reported child maltreatment and received inquiries were estimated and adjusted for sociodemographics, attitudes, trust, and collaborative routines in logistic regression analyses., Results: The likelihood of reported child maltreatment to and received inquiry from CWS was higher in 2019 than in 2014 (OR 1.4 [95% CI 1.2-1.7] and OR 1.1 [95% CI 0.9-1.4]). Significant associations occurred with sociodemographic characteristics, attitudes, and collaborative routines. The likelihood of receiving inquiry about whether being employed long versus short term was higher in 2019 than in 2014., Conclusion: Information sharing between dental healthcare workers and CWS improved across time and might promote beneficial outcomes., (© 2024 The Authors. International Journal of Paediatric Dentistry published by BSPD, IAPD and John Wiley & Sons Ltd.)

Background: Single parent families are at higher risk of re-report to Child Protective Services (CPS) than two-parent families. Yet, how single-family homes differ in risk from two-parent families remains under researched., Objective: To identify heterogenous patterns of child and caregiver factors among CPS-involved families and the subsequent risk for CPS re-report based on child and family characteristics (i.e., sociodemographic information, family structure, and risk indicators)., Participants and Setting: Data were from the 2017 National Child Abuse and Neglect Data System Child File (N = 249,026)., Methods: We conducted latent class analysis (LCA) to identify discrete patterns (i.e., classes) based on child and caregiver risk indicators (e.g., substance use, behavioral health). We then used logistic regression to examine family structure and other family characteristics and CPS indicators predicted CPS re-report for each class., Results: Results yielded five distinct classes: 1) Financial Stressors (25 % of the sample); 2) Caregiver Substance Use (16 %); 3) Complex Household Stressors (3 %); 4) Child Disabilities (4 %); and 5) Minimal Household Stressors (53 %). Family structure was significantly associated with CPS re-reports for Classes 1, 2, and 5. For Class 1, single father families had increased odds of CPS re-report compared to other family structures. For Classes 2 and 5, single father families' odds of CPS re-reports were greater than those of married families, but lower than single mother families., Conclusions: Children growing up in single father families have different likelihoods of repeat CPS involvement compared to those in single mother and married families. Financial stressors and parental substance use within single father families should be addressed., Competing Interests: Declaration of competing interest We declare that our work is original and constitutes details from our own study. This manuscript has not been published or submitted elsewhere. All of the contributions to this work were done by the named authors, and there are no conflicts of interest., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Child maltreatment (CM) is a major public health concern with life-long effects. Its impact on income support has rarely been studied., Objective: To examine the association between CM and receipt of income support payments and the budgetary impact for persons 16 to 33 years., Participants and Setting: A South Australian birth cohort, born 1986 to 2004 (n = 339,411)., Methods: We linked child protection (CP) administrative records with national welfare payment records, ending March 2020. Receipt of income support payments and mean payment amounts were described by CP contact (adjusted for child and family attributes). Budget impact was modelled at the national level., Results: Adjusted odds ratio (AOR) for receipt of any income support payment was 3.01 (2.95-3.07) for individuals with any CP contact versus no CP contact. Among those receiving any payment, adjusted annualised mean benefit payment was $3754 (US$1446) among individuals with no CP contact, $6262 (US$4,307) in persons with any CP contact, and $9,747 in persons who'd been in OOHC. Cumulative payments modelled from age 16 to 33 years totalled $38,570 (US$26,652) for individuals with no CP contact, and $181,743 (US$125,003) for individuals who'd been in OOHC. Modelled for the Australian population to age 33, the extra cost associated with CP contact added 39 % to the government income support budget., Conclusion: CM is strongly associated with receipt of income support payments. Investment in effective preventive and protective strategies for CP involved children could address this core social determinant of health, while providing budget savings., Competing Interests: Declaration of competing interest Both authors declare no competing interests., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Children with experience of maltreatment, abuse or neglect have higher prevalence of poor mental health. In the United Kingdom, child protection services identify children at risk of significant harm on the Child Protection Register (CPR) and intervene to reduce risk. Prevalence and incidence of mental health service use among this population of children are not well understood. We analysed records from one Scottish Local Authority's CPR, linked to electronic health records for all children in the broader health board region aged 0-17 years. We described mental health service use among children with a CPR registration using measures of mental health prescribing and referrals to child and adolescent mental health services (CAMHS). We calculated age- and sex-specific incidence rates for comparison with the general population. Between 2012 and 2022, we found 1498 children with a CPR registration, with 69% successfully linked to their health records. 20% were registered before birth and median age at registration was 3 years. Incidence rates in all measures of mental health service use were higher in children with a CPR record across all ages (at outcome) and genders compared to the general population. The largest absolute difference was for boys aged 5-9 with a CPR record, who had 31.8 additional mental health prescriptions per 1000 person-years compared to the general population (50.4 vs. 18.6 prescriptions per 1000 person-years, IRR: 2.7). Girls aged 0-4 years with a CPR registration had the largest relative difference, with a rate of CAMHS referral 5.4 times higher than the general population (12.3 vs. 2.3 per 1000 person-years). Our reproducible record linkage of the CPR to health records reveals an increased risk of mental health service use during childhood. Our findings have relevance to public mental health surveillance, service prioritisation and wider policy aiming to reduce childhood exposure to risk of harm., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Objectives: The aims of this study were to describe chief complaints provided at emergency department triage for young children ultimately given a diagnosed with injuries concerning for physical abuse and compare chief complaints by hospital child protection team assessment (abuse most likely, accident most likely, undetermined) among children younger than 2 years who were the subject of a report to child protective services., Methods: This is a retrospective review of children evaluated by the child protection team at an urban children's hospital over a 5-year period. Children younger than 2 years who were the subject of a report to child protective services for suspected physical abuse were included. Chief complaints noted in emergency department triage notes were categorized as follows: 1, medical sign or symptom; 2, accidental trauma incident; 3, identified injury; 4, concern for abuse; or 5, multiple unrelated complaints. Child protection team assessments were categorized as follows: 1, abuse most likely; 2, accident most likely; or 3, undetermined. We used descriptive statistics and tests of association (χ 2 , Fisher exact, Kruskal-Wallis)., Results: Median age of the 422 children included was 4.9 months. Child protection team assessment was abuse most likely in 44%, accident most likely in 23%, and undetermined in 34%. Chief complaints in the overall sample were 39% medical, 29% trauma incident, 16% injury, 10% abuse concern, and 6% multiple unrelated. When the abuse most likely and accident most likely groups were compared, medical chief complaints were more common in the former (47% vs 19%, P < 0.001), whereas trauma incident chief complaints were more common in the latter (19% vs 64%, P < 0.001). Most common medical complaints in the abuse most likely group were altered mental status, abnormal limb use, swelling, pain, apnea, and vomiting., Conclusion: Many children found to have injuries concerning for abuse (47%) present without mention of trauma, injury, or abuse concern as part of the chief complaint. Our findings suggest important topics to include in training physicians about recognition of abuse., Competing Interests: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

