(Published by Casey Family Program in January 2016)
Diana English, Senior Executive Fellow at Casey Family Programs, requested a literature research review regarding Frequently Encountered Families in U.S. child welfare systems. The following report concerns articles identified in a variety of ways regarding children and families with:
(a) Multiple child protective services (CPS) reports,
(b) Multiple substantiated CPS reports, and/or
(c) At least one substantiated re-report following an initial CPS report,
(d) Children and parents included in a typology that distinguishes degrees or patterns of child maltreatment or child neglect.
Studies of recurrent child maltreatment defined solely as a second CPS report on a child or family are not included in this review. This report is not a comprehensive review of every article published on “frequently encountered families” during the past 15-16 years; rather, it summarizes a selected “slice” of research studies that have contributed to a better understanding of children and families who come to the attention of public child welfare systems on multiple occasions (sometimes following an out- of- home placement).
Definitions, Studies and Samples
In 2006, the Institute of Applied Research in St. Louis, Missouri published Families Frequently Encountered by Child Protective Services: A Report on Chronic Child Abuse and Neglect by L. Anthony Loman. This report is a lengthy study of 33,395 families in Missouri with accepted CPS reports between July 1995 and June 2002, and 797 families reported to CPS in a single Minnesota county in 2001-2002. Loman defined “frequently encountered” (FE) as those families who had five or more accepted CPS reports during a five year period. Approximately one-fifth of families reported to CPS in both Missouri and Minnesota were classified as FE in this report.
“Understanding chronically reported families,” by Melissa Jonson- Reid, Clifton Emery, Brett Drake and Mary Jo Stahlschmidt was published in Child Maltreatment, 15 (4) in 2010. This article summarizes a study of CPS reports for 6,412 children under the age 10 at the time they were first reported to CPS in 1993-1994 in a Midwestern city. CPS reports on these children were tracked through 2006 or until age 18. In this study, 3,917 children had 2-3 CPS reports and 1,896 children and youth (29.6%) had 4 or more reports. The study examines factors associated with re-reports in “stages”, i.e., 2nd report to 3rd report, 4th report to 5th report, etc.
“Cross -type recidivism among child maltreatment victims and perpetrators,” by Melissa Jonson- Reid, Brett Drake, Sulki Chung and Ineke Way, was published in Child Abuse and Neglect, 27, in 2003. This study draws on a sample of 61,693 children and 39,143 perpetrators (the authors’ way of describing parents reported for child maltreatment) reported to Missouri’s child welfare system in 1993-1994. Children with substantiated reports or out-of- home placements prior to 1993 were excluded from the sample. CPS re-reports (up to 5 re-reports for each maltreatment type) and substantiation data were tracked for 4.5 years, i.e., 54 months. Allegations in each report were classified as one or more of several types of child maltreatment, including physical abuse, sexual abuse, neglect, emotional abuse, other and mixed maltreatment.
“Child and adult outcomes of chronic child maltreatment,” by Melissa Jonson-Reid, Brett Drake and Patricia Kohl was published in 2012 in Pediatrics. This study utilized a sample of 5,994 low income children ages 1.5-11 years old at baseline who were living in St. Louis, Missouri in 1993-1994. These children were followed through 2009 by use of several administrative data bases. Almost one-fifth (19%) of sampled children had 4 or more CPS reports by age 18. The study examines the relationship between number of CPS reports and rates of substance abuse, mental health treatment, brain/ head injury, sexually transmitted disease, suicide attempts and violent delinquency prior to age 18, and child maltreatment perpetration, mental health treatment and substance abuse in adulthood.
“Substance misuse, mental health problems and recurrent maltreatment,” by A. Laslett, R. Room and P. Dietze was published in Advances in Dual Diagnosis, 7 (1), in 2014. This study tracked a sample of 29,455 children and 38,487 cases reported to the Victoria, Australia Department of Human Services between 2001 and 2005. The authors state that “repeated substantiation of child abuse and neglect as recorded by child protection workers … was used as the outcome variable.” The study found that about one sixth (17%) of families with an open child welfare case at some point during 2001-2005 had co-occurring substance abuse and mental health disorders, according to information in agency case records.
