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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.

Objectives: To investigate the number of mental health-related hospitalisations of adolescents (12-17 years) in South Australia by level of contact with the child protection system (0-11 years)., Study Design: Whole-of-population descriptive study; analysis of de-identified linked administrative data from the Better Evidence Better Outcomes Linked Data (BEBOLD) platform., Setting, Participants: Adolescents born in South Australia, 1991-1999; linked SA Department for Child Protection, Admitted Patient Care (SA Health), and South Australian Perinatal Statistics collection (SA Department for Health and Wellbeing) data., Main Outcome Measures: Proportion of adolescents (12-17 years) hospitalised with mental health-related diagnoses; proportion of mental health-related hospitalisations of adolescents, by level of child protection contact (0-11 years) (no contact, notification but not screened in, screened-in notification but not investigated, investigation but not substantiated, substantiation, and out-of-home care)., Results: Of 175 115 adolescents born during 1991-1999, 5646 (3.2%) had been hospitalised with mental health conditions, and 27 203 (15.5%) had histories of contact with child protection services. The proportion of adolescents admitted to hospital with mental health-related diagnoses increased with the level of prior child protection contact, from 3366 of 147 912 adolescents with no contact (2.3%), to 398 of 6645 with notifications (6.0%), to 209 of 1191 who had been placed in out-of-home care (17.5%). Contact with child protection services was recorded for 2280 of 5646 adolescents admitted to hospital with mental health-related diagnoses (40.4%); 4477 of 10 633 mental health-related hospitalisations (44.9%) were of adolescents with histories of child protection services contact, including 1285 hospitalisations (12.1%) of adolescents for whom substantiated maltreatment (but not out-of-home care) was recorded, and 568 hospitalisations (5.3%) of adolescents who had been placed in out-of-home care., Conclusion: About 45% of mental health-related hospitalisations of 12-17-year-old adolescents were of people who had had contact with child protection services by the age of 11 years, although only 15.5% of all adolescents had histories of child protection contact. The trauma associated with a history of child protection can have longer term sequelae, and this should be considered when adolescents are hospitalised with mental health conditions., (© 2024 AMPCo Pty Ltd.)

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: Young people who were in out-of-home care (OHC) face an accelerated transition to independent adulthood. Current evidence on outcomes for Australian care-leavers is scant., Objective: This study aims to develop a better understanding of the outcomes for young people leaving care., Participants and Setting: A birth cohort of children and young people born in Western Australia (WA) from 1993 to 2008. Three groups were identified and compared: young people with care-experience (OHC Cohort), those with child protection involvement but not care experience (CP Contact Cohort), and peers in the general population (No Contact Cohort)., Methods: This is a retrospective, population-based study utilising de-identified, linked administrative records provided by the WA state government agencies. Data from the three cohorts were compared through descriptive statistics, independent samples t-tests, and logistic regression modelling., Results: The birth cohort contained records for 414,266 individuals. The smallest comparison group in this study was the OHC Cohort (n = 6526), followed by the CP Contact Cohort (n = 78,095), and the No Contact Cohort (n = 329,645). Care-experienced young people in WA fared significantly worse than their peers across the domains of health (physical and mental), disability, education, social housing and criminal justice involvement., Conclusions: Those who have had child protection involvement, but have not been placed in care, had better outcomes than those who had been in care. However, their outcomes were still poorer than the population cohort with no child protection contact., Competing Interests: Declaration of competing interest None., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

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: Research shows that families involved with Child Protective Services (CPS) have diverse needs not fully met by service referrals and provision. Furthermore, it is still unknown whether the service provision gaps are linked to child safety and permanency outcomes., Objective: This study aims to address this research gap by evaluating the rereport and foster care entry outcomes of child welfare services based on the needs, referrals, and receipt of services for families involved with CPS., Participant and Setting: The National Survey on Child and Adolescent Well-being II (NSCAW II) was used for this study, excluding children with prior reports and those in foster care to focus on re-report and foster care entry outcomes, reducing the sample from 5872 to 2580 children., Methods: Logistic Regression analyses were performed to investigate the relationship between services needed, referred, and receipts and child welfare outcomes. The analyses were structured into three sets of models to explore different aspects of service engagement and its impact on child welfare outcomes., Results: Our study shows that specific CPS services, particularly caregivers' needs for mental health and substance misuse services, significantly impact the likelihood of re-reporting and foster care placements., Conclusion: Most families contacting the child welfare system receive only case management services if their report moves beyond investigation. Such an approach requires that services are available, acceptable, and of sufficient quality to meet needs. This paper highlights crucial disparities in service needs, referrals, and receipts among families engaged with CPS., Competing Interests: Declaration of competing interest We have no conflicts of interest to disclose and did not receive funding for this research project., (Published by Elsevier Ltd.)