The relationship between childhood maltreatment and subsequent offending/victimization is well established. However, the magnitude of this relationship for different levels of child protection services (CPS) involvement is poorly understood, due to measurement issues, lack of longitudinal data, and reliance on reports of substantiated maltreatment, which can underestimate the impact of maltreatment. This study examined associations between CPS involvement during childhood (ages 0 to <11 years) and police services contact (as a victim and/or a person of interest) for criminal incidents in early adolescence (11 to ~14 years), differentiated according to levels of CPS involvement (i.e., no risk of significant harm [non-ROSH], unsubstantiated ROSH, substantiated ROSH, and out-of-home care; each examined relative to no CPS contact). Data for 71,465 children were drawn from the New South Wales Child Development Study, an intergenerational, longitudinal investigation that uses administrative records from CPS and police alongside other health, justice, and education data. Multinomial regression analyses were conducted to determine associations between increasing levels of CPS involvement and police contact as a victim only, a person of interest only, and as both victim and person of interest while accounting for covariates (i.e., child's sex, Aboriginal, and/or Torres Strait Islander background, socioeconomic status, maternal age at child's birth, and parental offending history). Children exposed to any of the four levels of CPS involvement had higher odds of police contact, relative to children with no CPS involvement. Odds ratios were higher for contact with police as both a victim and a person of interest, compared to police contact as a victim or a person of interest only. These findings highlight that children with even unsubstantiated CPS reports (i.e., non-ROSH and unsubstantiated ROSH reports) are at heightened risk of police contact compared to children who are unknown to CPS, underlining the need to support all families in contact with CPS., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interests with respect to the authorship and/or publication of this article.

Background: This study investigated the correlation between the prevalence of dental caries and the presence and type of abuse., Methods: Participants were 534 children admitted for care at two child guidance centers (CGCs) in Niigata, Japan. Data pertaining to abuse, including the reason for temporary protective care and the type of abuse, and the oral examination results of the children, were collected. These results were then compared with those of a national survey and analyzed in relation to the presence and type of abuse., Results: The odds ratio for decayed teeth was 4.1, indicating a higher risk in children admitted to the CGCs. However, no significant association was found between the presence of decayed, filled, or caries-experienced teeth and the presence of abuse. A significant positive association was observed between dental caries and one type of abuse, indicating a greater prevalence of dental caries in cases of neglect. The findings of this study suggest that the type of abuse, rather than its presence, is associated with dental caries., Conclusions: Our findings suggest that proactive support should be provided to children in problematic nurturing environments, regardless of whether they have been subjected to abuse., (© 2024. The Author(s).)

Objectives: The objective of this study was to assess demographic, clinical, and psychosocial factors associated with pediatric substance exposures, describe the medical evaluation, and identify factors associated with social work (SW) and hospital-based child protection team (CPT) safety assessments and reports to child protective services (CPS)., Methods: We retrospectively reviewed charts of electronic medical records for children ages 0 to 72 months presenting for accidental ingestion evaluated May 1, 2015 to May 1, 2021 at a level 1 pediatric trauma center. Cases of environmental exposures, iatrogenic medication errors, dosing errors, and allergies/adverse reactions were excluded. Data were analyzed using descriptive statistics; χ 2 and multivariable logistic regression analysis assessed factors associated with two primary outcomes of interest, SW/CPT assessment and CPS report., Results: Among 773 total cases of substance exposures during the studied time frame, 27% were referred to SW/CPT for further safety assessments and 15.4% were reported to CPS. Being admitted to the hospital, prescription medication or recreational/illegal/illicit substance exposures, and increasing psychosocial risk factors were found to be significantly associated with referrals. Age, race, and insurance status were not found to be associated. Toxicology screening was performed in only 24.7% of cases. Of those eligible for further imaging per hospital protocol, skeletal surveys were obtained in 5.5% of cases and head imaging was obtained in 9% of cases., Conclusions: There is significant variability in pediatric substance exposure assessment practices. Disparities based on demographic characteristics are uncommon. Perceived severity of condition, exposures involving recreational/illegal/illicit substances, and greater prevalence of family psychosocial adversities are associated with higher rates of SW/CPT assessment and CPS reports., Competing Interests: Disclosure: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To examine the characteristics of patients visiting the pediatric emergency department (PED) for unintentional ingestions and associations between patient race and ethnicity in referrals to Child Protective Services (CPS) for supervisory neglect., Methods: We conducted a cross-sectional analysis of children <12 years old who presented to the PED between October 2015 and December 2020 for an unintentional ingestion. Patients were identified by searching the electronic health record for diagnosis codes corresponding to unintentional ingestions. Patient demographics, ingestion type, disposition, and referrals to CPS were abstracted by manual chart review. Logistic regression models were used to evaluate associations between patient demographics and visit characteristics with referral to CPS., Results: We identified 129 PED encounters for unintentional ingestions that were included for analysis. Overall, 22 patients (17.1%) were referred to CPS for neglect. In the univariate analysis, both ingestion of an illicit drug and arrival to the PED by ambulance were associated with a higher odds of referral to CPS. In the multivariable model adjusted for parent language, ingestion type, and mode of arrival to the PED, Hispanic patients had higher odds of referral to CPS than White patients (adjusted odds ratio (aOR) = 17.2, 95% confidence intervals [1.8-162.3], P = .03). There was not a statistically significant association between Black race and referral to CPS., Conclusions: Referrals to CPS from the PED after unintentional ingestions are common and disproportionally involve Hispanic patients. More research is needed to promote equitable child maltreatment reporting for children presenting to the PED following unintentional ingestions., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Academic Pediatric Association. Published by Elsevier Inc. All rights reserved.)

Importance: Child maltreatment, which includes child abuse and neglect, can have profound effects on health, development, survival, and well-being throughout childhood and adulthood. The prevalence of child maltreatment in the US is uncertain and likely underestimated. In 2021, an estimated 600 000 children were identified by Child Protective Services as experiencing abuse or neglect and an estimated 1820 children died of abuse and neglect., Objective: The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate benefits and harms of primary care-feasible or referable behavioral counseling interventions to prevent child maltreatment in children and adolescents younger than 18 years without signs or symptoms of maltreatment., Population: Children and adolescents younger than 18 years who do not have signs or symptoms of or known exposure to maltreatment., Evidence Assessment: The USPSTF concludes that the evidence is insufficient to determine the balance of benefits and harms of primary care interventions to prevent child maltreatment in children and adolescents younger than 18 years without signs or symptoms of or known exposure to maltreatment., Recommendation: The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment. (I statement).

