Medically Documented Maternal Mental Health Disorders and Reported Maltreatment: A Birth Cohort Study

Background/Purpose:
Existing literature indicates that mental illness is a risk factor for maltreatment and involvement with child protective services (CPS). Unfortunately, studies documenting maternal mental health disorders and their impact on child outcomes have been limited by the scarcity of available mental health data, small or unrepresentative sample populations, and retrospective designs. The International Classification of Diseases 9, Clinical Modification (ICD-9-CM) offers a standardized measure of mental health diagnoses, and has been used to estimate the population-level prevalence of mental health disorders. Yet, the association between maternal mental health disorders and CPS involvement among full birth-cohorts remains largely unstudied.

We used linked, population-level administrative data to examine the prevalence of mental health disorders among mothers and the associated occurrence of CPS reporting during infancy.

Methods:
We linked the birth records of 551,232 infants born in California during 2006 to hospital discharge records containing ICD-9-CM diagnostic codes and CPS records concerning maltreatment allegations. ICD-9-CM codes were used to determine the presence or absence of maternal mental health disorders at the time of birth, and to examine the frequency of disorders falling into four diagnostic categories (psychotic disorders, mood disorders, anxiety disorders, and mental disorders at delivery). The associated risk of being reported to CPS during the first year of life was modeled using multivariable generalized linear models. We additionally modeled the co-occurrence of a substance use disorder.

Results:
Among the 2.8% of infants born to mothers with a mental health disorder diagnosed at the time of birth (n=15,516), 25% were reported to CPS during the first week of life and 34.6% were reported by age 1. In contrast, 4.41% of infants born to mothers without a mental health diagnosis were reported during the first year of life. Notable differences in CPS reporting emerged across mental health diagnostic categories. During the first week of life, more than half of all infants born to mothers with a psychotic disorder (51.45%) were reported to CPS, as compared with 26.76% for mental disorders at delivery, 9.15% for mood disorders, and 4.87% for anxiety disorders. Infants born to mothers with a mental health disorder, but no substance use disorder, were reported to CPS at nearly 2.5 times the rate of infants born to mothers with no mental health disorder (2.53, 95% CI=2.41, 2.66). That rate doubled among infants born to mothers with co-occurring mental health and substance use disorders (RR = 5.20, 95% CI=5.03, 5.37).

Conclusions and Implications:

Infants born to mothers with medically documented mental health disorders at birth were at heightened risk for early CPS involvement, and that risk was acute during the first week of life. Risk varied by type of mental health disorder, and was greatest for infants born to mothers with psychotic disorders and mental disorders at delivery. Risk was also greater for infants of mothers with comorbid mental health and substance use disorders. Administrative data allow us to track rates over time and generate population-level information for policy development and improved service delivery.