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Mitigating the Effects of Adverse Childhood Experiences in Chronic Multitype Maltreatment

(Originally published November 2022)

By Dee Wilson and Toni Sebastian


Last month’s  commentary discussed the characteristics of chronic multitype child maltreatment that develops from chronic neglect through two main dynamics: (1) the erosion or collapse of social norms around parenting and (2) gradual loss of control over body, mind, emotions, interpersonal relationships and living conditions due to substance abuse, mood disorders  (often co-occurring), and sometimes domestic violence, as well, combined with poverty.


Cathy Widom is one of the few child welfare researchers who has pointed out the devastating effects on life course development of the combination of poverty with psychological afflictions such as Major Depressive Disorder. The effects on parenting are often equally devastating, especially on the capacity to engage children in emotionally responsive, “Serve and Return,” interactions (The Science of Neglect, 2012). For this reason, therapeutic interventions must have both an empowerment focus, and an emphasis on developing parents’ capacity for nurturance, difficult tasks that cannot be achieved through brief evidence-based programs targeted at parenting skills. Much more is required.


We have proposed utilizing 4–5 person co-located case management teams that work with 20-25 families/40 children at any one time. These teams would be similar to ones employed in Oregon’s child welfare system in the early 2000’s  to intervene in chronic neglect and chronic multitype maltreatment. It is next to impossible for a CPS caseworker to bear full responsibility for working with families with such overwhelming needs. It’s often difficult to know where to start in case plans once immediate child safety issues have been addressed, and difficult to sustain the morale of professionals involved with families.  To be effective, caseworkers and other professionals must organize themselves in ways that create immunity to the hopeless/helpless feelings and attitudes of demoralized parents. This is easier said than done.


A practice framework based on children’s needs

We recommend a practice framework that begins with an appreciation of the heavy load of adverse childhood experiences

(ACEs) among children in these troubled families. Consider the following list of adversities from early ACEs research:


  • Recurrent physical abuse that resulted in physical injury

  • Sexual abuse

  • Emotional abuse

  • Parental/ caregiver substance abuse

  • Chronic mental illness

  • Domestic violence

  • Loss of a parent due to illness, death, divorce, foster care, informal kinship care, etc.


Add ACEs included in more recent research:

  • Extensive neglect of basic needs

  • Emotional neglect; lack of nurturance


Children of parents engaged in multitype maltreatment for months or years typically have at least six of these adversities, the heaviest ACEs load of all children served by child welfare systems. A recently released CDC study of 4390 high school students found that, “Youths reporting multiple adverse childhood experiences, or ACEs, were substantially more likely to report poor mental health or a past year suicide attempt than those without these experiences.” Approximately 8% of adolescents reported 4 or more ACEs during the past year. (Kuehn, 2022)    


However, this daunting list of adversities does not fully account for the developmental challenges of children in chronically maltreating families who live in poverty and have chronic illnesses and/or disabilities. Material hardships such as food insecurity, periodic homelessness and lack of medical/dental care are fertile ground for the growth of ACEs. It would be an understatement to say that US child welfare systems have(for the most part) displayed a large blind spot in noticing or responding to the poverty related needs of families. What can trauma informed care mean that ignores children’s experiences of recurrent food insecurity or homelessness, or leaves both parents and children without medical or dental care?


A study of infants published in Pediatrics found that after controlling for covariates such as Medicaid eligibility, maternal age, birth weight and race/ethnicity, infants reported to CPS for maltreatment died from medical causes 1.77-3.27 times more frequently than infants not reported to CPS. According to the authors, “Among infants reported for maltreatment, when in foster care, the rate of death was roughly 50% lower.” And “as more reports were received, the associated risk (of death from medical causes) increased,” a finding that “held regardless of whether we included or excluded deaths during the neonatal period.” The authors assert that “Differences in death rates signal unmet service needs among infants who remain at home.” (Schneiderman, et al, 2021)


