Subsequent Child Protective Services Involvement after a Child Maltreatment-Related Hospitalization

Background and Purpose: Over 3.9 million reports were made to child protective services (CPS) in 2020 and medical professionals accounted for 11.6% of screened-in reports. Prior research suggests doctors underreport suspected child maltreatment (CM) and reporting varies based on socioeconomic status and race. When suspected CM occurs without intervention, there is the potential for re-occurring CM. However, limited evidence exists regarding CPS reports among children who were not initially reported for suspected CM. Therefore, this study used a population-based linked administrative dataset to examine the time to a subsequent CPS report among children who experienced a CM-related hospitalization under the age of three and whether this varied by initial CPS report status.

Methods: Birth, hospitalization, and CPS administrative records were linked for all children born in Washington State between 1999 and 2013 (N = 1,271,416). CM-related hospitalizations were identified using standardized, validated diagnostic codes. CPS records were linked through the second quarter of 2018 with an observation window of 5 years following the child’s discharge from the hospitalization. Children were included if they had a CM-related hospitalization before age three but were not removed due to the incident. The independent variable was a whether the child was reported to CPS during the CM-related hospitalization.

The survival probability of a subsequent CPS report was calculated using the Kaplan-Meier estimator. Cox proportional hazard models estimated the impact of a CPS report during the CM-hospitalization and other sociodemographic variables on the time to a subsequent CPS report.

Results: 3,400 children were identified experiencing a CM-related hospitalization before age three and did not experience a removal by CPS related to the hospitalization. 38.9% had a CPS report within 5 years of their hospitalization discharge. A higher percentage of children who had been reported to CPS during the CM-related hospitalization had a subsequent CPS report (51.9%) than children who were not initially reported (30.0%).

In the adjusted Cox proportional hazards model, a CPS report during the CM-related hospitalization was a risk factor for a subsequent CPS report (HR: 1.93; 95% CI: 1.70-2.20). Other risk factors included public health insurance used to pay for the CM-related hospitalization (HR: 2.31, CI: 2.00-2.66), teenaged mother at the time of birth (HR: 1.35, CI: 1.14-1.60), and low birth weight (HR: 1.31, CI: 1.09-1.58). Variables that decreased the hazard rate included a CM-related hospitalization diagnosis of physical abuse (HR: 0.67, CI: 0.59-0.77), and the child being the mother’s first born (HR: 0.68, CI: 0.59-0.77). Compared to children with White mothers, children with Native American mothers (HR: 1.29, CI: 1.03-1.62) had higher risk while children with Asian/Pacific Islander (HR: 0.55, CI: 0.42-0.72) and Hispanic (HR: 0.69, CI: 0.59-0.82) mothers had lower risk.

Conclusions and Implications: The results provide new knowledge regarding recurrent CM. Specifically, a significant proportion of children who experienced a CM-related hospitalization, but not removed by CPS, experienced a subsequent CPS report indicating recurrent concerns of CM. The identification of risk factors that are consistent with previous studies of CM-related outcomes indicate opportunities for targeted prevention and intervention efforts.