Maltreated Infants: Identifying Factors Associated with Poorer Outcomes

The research for this presentation was funded by the Administration on Children, Youth, and Families of the U.S. Department of Health and Human Services, Award 90PH0014.

Anita Scarborough, Ph.D.Frank Porter Graham Child Development Institute

University of North Carolina

Julie McCrae, MSW, Ph.D.University of Pittsburgh, School of Social Work

Child Welfare Education and Research Programs

2007 OSEP National Early Childhood ConferenceMarriott Crystal Gateway Hotel

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Organization of Presentation

1. Data Source

2. Research Questions

3. Findings

4. Discussion

Implications for Service Provision

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Source of Information• The Administration for Children and Families

(ACF), funded the National Survey of Child and Adolescent Well-Being, the first national probability study of children and adolescents investigated by Child Welfare Services.

• Baseline data was collected in 1999 and 2000.

• This session will present the developmental characteristics of a nationally representative sub-sample of 1,196 infants, representing 149,398 maltreated infants shortly after investigation and again, 3 and 4½ years later.

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Long-term Outcomes of Abused and Neglected Children

• More likely to be arrested as juveniles, to become pregnant during adolescence, use drugs, have lower grade point averages, and experience mental health problems.

• 16% of males and 57% of females in State prisons experienced childhood physical or sexual abuse.

• Research has become quite conclusive regarding the negative impact of the experience of child maltreatment on adult outcomes in cognitive, economic and mental health domains.

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Growing Public Awareness and Policy Change• Amendment of the Child Abuse and Prevention

Treatment Act (CAPTA, 2003) “requires referral of a child under the age of 3 who is involved in a substantiated case of child abuse or neglect to early intervention services funded under Part C” (section 106(b)(2)(A)(xxi)).

• The Individuals with Disability Education Act (IDEA, 2004), requires state Part C programs to have a description of their policy and procedures that require the referral for early intervention services for children under the age of 3 who are involved in a substantiated case of child abuse or neglect. Eligibility requirements for Part C are determined by individual states.

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Definition of Substantiation

• Where the allegation of maltreatment was supported or founded by state law or state policy (US Department of Health and Human Services, 2006).

• Each state requires a specific standard of proof to substantiate maltreatment.

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Part C Services• The goal of Part C is to provide services to children from

birth through two years of age with disabilities. • Children in this age range experiencing developmental

delays, as defined by the individual states, are entitled to services.

• States vary according to the agency serving as the lead agency, the eligibility definition for delay, if services are provided to children “at risk” for developmental delays (currently 5 states), and in the percentage of children served.

• Part C services are provided to 2.4% of children between birth and 2 years of age nationally. The percentage of children and families served among the individual states varies, ranging from 1.34 to 6.71% (U.S. Department of Education, 2006).

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Basis for the Research• An under utilization of Part C services among

maltreated infants and toddlers, based on scores on developmental measure shortly after investigation by child welfare, has been reported (Rosenberg et al., 2004; Stahmer et al., 2005; Zimmer & Panko, 2006),

• Clearly it difficult to determine developmental delay as an eligibility criteria among infants who do not have established risk conditions.

• This study is looking at the developmental characteristics of maltreated infants over time to stress the need for intervention services, and to determine factors present in infancy associated with poorer developmental outcomes.

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Research Questions• What are the characteristics of infants, their caregivers

and type of maltreatment shortly after the time of investigation by Child Welfare Services?

• Are there discernible developmental profiles for maltreated infants, 3 and 4½ years after investigation?

• What proportion of maltreated infants were reported to have an IFSP 12 months after investigation and what proportion had an IEP 4½ years later?

• Are characteristics of maltreated infants, their caregivers, or maltreatment type related to developmental outcomes 4½ years later?

• What do those findings suggest about the need for Part C early intervention services?

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Characteristics of Maltreated Infants

• Age• Gender• Race• Health Status• Neurodevelopmental risk status as assessed by

the Bayley Neurodevelopmental Screener• Cognitive development as indicated by scores

in the cognitive domain of the Battelle Developmental Inventory

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Caregiver Characteristics

• Age• Education• Cognitive impairment• Mental illness/depression• Substance abuse• Domestic violence• Poverty• Poor quality home environment as

measured by the HOME

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Maltreatment Characteristics• Prior reports of maltreatment• Maltreatment type

– Physical abuse– Sexual abuse– Physical neglect – Supervisory neglect– Other

• Maltreatment case substantiated • Reported level of harm to the child• Child placed out of home

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Developmental Characteristics Examined 3 and 4 ½ Years after Investigation

• Cognitive development

• Language skill

• Adaptive behavior

• Behavioral concerns

• Loneliness & social dissatisfaction

NSCAW Sample6,231 children, birth to 14 years of age, who had contact with the Child

Welfare System

Over Sampled on the basis of:

• Children/Families Receiving Child Welfare Services

• Infants

• Sexually Abused Children

Baseline collection from Nov. 1999 to Apr. 2001

• Follow-Ups at 12, 18, 36, and 54 months after baseline

• 12 month follow-up included only limited data collection

• 54 months follow-up currently available only on infants at baseline

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MeasuresNeurodevelopment

Bayley Infant Neurodevelopmental Screener (BINS; 0-2 years)

