1. RISK OF RE-REFERRAL AMONG INFANTS WHO REMAIN AT HOME FOLLOWING REPORTED MALTREATMENT Emily Putnam-Hornstein, PhD James Simon, MSW Joseph Magruder, PhD Barbara Needell, PhD Society for Social Work Research San Diego, CA

2.  Thank you to our colleagues at the Center for Social Services Research and the California Department of Social Services  Data linkages funded by the H.F. Guggenheim Foundation  Support for this and other research arising from the California Performance Indicators Project generously provided by the California Department of Social Services, the Stuart Foundation, & Casey Family Programs acknowledgements

3. background  In 2011, referrals involving approximately 6.2 million children were made in the US, yet only 3 million were included in an investigation  California is one of the few states that collects data on these “evaluated out” cases  Large body of research indicates a limited ability to accurately and consistently determine if a child has been a victim, or to accurately discern future risk among investigated cases – are we better at screening out cases?  In this study we longitudinally follow a cohort of children remaining in the home following a referral for maltreatment during infancy  We look at the cumulative risk of begin reported again over a five year window  We examine differences by CPS disposition/response

4. 1.Among infants remaining in the home following a report of maltreatment, how many are re-reported within 5 years?  How many infants who were evaluated out are re- reported? 2.Do the risk factors observed at birth vary with the initial CPS response/disposition? 3.Does the likelihood of being re-reported vary by initial CPS response/disposition, after adjusting for baseline risk differences? epidemiological questions addressed

5. data File AFile B 2006 birth records infant cps records 91.9%

6. from birth to re-report…

7. variables first referral disposition First Maltreatment confounders Sex Birth Weight Race/Ethnicity (by birth place) Prenatal Care Maternal Age Birth Order Paternity Birth Payment Method outcome Re-report

8. analysis Evaluated Out Unfounded/ Inconclusive Risk factors that may influence re- reporting risk 5 years Re-Referral (?)  χ 2 tests used to assess covariate distributions across initial CPS response types  Cox Regression Models used to estimate relative differences in likelihood of being re-reported within 5 years Substantiated, FM Services Substantiated, No FM Services

9. Population Characteristics

10.  563,871 children born in California in 2006  5.2% (29,927) were reported for maltreatment before age 1  First reported maltreatment type:  82% = neglect; 9% = emotional abuse (e.g., DV exposure); 8% = at risk, sibling abused; 6% = physical abuse  89% of referrals received from a mandated reporter  29% of reported infants were reported to CPS within three days of birth  Not surprisingly, among these 3-day referrals, 98% involved an allegation of neglect or substantial risk of maltreatment.  Unfortunately, we do not have data as to how many of these allegations involved maternal substance abuse  70% of these infants had older siblings. And among those with older siblings, 49% had an older sibling who had been referred for maltreatment prior to the infant’s birth. infants reported for maltreatment

11. stark and consistent differences between overall birth cohort and infants reported for maltreatment

12. Question 1 Among infants remaining in the home following a report of maltreatment, how many are re-reported within 5 years?

13. initial CPS response 563,871 5.2% (29,927) 24% (5,774) 61% (14,647) 15% (3,450) 41% (2,372) 59% (3,402) 47% of substantiated infants placed in foster care and excluded (5,339) 82% of all referred infants remained at home, 10% received CPS FM services

14. we will see 6 out of every 10 of these infants again… 563,871 5.2% (29,927) 24% (5,774) 61% (14,647) 15% (3,578) 41% (2,372) 59% (3,402) 47% of substantiated infants placed in foster care and excluded (5,339) 82% of all referred infants remained at home, 10% received CPS FM services 60% 61% 69% 64%

15. within a relatively short period of time.

16. Question 2 Do the risk factors observed at birth vary by initial cps response/disposition?

17. high risk (relative to full cohort) …difficult to discern a risk pattern

18. among substantiated infants, suggestion of some triaging of highest risk infants to formal CPS services

19. among substantiated infants, modest differences by race

20. Question 3 Does the likelihood of being re-reported vary by initial cps response/disposition, after adjusting for baseline risk differences?

21. Any Follow-up Report (Unadjusted) Any Follow-up Report (Adjusted) Follow-up Substantiation (Unadjusted) Follow-up Substantiation (Adjusted) HR95% CIHR95% CIHR95% CIHR95% CI Evaluated Out 1.09**(1.03, 1.14)1.04(0.99, 1.10)1.19***(1.07, 1.32)1.12*(1.01, 1.24) UnfoundedRef-----Ref-----Ref-----Ref----- Inconclusive1.17**(1.12, 1.22)1.13***(1.08, 1.19)1.47***(1.34, 1.61)1.40***(1.28, 1.54) Subst., no services 1.18***(1.13, 1.24)1.11***(1.06, 1.17)1.82***(1.66, 2.00)1.66***(1.51, 1.83) Subst., services 1.11**(1.04, 1.19)1.07*(1.01, 1.14)1.01(0.90, 1.14)1.00(0.88, 1.12) unadjusted and adjusted Cox Regression models (hazard ratios & 95% confidence intervals) Notes: *<.05, **<.01, ***<.001; adjusted models included sex, birth weight, birth abnormality race, maternal age, paternity establishment, prenatal care, birth order,

22.  among infants remaining in the home following an initial report – rates of re-reports are VERY high  Why wouldn’t they be? Fewer than 10% of these infants were provided with formal services…not clear if these highly vulnerable/chaotic families with young infants can be informally served  infants initially evaluated out/screened out have a higher likelihood of being re-reported than infants who received an investigation in which the CPS worker deemed the referral to be unfounded  Are we really able to effectively screen over the phone?  a story of missed opportunities – only 5% of all infants - yet the data indicate we do little by way of formal interventions… conclusions

23.  No counterfactual – it may be that absent whatever informal/formal services were provided – the rates of re-reporting would have been even higher (i.e., these data do not necessarily indicate our services are poor – although certainly we wish there was evidence they were better)  No information concerning informal/community based services  More careful modeling of family-level CPS history  Exploration of first vs. follow-up substantiation timing and disposition dates – not sure what to make of it limitations / next steps

24. questions? ehornste@usc.edu