This study contributes to our knowledge about patterns of risk among maltreated youths placed in out-of-home care. Findings demonstrate that although all children placed in out-of-home care have experienced serious life adversities, they are not identical with regard to their exposure to risk factors—nor are they homogeneous with regard to their likelihood of experiencing mental health symptoms. Results also replicate previous research and support the cumulative risk hypothesis. Even in this high-risk sample (in which 48% of children in the overall sample were in the clinical range with regard to externalizing behaviors according to caregiver report), the empirically-derived cumulative risk index significantly predicts mental health symptoms. Furthermore, the cumulative risk index differentiates between children who score in the clinical range with regard to mental health symptoms versus those who do not. The data support a linear model in which each incremental increase in cumulative risk is accompanied by a similar increase in mental health problems.
Although not surprising, one of the most striking findings of this study is the catastrophic accumulation of risks faced by maltreated children placed in out-of-home care. In addition to exposure to various types of maltreatment, over half the sample came from a single parent household, had been removed from caregivers with a history of substance abuse and/or criminal involvement, and had been exposed to domestic violence. As compared to other studies, these rates are quite high. For example, Fergusson & Horwood (2003)
report that approximately 33% of their urban community sample was born into a single-parent family, approximately 20% had experienced inter-parental violence, 12.1% of parents had a history of alcohol problems, 13.3% had a history of criminal involvement, and 24.8% had a history of substance abuse. Furthermore, the cutpoints for assignment to a high-risk group within the context of our sample of children are also considerably higher than those found in studies of cumulative risk conducted with community samples. Given the prevalence of risk exposure and elevated thresholds for being considered high risk within this sample, any cumulative risk index constructed for this population by definition differs substantially from cumulative risk indices used with more heterogeneous samples. Nevertheless, the empirical risk index created for the present study was useful in predicting participants' mental health functioning.
Although the empirical risk index operated in ways consistent with the cumulative risk literature, the theoretical risk index did not appear to capture the co-occurring factors that place maltreated youths at risk. As we examined the eighteen hypothesized risk factors, two surprising findings emerged. First, many of the risk factors we proposed did not correlate in expected ways with one another; and second, the risk factors did not correlate in expected ways with the mental health outcome variables, illustrating the importance of considering the characteristics of the sample at hand, rather than generalizing from research conducted with less risky samples.
While a large body of literature has demonstrated that risk factors tend to cluster within individuals (e.g., Masten & Wright, 1998
), many of the correlations among the eighteen hypothesized risk factors were low or non-significant. In addition, some counter-intuitive correlations between risk factors emerged. Specifically, although research has documented that the prevalence of physical and sexual abuse is higher in families in which a parent is abusing substances (Walsh, MacMillan, & Jamieson, 2003
), in our sample, parental substance use was associated with a lower likelihood that the child had been physically and sexually abused. On the other hand, parental substance use was associated with a higher likelihood that the child had been neglected in the form of lack of supervision or educational neglect or had experienced moral/legal abuse. This suggests that although parental substance use may elevate risk for maltreatment in general within community populations, perhaps patterns of differing etiologies for different types of abuse emerge when examining the population of children removed from their homes due to substantiated abuse or neglect, with substance abusing parents being more likely to neglect children than to physically or sexually abuse them.
Although few people would argue that exposure to adverse life experiences such as neglect in the form of failing to provide or witnessing domestic violence do not pose a risk to children's mental health, many of the proposed risk variables did not demonstrate significant correlations with mental health symptomatology. There are at least two potential explanations for the lack of significant correlations between some well-established risk factors and mental health functioning in this sample. The first possibility is that the high percentage of children in this sample with exposure to certain risk factors limits the predictive value of these variables for this sample and attenuates these correlations. Second, since all participants in this sample are already at high risk for mental health problems, it logically follows that few risk factors would be salient enough to differentiate between participants' levels of risk.
Another reason that context is important to consider in the interpretation of the findings reported herein is that children exposed to some of the proposed risk factors (such as neglect in the form of lack of supervision, educational neglect, and parental alcohol and substance use) do not seem to fare as poorly as maltreated children who were not exposed to these risk factors. Clearly, neglect and parental substance use are not factors that promote positive functioning (e.g., Gilbert, Widom, Browne, Fergusson, Webb, & Janson, 2009
). However, there is some evidence that certain profiles of maltreatment (i.e., those that include physical or sexual abuse with or without exposure to additional types of maltreatment) are more highly associated with internalizing and externalizing symptoms than are other profiles (Pears, Kim, & Fisher, 2008
). Pears, Kim, and Fisher (2008)
found that children who had experienced neglect in the form of lack of supervision had more positive scores on measures of adjustment within their maltreated sample of preschoolers. The authors were careful to note that neglect has serious negative consequences and that their results “…simply suggest that children in this group may not fare as poorly as
children who have experienced physical or sexual abuse (or both) in addition to neglect.” (p. 969).
