The recurrence rate for our sample was 47.7% at the end of 3 years and 62.1% at 7.5 years. Because of the inclusion criteria for the study, all children in the sample were participants in at least two systems at the start of the study period (child welfare and AFDC). Additionally, at the time of the first report of child abuse or neglect, 12.4% of the cases had already had a contact with either adult or child Medicaid mental health services, child health services for a chronic condition, special education, or juvenile court. These 12.4% of the cases had higher rates of later re-reports (69.7% v. 61.1%, p =.0001).
Bivariate analyses (full sample)
Rates of recurrence at 3 and 7.5 years and the Log Rank X2 statistics can be found in . Among child level characteristics, only the child’s age was significant, with younger children having higher recurrence rates (67.2% of infants [12 months or younger] compared to 60.2% of children aged 10 or 11, p <.0001). Among family level characteristics, the presence of more children in the household was significantly associated with recurrence (57.7% for 1 or 2 children, 65% for 3–5 children and 76.8% for households with 6 or more children, p <.0001). Whether a caregiver graduated from high school was associated with a lower risk of recurrence (50.4% vs. 68.1%, p <.0001). A caregiver’s history of being a foster child was associated with a higher recurrence rate (68.5% vs. 62.4%, p =.025), as was being under the age of 19 at the birth of the first child (65.1% vs. 61.4%, p =.043). Children reported for either neglect or mixed types of maltreatment (65.4% and 66.5%) had higher recurrence rates than children initially reported for physical (57.5%) or sexual abuse only (52.3%, p <.0001). There was no significant association between substantiation of the initial report and recurrence. If there was more than one child officially listed as a victim on the case, the recurrence rate was higher (68.5% vs. 59.0%, p <.0001).
Children Birth through age 11: Percent Re-reported at 3 and 7.5 years Controlling for Time
The association of caregiver service participation was broken out according to whether the services began before or after the initial maltreatment report (see Methods section). For cases with a recurrent report, service use after the index report was only considered if it occurred prior to the second report. Caregivers with mental health or substance abuse Medicaid treatment had higher rates of recurrence (79.2% [prior to index] vs.64.8% [after index] vs. 61.8% [no record of treatment], p <.0001). Caretaker exit from AFDC after a first spell within a year of the index event with no further re-entry or negative reason for exit was associated with a lower recurrence rate (46.2% [prior to index] and 35.3% [after index]) than children whose caretakers continued on AFDC, re-entered AFDC or experienced a negative known exit (64.9%, p <.0001). For purposes of this paper, we define a “spell” as one interrupted time period using a given service, in this case, AFDC. For example, an individual entering AFDC for the first time, exiting and then re-entering AFDC would have had two spells. Families who were referred to and accessed Family Centered Services (FCS) following the report of maltreatment had lower rates of recurrence (50%) than all other child welfare service levels (72.0% and 64.5%) and those cases who were not assessed as needing services (63.3%) or were assessed as needing services but never began services (76.7%, p <.0001).
Among community variables, higher levels of median household income were associated with lower rates of recurrence for levels above $20,000 per year (p <.001). Higher mobility was associated with higher recurrence (64% v. 61.3 p %, <.05).
Bivariate analyses (restricted sample of children aged 4 through 11 years at index report)
The same process was repeated for the sample restricted to older children in order to assess a variety of children’s services that were too uncommon to examine among younger children (e.g., mental health services, special education, etc.) (see ). Again, service use was broken out by whether it was initiated prior to or following the maltreatment report (index) with one exception. Because Medicaid hospital care for a chronic health condition was so rare prior to the initial maltreatment report, this variable had to be collapsed into a single (yes=1) value that included prior and post-index participation. Because violent crime and mobility in census tract, caregiver age at birth of the oldest child, and caregiver history of foster care were not significant in bivariate analyses, they are not shown in the table to conserve space.
Children Aged 4 or older: Percent Re-reported at 3 and 7.5 years Controlling for Time
The child’s age was not significant in the restricted sample. Female children had a lower rate of recurrence (58.7% v. 62%, p =.04). Record of either caregiver or child’s Medicaid mental health or substance abuse treatment was positively associated with recurrence. Also, a child’s Special Education eligibility for emotional disturbance was significant and positively associated with recurrence.