Any physical condition of infants and toddlers such as chronic illness or disability that increases the difficulty of basic care increases the risk of child maltreatment death, which arguably is why the ratio of male/female child fatality victims is about 58%/42% in annual NCANDS data. Boys are likely to have disabilities in early childhood than girls, i.e., males are by far the most physically vulnerable gender in the pre-school years. A longitudinal study of a large birth cohort in Washington State found that most child deaths in early childhood were due to birth defects, complications of prematurity and pregnancy, infections, SIDS and unintentional injuries. The authors comment that “higher mortality rates among children experiencing CPS involvement may, in part, have been due to a higher frequency of physical ailments.” (Cawthon & Hopps, 1997).


Safety assessments in chronically maltreating families should focus on the physical health needs of children and on the extent to which parents with impairments caused by substance abuse and or mental illness can reliably meet these needs. When chronically maltreated children remain in the home (and they often will for a variety of reasons) case plans should do everything possible to assist parents in meeting their child’s special needs with in-home supports and respite care. A critically important aspect of CPS interventions with newborns is the assessment of post-partum depression with co-occurring substance misuse. Sleep deprived mothers with post-partum depression who are self-medicating with drugs or alcohol pose a significant risk to newborns from accidental roll-over deaths. 


Reducing all-cause mortality should be an explicit goal of program developers and of case plans in chronic neglect and chronic multitype maltreatment. Safety frameworks that conflate safety with concrete observable danger, or with risk of imminent harm, will inevitably leave many chronically maltreated children in harm’s way, without lifelines. This approach to child safety can lead caseworkers to ignore or minimize persistent safety concerns in families where parents are unable, without support, to consistently meet their child’s special needs.


A practice framework focused on mitigating the damaging effects of multiple childhood adversities must be as concerned with cumulative developmental and emotional harm to children as with immediate safety threats. Multidisciplinary case management teams should include a public health nurse and/or child mental health specialist and utilize developmental screening, assessment, and services (when needed), therapeutic childcare, periodic medical/dental examinations, and public health nurse home visits with preschool children.


Early intervention services can often prevent the emergence of chronic neglect and multitype maltreatment, but once chronic neglect or chronic maltreatment has become embedded in family life, case management teams must take seriously the heightened risk of long-term development harm to the physical and mental health of children. Children with high ACE scores are at elevated risk of serious illness, mental health problems, suicide and suicide attempts, drug/alcohol abuse in adolescence, juvenile offending (including violent offenses) and early death. It is a strange version of child protection that ignores the effects of ACEs unless a child has a current physical injury or has been sexually abused; and does so under a social justice banner! 


Addressing a Skeptical Perspective

Some readers may question whether chronic multitype maltreatment is as common as we suggest or maintain that these are exceedingly rare “outlier” cases among families with CPS reports. This view is mistaken. Research studies indicate that one-fifth to more than one-third of families with screened in initial CPS reports (mostly for neglect) have 4 or more additional reports within 5 years; and that the more reports received on a family the more likely some of these reports will contain allegations of physical abuse or sexual abuse, in addition to pervasive neglect. (Loman, 2006, English,2005)In Washington State, it is common to encounter families with 30, 40, 50 or more CPS reports, several of which have been substantiated. Diana English’s research in Washington state found recurrence rates, i.e., multiple substantiations, that were about one-third of re-report rates.


In “Frequently Encountered Families,” one of best studies ever done on multitype maltreatment, Anthony Loman expresses skepticism regarding estimates of the scale of multitype maltreatment based on substantiation rates because he discovered in interviews with caseworkers that they were often aware of instances of abuse and neglect they had not substantiated. We have little or no confidence in substantiation rates as a measure of recurrent maltreatment, a skepticism widely shared among child welfare scholars.