Importance: Child maltreatment is associated with serious negative physical, psychological, and behavioral consequences., Objective: To review the evidence on primary care-feasible or referable interventions to prevent child maltreatment to inform the US Preventive Services Task Force., Data Sources: PubMed, Cochrane Library, and trial registries through February 2, 2023; references, experts, and surveillance through December 6, 2023., Study Selection: English-language, randomized clinical trials of youth through age 18 years (or their caregivers) with no known exposure or signs or symptoms of current or past maltreatment., Data Extraction and Synthesis: Two reviewers assessed titles/abstracts, full-text articles, and study quality, and extracted data; when at least 3 similar studies were available, meta-analyses were conducted., Main Outcomes and Measures: Directly measured reports of child abuse or neglect (reports to Child Protective Services or removal of the child from the home); proxy measures of abuse or neglect (injury, visits to the emergency department, hospitalization); behavioral, developmental, emotional, mental, or physical health and well-being; mortality; harms., Results: Twenty-five trials (N = 14 355 participants) were included; 23 included home visits. Evidence from 11 studies (5311 participants) indicated no differences in likelihood of reports to Child Protective Services within 1 year of intervention completion (pooled odds ratio, 1.03 [95% CI, 0.84-1.27]). Five studies (3336 participants) found no differences in removal of the child from the home within 1 to 3 years of follow-up (pooled risk ratio, 1.06 [95% CI, 0.37-2.99]). The evidence suggested no benefit for emergency department visits in the short term (<2 years) and hospitalizations. The evidence was inconclusive for all other outcomes because of the limited number of trials on each outcome and imprecise results. Among 2 trials reporting harms, neither reported statistically significant differences. Contextual evidence indicated (1) widely varying practices when screening, identifying, and reporting child maltreatment to Child Protective Services, including variations by race or ethnicity; (2) widely varying accuracy of screening instruments; and (3) evidence that child maltreatment interventions may be associated with improvements in some social determinants of health., Conclusion and Relevance: The evidence base on interventions feasible in or referable from primary care settings to prevent child maltreatment suggested no benefit or insufficient evidence for direct or proxy measures of child maltreatment. Little information was available about possible harms. Contextual evidence pointed to the potential for bias or inaccuracy in screening, identification, and reporting of child maltreatment but also highlighted the importance of addressing social determinants when intervening to prevent child maltreatment.

Introduction: Managing child abuse and neglect in pediatric emergency departments (PEDs) is difficult because of the complexity of screening and the prolonged care process. This study's main objective was to measure the child protection activity in a PED., Methods: A retrospective, single-center study was conducted in the PED of the Lille University Hospital from 16 September∫2017 to 11 February 2019. All patients who required a social evaluation by the PED staff were included. Children admitted at first to the PED but for whom social management was exclusively performed by other units were not included. The whole population was analyzed first and then by type of abuse. The primary endpoint was the rate of patients who needed social management in the PED. The length of stay in the PED, the number of reports for investigation by child protective services, and reports to a judge were secondary assessment criteria., Results: The study involved 245 patients (median age, 5 years; interquartile range [IQR], 2-13; boys, 49%), accounting for 0.6% of the PED visits. The main reasons for visiting the PED were somatic complaints (31%), sexual assault (23%), and behavioral disorders (20%). The median length of care in the PED was 5 h (IQR, 3-13). Thirty-three percent of the patients were monitored in the short-stay unit of the PED; 78% returned home. The main social measures taken were reports to child protective services (34%) and reports to a judge (24%); 51% of the patients required further actions by the PED physician after discharge., Conclusion: Management of child abuse in the PED is important and time-consuming. A hospital team specialized in child protection is essential for the initial care and monitoring of child victims., (Copyright © 2021 French Society of Pediatrics. Published by Elsevier Masson SAS. All rights reserved.)

This article provides county-level estimates of the cumulative prevalence of four levels of Child Protective Services (CPS) contact using administrative data from the 20 most populous counties in the United States. Rates of CPS investigation are extremely high in almost every county. Racial and ethnic inequality in case outcomes is large in some counties. The total median investigation rate was 41.3%; the risk for Black, Hispanic, and White children exceeded 20% in all counties. Risks of having a CPS investigation were highest for Black children (43.2 to 72.0%). Black children also experienced high rates of later-stage CPS contact, with rates often above 20% for confirmed maltreatment, 10% for foster care placement, and 2% for termination of parental rights (TPR). The only other children who experienced such extreme rates of later-stage CPS interventions were American Indian/Alaska Native children in Middlesex, MA; Hispanic children in Bexar, TX; and all children except Asian/Pacific Islander children in Maricopa, AZ. The latter has uniquely high rates of late-stage CPS interventions. In some jurisdictions, such as New York, NY, (0.2%) and Cook, IL (0.2%), very few children experienced TPR. These results show that early CPS interventions are ubiquitous in large counties but with marked variation in how CPS systems respond to these investigations., Competing Interests: The authors declare no competing interest., (Copyright © 2021 the Author(s). Published by PNAS.)

Background: COVID-19 has become a worldwide pandemic impacting child protection services (CPSs) in many countries. With quarantine and social distancing restrictions, school closures, and recreational venues suspended or providing reduced access, the social safety net for violence prevention has been disrupted significantly. Impacts include the concerns of underreporting and increased risk of child abuse and neglect, as well as challenges in operating CPSs and keeping their workforce safe., Objective: The current discussion paper explored the impact of COVID-19 on child maltreatment reports and CPS responses by comparing countries using available population data., Method: Information was gathered from researchers in eight countries, including contextual information about the country's demographics and economic situation, key elements of the CPS, and the CPS response to COVID-19. Where available, information about other factors affecting children was also collected. These data informed a discussion about between-country similarities and differences., Results: COVID-19 had significant impact on the operation of every CPS, whether in high- income or low-income countries. Most systems encountered some degree of service disruption or change. Risk factors for children appeared to increase while there were often substantial deficits in CPS responses, and in most countries there was at a temporary decrease in CM reports despite the increased risks to children., Conclusions: The initial data presented and discussed among the international teams pointed to the way COVID-19 has hampered CPS responses and the protection of children more generally in most jurisdictions, highlighting that children appear to have been at greater risk for maltreatment during COVID-19., (Copyright © 2021. Published by Elsevier Ltd.)

Objectives. To document the cumulative childhood risk of different levels of involvement with the child protection system (CPS), including terminations of parental rights (TPRs). Methods. We linked vital records for California's 1999 birth cohort (n = 519 248) to CPS records from 1999 to 2017. We used sociodemographic information captured at birth to estimate differences in the cumulative percentage of children investigated, substantiated, placed in foster care, and with a TPR. Results. Overall, 26.3% of children were investigated for maltreatment, 10.5% were substantiated, 4.3% were placed in foster care, and 1.1% experienced a TPR. Roughly 1 in 2 Black and Native American children were investigated during childhood. Children receiving public insurance experienced CPS involvement at more than twice the rate of children with private insurance. Conclusions. Findings provide a lower-bound estimate of CPS involvement and extend previous research by documenting demographic differences, including in TPRs. Public Health Implications. Conservatively, CPS investigates more than a quarter of children born in California for abuse or neglect. These data reinforce policy questions about the current scope and reach of our modern CPS.