Although 11 of the hypothesized risk factors did not emerge as salient predictors of mental health functioning in this sample, seven risk variables demonstrated significant relations with mental health symptoms: physical abuse, sexual abuse, coming from a single parent household, number of caregiver transitions, number of school transitions, exposure to community violence, and low intellectual functioning. Of these variables, the latter four represent characteristics of the child or of the child's experience that are external to his or her immediate family. This finding is intriguing. Since all children in this sample come from families that are risky by definition, perhaps what differentiates those individuals that are at higher risk is exposure to risk in domains outside of their immediate family. One factor that may link family-related risk factors, such as single parenthood, and sociocultural risk factors, such as exposure to community violence, is poverty. Although we were not able to measure socioeconomic status in the current study, this may be an important intervening variable to consider in future research.
Of the maltreatment variables, physical and sexual abuse emerged as important risk variables, while other maltreatment types did not. One study that classified maltreatment cases according to the predominant type of maltreatment utilized a hierarchy in which “active” forms of abuse (e.g., physical and sexual abuse) were prioritized over “passive” forms of abuse (e.g., neglect). This classification system predicted more mental health symptoms, even after accounting for the co-occurrence of multiple maltreatment subtypes (Lau et al., 2005
). This finding lends some support to the notion that, even among maltreated youths who have likely experienced multiple types of maltreatment, maltreatment of commission may have more serious emotional and behavioral consequences than maltreatment by omission. However, this finding requires replication prior to drawing definitive conclusions.
Although some other studies have found certain levels of risk at which the likelihood of adverse outcomes increases dramatically, such a threshold effect is not supported for this sample. The only outcome to demonstrate a significant quadratic relationship to the cumulative risk index was the sexual concerns subscale of the TSCC. However, examination of the shape of this effect indicated that it was U-shaped, and was not consistent with the shape of the relationships posited by a threshold model. The reasons for the existence of a U-shaped curve (and the decrease in scores from a cumulative risk score of 0 to a cumulative risk score of 1) are not clear, and require further investigation and replication prior to drawing conclusions. However, the linear relationship that was supported for all outcomes with the exception of CBCL internalizing symptoms indicates that the effect of risk factors is additive. It is possible that all participants within this high risk sample were above the “threshold” at which risk would increase in a dramatic fashion. Future studies could attempt to determine whether threshold effects are more likely to occur within more heterogeneous or low risk samples.
The empirical cumulative risk index predicted both children's and caregiver's reports of mental health outcomes. Furthermore, different levels of cumulative risk were related to striking differences in the percentage of children scoring in the clinical range with regard to emotional or behavioral problems, indicating that this index has clinical utility. However, several limitations of this study must be noted. First, although the method used for the calculation of cumulative risk replicated that used in multiple previous studies, a potential downside to this procedure is that the cutoffs used to dichotomize continuous risk variables are sample-specific, limiting the generalizability of these findings to other samples. The empirical derivation of the cumulative risk index may also render findings more sample-specific; thus, replication of the results of this study is important. Second, because we coded maltreatment variables and characteristics of the child's family of origin based on child welfare records that were relevant to the current filing, we have little information about the chronicity or timing of exposure to these risk factors. Furthermore, although the Maltreatment Classification System is the gold-standard in the field, all coding techniques are by definition limited by the information that is reported in the child's case files. Third, multiple analyses were conducted with these data, thus inflating the chance of Type I errors. Finally, there are other potentially important risk variables that we were unable to examine due to their unavailability in the current dataset. Most notably, we did not have measures of socioeconomic status/poverty or parental psychopathology.
Despite these limitations, to our knowledge, the present study is the first to examine the relation between cumulative risk among maltreated children in out-of-home care and their mental health functioning and suggests several directions for future research as well as implications for intervention. The cumulative risk index was developed within the context of a prevention program. We intend to use this index in future studies to investigate whether initial levels of cumulative risk may moderate the effects of the prevention program. Although all maltreated children who have been removed from their homes require some type of intervention to optimize their outcomes, the results of moderational analyses could help allocate resources more effectively, by shedding light on the effectiveness of interventions for maltreated children who are at relatively lower versus higher risk. Specifically, in the current study, nearly three-quarters of individuals with high cumulative risk scores exhibited clinical levels of externalizing behaviors. In addition, these children were likely to be exposed to risk factors in multiple domains. Thus, children with high cumulative risk scores may require immediate stabilization of problem behaviors combined with multi-systemic interventions. On the other hand, those children with lower cumulative risk scores may be more likely to reap benefits from more traditional types of interventions, including individual or group programs. It is our hope this research will help inform prevention and intervention efforts that will mitigate some of the destructive effects of child maltreatment.