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: About 50 % of children in the care of child protective services present at least one mental disorder, but few studies have looked at whether there are differences in mental disorders or symptoms between children placed in out-of-home care (foster care and residential care) and their community peers., Objective: This study documents the mental disorder diagnoses and symptoms among children in out-of-home care and their associations with children functional impairment. It also compares out-of-home care children with those from the community., Participants and Setting: The sample was composed of children aged 5 to 12 years in foster care (n = 154), in residential care (n = 111), and from the community (n = 92)., Methods: Caregivers reported the children's diagnoses and completed questionnaires on the children's symptoms., Results: 1) Proportionally more children in out-of-home care presented a mental disorder than did children from the community. Proportions were similar for those in foster care and those in residential care; 2) Children in out-of-home care presented more symptoms than those from the community for all the mental disorders considered and the children in residential care presented more symptoms than did those in foster care for about half of the disorders considered; 3) symptoms were strongly associated with functional impairment; and 4) the symptoms of RAD, ADHD, OCD, CD, and ODD proved significant predictors of functional impairment., Conclusions: This study provides a picture of the mental disorders and symptoms among samples of school-age children in the care of child protective services and raises questions about the proportions of some of the diagnosis that children receive., Competing Interests: Declaration of competing interest The authors report there are no competing interests to declare., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Purpose: Traumatic brain injury (TBI) is a leading cause of pediatric death and disability. Abusive head trauma confers greater morbidity and mortality compared with accidental TBI. National trends reveal disproportionate involvement of minority children in the child welfare system. The study investigates socioeconomic disparities in child protective services (CPS) involvement in pediatric TBI., Methods: Retrospective chart review was conducted for TBI patients (n = 596) admitted to an academic pediatric level I trauma center from 2015 to 2022, where institutional policy dictates automatic CPS referral for TBI patients ≤ 2 years. Analysis of variance, chi-squared, and logistic regressions compared racial and ethnic groups and calculated adjusted odds of CPS case acceptance., Results: Rates of non-accidental trauma, CPS involvement, insurance, and marital status differed across racial and ethnic backgrounds (p < 0.05). Of patients ≤ 2 years, Hispanic patients (OR: 0.38, 95%CI [0.16,0.91]) had decreased odds of CPS involvement compared to non-Hispanic White patients when adjusting for confounders including injury severity, injury type, and socioeconomic status., Conclusions: We highlight racial and ethnic differences in incidence of pediatric TBI and CPS involvement, even in the setting of an automatic CPS referral policy for pediatric TBI patients ≤ 2 years., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objectives: Knowledge gaps exist regarding the effects of experiencing child protective services (CPS) out-of-home care (e.g. foster homes) among women with HIV. We examined whether CPS out-of-home care was associated with HIV clinical outcome trajectories among women with HIV in a longitudinal cohort study in Ontario, British Columbia, and Quebec, Canada., Methods: At three timepoints across 5 years (2013-2018), we examined self-reported current antiretroviral therapy (ART) use and viral load (VL) detectability (>50 copies/mL). We used latent class growth analysis (LCGA) to identify trajectories of ART use and VL outcomes across study waves. LCGA identifies subgroups (classes) with similar trajectories within the sample. We assessed whether HIV outcome trajectories could be predicted by CPS history. We then conducted a mediation analysis to test whether a mental health latent construct mediated the association between CPS history and detectable VL., Results: Nearly one-fifth (n = 272; 19%) of participants (n = 1422; mean age 42.8 years) reported CPS out-of-home care. Most participants (89%) were in classes that consistently used ART and had an undetectable VL. Individuals with CPS out-of-home care histories were twice as likely to have a consistently detectable VL (β = 0.72, p = 0.02); there were no differences in ART use trajectories. In mediation analyses, we found an indirect path from CPS history to a consistently detectable VL via baseline mental health status (β = 0.02, 95% confidence interval 0.005-0.04, p = 0.02), with a significant odds ratio (1.12, z = 2.43, p = 0.02)., Conclusion: Among women with HIV in Canada, experiencing childhood CPS out-of-home care was associated with a reduced likelihood of achieving viral suppression, via poorer mental health., (© 2024 The Authors. HIV Medicine published by John Wiley & Sons Ltd on behalf of British HIV Association.)