Importance: Child maltreatment is a prominent public health concern affecting 20% to 50% of children worldwide. Consequences for mental and physical health have been reported, but population-level estimates of risk of death during childhood that are adjusted for confounders have not been published to date., Objective: To estimate the association of documented child protection concerns regarding maltreatment with risk of death from infancy to 16 years of age., Design, Setting, and Participants: This case-control study was nested in a population birth cohort of 608 547 persons born in South Australia, Australia. Case children were those who died between 1 month and 16 years of age (with the death registered by May 31, 2019). Control children were randomly selected individuals from the same population who were alive at the age at which the case child died, matched 5:1 for age, sex, and Aboriginal status. Data were analyzed from January 2019 to March 2021., Exposure: Children were assigned to 1 of 4 child protection concern categories (child protection system notification[s] only, investigation[s] [not substantiated], substantiated maltreatment, and ever placed in out-of-home care) based on administrative data from the South Australia Department for Child Protection or were classified as unexposed., Main Outcomes and Measures: Mortality rate ratios for death before 16 years of age, by child protection concern category, were estimated using conditional logistic regression, adjusted for birth outcomes, maternal attributes, and area-based socioeconomic status. Patterns of cause of death were compared for children with vs without child protection concerns., Results: Of 606 665 children included in the study, 1635 were case children (57.9% male [when sex was known]; mean [SD] age, 3.59 [4.56] years) and 8175 were control children (57.7% male; mean [SD] age, 3.59 [4.56] years [age censored at the time of death of the matched control child]). Compared with children with no child protection system contact, adjusted mortality rate ratios among children who died before 16 years of age were 2.69 (95% CI, 2.05-3.54) for children with child protection system notification(s) only; 3.16 (95% CI, 2.25-4.43) for children with investigation(s) (not substantiated); 2.93 (95% CI, 1.95-4.40) with substantiated maltreatment; and 3.79 (95% CI, 2.46-5.85) for children ever placed in out-of-home care. External causes represented 136 of 314 deaths (43.3%) among children with a documented child protection concern and 288 of 1306 deaths (22.1%) among other children. Deaths from assault or self-harm were most overrepresented, accounting for 11.1% of deaths in children with child protection concerns but just 0.8% of deaths among other children., Conclusions and Relevance: In this case-control study, children with documented child protection concerns, who were known to child protection agencies and were typically seen by clinicians and other service providers, had a higher risk of death compared with children with no child protection service contact. These findings suggest the need for a more comprehensive service response for children with protection concerns.

Objectives: The objective of this study was to describe the outcomes of implementing a high-risk bruise screening pathway in a pediatric emergency department (ED)., Methods: A retrospective observational study was performed of children aged 0 to <48 months who presented to the ED between December 1, 2016, and April 1, 2019, and had bruising that is high-risk for physical abuse on a nurse screening examination. A high-risk bruise was defined as any bruise if aged <6 months or a bruise to the torso, ears, or neck if aged 6 to <48 months. Records of children with provider-confirmed high-risk bruising were reviewed., Results: Of the 49 726 age-eligible children presenting to the ED, 43 771 (88%) were screened for bruising. Seven hundred eighty-three (1.8%) of those children had positive screen results and 163 (0.4%) had provider-confirmed high-risk bruising. Of the 8635 infants aged <6 months who were screened, 48 (0.6%) had high-risk bruising and 24 of 48 (50%) were classified as cases of likely or definite abuse. Skeletal surveys were performed in 29 of 48 (60%) infants, and 11 of 29 (38%) had occult fracture. Of the 35 136 children aged 6 to <48 months who were screened, 115 of 35 136 (0.3%) had high-risk bruising and 32 of 115 (28%) were classified as cases of likely or definite abuse., Conclusions: High-risk bruising was rarely present. When infants aged <6 months were evaluated per recommendations, occult fracture was identified in one-third of patients. The screening pathway could help other institutions identify occult injuries in pediatric ED patients., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Drs Crumm, Brown, Metz, and Feldman provide legal consultation and testimony in child abuse cases. Drs Feldman and Metz have received financial compensation for consultation or legal testimony in child abuse cases., (Copyright © 2021 by the American Academy of Pediatrics.)