In their discussion of cross recidivism of maltreatment types among families with multiple CPS reports, Jonson-Reid, et al comment that research studies using different methodologies have found widely varying rates of multitype maltreatment histories among families with CPS reports (from 5% to 54%) and add, “NIS-3 (National Incidence Study, not based on CPS reports) shows approximately 15% of cases with multitypes of maltreatment …”  (2003)Our estimate is that no less than 10% of families with screened in CPS reports, and possibly a much higher percentage, have histories of chronic multitype maltreatment. The likelihood that children have been both chronically neglected and occasionally abused in various ways increases steadily with the number of CPS reports on the family.


Placement guidelines in chronic multitype maltreatment

Readers who have not worked in child welfare or in court systems may be surprised to learn that many children grow up in families

with double digit CPS reports, sometimes 30, 40, 50 or more reports. Legal standards for emergency out-of-home placement require evidence of risk of imminent harm, or an immediate safety threat as indicated by current injury or sexual abuse, or parental incapacity due to substance misuse or mental health conditions. For this reason, lengthy histories of CPS reports, including multiple substantiations, are often ignored in CPS decision making. Many CPS reports allege low level neglect or minor physical abuse of children and may be quickly closed without services. Developmental harm to children is rarely considered in placement decisions; and Washington’s neglect statute does not even include a reference to emotional maltreatment.


In addition, juvenile courts in Washington have reportedly been greatly influenced by an American Bar Association report, “A Toolkit for Lawyers: Trauma Caused by Separation of Children from Parents,” (2019) that cites a research study which “asserts that removal and placement in foster care may have a worse impact on the child than neglect,” a perspective which is complete nonsense when applied to young children who have experienced chronic neglect and are at highly elevated risk of serious injury or death, as well as life-long harm to physical and mental health.


In cases of chronic multitype maltreatment risk of serious harm to children greatly increases when:

  • Parents are unable due to substance misuse or mental illness to consistently maintain a parenting structure to care for children’s basic needs, or their special needs resulting from illness or disability.

  • Parents do not recognize or respond to dangerous conditions or circumstances or keep dangerous persons from outside the family away from their child.

  •  A parent isolates a baby or young child for most of her/his waking hours and has minimal interactions with their child.

  • A parent responds to normal child behaviors such as crying or attention seeking with a pattern of harsh physical punishment, and/or emotional abuse.

  • A parent ignores, minimizes, or facilitates the sexual abuse of a child by a romantic partner, or by an older sibling or extended family member.

  • A parent engages in deliberate cruel punishment, e.g.,  systematic denial of food and water, placing a child in ice cold bath water for an extended period of time.

  • Parents are unwilling to accept support services from professionals or family members to reduce their childcare burden.


When children are 0-5, and multitype maltreatment can be proven (not merely alleged or suspected) in a dependency action according to the legal standard set forth in statute, a child or sibling group should be placed in kinship care if possible, or in non-kin foster care if a kinship placement is not available. In-home safety plans are frequently unreliable when used with infants and toddlers to control extreme safety threats and caseworkers should use them sparingly, if at all, to control immediate safety threats with very young children.


Another set of placement guidelines should be utilized for school age children, 6-17, due to the distinct possibility that foster care will do more harm than good. By the time a child  has survived multitype maltreatment in early childhood starts school, he/she may have developed behavior problems, including oppositional behavior, aggression, and difficulty with emotion regulation with which foster parents and unlicensed relatives cannot cope and will not tolerate. These foster youth often experience multiple placements, bullying by peers, maltreatment by caregivers, while being prescribed cocktails of psychotropic drugs for years. These youth are often difficult to stabilize in any type of foster care, and when a child or adolescent cannot be stabilized in care, they become highly vulnerable in multiple ways. Given these considerations, we recommend the following placement guidelines for school age youth:


  • Except when a child or adolescent is in extreme physical danger due to maltreatment or threats of parents/ caregivers, a youth should be placed out-of-home only when a child welfare agency has a therapeutic resource in which agency staff have confidence based on past experience, or when there is an extended family member, friend of the family or community professional with whom the youth has a good relationship and who is willing to stick with the youth through thick and thin.