“A developmental approach to the risk of a first recurrence in child protective services,” by S. Helie, C. Laurier, C. Pineau-Villenuve and M. Royer was published in Child Abuse and Neglect, 37, in 2014. This was a Canadian (Quebec) study of 25,897 children who received CPS post- investigation services for the first time between 2005 and 2009. The authors tracked substantiated CPS reports subsequent to the closure of the initial index report for this sample of families for 6 months to 5.5 years depending on the date of the index report. The rate of recurrence as measured by substantiation of a CPS report following case closure for families who received post- investigation services at the time of the initial index referral was 36%. Children, 6-11 years old, at the time of initial case closure had a recurrence rate of 39%, the highest of any age group.
“Characteristics of repeated referrals to child protective services in Washington State,” by Diana English, David Marshall, Sherry Brummel and Matthew Orme was published in Child Maltreatment, 4, (4) in 1999. This study utilized a sample of 12,329 initial CPS referrals received between July 1, 1994 and December 31, 1996 by Washington State’s child welfare system. Re-reports and multiple substantiations were tracked for 18 months. Almost one-fourth of the families (24%) were re-reported to CPS within 12 months and almost 29% were re-reported within 18 months. There were multiple substantiations of reports in 10.6% of cases over 18 months.
“The impact of repeated maltreatment on behavioral trajectories from early childhood to early adolescence,” by F. Li and M. Godinet, was published in Children and Youth Services Review, 36, in 2014. This study drew on a sample of 685 children from five LONGSCAN sites reported to CPS by age 4. Subsequent CPS reports and children’s behavioral functioning was examined for these children at ages 6,8,10 and 12. Repeat child maltreatment was defined as a CPS report after age 4 in one of these two year periods. However, the main focus of the study was a comparison of the behavioral functioning of children who had CPS reports in all five periods vs. children with no CPS reports after their fourth birthday. Sixty two percent of the sample had more than one CPS report by age 4; 38% of children in the sample met the criterion for “repeat maltreatment,” that is at least one CPS report in each two year period.
LONGSCAN Brief: Chronic CPS Referral Histories and the Effects on Children’s Development by Dee Wilson, Casey Family Programs, 2013. This unpublished report summarizes the findings of several LONGSCAN studies, including “Maltreatment’s wake: The relationship of maltreatment dimensions to child outcomes,” by D. English, A.J. Litrownik, J.M. Marshall, D. Runyan, J. Graham and H. Dubowitz, Child Abuse and Neglect, 29, 2005; “Trajectories of maltreatment reports from ages 4-12: Evidence for persistent risk after early exposure,” by L. Proctor,et al Child Maltreatment, 17, 2012; and “Maltreatment chronicity defined with reference to development: Extension of social adaptation outcomes findings to peer relations,” by C. Graham, et al Journal of Family Violence, 25, 2010. LONGSCAN is a twenty year longitudinal study (1993-2013) which has examined the long term effects of child maltreatment on children’s development in five sites. Two LONGSCAN sites (Southwest and Northwest) followed CPS referral histories on 501 children from birth to age 18. Two of the articles listed above, English, et al, and Proctor, et al, were based on LONGSCAN data from either the Northwest site or from the Northwest and Southwest sites combined, and the third article by Graham, et al, drew on a sample of children from all five sites.
"Risk of re-reporting among infants who remain at home following alleged maltreatment," by Emily Putnam-Hornstein, James Simon, Andrea Eastman, Joseph Macgruder, Child Maltreatment, 20 (2), 2015. This study examines CPS reports and re-reports (both screened in and screened out) for children born in California in 2006 for a 5 year period ending at the end of 2012. In 2006, 29,135 (5.2%) of infants born in California had a CPS report before their first birthday. The study tracks re-report rates for categories of infants who remained at home following an initial CPS report and identifies factors associated with re-reports.
"Risk of maltreatment recurrence after exiting substitute care: Impact of placement characteristics," by S. Helie, M. Poirier & D. Turcotte, Children and Youth Services Review, 46, 2014. This Canadian study followed 4,120 children placed in substitute care due either to child abuse or neglect or behavior problems in Quebec in either 2003 or 2007 for several years after their exit from care. The authors tracked substantiated reports of child maltreatment for these children and youth. The authors found that one-third of these children had substantiated CPS reports within 5.3 years following exit from care. The study identifies factors associated with risk of substantiated maltreatment after the closure of placement episodes.