Background: Child maltreatment (CM) is a global public health issue, with reported impacts on health and social outcomes. Evidence on mortality is lacking. In this study, we aimed to estimate the impact of CM on death rates in persons 16 to 33 years., Methods: A retrospective cohort study of all persons born in South Australia 1986 to 2003 using linked administrative data. CM exposure was based on child protection service (CPS) contact: unexposed, no CPS contact before 16 years, and 7 exposed groups. Deaths were observed until May 31, 2019 and plotted from 16 years. Adjusted hazard ratios (aHRs) by CPS category were estimated using Cox proportional hazards models, adjusting for child and maternal characteristics. Incident rate ratios (IRRs) were derived for major causes of death, with and without CPS contact., Results: The cohort included 331 254 persons, 20% with CPS contact. Persons with a child protection matter notification and nonsubstantiated or substantiated investigation had more than twice the death rate compared with persons with no CPS contact: aHR = 2.09 (95% confidence interval [CI] = 1.62-2.70) to aHR = 2.61 (95% CI = 1.99-3.43). Relative to no CPS contact, persons ever placed in out-of-home care had the highest mortality if first placed in care aged ≥3 years (aHR = 4.67 [95% CI = 3.52-6.20]); aHR was 1.75(95% CI = 0.98-3.14) if first placed in care aged <3 years. The largest differential cause-specific mortality (any contact versus no CPS contact) was death from poisonings, alcohol, and/or other substances (IRR = 4.82 [95% CI = 3.31-7.01]) and from suicide (IRR = 2.82 [95% CI = 2.15-3.68])., Conclusions: CM is a major underlying cause of potentially avoidable deaths in early adulthood. Clinical and family-based support for children and families in which CM is occurring must be a priority to protect children from imminent risk of harm and early death as young adults., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Background: The Ontario Incidence Study of Reported Child Abuse and Neglect (OIS) is the only source of province-wide statistics on families investigated by child welfare., Objective: This paper presents key findings from the 2018 cycle of the OIS (OIS-2018) and highlights select policy and practice implications of these findings., Participants and Settings: The OIS-2018 captured information directly from investigating child protection workers about children and families who were the subject of a child protection investigation sampled for inclusion in the study., Methods: The OIS-2018 sample was drawn in three stages: first, a representative sample of child welfare agencies in Ontario was selected, then cases were sampled over a three-month period within selected agencies, and, finally, investigations that met the study criteria were identified from the sampled cases. The data collected for the OIS-2018 were weighted in order to derive provincial, annual incidence estimates., Results: An estimated 158,476 child maltreatment-related investigations were conducted in Ontario in 2018. In the majority of investigations, there was no documented physical or emotional harm to the child. The overall incidence of investigations remains unchanged between 2008 and 2018. The only statistically significant difference during this time period is an increase in risk investigations between 2013 and 2018., Conclusions: Data from the OIS gives Ontario child welfare policymakers and practitioners an empirical basis for making evidence-informed decisions. Findings are compared to the United States and Australia., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: There is little known about how two sources of child maltreatment reports correspond, specifically for emotional, physical, sexual abuse and emotional or physical neglect., Objective: To compare agency and self-reports of child maltreatment and determine whether they are predicted by similar early life course adverse experiences. Participants Data are taken from a long running birth cohort study (Mater-University of Queensland Study of Pregnancy - MUSP). Mothers (N=7223) were recruited in 1981-83 and their children were followed-up 30 years later (2010-14). In 2000 data from the relevant child protection agency were accessed and linked to the survey data. Setting Consecutive women giving birth to a live singleton baby at a major obstetrical service in Brisbane, Australia were recruited and both mother and child were repeatedly follow-up over a 30 year period. Methods Birth cohort study with data linkage of child protection agency records and self-report survey data (using the Childhood Trauma Questionnaire - CTQ) of childhood maltreatment experiences. We compare reports of emotional, physical and sexual abuse and neglect using agency and self-reports (Cramer's V and kappa)., Results: Most children who are notified cases of maltreatment subsequently self-report they experienced little or no maltreatment in childhood. Most children who report experiencing severe maltreatment have not previously been notified to the protection agency. Teenage mothers have children who are notified 2.89 (1.52, 5.52) times, self-report 2.01 (1.31, 3.09) times and both notified and self-report 3.61 (2.26, 6.10) times more than their older comparison mothers., Conclusions: Different methods of assessing maltreatment identify different subsets of those children who have experienced maltreatment., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objectives: To determine any change in referral patterns and outcomes in children (0-18) referred for child protection medical examination (CPME) during the COVID-19 pandemic compared with previous years., Design: Retrospective observational study, analysing routinely collected clinical data from CPME reports in a rapid response to the pandemic lockdown., Setting: Birmingham Community Healthcare NHS Trust, which provides all routine CPME for Birmingham, England, population 1.1 million including 288 000 children., Participants: Children aged under 18 years attending CPME during an 18-week period from late February to late June during the years 2018-2020., Main Outcome Measures: Numbers of referrals, source of disclosure and outcomes from CPME., Results: There were 78 CPME referrals in 2018, 75 in 2019 and 47 in 2020, this was a 39.7% (95% CI 12.4% to 59.0%) reduction in referrals from 2018 to 2020, and a 37.3% (95% CI 8.6% to 57.4%) reduction from 2019 to 2020. There were fewer CPME referrals initiated by school staff in 2020, 12 (26%) compared with 36 (47%) and 38 (52%) in 2018 and 2019, respectively. In all years 75.9% of children were known to social care prior to CPME, and 94% of CPME concluded that there were significant safeguarding concerns., Conclusions: School closure due to COVID-19 may have harmed children as child abuse has remained hidden. There needs to be either mandatory attendance at schools in future or viable alternatives found. There may be a significant increase in safeguarding referrals when schools fully reopen as children disclose the abuse they have experienced at home., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Millions of children cared for by their grandparents or other kin without a biological parent present are not part of the foster care system. Maltreatment may have precipitated out-of-home care arrangements, but most children in informal kinship care are not being tracked or receiving services. Importantly, the extent of previous child welfare involvement and its association with well-being among this population are not well known., Methods: Kinship caregivers known to social service and community agencies were recruited for this study. Caregivers who agreed to participate rated the physical and emotional health of children under their care. Maternal mental health and demographic data were collected, and matched records of children were retrieved from the state child welfare database. The nested structure of children within families was addressed using a generalized estimating equation model., Results: The sample included 365 children from 274 families. Only 25% of the children were in private kinship care with no known Child Protective Services (CPS) involvement. An average of 2.37 open CPS cases were observed for those in voluntary kinship care. One out of 4 children scored below the clinical level of emotional health. The number of CPS cases and kin caregiver's parenting stress were inversely associated with child's physical and emotional health. The presence of maternal mental health problem was significantly associated with poor child emotional well-being., Conclusion: Many children in informal kinship care experienced multiple episodes of maltreatment. This study's results add further evidence of the cumulative negative effects of child maltreatment on child well-being. Children in informal kinship care are in need of services to mitigate their traumatic experiences.

Background: International studies provide evidence of an association between child disabilities, including hearing impairment (HI), and child maltreatment. There are high prevalences of ear disease with associated HI, and child maltreatment among Australian Aboriginal children, but the link between HI and child maltreatment is unknown. This study investigates the association between HI and child maltreatment for Aboriginal children living in the Northern Territory (NT) of Australia., Methods: This was a retrospective cohort study of 3895 Aboriginal school-aged children (born between 1999 and 2008) living in remote NT communities. The study used linked individual-level information from health, education and child protection services. The outcome variables were child maltreatment notifications and substantiations. The key explanatory variable, HI, was based on audiometric assessment. The Kaplan-Meier estimator method was used in univariate analysis; Cox proportional hazards regression was used in multivariable analysis., Results: A majority of the study cohort lived in very remote (94.5%) and most disadvantaged (93.1%) regions. Among all children in the study cohort, 56.1% had a record of either HI or unilateral hearing loss (UHL), and for those with a history of contact with child protection services (n = 2757), 56.7% had a record of HI/UHL (n = 1564). In the 1999-2003 birth cohort, by age 12 years, 53.5% of children with a record of moderate or worse HI had at least one maltreatment notification, compared to 47.3% of children with normal hearing. In the 2004-2008 cohort, the corresponding results were 83.4 and 71.7% respectively. In multivariable analysis, using the full cohort, children with moderate or worse HI had higher risk of any child maltreatment notification (adjusted Hazard Ratios (adjHR): 1.16, 95% CI:1.04-1.30), notification for neglect (adjHR:1.17, 95% CI:1.04-1.31) and substantiation (adjHR:1.20, 95% CI:1.04-1.40), than children with normal hearing. In the 2004-2008 birth cohort, children with moderate or worse HI had higher risk of a substantiated episode of physical abuse (adjHR:1.47, 95% CI:1.07-2.03) than children with normal hearing., Conclusion: Our findings demonstrate the urgent need for HI and child maltreatment prevention strategies through raised community awareness and inter-agency collaboration. Effective information-sharing between service providers is a critical first step to a public health approach in child protection.