Cognitive DomainBattelle Developmental Inventory – Cognitive Domain (BDI; 0 – 3 years)

Kaufman Brief Intelligence Test (K-BIT; 4+ years)

Adaptive Behavior DomainVineland Adaptive Behavior Scale Screener, Daily Living Skills sub-domain (VABS)

Communication DomainPreschool Language Scale-3 (PLS-3)

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Measures

Behavior DomainChild Behavior Checklist (CBCL; 2+ years for parent; 5+ years for teacher)

SocializationLoneliness and Social Dissatisfaction Questionnaire for Young Children (self report 5+ years)

Home environmentThe Home Observation for Measurement of the Environment (HOME)

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Definition of Delay• Children scoring 1.5 standard deviations or more below

the mean on a developmental measure were considered to have a delay.

• High Risk for subsequent developmental difficulties based on the BINS.

Described 3 and 4 ½ years later using:• PLS – 3• VABS• CBCL- parent and teacher• KBIT• Loneliness & Social Dissatisfaction

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Age in months at baseline %

0-6 45

7-12 55

Male 49

Race/ethnicity

White 44

African-American 30

Hispanic 21

Other 5

Fair/poor health 8

High risk on the BINS 53

Characteristics of Infants Investigated by Child Welfare

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At baseline %

Less than high school education 37

Cognitive impairment 13

Mental illness/depression 34

Active or history of domestic violence 56

Poverty 45

Low score on HOME 12

High number of risk factors 34

Caregiver Characteristics

20

68

32

19 to 34

35 and older

Female Caregiver age

37

55

8

<HSHS or GEDCollege

Education-level

Caregiver Characteristics

21

Household Characteristics

23

48

11

45

0

10

20

30

40

50

60

TANFrecipient

At or belowpoverty line

Singleparent

4 or morechildren

Pro

po

rtio

n

22

Family Risks

35

31

61

41

34

0 10 20 30 40 50 60 70

Trouble paying basicnecessities

Low social support

High stress

Prior reports

Substance abuse

Proportion with risk present

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At baseline %

Prior report of maltreatment 41

Maltreatment type

Physical abuse 20

Sexual abuse 2

Physical neglect 40

Supervisory neglect 33

Other 5

Severe level of harm 16

Clear evidence of maltreatment 41

Worker reports the child has special needs 14

Maltreatment substantiated 38

Out of home placement 22

Characteristics of Maltreatment

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Low Scores at Baseline by Age in Months

1614

3

21

10

1

0

5

10

15

20

25

Cognitive Language Adaptive Behavior

0-6 mos.

7-12 mos.

25

High Risk on BINS by Age at Baseline

69

39

0

10

20

30

40

50

60

70

80

0-6 mos 7-12 mos

Pro

po

rtio

n

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Low Scores 3 Years Later, by Ageat Baseline

Domain 0-6 mos. %

7-12 mos. %

Total

%

Cognitive 37 32 34

Language 35 38 37

Adaptive Behavior 25 10 17

At least 1

Problem score

59 57 57

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Combinations of Low Score Areas3 Years After Baseline

Developmental areas %

No problem scores 42

Cognitive 12

Language 14

Adaptive behavior 6

Cognitive & Language 15

Adaptive + Cognitive or Language

5

All problems 6

Total 100

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Low Scores 3 Years after Baseline by Race/ethnicity

32

1719

3

19

46

128 8

14

74

9

14

7

12

57

47 46

0

5

10

15

20

25

30

35

40

45

50

Noproblems

Cog only Lang only AdaptiveBehav only

Cog +Lang

AdaptiveBehav +Cog orLang

All

BlackWhiteHispanic or other

p<.10

29

36

149 8

20

8 6

48

10

19

4

10

36

0

10

20

30

40

50

60

Noproblems

Cog only Lang only AdaptiveBehavonly

Cog +Lang

AdaptiveBehav +Cog orLang

All

Boys Girls

Low Scores 3 Years After Baseline by Gender

p<.05

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Infants with an IFSP, or 4 ½ Years Later an IEP

IFSP in the12 months after baseline 32%

IEP 54 months after baseline 20%

IFSP 12 months, or IEP 54 months after baseline 37%

Those with an IEP who also had an IFSP 54%

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Teacher Report of Areas of Concern for Those with an IEP

Category % Category %

Learning disability 24 Speech language delay 66

Autism 18 Traumatic brain injury 5

Emotional disturbance 22 ADHD 25

Mental retardation 15 Developmental disability 26

Multiple disabilities 11 Visual impairment 2

Orthopedic 6 Deafness or hearing impaired

2

Other/unknown 13

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Low Score Areas 4 ½ Years Later, by Age at Baseline

Domain 0-6 mos.

%

7-12 mos.