The Science of Neglect: The Persistent Absence of Responsive Care Disrupts the Developing Brain from the Center for the Developing Child at Harvard, 2012.  This report summarizes decades of research regarding the effects of chronic and severe neglect on young children's brain development, cognitive development, executive functioning, emotion control, social relationships, immune systems and capacity to rebound from adversity. The report utilizes a typology of neglect which will be described in the next section.
Referral Patterns, Recurrent Maltreatment and Typologies of Chronic Maltreatment
Approximately 20-30% of families in child welfare samples from Missouri and Minnesota had 4-5 or more CPS reports over a period of 5-10 years (Loman, 2006; Jonson -Reid, 2010); however, studies in other states or countries have found a wide range of re-report and recurrence rates depending on the children sampled and the duration of follow up in the study.
Putnam-Hornstein’s, et al’s, study of infants with an initial CPS report before age 1 in California found that 60% of children who remained in the home following the initial report were re-reported within 5 years; 20% of these children had 5 or more CPS reports within 5 years. Screened out families had about the same re-report rate as screened in families in this study.
Helie’s, et al’s Canadian studies of children with substantiated CPS reports following post-investigation services or out-of-home placement found recurrence rates of 33-36% over 5.3 to 5.5 years.
English, et al’s study of re-reports and multiple substantiations in Washington State (1999) found that 29% of families were re-reported within 18 months; 10.6% of families had a substantiated re-report within 18 months; the authors assert that the recurrence rate was about one-third of the re-report rate in Washington State.
Substantiation increased the risk of re-report by 20-41% (depending on the “stage”) in Jonson- Reid’s, et al’s 2010 study; Loman (2006) found that the risk of a subsequent substantiated re-report greatly increased as the number of unsubstantiated reports increased, from about 1 in 10 for a single unsubstantiated report to almost 3 in 10 for 4 or more unsubstantiated reports.
Prior CPS reports, substantiated reports and children placed out of the parents’ home and then returned to the home were some of the strongest predictors of re-reports (English, et al, 1999; Helie & Laurier, et al, 2014). 39% of reunified children were re-reported within 18 months in Washington State (English, et al, 1999).
One half to two-thirds of families reported to CPS had no subsequent reports over a 4-5 year period in a Missouri sample (Jonson- Reid, et al, 2003).
Neglect was the most recurrent type of maltreatment by far; even when the initial (index) CPS report was for abuse, the second report was likely to allege some form of neglect (Loman, 2006; Jonson-Reid, et al, 2010; Jonson- Reid, et al, 2003; Putnam-Hornstein, 2015; Helie, et al, 2014).
The more CPS reports were made on a family, the more likely that these reports contained allegations of multiple types of maltreatment (Loman, 2006; Jonson- Reid, et al, 2010; Jonson Reid, et al, 2003; Wilson, 2013; English, 2005). There is very little speculation or explanation in these articles regarding why "cross recidivism," i.e., reports of more than one type of maltreatment, was the rule rather than the exception in families with multiple CPS reports. Jonson- Reid, et al, (2003) speculate that ”when children move from one type of maltreatment to the next, that there is some contributory of evolutionary role of the first type of maltreatment.” Unfortunately, the authors do not follow up on this interesting hypothesis.
Many of the allegations in families with multiple CPS reports were of “low level”, minor neglect or abuse; nevertheless, families with these “low level” reports had the highest rates of re-report (English, et al, 1999; English, et al, 2005).
In FE families as described by Loman, the allegations in a specific CPS report did not predict the type of allegations in subsequent reports, i.e., there was quite a bit of "scatter" of allegations in multiple reports on FE families. Loman uses the metaphor of a frame of a film to describe the relationship between the allegations in a single report and the scope of maltreatment that may be occurring in the entire "film" of a family.
As children in families with multiple CPS reports become older, CPS reports are likely to be based on or refer to parent-child conflicts and/or children's behavior problems (Loman, 2006; Helie, Laurier, et al, 2014; Helie, Poirier, et al; 2014, Wilson, 2013). According to Loman, "... as younger children age in FE families, certain problems of child abuse and neglect, more characteristic of younger children, give way to interactions within the family that would be better describes as conflicts, fights, locking children out of homes, rejection, and the like."