Background: Neglect is the most common allegation in Child Protective Services (CPS) investigations. Researchers and media have questioned whether and how CPS-investigated neglect differs from poverty. Prior studies are limited by self-reported or cross-sectional measures, small samples, and short observation periods., Objective: (1) To estimate the "added harm" of CPS-investigated neglect, net of poverty exposure (depth and duration), on high school completion, employment and earnings, incarceration, and teen parenthood; (2) To assess whether abuse is a stronger risk factor for adverse outcomes than neglect., Participants and Setting: 29,154 individuals born in 1993-1996 from Milwaukee County, WI, who either received food assistance or were reported to CPS before age 16., Method: Using logistic regression with a rich set of social and demographic controls, we compared individuals with CPS-investigated neglect, abuse, or both abuse and neglect in early childhood or adolescence to those who experienced poverty but not CPS involvement. We calculated cumulative measures of poverty duration and poverty depth between ages 0 and 16 for the full sample using public benefit records., Results: Outcomes among children with alleged or confirmed neglect were statistically significantly worse in all domains than impoverished children without maltreatment allegations, and similar to children with alleged or confirmed abuse. Effect sizes varied by outcome., Conclusions: Overall, this study suggests that CPS allegations of neglect are distinct from poverty and an important risk factor for adverse outcomes in adulthood., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

The present research examines child maltreatment allegations (CMAs) in San Diego County, California, exploring spatial patterns of Child Protective Services involvement and multiple, multidimensional measures of neighborhood social vulnerability. Results showed significant patterns of spatial clustering (i.e., hot and cold spots) of CMAs across the county (Moran's I = .316, p < .001). A geographically weighted regression (GWR) was implemented to examine the relationship between CMAs and social vulnerability at the census-tract level, thereby overcoming the deficiencies of global models. Nonstationarity was detected across four indices of vulnerability (socioeconomic status, race/ethnicity, household composition, and health vulnerability) as well as proximity to on-premise alcohol outlets, percentage of residents in each census tract affected by food deserts, and population density, in some cases showing countervailing effects depending on spatial location. A hierarchical clustering was performed on the GWR coefficients to identify spatial regimes, or clusters, across the county. The results yielded six spatial regimes of social vulnerability differentially related to CMA rates. The present study demonstrates the novelty of GWR in combination with a hierarchical cluster analysis for exploring how local contextual processes influence child maltreatment reporting rates across the county.

Recent research has used synthetic cohort life tables to show that having a Child Protective Services investigation, experiencing confirmed maltreatment, and being placed in foster care are more common for American children than would be expected based on daily or annual rates for these events. In this article, we extend this literature by using synthetic cohort life tables and data from the Adoption and Foster Care Analysis and Reporting System to generate the first cumulative prevalence estimates of termination of parental rights. The results provide support for four conclusions. First, according to the 2016 estimate, 1 in 100 U.S. children will experience the termination of parental rights by age 18. Second, the risk of experiencing this event is highest in the first few years of life. Third, risks are highest for Native American and African American children. Nearly 3.0% of Native American children and around 1.5% of African American children will ever experience this event. Finally, there is dramatic variation across states in the risk of experiencing this event and in racial/ethnic inequality in this risk. Taken together, these findings suggest that parental rights termination, which involves the permanent loss of access to children for parents, is far more common than often thought.

Child sexual abuse (CSA) is associated with a range of negative consequences for victims that are compounded when it recurs. We used the National Child Abuse and Neglect Data System to study a cohort of 42,036 children in 45 U.S. states with sexual abuse reports first confirmed by child protective services (CPS) during 2010 in order to identify children with increased risk for recurrence. A small proportion (3.6%) had a second confirmed sexual abuse report through 2015. In multivariate models, female gender, family hearing and vision problems, other child maltreatment, and other family violence were associated with increased risk of recurrence, while younger children, Hispanic families, and those with substance abuse tended to have less risk. One fourth of recurrence involved the same offender, usually a parent or caretaker. One fourth of cases were referred for any CPS services, which were more likely to be provided for families with poverty, drug or alcohol problems, or other violence. Only substance abuse services significantly reduced recurrence in multivariable models. Those trying to reduce CSA recurrence should recognize that certain case characteristics are associated with greater recurrence, and most CPS services do not significantly reduce CSA recurrence.

The current study investigates the role of race and county characteristics in substantiation and out-of-home placement decisions in the United States. Using multilevel models, we analyzed data from counties in the United States available through the National Child Abuse and Neglect Data Systems and Adoption and Foster Care Analysis and Reporting System to investigate the interactions between children's race and the context in which they live. Our sample consisted exclusively of children whose cases had been investigated; therefore, we were able to focus on the role played by race and county characteristics in substantiation and out-of-home placement decisions made by Child Protective Services, net of the heightened risk factors (or potential biases) that lead to disparate rates of reporting. Adjusting for state and county of investigation, Black, American Indian/Alaskan Native, and multiracial children were more likely than White (non-Hispanic) children to be substantiated or placed out of home, whereas Asian children were less likely to be substantiated or placed out of home. Notably, differences across groups are far smaller in magnitude when demographic and geographic differences are taken into account. Higher county-level poverty, percentages of Black residents, and juvenile arrest rates were associated with lower odds of substantiation and out-of-home placement among investigated children, whereas an elevated percentage of single-headed households was associated with higher odds of both outcomes. We also found that living in a rural county was associated with greater odds of substantiation but lower odds of out-of-home placement. Important differences by race were found for these associations. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Objectives: To examine associations between being the subject of child protection reports in early childhood and diagnoses of mental disorders during middle childhood, by level of service response., Design, Setting, Participants: Retrospective analysis of linked New South Wales administrative data, 2001-2016, for a population cohort of children (mean age in 2016, 13.2 years; SD, 0.37 years) enrolled in the longitudinal NSW Child Development Study (NSW-CDS), wave 2 linkage., Main Outcome Measures: Associations between being the subject of a child protection report (any, and by level of child protection response) during early childhood (birth to 6 years of age) and diagnoses of mental disorders during middle childhood (6-14 years)., Results: 13 796 of 74 462 children in the NSW-CDS (18.5%) had been the subjects of reports to child protection services during early childhood: 1148 children had been placed in out-of-home care at least once, and 1680 had been the subjects of substantiated risk-of-significant-harm reports but were not placed in care, while 9161 had non-substantiated reports, and 1807 had reports of facts that did not reach the threshold for significant harm. After adjusting for sex, socio-economic disadvantage, perinatal complications, and parental mental illness, early childhood contact with protection services was associated with increased frequency of being diagnosed with a mental disorder during middle childhood (adjusted odds ratio [aOR], 2.72; 95% CI, 2.51-2.95). The frequency was highest for children who had been placed in out-of-home care (aOR, 5.25; 95% CI, 4.46-6.18)., Conclusion: Childhood-onset mental disorders are more frequently diagnosed in children who come to the attention of child protection services during early childhood, particularly in children placed in out-of-home care., (© 2019 AMPCo Pty Ltd.)