Background: While child welfare scholarship has paid much attention to workforce well-being such as burnout, secondary traumatic stress (STS), and compassion satisfaction, few studies have investigated how these outcomes influence utilization of casework skills., Objectives: This study aimed to understand the relationship between child welfare workforce well-being and use of casework skills. Specifically, we examined associations between burnout, STS, and compassion satisfaction and casework skills including parent/youth engagement, safety and risk assessment/case planning, and relative/kin connections., Participants and Setting: Participants comprised 786 child welfare direct service workers and supervisors in a Midwestern state., Method: Using a repeated cross-sectional design, data were collected via online surveys. Multivariate regression tested relationships between measures of well-being and casework skills., Results: First, higher compassion satisfaction was positively associated (p = 0.000, f 2  = 0.14) while higher burnout (p = 0.000, f 2  = 0.04) and STS (p = 0.002, f 2  = 0.01) were negatively associated with use of engagement skills. Similarly, higher compassion satisfaction was positively associated (p = 0.000, f 2  = 0.18) and higher burnout (p = 0.000, f 2  = 0.06) and STS (p = 0.001, f 2  = 0.02) were negatively associated with use of assessment/case planning skills. Lastly, compassion satisfaction (p = 0.000, f 2  = 0.06) was positively associated and burnout was negatively associated (p = 0.000, f 2  = 0.02) with relative/kin connections., Conclusion: Child welfare workforce well-being may influence use of casework skills. More research is needed to understand how positive workforce well-being impacts service delivery and, ultimately, child and family outcomes., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to disclose. This study was part of a grant funded by the Children's Bureau, Administration for Children and Families, U.S. Department of Health and Human Services, under grant number 90-CO-1139. The paper's contents are solely the responsibility of the authors and do not necessarily represent the official views of the Children's Bureau., (Copyright © 2024 The Authors. Published by 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.)

Background: In the U.S., the opioid epidemic has revitalized national attention to newborns with prenatal substance exposure (PSE). These newborns and their caregivers have specific health and treatment needs and frequently interact with multiple systems, including child protection systems (CPS)., Methods: This study calculated rates of newborns (less than 15 days old) reported to CPS per 1,000 births due to PSE by state and year using data from the National Child Abuse and Neglect Data System (NCANDS). Given the lack of a clear definition of PSE reports in the data, we calculated rates using three different definitions. To examine the relationship between different state laws regarding the mandated reporting of PSE and PSE reports rates, we used panel data analysis., Results: Rates of newborn reports more than doubled between 2011 and 2019. There was extensive state variability of rates including some states that were consistently more than 100 % greater than and others consistently more than 150 % less than the annual national mean. Reporting rates were not associated with state requirements to report PSE, but were positively associated with rates of diagnosed neonatal abstinence syndrome., Conclusion: State-level inconsistencies in identification, reporting, and CPS responses prevent a clear understanding of the scope of the affected population and service needs., Competing Interests: Declaration of competing interest We have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: North American studies find that geographic indicators of disadvantage, such as concentrated poverty, significantly increase the risk of child protection involvement. Despite having one of the most extensive family support systems and progressive income redistribution policies in North America, the Canadian province of Québec still faces geographic variations in socioeconomic conditions that remain a major risk factor for child protection involvement., Objective: This study asks how child protection involvement is distributed across socioeconomically distinct geographic areas of the province. Drawing from prior literature, we hypothesize that the highest level of child protection involvement across childhood (age 0-17) is found in the lowest socioeconomic areas., Participants & Setting: This is a population-based prevalence study using administrative child protection data spanning the years 2000 to 2017 across Québec., Methods: We constructed cumulative risk life tables of first instances of child protection events (report confirmation, compromised security or development, and out-of-home placement). Prevalence rates were mapped onto 10,650 Census dissemination areas divided into three tiers according to a validated socioeconomic status (SES) index., Results: The highest childhood prevalence of confirmed child protection reports, finding of compromised security or development, and out-of-home placement was found in the lowest SES areas. Rates in low SES areas can be over twice the rates in high SES areas., Conclusions: Area-level socioeconomic vulnerability remains a robust predictor of child protection involvement even in a socially progressive context. Our findings underscore that without targeted pediatric and family services, as well as poverty-alleviation programs for high-need families in high-need areas, even well-intentioned systems may fall short of reaching the families most in need., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Rates of child removal by child protective services (CPS) in Manitoba are the highest in Canada with a profoundly disproportionate impact on First Nations families. Despite infants constituting the highest proportion of children affected, no research has examined population-level rates of infant contact with CPS., Objective: We examined the incidence of infant contact with different levels of CPS, including termination of parental rights (TPR), according to First Nations status., Participants: We identified 217,261 infants (47,416 First Nations; 169,845 non-First Nations) born between 1998 and 2014 in Manitoba, Canada and residing in the province until at least age 5., Methods: We used linked administrative data to calculate population-level rates of contact with different levels of CPS by First Nations status, including an open file before age 1, out-of-home placement before age 1, and TPR before age 5., Results: Overall 35.8 % of First Nations infants had an open file, 8.5 % experienced out-of-home placement, and 5.4 % experienced TPR. Among other infants, 8.5 % had an open file, 1.3 % experienced out-of-home placement and 0.7 % experienced TPR. The rate of early-stage contact increased the fastest among First Nations infants, with a rise of 22.4 % in our study period, compared to a rise of 1.7 % among all other infants., Conclusions: CPS contact was exceptionally high among First Nations infants compared to other infants, with early-stage contact accelerating most dramatically over time. Findings support calls to greatly reduce the disruption of system contact in the lives of First Nations families., Competing Interests: Declaration of competing interest Cheryle Dreaver and Mary Burton received honoraria from research staff for participation in the study's advisory board. All other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2024. Published by Elsevier Ltd.)

