Fallon et al. Child and Adolescent Psychiatry and Mental Health 2013, 7:4 http://www.capmh.com/content/7/1/4 RESEARCH Open Access Opportunities for prevention and intervention with young children: lessons from the Canadian incidence study of reported child abuse and neglect Barbara Fallon1*, Jennifer Ma1, Kate Allan1, Melanie Pillhofer2, Nico Trocmé3 and Andreas Jud3 Abstract Background: The most effective way to provide support to caregivers with infants in order to promote good health, social, emotional and developmental outcomes is the subject of numerous debates in the literature. In Canada, each province adopts a different approach which range from universal to targeted programs. Nonetheless, each year a group of vulnerable infants is identified to the child welfare system with concerns about their wellbeing and safety. This study examines maltreatment-related investigations in Canada involving children under the age of one year to identify which factors determine service provision at the conclusion of the investigation. Methods: A secondary analysis of the Canadian Incidence Study of Reported Child Abuse and Neglect CIS-2008 (PHAC, 2010) dataset was conducted. Multivariate analyses were conducted to understand the profile of investigations involving infants (n=1,203) and which predictors were significant in the decision to transfer a case to ongoing services at the conclusion of the investigation. Logistic Regression and Classification and Regression Trees (CART) were conducted to examine the relationship between the outcome and predictors. Results: The results suggest that there are three main sources that refer infants to the Canadian child welfare system: hospital, police, and non-professionals. Infant maltreatment-related investigations involve young caregivers who struggle with poverty, single-parenthood, drug/solvent and alcohol abuse, mental health issues, lack of social supports, and intimate partner violence. Across the three referral sources, primary caregiver risk factors are the strongest predictor of the decision to transfer a case to ongoing services. Conclusions: Multivariate analyses indicate that the presence of infant concerns does not predict ongoing service provision, except when the infant is identified with positive toxicology at birth. The opportunity for early intervention and the need to tailor interventions for specific caregiver risk factors is discussed. Keywords: Child welfare, Child maltreatment, Infants, Young parents, Referral source, Decision-making, Ongoing services Introduction and Background The most effective way to provide support to caregivers with infants in order to promote good health, social, emotional and developmental outcomes is the subject of numerous debates in the empirical literature. Each province/territory in Canada adopts a different approach which range from universal to targeted programs. * Correspondence: barbara.fallon@utoronto.ca 1 Factor-Inwentash Faculty of Social Work, University of Toronto, 246 Bloor Street W, Toronto, Ontario M5S 1V4, Canada Full list of author information is available at the end of the article Nonetheless, each year a group of vulnerable infants is identified to the Canadian child welfare system with concerns about their well-being and safety. In Canada, both non-professionals and professionals who have concerns about child maltreatment can make a referral to a child welfare agency. The child welfare agency determines whether or not an initial investigation will occur after they receive the referral. If there is an initial investigation, child welfare workers typically determine whether or not maltreatment has occurred, and whether or not the family will receive voluntary or non-voluntary © 2013 Fallon et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Fallon et al. Child and Adolescent Psychiatry and Mental Health 2013, 7:4 http://www.capmh.com/content/7/1/4 child welfare services. Workers may decide to provide ongoing child welfare services at the conclusion of the investigation, meaning that the child and/or family will have an open case file with the child welfare agency, and will maintain ongoing contact with an agency employee until it is determined that supportive services are no longer necessary. The primary objectives of this paper are (1) to examine the decision to provide ongoing child welfare services to infants identified to the child welfare system using a Canadian national dataset, (2) to understand the clinical factors that influence the decision to provide ongoing child welfare services to infants and their caregivers, and (3) to situate the findings in a public health context and understand opportunities for prevention and intervention in families struggling with maltreatment-related issues. Infants are the most vulnerable subset of children involved with the child welfare system given their dependency on a caregiver to take care of their daily needs, and their inability to protect themselves from any form of harm [1,2]. In 2008, children under the age of one were the most likely to be the subject of maltreatmentrelated investigations in Canada with rates of investigations decreasing with age [3]. This pattern was also observed in 1998 and 2003 [3]. Given the high incidence of investigations involving infants, understanding the factors that impact child welfare service delivery to infants and their families is important. The rate of infant maltreatment related investigations in Canada in 2008 was 51.81 per 1,000 children, a nonsignificant increase from the 2003 rate of investigation [3]. A dramatic increase in the