Background: Abusive head trauma (AHT) is a severe form of child abuse causing devastating outcomes for children and families, but its economic costs in Canada has yet to be determined. The Period of PURPLE crying program (PURPLE) is an AHT prevention program implemented in British Columbia for which success in reducing AHT events was recently reported., Objective: This study estimated the lifetime costs to society of incidental AHT events and compared the benefits and associated costs of AHT before and after the implementation of the PURPLE program., Participants and Setting: Children aged 0-24 months old with a definite diagnosis of AHT between 2002 and 2014 in British Columbia were included in this study., Methods: An incidence-based cost-of-illness analysis, using the human capital approach was used to quantify the lifetime costs of AHT events according to their severity (least severe, severe and fatal). A cost-effectiveness analysis of the PURPLE program was conducted from both a societal and a health services' perspectives using decision tree models., Results: There were sixty-four AHT events between 2002-2014, resulting in a total cost of $354,359,080 to society. The costs associated with fatal, severe and least severe AHT averaged $7,147,548, $6,057,761 and $1,675,099, respectively. The investment of $5 per newborn through the PURPLE program resulted in a $273.52 and $14.49 per child cost avoidance by society and by the healthcare system., Conclusions: This study provides evidence to policymakers and health practitioners that investing upstream in well-developed AHT prevention programs, such as PURPLE, not only promote child safety and health, but also translates into avoided costs to society., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Child protection services exist to reduce potential harms from child maltreatment. Many jurisdictions produce annual data on child protection system (CPS) involvement, leaving a gap in knowledge of lifetime involvement., Objective: To describe lifetime involvement in CPS, by type of contact., Participants: All 608,547 children born in South Australia (SA), Australia between 1986 and 2017., Methods: A retrospective cohort design using linked administrative data to report cumulative incidence of CPS involvement from birth to age <18 (or June30 2017) by Aboriginal status. CPS involvement was categorised into notifications (3 levels), investigations, substantiations and out-of-home care (OOHC). Cumulative incidence curves were derived for 5 birth cohorts., Results: Across childhood (to age <18 years), substantiated maltreatment was experienced by 3.2-3.6% of non-Aboriginal and 19-25% of Aboriginal children, 7 times reported annual substantiation rates. For most CPS categories CPS involvement increased until 2010, and was occurring earlier in life. By age 3, 0.5% of non-Aboriginal and 4.5% of Aboriginal children born 1986-1991 were the subject of a substantiation compared with 1.9% and 15% of non-Aboriginal and Aboriginal children, respectively, born 2010-2017. Incidence rates beyond age 3 were similar. OOHC contact was similar across cohorts, with ˜1.5% of non-Aboriginal and 12.7% of Aboriginal children ever-placed in care., Conclusions: Data linkage is an essential tool for understanding life course involvement with the CPS and describing trends not observable from annual snapshots. Such information is critical for burden of disease estimates, informing policy and monitoring CPS performance., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Previous research has demonstrated the association between child maltreatment and household composition, with increased maltreatment risk generally present in single mother households. However, existing research does not fully examine the complexity and configuration of single mother households. In particular, less is known about important variants of single parent family structures, such as grandparents residing in the home, and the extent to which household compositions change across time., Objective: The present study examines rates of maltreatment allegations across various household compositions in a sample of single biological mother households., Participants and Setting: Youth participants (N = 417) were part of the larger multi-site Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) study., Methods: Participants completed longitudinal assessments of household composition and maltreatment allegations from ages 4 to 10., Results: The present study illustrates substantial variability in the rate of maltreatment allegations across different types of single mother household compositions. In particular, the presence of non-relatives, especially unrelated males, demonstrated an increased risk for maltreatment allegations in the home. Conversely, single mother homes with two or more adult relatives, especially grandmothers, were at reduced risk for child maltreatment allegations., Conclusions: This study highlights variability in maltreatment allegations among single mother homes, including how maltreatment allegations vary across different household configurations, across child age periods and across different risk levels., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

In this study, we use population-based linked administrative data to document the full child protective service (CPS) histories of arrested youth and young adults. We extracted records for all individuals aged 24 and under who were arrested in California in 2014 and 2015. These records were probabilistically linked to statewide CPS records dating back to 1998. Overall, 43.4% of those arrested had a history of CPS involvement. Among individuals with uncensored CPS records (born in 1998 or later), 60.2% had past CPS involvement. Findings indicate that youth and young adults booked for a felony offense were more likely to have a history of CPS involvement than those booked for misdemeanors. A multinomial model served to confirm bivariate findings. This study provides further evidence that community concerns of childhood maltreatment were common among criminal justice-involved young adults.

Objective: To identify the clustering of adverse childhood experiences (ACEs) that best characterize child welfare-involved children with known complex health concerns., Data Source: Multi-informant data were obtained from Wave I of the National Survey of Child and Adolescent Well-Being (NSCAW II)., Study Design: This study used a cross-sectional design and classification and regression tree (CART) analyses., Data Collection: Data were collected from families with children, aged birth to 17, investigated for child maltreatment and their child protective services caseworkers, including demographic characteristics of the children, their histories of adversity, and a wide range of health concerns., Principal Findings: Results indicate that for children between the ages of six and 17, experiences of physical abuse alone, as well as experiences of physical abuse combined with having a caregiver with mental illness, are most strongly associated with complex health concerns. For children aged 2-5 years, results suggest that caregiver mental illness is a key adverse experience associated with complex health concerns., Conclusions: Identifying specific combinations of ACEs may be a critical next step for child- and youth-serving agencies to allow providers to better calculate risk of health problems among children exposed to adversity., (© Health Research and Educational Trust.)

Background: Neglect is the most common form of child maltreatment with consequences that appear to be as serious as for abuse. Despite this, the problem has received less than its due attention., Objective: To examine the relationship between the timing and chronicity of neglect during childhood and substance use in early adulthood., Participants and Setting: The sample consisted of a subset of 475 participants from the prospective Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) consortium from five geographic areas around the U.S., Method: Neglect was assessed using abstracted information from CPS reports (birth-18) and self-reports of neglect (12-18). Participants completed a follow-up online survey (mean age of 24 years) that probed their use of substances., Results: The prevalence of substance use during the past year was comparable in this high-risk sample to the general population. Latent class analysis supported the presence of three groups related to the presence and timing of neglect: Chronic Neglect, Late Neglect and Limited Neglect. Late Neglect was the pattern most strongly linked to substance use in early adulthood., Conclusions: High-risk youth experiencing neglect beginning in mid- adolescence are especially vulnerable to later substance use. Those working with such youth and their families can play a valuable role helping ensure their basic needs are adequately met, and recognizing early signs of substance use and abuse., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Childhood exposure to domestic violence (CEDV) is widely understood as potentially harmful to children. Accordingly, many child welfare systems in the United States construe CEDV as maltreatment when the exposure results in harm or threatened harm to the child. The purpose of the current study was to investigate substantiated child welfare referrals directly related to CEDV to better understand the prevalence and patterns of CEDV-related maltreatment and how child welfare workers respond under the "harm or threatened harm" standard. Data were drawn from 23,704 substantiated referrals between 2009 and 2013 in a large Midwestern child welfare system. Approximately 20% of substantiated referrals were CEDV related. A plurality of CEDV-related referrals included both a male caregiver and female caregiver who were co-substantiated for maltreatment. The most common maltreatment types substantiated for these referrals were neglect based rather than abuse based, and just under a quarter (23%) of CEDV-related referrals were formally opened for services. Referrals involving co-occurring substance abuse were most likely to be opened for services based on predicted probabilities derived from multilevel modeling. Implications for policy and practice are considered.