  • Even when a behaviorally troubled youth must be placed due to extreme safety concerns, the placement should be terminated when the safety threat is neutralized unless the child welfare agency has a therapeutic resource as described above.

Foster care systems that depend on volunteer foster parents have earned their reputation for often being unable to provide therapeutic (or even safe and humane) care for behaviorally troubled youth. However, it is not true that all foster homes and residential care facilities are unsafe and unskilled in providing therapeutic care, or routinely eject youth from the home/ facility without adequate planning.  In our lengthy careers, we have encountered many outstanding foster parents and residential programs, some of whom by long experience and trial and error have developed outstanding therapeutic skills and knowledge. Experienced child welfare staff know who these foster parents and residential care programs are. These are the resources they should be utilizing for the hard challenge of developmental repair for youth who have experienced multitype maltreatment prior to entry into foster care.


In the absence of such resources, or family members, or others in the community willing to make a full commitment to a troubled youth, at least do no harm.  Child welfare staff and other professionals will sometimes have to engage with troubled youth for whom there is no good placement option. For these youth, it is of the utmost importance to encourage and invest in the development of talents, interests and prosocial skills, while doing everything possible to keep them in school. ©



"Trauma caused by separation of children from parents: A tool to help lawyers". (2020), American Bar Association, Chicago, Ill.  


Cawthon, L. & Hopps, D., "Mortality of CPS clients in Washington State". (1997) unpublished; Research and Data Analysis, Department ofSocial and Health Services, Olympia, Washington; available from authors on request.


Cort, N. A., Toth, S. L., Cerulli, C., & Rogosch, F. (2011). Maternal intergenerational transmission of childhood multitype maltreatment. Journal of Aggression, Maltreatment & Trauma, 20(1), 20–39.


English, D., Marshall. D. & Orme, M., “Characteristics of Repeated Referrals to Child Protective Services in Washington State,” (1999), Child Maltreatment, vol. 4, issue 4.


English, D, Upadhyaya, M., Litrownik, A., Kotch, J., Marshall, D. , Dubowitz, H. & Schneider, M., “ (2005), “Maltreatment’s wake: The relationship of maltreatment dimensions to child outcomes,” Child Abuse and Neglect, 29, vol. 5.


Hunter, W. & Knight, E., LONGSCAN Research Briefs, vol. 1 (1998), National Center on Child Abuse and Neglect.


Jonson- Reid, M., Drake, B., Chung, S. & Way, I. “Cross type recidivism among child maltreatment victims and perpetrators,” (2003), Child Abuse and Neglect, 27 (8).


Kelley-Irving, M., Lepage, B., Dedieu, D., Bartley, M., Grosclaude, P., Lang, T. & Delpierre, C., “Adverse childhood experiences and premature all -cause mortality,” Journal of European Epidemiology, published online, July 26, 2013.

Kuehn, B., CDC Report: Urgent Need to Address Teens’ Adverse Experiences During Pandemic. (2022), JAMA, 328 (2), published online, Nov. 22, 2022.


Loman, L.A., “Families Frequently Encountered by Child Protection Services: A Report on Chronic Child abuse and Neglect, (2006), Institute for Applied Research, St. Louis, Missouri.


Palmer, L., Prindle, J.,& Putnam-Hornstein, E., “A Population Base Examination of Suicide and Child Protection System Involvement, (2021), Child Abuse and Neglect, 117, available online, April 9, 2021.


Schneiderman, J., Prindle, J. & Putnam-Hornstein, E., “Infant Deaths from Medical Causes Following a CPS Report,” (2021), Pediatrics. 148(3).


The Science of Neglect: the persistent absence of responsive care disrupts the developing brain: Working paper no.12, Center for the Developing Child at Harvard University, Cambridge, Mass.


Widom, C. & Nikulina, V., “Long Term Consequences of Child Maltreatment in Low- Income Families,” in The Oxford Handbook of Poverty and Child Development (2012), eds, Maholmes, V. & King, R., Oxford University Press.


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