rate of infant investigation occurred earlier, between 1998 and 2003 when the rate increased from 17.23 to 49.54 [3]. This increase was consistent with an overall increase in the rate of all child maltreatment investigations in Canada [3]. Various factors may have contributed to this increase in investigations including changes in detection, reporting and investigation practices [3]. Furthermore, legislative changes introduced provincially expanded reporting criteria to include cases where a child had not yet been harmed, but where a risk of future maltreatment was evident [4]. Differential service response models have been recently introduced in several Canadian jurisdictions, which permit workers to conduct family needs assessments as opposed to full investigations in cases where the risk level is found to be low to moderate, including British Columbia [5], Alberta [6], and Ontario [7]. Cases involving infants, however, are generally considered high-risk due to the vulnerability of this population [2]. A study found that caregivers of infants were more likely to have a drug, alcohol, learning or medical problem and to be experiencing domestic violence compared to caregivers of older children involved with the child welfare system [8]. Page 2 of 13 Federally-mandated developmental screening in the United States suggests that children who become involved with the child welfare system in infancy present developmental delays more often than children in the general population [9]). In the 2003 Canadian Incidence Study of Reported Child Abuse and Neglect, workers noted few developmental concerns and positive toxicology at birth or substance abuse birth defects in 93% of investigations involving infants [10]. However, several studies suggest that children involved with the child welfare system may be under-identified for developmental difficulties [9,11,12]. Currently, at the point at which infants come into contact with the child welfare system, there is at minimum risk factors present that could potentially impact the child’s social, emotional, cognitive, intellectual or physical development [3]. In Canada, infants are most often brought to the attention of the child welfare system by health professionals and second most often by police, often while law enforcement is responding to an incident of domestic violence [2]. Preventive programs, which may begin prenatally, may help to support parents and mitigate risk factors for maltreatment prior to the birth of the child (e.g., Nurse Family Partnership Program) [13,14]. It is important to understand the clinical profile of families with risk factors for maltreatment, as this may assist in preventing harm to children, supporting wellbeing, and preventing intrusive child welfare intervention. Early prevention of maltreatment is a public health issue, and programs that are tailored and responsive to the needs of at-risk families are necessary. Preventing maltreatment will in turn help to prevent the consequences of maltreatment, such as childhood injury and developmental difficulties, and it will also lessen the case volume at child protection agencies. Overall, investing in early identification and prevention is beneficial for individuals and families as well as society as a whole, with efforts in the early years producing excellent economic returns and other positive outcomes [15]. Methods A secondary analysis of the Canadian Incidence Study of Reported Child Abuse and Neglect CIS-2008 [16] dataset was conducted. Ethics approval for this study was provided by University of Toronto, McGill University and University of Calgary. Please refer to Chapter 2 in the CIS-2008 Major Findings Report for more detailed information about methods [3]. The CIS-2008 dataset contains information about key clinical factors collected during routine child maltreatment investigations [3]. A multi-stage sampling design was employed to first obtain a representative sample of 112 child welfare agencies selected from 412 child welfare service areas in Canada, and then to sample cases within these agencies [3]. Fallon et al. Child and Adolescent Psychiatry and Mental Health 2013, 7:4 http://www.capmh.com/content/7/1/4 Maltreatment-related cases opened for investigation at the agencies between October 1st and December 31sta were eligible for inclusion [3]. Three months was considered to be the optimal period for participation and compliance with study procedures. The final sample selection stage involved identifying children who had been investigated due to concerns related to possible maltreatment. Maltreatment-related investigations included situations where there were concerns that a child may have already been abused or neglected as well as situations where there was no specific concern about past maltreatment but where the risk of future maltreatment was being assessed. A maltreatment investigation occurred when there was an allegation made about a known or suspected past incident of abuse or neglect. Risk investigations were conducted when there were no allegations or suspicions of past abuse or neglect, but rather the concern was the risk of future maltreatment. Together, maltreatment and risk investigations are referred to as “maltreatment-related investigations” throughout this paper. In most jurisdictions cases were counted as families, so procedures were developed to determine which specific children in each family had been investigated for maltreatment-related concerns. In jurisdictions outside of Québec, children were eligible for inclusion in the final study sample if the worker investigated a