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.

The study examined the impact of child protective services (CPS) contact on out-of-school suspensions for 49,918 Wisconsin students (followed from ages 5-6 to 14-15; [school years 2010-2019; 74% White; 7% Black; 11% Hispanic; 8% other; 49% female]). A quasi-experimental design comparing recent CPS contact to upcoming (future) CPS contact shows that both recent CPS contact without foster care and future CPS contact predict higher odds of suspension compared with no contact. Higher odds of suspension emerged prior to CPS contact and did not substantially increase during or after CPS contact, suggesting that system-induced stress is not a primary driver of behavioral problems leading to suspension. Foster care reduced the odds of suspension among White children and children in special education., (© 2023 The Authors. Child Development published by Wiley Periodicals LLC on behalf of Society for Research in Child Development.)

Background: Reducing the over-representation of Aboriginal children in the child protection system is a key target for the Australian government., Objective: We aimed to provide more recent evidence on the population-level cumulative incidence of contacts for Aboriginal children with child protective services (CPS) in Western Australia (WA)., Participants and Setting: Linked administrative data was provided for WA CPS between 2000 and 2015 for 33,709 Aboriginal children born in WA between 2000 and 2013., Methods: Descriptive summaries and cumulative incidence estimates were used to examine changes in CPS contact trends over time and within sibling groups., Results: There was an increase in early-childhood contacts for children born more recently, with 7.6 % and 2.3 % of children born in 2000-2001 having a notification and placement in out-of-home care by age one, respectively, compared to 15.1 % and 4.3 % of children born in 2012-2013. Among sibling groups where at least one sibling had a CPS contact, approximately half of children had their first contacts on the same date as another sibling. For children born after one of their siblings had been placed in out-of-home care, 31.9 % had themselves been placed in out-of-home care by age one., Conclusions: Multiple children tend to be placed into out-of-home care when at least one sibling is, which is likely to have a significant impact on families affected. The additional risk of placement also carries over to children born after the first removal in a sibling group, highlighting the need for further support to prevent future removals., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

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.)

Aim: The New Zealand National Child Protection Alert System is administered by multidisciplinary teams in every district health board. The aim of this study was to investigate the factors that influence multidisciplinary child protection teams' (MDTs') decisions about whether to place a child protection alert., Method: Members of the Child Protection Alert System teams were invited to participate in semi-structured interviews. Interview data were coded and grouped into themes using inductive thematic analysis., Results: Six themes were identified: the system works well; a wide range of factors are considered in multidisciplinary team decision-making; there are some difficulties with multidisciplinary team meetings; there are problems with the administration of the system across district health boards; there is concern about the potential for the Child Protection Alert System to stigmatise families or cause unjustified responses; improvements can be made to the system., Conclusion: There is overall support for the National Child Protection Alert System and a consensus that the benefits outweigh any potential risks. There is a need for further improvements to the system, including consistent training, further standardisation and increased accessibility of the information to health professionals, including making information on the system available to primary healthcare., Competing Interests: Miranda Ritchie is employed by contract to the Ministry of Health to audit implementation of the National Child Protection Alert System. Patrick Kelly is a member of the Clinical Reference Group of the Child Protection Special Interest Group of the Paediatric Society of New Zealand, which participates in the governance structure and quality assurance mechanisms of the National Child Protection Alert System. This position is unpaid.