In Helie and Laurier's 2014 Canadian study, children ages 6-11 had the highest rate of recurrence defined as a substantiated CPS re-report following post-investigation services and closure of the index report.
Children placed in kinship care had a lower rate of recurrence than children placed in non-kinship care (Helie & Poirer, 2014) even after controlling for a variety of risk factors; length of stay, number of moves or homes while in care did not affect the recurrence rate.
Children reported for physical abuse who were older at the time of the first CPS report were more likely to remain “within type”, i.e., be re-reported for physical abuse, in subsequent reports (Jonson-Reid, et al, 2003).
Children alleged to have been sexually abused in an initial CPS report had much lower re-report rates (about 1/7) than children alleged to have been neglected (Jonson- Reid, et al, 2003).
In Helie & Poirier’s, et al’s Quebec study (2014) of recurrence following exit from out-of- home- care, a substantiated re-report was strongly associated with failed reunification and behavior problems of children.
Jonson Reid, et al (2010) assert that risk factors associated with “early stage” re-reports, for example, first to second report, were often different than factors associated with “late stage” re-reports; for example, younger children with multiple CPS reports were more likely to be re-reported in early stages and less likely to be reported in late stages (Jonson- Reid, et al, 2010).
The Science of Neglect (2012) classifies neglect using four categories: Occasional Inattention, Chronic Under-stimulation, Severe Neglect in a Family Context and Severe Neglect in an Institutional Context. Severe Neglect in a Family Context is defined as “a significant ongoing absence of serve and return interactions (i.e., between parents and child) and is often associated with failure to provide for basic needs.”
English’s, et al’s (2005) LONGSCAN study classified CPS referral histories as:
Situational maltreatment: reports in only one developmental period, i.e., 0-4, 4-6, 6-8, 8-10, 10-12,
Limited maltreatment: maltreatment reports in two developmental periods,
Extended maltreatment: reports in three or four developmental periods, and
Episodic maltreatment: maltreatment occurring in more than one developmental period, with an intervening developmental period free from reported maltreatment.
Li and Godinet’s study (2014) of behavioral trajectories from early childhood to early adolescence defines “repeat maltreatment” as a CPS report in more than one of the two year periods used in LONGSCAN, 0-4, 4-6, 6-8, 8-10, 10-12. However, this study is focused on a comparison of children with CPS reports prior to age 4 and children with CPS reports in all 5 two-year periods.
Characteristics of Children and Families with Multiple Re-reports or Recurrent Maltreatment:
Babies and other young children with medical conditions or disabilities related to potential developmental delay were found to be at increased risk of multiple re-reports (Jonson- Reid, 2010; Loman, 2006).
Children in large families were at increased risk of multiple CPS reports (Loman, 2006).
Behavior/ emotional problems, including both internalizing and externalizing problems, became increasingly common in families with multiple reports or substantiated maltreatment following case closure (Loman, 2006; Helie, et al, 2014; English, et al, 2005; Graham, et al, 2010; Proctor, et al, 2012). Some of these emotional problems were extremely serious, e.g., suicide attempts and mental health crises which led to psychiatric hospitalizations (Loman, 2006; Jonson- Reid, et al, 2012). Children with emergency room visits due to mental health concerns were at high risk of re-reports (Jonson-Reid, 2010).
Children were often the subject of CPS reports in successive developmental phases from birth through early adolescence ( Proctor, et al, 2012; English, et al, 2005; Graham, et al, 2010; Loman, 2006; Helie, et al, 2014; Li & Godinet, 2014); FE families with teens were often reported for parent-child conflict (Loman, 2006).
Poor families (Loman, 2006) or families receiving public assistance (Jonson- Reid, et al, 2010) were at increased risk of multiple reports.
Mothers with low educational achievement were 18-40% more likely to be re-reported to CPS depending on the “stage” of re-report (Jonson- Reid, 2010)
Substance abuse, chronic mental health conditions and domestic violence greatly increased the risk of re-reports (English, et al, 1999; Loman, 2006; Jonson- Reid, et al, 2010; Laslett, et al, 2014).
