1. RISK OF INJURY DEATH FOLLOWING A REPORT OF PHYSICAL ABUSE: EVIDENCE FROM A PROSPECTIVE, POPULATION-BASED STUDY Emily Putnam-Hornstein, PhD January 13, 2012 Society for Social Work Research Washington, DC

2.  Thank you to my colleagues at the Center for Social Services Research and the California Department of Social Services  Funding received from the HF Guggenheim Foundation, the Fahs-Beck Foundation, and the Center for Child and Youth Policy  Additional support for this and other research arising from the California Performance Indicators Project generously provided by the California Department of Social Services, the Stuart Foundation, & Casey Family Programs ACKNOWLEDGEMENTS

3. OVERVIEW A mortality-based standard for evaluating parental behavior may be the closest we can get to “culture- free” definitions of neglect and abuse (S.R. Johannson, 1987)  first prospective birth cohort analysis of injury mortality among children reported to child protective services  captures all children reported for maltreatment (including those screened out over the phone)  examines both unintentional and intentional injury fatalities  controls for sociodemographic and health characteristics present at birth

4. LINKED DATASET birth records LINKED DATA birth no cps no death birth cps no death birth no cps death birth cps death 4.3 million 514,000 25,000 1,900 injury deaths all deaths cps records death records

5. 1.Are children reported for non-fatal maltreatment at greater risk of preventable injury death before age five compared with sociodemographically similar children not reported? 2.Among children reported for non-fatal maltreatment, does subsequent risk of injury death vary by allegation type? QUESTIONS

6. VARIABLES  sex  health risk  public insurance  maternal age  maternal education  established paternity  race / ethnicity  birth order  allegation  type baseline birth variables child welfare variables  icd-10 e-codes  unintentional  intentional death variables

7. METHOD  Extended Cox Regression Models  censored data for more recent birth cohorts  first report to CPS inherently time-varying  results nearly identical to those obtained using Competing Risk Models 1999 2000 2001 2002 2003 2004 2005 2006 5 th birthday

8. INJURY DEATHS

9. QUESTION 1: ARE CHILDREN REPORTED FOR NON- FATAL MALTREATMENT AT GREATER RISK OF PREVENTABLE INJURY DEATH BEFORE AGE OF FIVE COMPARED WITH SOCIODEMOGRAPHICALLY SIMILAR CHILDREN NOT REPORTED?

10. ANSWER? Yes.  after adjusting for other risk factors at birth, a prior report to CPS emerged as the strongest predictor of injury death during a child’s first five years of life  a prior report to CPS was significantly associated with a child’s risk of both unintentional and intentional injury death

11. ADJUSTED RATE OF INJURY DEATH FOR CHILDREN WITH A PRIOR ALLEGATION OF MALTREATMENT, BY CAUSE OF DEATH HR: 2.59 HR: 2.00 HR: 5.86

12. QUESTION 2: AMONG CHILDREN REPORTED FOR NON-FATAL MALTREATMENT, DOES SUBSEQUENT RISK OF INJURY DEATH VARY BY ALLEGATION TYPE?

13. ANSWER?  Yes.  children with a prior allegation of physical abuse were found to have intentional injury death rates that were dramatically higher than not only unreported children, but also children reported for neglect  rates of unintentional injury death were statistically indistinguishable

14. INJURY DEATH RATES BY PRIOR MALTREATMENT ALLEGATION TYPE (UNADJUSTED) all injury deaths (1,917*) inflicted injury deaths (381) unintentional injury deaths (1,438) HR95% CIHR95% CIHR95% CI β 1 (t): physical abuse 2.47***(1.97, 3.09)9.84***(6.73, 14.38)0.65(0.41, 1.01) β 2 (t): sexual abuse 0.60(0.30, 1.22)0.83(0.20, 3.43)0.50(0.20, 1.21) β 3 (t): other abuse 0.35***(0.25, 0.48)0.27**(0.11, 0.64)0.38***(0.27, 0.54) β 4 (t): neglect ref--ref--ref-- * Includes injury deaths of undetermined intent.

15. INJURY DEATH RATES BY PRIOR MALTREATMENT ALLEGATION TYPE (ADJUSTED) all injury Deaths (1,917*) inflicted injury Deaths (381) unintentional injury deaths (1,438) HR95% CIHR95% CIHR95% CI β 1 (t): physical abuse 2.48***(1.94, 3.17)9.23***(6.15, 13.87)0.66(0.41, 1.05) β 2 (t): sexual abuse 0.74(0.36, 1.52)0.97(0.23, 4.12)0.61(0.25, 1.53) β 3 (t): other abuse 0.39***(0.28, 0.54)0.26**(0.11, 0.68)0.42***(0.29, 0.60) β 4 (t): neglect ref--ref--ref-- * Includes injury deaths of undetermined intent.

16. SUMMARY AND IMPLICATIONS  Population-level linked birth-CPS-death data indicate that a report to CPS is not a random event. Reports of maltreatment, including those evaluated out without investigation, reflect more than just poverty and serve as a signal of unmeasured family dysfunction and child risk not otherwise captured in sociodemographic markers  These data indicate that an allegation of physical abuse signals a consistently greater level of physical risk in the form of death than neglect or other forms of maltreatment. From a public health control and prevention stand-point, unique protocols for investigating and intervening in cases in which physical abuse is alleged for a child under the age of five may be justified.

17. QUESTIONS? ehornste@usc.edu