Objectives: To determine mental health outcomes for children with a history of child protection system involvement, accounting for pre-existing adversity, and to examine variation in risk across diagnostic groupings and child protection subgroups., Design: A longitudinal, population-based record-linkage study., Participants: All children in Western Australia (WA) with birth records between 1990 and 2009., Outcome Measures: Mental health diagnoses, mental health contacts and any mental health event ascertained from International Classification of Diseases codes within WA's Hospital Morbidity Data Collection and Mental Health Information System from birth until 2013., Results: Compared with children without child protection contact, children with substantiated maltreatment had higher prevalence of mental health events (37.4% vs 5.9%) and diagnoses (20% vs 3.6%). After adjusting for background risks, all maltreatment types were associated with an almost twofold to almost threefold increased hazard for mental health events. Multivariate analysis also showed mental health events were elevated across all child protection groups, ranging from HR: 3.54 (95% CI 3.28 to 3.82) for children who had entered care to HR: 2.31 (95% CI 2.18 to 2.46) for unsubstantiated allegations. Maternal mental health, aboriginality, young maternal age and living in socially disadvantaged neighbourhoods were all associated with an increased likelihood of mental health events. The increase varied across diagnostic categories, with particularly increased risk for personality disorder, and frequent comorbidity of mental health and substance abuse disorders., Conclusions: Young people who have been involved in the child protection system are at increased risk for mental health events and diagnoses. These findings emphasise the importance of services and supports to improve mental health outcomes in this vulnerable population. Adversities in childhood along with genetic or environmental vulnerabilities resulting from maternal mental health issues also contribute to young people's mental health outcomes, suggesting a role for broader social supports and early intervention services in addition to targeted mental health programmes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Childhood maltreatment is associated with early childhood developmental vulnerabilities. However, the extent to which higher levels of child protection responses confer benefit to developmental competencies, and the impact of earlier timing of first reports in relation to early childhood vulnerability remains unclear., Objective: We examined associations between early developmental vulnerabilities and (1) the highest level of child protection response (where OOHC was deemed the highest response among other types of reports/responses), and (2) the developmental timing of the first child protection report., Participants and Setting: Participants included 67,027 children from the New South Wales Child Development Study, of whom 10,944 were reported to child protection services up to age 5 years., Methods: A series of Multinomial Logistic Regressions were conducted to examine focal associations., Results: Children with substantiated maltreatment reports showed the strongest odds of vulnerability on three or more developmental domains (adjusted OR = 4.90; 95% CI = 4.13-5.80); children placed in OOHC showed slightly better physical, cognitive and communication competencies (adjusted ORs from 1.83 to 2.65) than those with substantiated reports that did not result in OOHC placements (adjusted OR from 2.77 to 3.67), when each group was compared to children with no child protection reports. Children with first maltreatment reports occurring in the first 18 months of life showed the strongest likelihood of developmental vulnerabilities on three or more developmental domains (adjusted OR = 3.56; 95% CI = 3.15-4.01) relative to children with no child protection reports., Conclusion: Earlier reports of maltreatment may signal the need for targeted remediation of early developmental competencies to mitigate early developmental difficulties., (Crown Copyright © 2019. Published by Elsevier Ltd. All rights reserved.)

The negative impact of opioids on those who misuse them has been widely documented. Despite significant spillover effects in the form of elevated rates of child maltreatment and child welfare system (CWS) involvement for children affected by parental opioid misuse, the public costs of opioid misuse to the CWS remain largely undocumented. This work seeks to understand the value and limitations of public data in estimating the costs of the opioid epidemic on the CWS. National data from federal sources are combined with best estimates of the association between opioid misuse and child services system utilization. The limitations of this work are explored, and future research priorities are outlined. Ultimately, this work illustrates the need to (1) improve data quality related to parental opioid misuse and CWS linkages; (2) better estimate the number of children and families coming into contact with the CWS as a result of parental opioid misuse; (3) improve predictions of CWS trajectories, including investigation, service provision, and foster care entry among this population; and (4) better estimate the CWS costs associated with patterns of system involvement resulting from parental opioid misuse. This information is crucial to ensuring the production of high-quality system involvement and cost projections related to the opioid crisis.

Background: Public health surveillance is essential to inform programs that aim to eradicate child maltreatment (CM) and to provide services to children and families. However, collection of CM data imposes a burden on child welfare workers (CWWs). This study assesses the feasibility of hiring coders to abstract the required information from administrative records and case narratives., Methods: Based on a convenience sample of child welfare data from Manitoba, Canada, two coders abstracted information on 181 alleged CM cases. The coders completed a short web-based questionnaire for each case to identify which of five types of CM had been investigated, level of substantiation for each type, and risk of future CM. The CWWs responsible for each case completed the same questionnaire. Percentages of the occurrence of CM by the three sources were compared. The validity of the coders' classifications was assessed by calculating sensitivity, specificity, and positive and negative predictive values, against the CWWs' classifications as the "gold standard." Cohen's kappa was also calculated., Results: The coders' classifications of physical abuse, sexual abuse and neglect generally matched those of CWWs; for exposure to intimate partner violence, agreement was weak for one coder. Coding of emotional maltreatment and risk investigations could not be evaluated., Conclusion: Results were promising. Abstraction was not time-consuming. Differences between coders and CWWs can be largely explained by the administrative data system, child welfare practice, and legislation. Further investigation is required to determine if additional training could improve coders' classifications of CM., (Copyright © 2019. Published by Elsevier Ltd.)

Background: Despite reporting legislation, healthcare providers (HCPs) do not always report and collaborate in cases of suspected child abuse. Recognizing this leaves children at risk, the Wisconsin Child Abuse Network (WI CAN) sought to understand barriers to mandated reporting and collaboration with child abuse investigators., Objective: The purpose of the study was to investigate barriers for professionals in providing and obtaining high-quality medical information in child abuse investigations., Participants and Setting: Participants included five discipline-specific focus groups: HCPs, child protective services (CPS), law enforcement, lawyers, and judges. All professionals had been directly involved in Wisconsin child abuse cases., Methods: This qualitative study consisted of discipline-specific focus groups, directed by open-ended interview questions. Data analysis was completed through the narrative inquiry methodology., Results: Barriers to providing and obtaining high-quality medical information in child abuse investigations were both discipline-specific and universal amongst all groups. Discipline-specific barriers included: HCPs' discomfort with uncertainty; CPS' perception of disrespect and mistrust by HCPs; law enforcement's concerns with HCPs' overstepping professional boundaries; lawyers' concern of HCPs' discomfort with court proceedings; and judges' perception of a lack of understanding between all disciplines. Universal barriers included: value of high-quality medical information in child abuse investigations, burden of time and money; unequal resources between counties; a need for protocols, and a need for interdisciplinary collaboration., Conclusion: Findings from this study suggest several ways to address identified barriers. Possible interventions include equalizing resources between urban and rural counties (specifically financial resources and access to child abuse experts); protocolizing reporting and investigations; and, increasing interprofessional education., (Copyright © 2019 Elsevier Ltd. All rights reserved.)