Parents with co-occurring substance abuse and mental health disorders had the highest rates of recurrent maltreatment defined as a substantiated re-report following an initial report (Laslett, et al, 2014); however, recurrence rates for parents with dual diagnoses were either about the same or only slightly higher than recurrence rates for alcoholic parents or parents with other drug misuse (Laslett, et al, 2014).
FE families often had weak social support, including emotional support and concrete “instrumental” support, from extended families and friends (Loman, 2006).
Effects of Chronic Maltreatment on Children's Development
The Science of Neglect (2012) maintains that the adverse effects of severe neglect is due to the persistent absence of “Serve and Return,” i.e., emotionally responsive interactions between children and caregivers. This report summarizes a large body of research which has found that severe neglect within families over time results in a wide range of adverse effects on children's cognitive, emotional and social development, including reductions in IQ and educational achievement, compromised executive functioning, problems with emotion regulation and reactions to stress and impaired peer relationships. In addition, severe neglect, defined as the persistent absence of “Serve and Return” interactions between children and caregivers, causes "severe physiological disruptions," compromises children's immune systems and undermines their ability to bounce back from adversity.
LONGSCAN studies (English, et, 2005; Proctor, et al, 2012; Graham, et al, 2010) contain a number of findings similar to the main themes of The Science of Neglect. Some of these findings as summarized by Wilson (2013) are:
"Early neglect was found to have an especially powerful effect on children's development."
"Experiences of early nurturance were found to be a source of children's resilience."
Referral histories suggesting chronic neglect throughout early childhood and that included emotional maltreatment were associated with children's behavior problems."
"Chronic child maltreatment affects children's ability to make and keep friends," in part due to maltreated children's aggressive behavior with peers.
"... severe abuse or neglect were associated with school age children's problem's in adaptive functioning."
In another LONGSCAN study, Li and Godinet (2014) found that almost 40% of children with at least one CPS report by age 4 had externalizing behavior problems at baseline; but that internalizing problems, for example depression, increased from 15% at age 4 to 27% of sampled children by age 12.
Li and Godinet ( 2014) found that children reported to CPS in all five developmental periods, i.e., prior to age 4, 4-6, 6-8, 8-10 and 10-12 had slightly higher rates of internalizing and externalizing problems than children with a CPS report prior to age 4 but with no subsequent reports.
LONGSCAN studies have found that "The older age of children at the time of the first CPS report did not protect children from trauma, especially when referral histories included allegations of sexual abuse” (Wilson, 2013).
Jonson-Reid, et al (2012) found a dose related effect between number of CPS reports and six adverse outcomes in childhood or adulthood, including substance use, suicide attempts, mental health treatment, STD treatment in adolescence and adult substance use. Almost 30% of the sample with no CPS reports had at least one of nine adverse outcomes in adolescence or adulthood which included the outcomes already listed as well as child abuse and neglect perpetration, violent delinquency and head/brain jury. Two-thirds of the sample with four or more reports and more than 90% of children with 12 or more reports had at least one of these adverse outcomes.
Prevention and Early Intervention
The Science of Neglect (2012) comments that "there is a compelling need for more effective outreach to families facing enormous adversity" with an emphasis on providing non-stigmatizing community based interventions to vulnerable children and families; these children and families need to be identified as early as possible in children's lives. This report also:
Advocates for "systematic, empirically supported and often long term interventions (6-9 months or longer)... to promote effective healing” and
Cautions that "longer periods of deprivation have been associated with greater deficiencies in attention and cognitive control...” which indicates the urgent need for early intervention.
Li and Godinet (2014), and Jonson- Reid, et al (2012) also call for greater investments in prevention and early intervention.
Loman (2006) recommends "shifting CPS in the direction of prevention;" a perspective shared by Putnam- Hornstein, et al, (2015). Loman recommends that CPS programs view CPS reports, both substantiated and unsubstantiated, as "occasions of assistance." Loman also supports voluntary, non-adversarial, engagement-oriented services. Loman advocates that child welfare agencies assign a single caseworker to FE families rather than having multiple caseworkers work with families over several years.
Several authors emphasize the importance of involving community agencies in service provision to families with multiple reports and substantiated maltreatment prior to and following CPS investigations, post- investigation services and out- of- home placements. (Jonson Reid, et al, 2012; Helie, et al, 2014; Loman, 2006).