maltreatment-related concern (i.e., investigation of possible past incident(s) of maltreatment or assessment of risk of future maltreatment). In Québec, children were eligible for inclusion in the final study sample if the case was “retained”b with maltreatment-related classification codes. Data collection instruments Workers in the sampled child welfare agencies completed the three-page data collection instrument at the conclusion of their initial maltreatment-related investigation. The CIS-2008 data collection instrument was based on the instrument used in previous cycles of the CIS. In preparation for the CIS-2008, the instrument was revised and validated through a case file validation study, validation focus groups, and a reliability study (please see Trocmé et al., 2010 for details). The data collection instrument included clinical information that workers would have collected as part of their initial investigation. Workers were trained on completing the instrument, and were asked to use their clinical judgment to respond to the questions. Data collected included: referral source; type of investigation (maltreatment or risk only); type of abuse and neglect investigated; level of substantiation; functioning concerns for the children and risk factors for their caregivers; income source; housing information; and information about short-term service dispositions. Key clinical variables were included Page 3 of 13 in the analysis in order to reflect an ecological model and to determine the relative contribution of clinical variables to the decision to provide ongoing services (please see Table 1). Completion rates were over 98% on most items; this high item completion rate can be attributed to the design of the instrument and the verification procedures [3]. Study sample The CIS-2008 sampling procedures yielded a final sample of 15,980 children investigated because of maltreatmentrelated concerns (i.e., incident of maltreatment or risk assessment). This analysis focused on investigations involving children under the age of one year (n=1,203), examining whether the case was transferred to ongoing services at the conclusion of the investigation. The sample was further divided into three categories of referral sources: hospital referrals; police referrals; and non-professional referrals. The categories were selected for practical reasons, because the majority of infant investigations were referred by one of these referral sources. Almost one quarter of investigations involving infants were referred by hospital personnel (23%). Approximately 22% of infant investigations were referred by the police. Non-professional referral sources comprised 23% of investigations involving infants. This implies that approximately 68% of all infant investigations were referred to by hospital personnel, police, or non-professionals. The remaining infant investigations were referred by other professional sources (e.g., community or social services, day care centre, etc.; please see Table 1 for complete list). Workers could list multiple referral sources, if there were multiple independent contacts with the child welfare agency. Two sets of weights were applied to the data to derive national annual estimates. First, results were annualized to estimate the volume of cases investigated by each study site over the entire year. To account for the nonproportional sampling design, regional weights were then applied to reflect the size of each site relative to the child population in the region from which the site was sampled. Annualization weights are based on service statistics from the study sites; these service statistics include an unknown number of “duplicate” cases, or in other words, children or families reported and opened for investigation two or more times during the year. Although each investigation represents a new maltreatment-related concern, confusion arises if these investigations are interpreted to represent an “unduplicated” count of children. To avoid this confusion, the CIS-2008 uses the term “child investigations” rather than “investigated children” [3]. The final weighted sample for child maltreatment investigations involving infants was 17,339. Fallon et al. Child and Adolescent Psychiatry and Mental Health 2013, 7:4 http://www.capmh.com/content/7/1/4 Page 4 of 13 Table 1 Variable definitions Outcome Variable Transferred to Ongoing Service Measurement Dichotomous variable Transfer to ongoing service(1) Close case (0) Description Workers were asked to indicate whether the investigation would be opened for ongoing child welfare services at the conclusion of the investigation. Predictor Variables Primary Caregiver Age Categorical variable 18 years and under (1) Workers were asked to indicate the age category of the primary caregiver. 