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: Health administrative data offer a vital source of data on maternal prenatal opioid exposure (POE). The impact of different methods to estimate POE, especially combining maternal and newborn records, is not known., Methods: This population-based cross-sectional study included 454 746 hospital births with linked administrative data in Ontario, Canada, in 2014-2017. POE ascertainment included 3 sources: (1) prenatal opioid prescriptions, (2) maternal opioid-related hospital records, and (3) newborn hospital records with neonatal abstinence syndrome (NAS). Positive percent agreement was calculated comparing cases identified by source, and a comprehensive method was developed combining all 3 sources. We replicated common definitions of POE and NAS from existing literature and compared both number of cases ascertained and maternal socio-demographics and medical history using the comprehensive method., Results: Using all 3 data sources, there were 9624 cases with POE (21.2 per 1000 births). Among these, positive percent agreement (95% confidence interval) was 79.0% (78.2-79.8) for prenatal opioid prescriptions, 19.0% (18.2-19.8) for maternal opioid-related hospital records, and 44.7% (43.7-45.7) for newborn NAS. Compared with other definitions, our comprehensive method identified up to 523% additional cases. Contrasting ascertainment with maternal opioid-related hospital records, newborn NAS, and prenatal opioid prescriptions respective rates of maternal low income were 57%, 48%, and 39%; mental health hospitalization history was 33%, 28%, and 17%; and infant discharge to social services was 8%, 13%, and 5%., Conclusions: Combining prenatal opioid prescriptions and maternal and newborn opioid-related hospital codes improves identification of a broader population of mothers and infants with POE., 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: The COVID-19 pandemic and associated response measures have led to unprecedented challenges for service providers working with vulnerable children and families around the world., Objective: The goal of the present study was to better understand the impact of the pandemic and associated response measures on vulnerable children and families and provide data-informed recommendations for public and private service providers working with this population., Participants and Setting: Representatives from 87 non-government organizations (NGOs) providing a variety of direct services (i.e. residential care, family preservation, foster care, etc.) to 454,637 vulnerable children and families in 43 countries completed a brief online survey., Methods: Using a mixed methods design, results examined 1) ways in which children and families have been directly impacted by COVID-19, 2) the impact of the pandemic on services provided by NGOs, 3) government responses and gaps in services for this population during the pandemic, and 4) strategies that have been effective in filling these gaps., Results: Data revealed that the pandemic and restrictive measures were associated with increased risk factors for vulnerable children and families, including not having access to vital services. The NGOs experienced government restrictions, decreased financial support, and inability to adequately provide services. Increased communication and supportive activities had a positive impact on both NGO staff and the families they serve., Conclusions: Based on the findings, ten recommendations were made for service providers working with vulnerable children and families during the COVID-19 pandemic., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Aboriginal and Torres Strait Islander children are disproportionately represented in the statutory child protection system across Australia. A strategy gaining traction to address this disproportionate representation is to recruit more Indigenous practitioners into statutory child protection work. However, the experiences of Indigenous people who undertake child protection work have not been explored thoroughly, particularly in an Australian research context., Objective: While it has been established in contemporary literature that exposure to trauma is an expected occupational hazard of undertaking statutory child protection work, the experience of racism as a potential source of traumatic stress for practitioners has not been explicitly explored., Participants and Setting: This paper reports on results from a recent doctoral study which explored the experiences of Indigenous child protection practitioners based in Queensland, Australia., Method: This research relied on the stories of participants, shared through qualitative in-depth semi-structured interviews, to answer the primary research question: what are the experiences of Indigenous child protection workers? The findings emerged from a research design that was underpinned by critical theory and decolonisation frameworks, which placed the participants as experts of their own experiences., Results: The experiences of the research participants tell the story of a deficiency within the statutory child protection system to meet the wellbeing needs of Indigenous workers and provide a workplace environment that is culturally safe. Participants described recurrent experiences of racist behaviour displayed by non-Indigenous colleagues and a lack of support that acknowledges the distinctive experience of Indigenous people who undertake child protection work., (Copyright © 2019 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.)