English, et al, (1999) recommend that CPS caseworkers give greater emphasis to and consistently assess risk factors that have the strongest association with re-reports and recurrence, including history of CPS reports, out- of- home placements, substance abuse and domestic violence.
Loman (2006) advocates for assessment of "root causes" of multiple CPS reports on families such as poverty, substance abuse and mental health problems of both parents and children and domestic violence.
LONGSCAN studies, for example Li and Godinet (2014), underline the importance of developmental and behavioral assessments of children.
Jonson-Reid, et al, (2003) state that "our findings suggest that ... careful screening for neglect should be given to all cases, and not be limited to cases initially identified as neglect." These authors go on to suggest that because "chronically reported cases are highly likely to involve multiple types of maltreatment ... It appears unlikely that treating an identified maltreatment type when a case is re-reported will forestall recidivism..." Loman strongly agrees with this perspective. In his view, CPS assessments should be focused on patterns evident in multiple reports, rather than narrowing CPS attention to allegations in a specific report.
Several of these articles emphasize the importance of mental health services to both young children and school age children (Li and Godinet, 2014; Jonson- Reid, 2010; Kaplow and Widom, 2012; Helie, et al, 2014). The Science of Neglect emphasizes the importance of evidence based services such as Child-Parent Psychotherapy.
Jonson-Reid, et al, found that family centered services, such as special education services and children's mental health services, were highly protective, in some "stages" of re-reports reducing re-report rates by half. These authors comment that "Any thought that chronic families should not receive services because ""we've tried before and it didn't work" should be abandoned."
Jonson- Reid, et al, (2010) maintain that "understanding how the broader social service and support system in helping these families is the key to understanding recurrence over time."
Helie & Laurier, et al, (2014) found that court structure was protective for young children under 12 during or following post- investigation services; these authors question the preference for voluntary services for younger children.
The Science of Neglect (2012) asserts that "generally speaking... the more profound and persistent the deprivation, the earlier the child needs to be removed in order to facilitate the greatest recovery."
These articles, taken together, provide a consistent description of children and families referred to as "frequently encountered" or "chronically reported" to CPS. The parents are usually poor, with histories of public assistance, often have limited education, chronically relapsing conditions such as substance abuse and mental health problems (frequently co-occurring), domestic violence, heavy child care burdens due to children's medical conditions or disabilities, or large numbers of children in the family and weak social support. Early CPS reports are overwhelmingly for neglect; but as children become older, these families are often reported for physical abuse, sexual abuse or emotional abuse, and for parent-child conflict when children reach early adolescence. Most chronically reported families are eventually reported for multiple types of child maltreatment; however, these articles describe, but do not explain, this "cross- recidivism" pattern in families with multiple CPS reports.
These studies demonstrate a strong connection between chronic maltreatment, especially maltreatment that begins in early childhood, and a wide range of mental health problems in childhood, adolescence and young adulthood. One longitudinal study (Kaplow & Widom, 2013) found that histories of early maltreatment is associated with internalizing mental health conditions such as depression in adulthood, while later onset of maltreatment is associated with anti-social behavior in adolescence and adulthood. These studies indicate the urgent need for early screening for children's developmental and mental health problems, and for investment in evidenced based programs for a wide range of internalizing and externalizing problems. These studies suggest that definitions of child safety in child welfare need to have a developmental perspective.
The connection between early and chronic child maltreatment and children's behavioral problems which is evident in these studies suggests a hypothesis for the prevalence of "cross- recidivism" in families with multiple CPS reports: early neglect, including deprivation of nurturance, leads to high rates of externalizing and internalizing mental health problems which in turn provoke incidents of harsh physical punishment by caregivers. It is also plausible that the number of risk factors present in FE families have additive and interactive effects that have been described in a few studies that have used LONGSCAN data.
Loman's and Jonson- Reid, et al's studies indicate that CPS investigations should focus on patterns of maltreatment in families over time rather than on specific allegations in a single report. These studies also suggest the need for operational typologies in child welfare practice that distinguish situational, sporadic and chronic neglect and chronic maltreatment, i.e., neglect combined with one or more types of abuse.
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