19 to 21 years (2) 22 to 30 years (3) 31 to 40 years (4) 41 years and up (5) Primary Caregiver Risk Factors Nine dichotomous variables Suspected or confirmed concern (1) No or unknown (0) Child Functioning Six dichotomous variables Suspected or confirmed concern (1) No or unknown (0) No Second Caregiver in the Home Dichotomous variable No Second caregiver in the home (1) Second caregiver in the home (0) Primary Income Categorical variable Full time employment (1) Workers could note up to nine risk factors for the primary caregiver. Risk factors were: alcohol abuse, drug/solvent abuse, cognitive impairment, mental health issues, physical health issues, few social supports, victim of domestic violence, perpetrator of domestic violence, and history of foster care/group home. Workers could note up to eighteen functioning concerns for the investigated child, indicating whether the concern had been confirmed, suspected, was not present or it was unknown to the worker. This analysis examined six age-appropriate concerns, including: attachment issues, intellectual/developmental disability, failure to meet developmental milestones, Fetal Alcohol Syndrone/Fetal Alcohol Effects (FAS/FAE), positive toxicology at birth, and physical disability. Workers were asked to describe up to two caregivers in the home. If there was only one caregiver described there was no second caregiver in the home. Workers were asked to indicate the primary source of the primary caregiver’s income. Part time/seasonal employment (2) Other benefits/ unemployment (3) No income (4) Household Hazards Dichotomous variable At least one household hazard (1) No household hazards (0) Household Regularly Runs Out of Money Dichotomous variable Noted (1) Not Noted (0) Workers were asked to note if the following hazards were present in the home at the time of the investigation: accessible weapons, accessible drugs, production/trafficking of drugs, chemicals/solvents used in drug production, other home injury hazards, and other home health hazards. Workers were asked to note if the household regularly runs out of money. Fallon et al. Child and Adolescent Psychiatry and Mental Health 2013, 7:4 http://www.capmh.com/content/7/1/4 Page 5 of 13 Table 1 Variable definitions (Continued) Number of Moves Categorical variable Number of moves reflects the number of moves the household had experienced in the past six months. No moves (0) One move (1) Two or more moves (2) Type of Investigation Maltreatment investigation (1) Risk-only investigation (2) Workers were asked to indicate whether the investigation was for an incident of maltreatment or if it was a risk investigation only. Referral Source Source of Allegation/ Referral Nine dichotomous variables Noted (1) Not Noted (0) Measures Outcome variable: transferred to ongoing services Workers were asked to indicate whether the case would be opened for ongoing child welfare services at the conclusion of the investigation. The decision to transfer a case to ongoing services is a dichotomous variable. Predictor variables Key clinical variables representing an ecological model of child maltreatment were examined to determine the relative contribution of clinical variables. Clinical variables were chosen based on empirical literature of factors related to child maltreatment or risk of child maltreatment. These included child functioning concerns, caregiver risk factors, and household characteristics. The operational definitions and codes used in the analysis are provided in Table 1. Analysis plan All analyses were conducted using SPSS, version 20.0. Descriptive analyses were conducted to explore the characteristics of investigations involving children under the age of one year (infants). Annualization and regionalization weights were applied in the descriptive analysis to derive national annual incidence estimates. National incidence estimates were calculated by dividing the weighted estimates by the child population. Bivariate analyses were also Workers were asked to indicate all sources of referral that were relevant for each investigation. This includes separate and independent contact with the child welfare agency. Workers could note up to nineteen referral sources for the investigation. Referral source variables were collapsed into nine categories: non-professional referral sources (custodial parent, non-custodial parent, relative, neighbour/friend), community or social services (social assistance worker, crisis service/shelter, community/recreation centre, community health nurse, community physician, community mental health professional, community agency), hospital, school, other child welfare service, day care centre, police, anonymous, and other. conducted to examine the relationship between the outcome variable and each relevant predictor variable. The sample weight was applied in the bivariate analyses to adjust for inflation of the chi-square statistic by the size of the estimate by weighting the estimate back down to the original sample size. Multivariate analyses were conducted to understand the profile of investigations involving infants (n=1,203) and which predictors were significant in the decision to transfer a case to ongoing services at the conclusion of the investigation. Logistic Regression and Classification and Regression Trees (CART) were conducted to examine the relationship between the outcome and predictors. Unweighted data were used in all models. The weights were not applied in the multivariate analyses to ensure unbiased results. Logistic Regression was completed to predict the outcome variable of transfers to ongoing services. Logistic regression is appropriate for the type of data that is found in social and behavioural research, where many of the dependent variables of interest are dichotomous and the relationships among the independent and dependent variables are not necessarily linear [17]. Logistic regression uses maximum likelihood estimation after the dependent variable has been transformed into a logit variable. The logit variable is the log of the odds of the dependent variable occurring. Through this means, logistic regression can estimate the probability of an event occurring [17]. Fallon et al. Child and Adolescent Psychiatry and Mental Health 2013, 7:4 http://www.capmh.com/content/7/1/4 Only significant predictor variables at the bivariate level (p
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