Background: The risk of entry to state care during infancy is increasing, both here in England and abroad, with most entering within a week of birth ('newborns'). However, little is known about these infants or of their pathways through care over early childhood., Objective: To characterize infant entries to care in England., Participants and Setting: All children in England who first entered care during infancy, between April 2006 and March 2014 (n = 42,000)., Methods: We compared sociodemographic and care characteristics for infants entering care over the study period by age at first entry (newborn: <1wks, older infant 1-51wks). Among those who entered before April 2010, we further characterized care over follow-up (i.e. 4 years from first entry) and employed latent class analysis to uncover any common pathways through care., Results: Almost 40 % of infants first entered care as a newborn. Most infants first entered care under s 20 arrangements (i.e. out-of-court, 60 % of newborns vs 47 % of older infants). Among infants entering before April 2010, most were adopted over follow-up (60 % vs 37 %), though many were restored to parental care (20 % vs 32 %) or exited care to live with extended family (13 % vs 19 %). One in six infants (17.7 %) had particularly unstable care trajectories over early childhood, typified by three or more placements or failed reunification., Conclusions: Evidence-based strengthening of pre-birth social work support is needed to improve preventive interventions before birth, to more effectively target infant placement into care. Linkages between child protection records and information on parents are needed to inform preventive strategies., (Copyright © 2020 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Child maltreatment is a global public health issue that has been linked with multiple negative health and life outcomes., Objective: This study evaluates the association between children placed in out-of-home care and neighborhood-level factors using eight years of administrative data., Participants and Setting: Between 2011-2018, 33,890 unique instances of child welfare involvement were captured in a department of child and family services database in a southern state in the United States., Methods: Removal addresses were geocoded and linked to the U.S. Census Bureau's American Community Survey to obtain census tract socioeconomic factors. Incidence overall and stratified by individual and neighborhood-level factors was computed. Rate ratios, relative indexes of inequality, and concentration curves quantified disparities in incidence of child welfare involvement by neighborhood-level factors., Results: Incidence of children less than 19 years old placed into out-of-home care was 255 per 100,000 person-years (95 % CI: 252, 258). At the individual level, incidence was highest among children <5 and 15-17 years old, comparable between male and female children, and higher among Black children. At the neighborhood level, incidence was highest in census tracts with lower median household incomes, higher percentages of households below poverty or of female-headed or single-parent households, higher unemployment rates, and fewer residents with some college education or health insurance., Conclusions: Incidence of children placed into out-of-home care is disproportionally higher for those who live in disadvantaged communities. Understanding neighborhood-level risk factors that may be linked to child welfare involvement can help inform policy and target prevention efforts., (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.)

Families in the child welfare (CW) system who cannot be engaged in services are at high risk of negative outcomes. As motivational interviewing (MI) has been shown to improve engagement in similar contexts. This study aimed to systematically review MI with CW families as well as MI training with CW workers and social work students training to become CW workers. The review used Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched multiple databases in June 2018. In September 2019, the initial search was repeated with additional searches to identify gray literature. Eight studies described the acquisition of MI among CW workers or student trainees, and 11 studies evaluated the impact of MI on families in CW. MI's impact on some family outcomes, such as engagement in services, was mixed, though MI paired with other evidence-based treatments showed positive effects. With regard to training CW workers and students in MI, differences in training duration, intensity, and modality make conclusions difficult, though trainees generally described MI favorably and some studies showed training increased worker empathy and self-efficacy. Importantly, few published studies have evaluated whether MI-trained CW workers impact out-of-home-care placement, and no studies have evaluated their impact on maltreatment.

Despite an increasing awareness about the existence and harms of commercial sexual exploitation of children (CSEC), the identification of victims remains a challenge for practitioners, hindering their ability to provide appropriate services. Tools that gauge risk of CSEC support the identification of victims but are underdeveloped because most tools assess risk of CSEC within a general youth population. An understanding of what predicts actual CSEC victimizations among youths at higher risk of CSEC due to experiences of childhood adversities has been left unassessed. Research in this area is limited in part because traditional methods do not allow for an assessment of the unique impact of childhood adversities that tend to co-occur. To address these difficulties, the current study applied predictive regularization methods to identify the most decisive risk items for CSEC. Proximal risk of CSEC was assessed among 317 youths who were referred to a specialized program in the Northeast of the United States due to suspicion of CSEC. With an innovative methodological approach, this study seeks to prompt other scholars to examine risk utilizing novel techniques and provides a foundation for the development of concise tools that assess risk of CSEC among populations of youths at higher levels of risk.