%

Total

%

Cognitive 16 11 13

Language 27 21 25

Adaptive Behavior 42 28 34

At least 1

Problem score

45 44 55

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Focus on Low Language Scores 4 ½ Years after Baseline (PLS-3)

• Low language scores associated with:– Severe level of harm reported at baseline (p<.05)– High risk rating on the Bayley scales of infant

neurodevelopment at baseline (p<.001)

• No association with: – Child demographic characteristics– Maltreatment characteristics, including substantiation– Caregiver risks, age, education-level, poverty status– Poor quality home environment– Baseline cognitive delay

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Low Language Scores 4 ½ Years after Baseline

Baseline characteristic Odds of age 5 language delay

p-value

Age: 0-6 months 1.36 .47

Male 1.41 .24

Black .67 .42

Hispanic or other .88 .71

Poor physical health 1.08 .80

High risk BINS 1.46 .28

Cognitive delay 1.52 .19

Regression using child characteristics, R-square: .03

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Low Language Scores 4 ½ Years after Baseline

Baseline characteristic Odds of age 5 language delay p-value

Age: 0-6 months 1.12 .80

Male 1.87 .15

Black .41 .16

Hispanic or other 1.64 .36

High risk BINS 2.34 .11

Poor health 3.00 .03

Cognitive delay .69 .53

Caregiver age: <35 years 1.20 .80

<HS education .57 .29

Caregiver cognitive impairment 10.59 .01

Mental illness .22 .05

Substance abuse 1.65 .43

Domestic violence 2.46 .14

Below poverty line .86 .80

Poor quality home environment 1.08 .87

Regression using child & caregiver characteristics, R-square: .17

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Low Language Scores 4 ½ Years After Baseline

Baseline characteristics related to low language scores

Odds of age 5 language delay

p-value

Caregiver cognitive impairment 16.12 .02

Caregiver mental illness .20 .03

Prior reports .27 .05

Severe level of harm 7.77 .02

Regression with child, caregiver & maltreatment characteristics, R-square: .27

Statistical trends (p<.10): High risk BINS, domestic violence, “Other” as the primary type of maltreatment

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Predictors of IEP 4 ½ After Baseline

Baseline characteristics related to Special Education 4 ½ years later

Odds of having an IEP p-value

Male 5.00 .01

Child cognitive problem .21 .02

Caregiver cognitive impairment

13.21 .002

Caregiver mental illness .30 .03

Statistical trends (p<.10): Age 0-6 months at baseline, Hispanic, low level of child harm

Regression with child, caregiver & maltreatment characteristics, R-square: .26

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Emotional-behavioral Problems Reported 4 ½ Years Later

Problem type

% with clinical-level score

Teacher report Parent report

Total problems 9 21

Internalizing 9 7

Externalizing 13 20

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Self-report of Loneliness and Social Dissatisfaction 4 ½ Years Later

Age at baseline % 1 SD or greater above the mean

0 – 6 months 16%

7 – 12 months 11%

Total 13%

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Summary• More than half of maltreated infants are at high risk for

poor developmental outcomes, based on the presence of multiple risk factors such as high family stress (61%), single parent (48%), and domestic violence (56%), coupled with a low score on a measure of cognition, language or neurodevelopmental risk status (BINS).

• 32% of maltreated infants were reported to have an IFSP in the period of time 12 months after baseline.

• Three years after baseline more than half are reported to have a delay in at least one of the domains measured, with cognitive (12%) and language delays (14%) being the most common.

• Three years after baseline 74% of boys were reported to have a low score in at least one domain.

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Summary• Using language as a global marker of

development revealed infant & caregiver characteristics associated with low scores 4 ½ years later:– Poor infant health – Caregivers with a cognitive impairment – Caregiver mental illness was associated with reduced likelihood

of language delay• Likely due to the self-report, laptop computer method used to have

caregivers describe their mental health/depression

• Adding maltreatment characteristics, infant health was no longer predictive, but reported severity of harm was.

• Prior report of maltreatment was negatively related to language delay.

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Summary continued• When infants were 5 years of age, 1/5 of

them were reported to have an IEP, but only about half of those children were reported to have had an IFSP.

• Factors associated with having an IEP 4 ½ years later:– Male infants– Caregiver cognitive impairment– Infant cognitive problem (-)– Caregiver mental illness (-)

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Summary continued• Maltreated infants at five years of age:

– 25% low score on a language measure– 20% IEP– 13-20% reported to have clinical level externalizing problems– 7-9% reported to have clinical level internalizing problems– 13% of the children report loneliness or social dissatisfaction

• Factors in infancy found to be associated:– Infant poor health– Caregiver cognitive impairment– Severe level of harm

• Maltreatment characteristics not found to be associated:– Substantiation– Poverty - though these children are disproportionately poor– Out of home placement

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Discussion Points• Have Part C services been adapted to meet the needs of

these children and families? • Many maltreated infants have multiple risk factors,

recognized as a Part C eligibility in only a few states, yet these findings support the increased likelihood of poor outcomes for these children. – What can be done to help meet the needs of these children and

families and to help children get services earlier?

• Has the CAPTA requirement to refer substantiated infants and toddlers resulted in more children being served?

• Substantiation is the criteria for referral, yet these findings show that this is not significantly related to outcomes.

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Anita_Scarborough@unc.edu