Re-Referral Rates and Risks: A Prospective Five-Year Study of Infants Remaining in the Home Following an Allegation of Maltreatment

Background/Purpose. Nationally, the maltreatment victimization rate is highest during infancy and has increased over the last decade.  Given the physical vulnerability that defines the first year of life, as well as a growing body of research linking early childhood adversities to developmental deficiencies through adulthood, there is perhaps no greater opportunity for child protective services (CPS) and other systems to positively intervene than during infancy. The purpose of this study was to generate knowledge concerning referral rates for children first reported to CPS during infancy. This study is the first to analyze re-referral and maltreatment recurrence for infants “evaluated out” after their first allegation.

Methods. This study utilizes a dataset consisting of CPS records linked to population-level birth records. Our sample includes all infants in California’s 2006 birth cohort who were: (1) referred for maltreatment during infancy, and (2) remained in the home following the index allegation. Infants were followed from birth through the age of five. Generalized Linear Models were used to calculate the relative risk of re-referral by age five, with sociodemographic adjustments based on birth record covariates. We specified a Poisson distribution and log link, an alternative method for use with prospective cohort studies in which the outcome of interest is binary.

Results. Of the 563,871 births in California in 2006, 29,889 (5.3%) of infants were referred for abuse or neglect prior to age one. Over one-quarter of these referrals were made within 3 days of birth. Twelve percent of referrals were evaluated out, 50% were investigated and deemed unfounded or inconclusive, while the remaining 38% were substantiated. Following this initial allegation, 82% of referred infants remained in the home and were included in this analysis. Among these infants, over half (56%) were re-referred by age five; the highest re-referral rate was observed for infants with an initial substantiation and service receipt (65%). Significant differences in a number of child and family characteristics were observed by the index disposition and included in multivariate models. Infants initially evaluated out faced a re-referral risk statistically comparable to children who received an investigation that was unfounded (RR: 0.99; 95% CI: 0.96-1.02), while those who were substantiated and received services had a slightly higher risk (RR: 1.10, 95% CI: 1.07-1.13). Among re-referred children, the receipt of services in the context of a prior substantiation predicted future substantiation, but there were no differences between other groups.

Conclusions and Implications.  Infants stand to benefit the most from efforts that successfully protect against abuse or neglect, both because maltreatment that begins during infancy is likely to be chronic in duration, and because its timing is developmentally consequential.  Our findings indicate that infants remaining in the home following an initial allegation of maltreatment are at very high risk of re-referral, much higher than suggested by other published estimates focused on non-infant populations, or those which track children for shorter periods of time. Additionally, these data indicate there is little basis for concluding that infants evaluated out without an investigation are a low risk group.