In all 50 states, professionals providing care for children are mandated to report suspicions of child maltreatment to state child protection agencies. Every year, these reports result in CPS investigation for millions of households.[1
] Although only one-quarter of these investigations are substantiated, and less than one-tenth of these investigations result in out-of-home placement of a child, prior research demonstrates that reported children remain at high risk for violence and for poor health over the coming years.[2
] Multiple studies find that the strongest predictor of CPS involvement in a household is prior CPS involvement in the household, suggesting that the first episode of CPS involvement in a household may be a critical window of opportunity to shift this negative trajectory for these families.[31
] The NSCAW database used in this analysis provides a nationally representative description of the experiences of over one million children and caregivers during the years following first-time CPS involvement.
Our analysis suggests that regardless of the outcome of the CPS investigation, children remaining in the home following a first-time CPS investigation live with poverty, family violence, and mental health problems well above national levels. CPS involvement in a household does not always result in provision of or referral to appropriate services even when risk factors are present, particularly when concerns of child maltreatment are unsubstantiated. In general, these risk factors persist at high levels over the years following initial CPS involvement in the home.
Exceptions to these general trends are encouraging, and may challenge common negative assumptions regarding families with CPS involvement. At baseline, primary caregivers remaining at home after a first-time CPS investigation report less drug and alcohol dependence than seen in a general U.S. population. When substance abuse is present, CPS referral for treatment is associated with a reduction in dependence over time. Despite questions regarding the effectiveness of IPV screening and intervention in the general population, referral for IPV services in this high-risk population is associated with a dramatic reduction in 12-month prevalence of IPV.[33
] Mental health service referrals for children are associated with reductions in aggressive and oppositional behavior problems. Similarly, caregivers with depression referred for mental health therapy show an encouraging though non-significant reduction in depression over time. Although we cannot assume a causal relationship between the observed reduction in risk and these referrals, our results should encourage professionals working with these families to continue to screen and refer for these risks when appropriate.
In contrast to these relative successes, the persistence of several risk factors despite appropriate referrals is disappointing. The high prevalence of corporal punishment in the CPS-involved population mirrors this practice in the general U.S. population.[23
] In this high-risk population, however, efforts to train parents in non-violent discipline techniques have been found to improve child outcomes and reduce subsequent maltreatment.[34
] Our results may support increased attention to these parent-training programs for CPS-involved families. The persistence of child internalizing behavior problems despite effective mental health therapy for these disorders is also concerning. For children remaining in the home, caregivers may be more motivated to seek help for aggressive and disruptive behavior problems than for depressive behaviors. Identification of barriers to effective mental health treatment for children in this population should receive attention in future research.
The results of our analysis must be viewed in light of several limitations. Missing data in the NSCAW dataset may introduce bias to our results; however, the missing data likely resulted in underestimates of the risk factors. Our risk measures rely upon caregiver response, which introduces the potential of response bias and underestimation of the prevalence of risks such as IPV and substance abuse. Similar response bias would be expected in the general population data used for comparison; moreover, NSCAW reduced the likelihood of this bias through the use of an audio-computer assisted self-interview. Our reliance on caseworker referrals to risk-specific services is limited because it does not represent actual service utilization by caregivers. This limitation, however, also reflects practical reality. Professionals working with CPS-involved families are often only able to provide referrals and recommendations. Understanding that these actions are associated with longitudinal improvement is both encouraging and important.
We recognize additional limitations in assessing repeat CPS involvement after a first-time investigation of child maltreatment. NSCAW investigators did not gather data on household income, social support, caregiver mental health or intimate partner violence on children out of the home, so we cannot generalize conclusions regarding these household and caregiver characteristics to children in out-of-home placements at a given wave. Excluding risk outcomes for subjects with subsequent out-of-home placement would likely result in an underestimation of the prevalence of these risks at any given timepoint, and an overestimation of any change over time observed. NSCAW did not systematically collect data on repeat CPS involvement in households, making estimates of recidivism in this dataset unreliable.[36
] To address this, we relied upon a combination of caseworker and caregiver reports to determine whether a child was placed in out of home care over subsequent survey waves. These reports may be limited, as caseworkers may not have access to full records, and caregivers may have had variable understanding of questions related to out of home placement. This bias may result in an overestimate or underestimate of the true rate of removal over this study’s time horizon. Finally, NSCAW data is now 10 years old, and changes in CPS practice over the past decade may not be reflected in these cases. As data from the second NSCAW study is released in the coming years, comparison of our findings with more recent subjects will be needed.
Despite these limitations, the results of this analysis have practical implications for physicians and policymakers. Pediatricians working with families with a history of CPS involvement should be aware that these are children at risk, regardless of the outcome of CPS investigation or placement decision. Almost one in ten of children remaining at home after a first CPS investigation will enter foster care within 3 years. CPS case closure does not mean that household, caregiver, or child risks have been resolved—or even addressed—during the course of the investigation. Our findings suggest, however, that referral to risk-specific services at the time of CPS involvement may be associated with improvements over time in IPV, substance abuse, and child behavior problems. Pediatricians may be able to support CPS-involved families with close follow-up and careful referrals to appropriate services in the community. Policymakers should be aware of the risks that remain unchanged in these families after CPS closes these investigations, as well as the risk for future out-of-home placement among these children. Investments in providing effective interventions where available, and in developing new interventions where required, are needed to improve outcomes for children and caregivers living together after a first investigation for suspected child maltreatment.