Multivariate model of recurrence (full model)
A Cox regression model was constructed for the full model, using the robust standard error estimates based on the sandwich estimator. The model was re-run for every additional cluster of variables entered from the child level, to the caregiver level, to the service level, to the community level with the Wald (sandwich) X2 reported for each cluster. Hazard Ratios are reported for the independent variables (). At each stage, the change in the model X2 was significant. Outside of retaining all child demographic variables, only those variables with significant coefficients or significant model effects were retained. Only the results from the final model or variables that changed across models are discussed in the text.
Cox Regression: Re-report of Maltreatment Among Children ages Birth through 11 years (n=4,957)
Child, index report, and family variables
Similar to bivariate results, the likelihood of recurrence declined according to the age of the child (HR =.970 [about 3% decrease in risk per year of age from birth through 11], p <.0001), but this was somewhat offset for children between 12 months and 36 months after the index report (child age and time interaction, HR = 1.026, p <.05). Race became significant after entering family characteristics (see Model 3, ), and children of color had about a 17% lower risk of being re-reported (HR =.825, p <.0001). Both physical abuse and sexual abuse cases were less likely to be re-reported than children with initial reports of neglect or mixed type. Substantiation status interacted with service provision (discussed below). Children reported along with other victims at the same time had about 22% higher risk of being re-reported. Having a caregiver that graduated high school reduced the risk of being re-reported (HR =.878, p <.0001), while having more siblings increased the risk (about 16% per recoded category per sibling in the family).
Caregiver history of mental health or substance abuse treatment prior to the index report was associated with higher risk of recurrence (HR = 1.576, p <.0001), but similar record after the index maltreatment report (or before recurrence) was not significant. A permanent (see Methods section) exit from a first known period on AFDC was associated with a decreased risk of re-reporting (HR =.878, p <.005 (if exited prior to index report); HR =.684, p <.005 (within 1 year of index or before recurrence)). Children whose cases indicated need for child welfare services but did not begin services had higher rates of recurrence (HR = 1.467, p <.005). The association between recurrence and participation in child welfare services varied by type of service, time after index report (for foster care), and substantiation. Among children whose cases were not judged to require services after the index report, children with substantiated cases had about a 30% higher rate of recurrence (HR = 1.293) than children with unsubstantiated cases. Children in families that received Family Centered Services (FCS) had lower rates of recurrence than those not served or who received more intensive in-home or foster care services (FCS: HR =.715, p <.005). Other child welfare service categories had significant interaction with substantiation status. For example, FPS services was associated with a higher risk of a re-report (O.R. = 1.44) that was entirely offset if the case was also substantiated (see Substantiation & FPS interaction HR =.553, p <.05). The relationships between foster care and re-reporting was even more complex. Children who entered (and exited) foster care had over twice the likelihood of a re-report (O.R. 2.49), but this was offset for cases who entered foster care following a substantiated report (O.R. =.48) and fully offset for children entering after a substantiated report for the first 57 months after the initial report (censoring out time in care) (O.R =.50)
The only census tract variable that remained significant was median household income. Each increase in $1,000 of income was associated with a half percentage point drop in risk (HR =.995, p <.005).
Model of re-reporting with children’s service participation (children over the age of 4 only)
The multivariate model for the restricted sample was constructed in the same way as for the full model (see ). Being female was associated with a decreased risk of recurrence until we controlled for child welfare service provision (compare Models 1–4 with 5 and after). Older children initially had higher rates of recurrence but this changed over time, dropping by about 0.002% per month, per year of age over the 90 months. Maltreatment type was not significant in the model restricted to older children. Compared to the full sample model, the receipt of FCS services was associated with lower recurrence, while foster care was associated with a greater risk of recurrence.
Cox Regression: Re-report of Maltreatment Among Children Ages 4 or Older (n=2,520)
Due to sample size, children’s cross-sector service participation before and after but within 1 year of the index event was collapsed into an ever used (yes/no) variable. Children with a record of Medicaid mental health or substance abuse treatment had about twice the risk of later recurrence (HR = 2.063, p <.0001). Children eligible for Special Education services for Emotional Disturbance had about a 50% higher risk of a re-report (HR = 1.493, p <.001). An interaction with time indicated that children eligible for special education for other disabilities (not Emotional Disturbance) had increased risk of a re-report only after about 3 years following the index report. Initially, children with juvenile court petitions had lower risk of recurrence (HR = 0.610, p <.05) but their risk increases over time at about 2% per month (HR = 1.020, p <.05, court petition * months interaction).