PMCCPMCCPMCC

Search tips
Search criteria 

Advanced

 
Logo of nihpaAbout Author manuscriptsSubmit a manuscriptHHS Public Access; Author Manuscript; Accepted for publication in peer reviewed journal;
 
Qual Health Res. Author manuscript; available in PMC 2018 January 1.
Published in final edited form as:
PMCID: PMC4955648
NIHMSID: NIHMS754224

What happened next: Interviews with mothers after a finding of child maltreatment in the household

Abstract

Child Protective Services (CPS) identifies over 700,000 victims of child maltreatment in the U.S. annually. Research shows that risk factors for these children may persist despite CPS intervention. Mothers have unique and often untapped perspectives on the experiences and consequences of CPS intervention that may inform future practice. We explored these perspectives through interviews with 24 mothers after a first-time CPS finding of maltreatment not resulting in out-of-home placement. Male partners were primary perpetrators in 21 cases, with mothers or sitters identified as perpetrators in remaining cases. Data were analyzed using grounded theory. Mothers described risk factors or Roots of maltreatment prior to CPS involvement and reported variable experiences with Recognition of and Response to maltreatment. Divergent Outcomes emerged: I Feel Stronger and We’re No Better. These findings provide an understanding of household experiences around child maltreatment that may support practice and policy changes to improve outcomes for vulnerable children.

Keywords: Child abuse, High risk families, Mothers, Determinants of Health, Interviews, Grounded Theory, Qualitative Analysis

Every year, Child Protective Services (CPS) substantiates reported concerns for child maltreatment (child abuse or neglect) in almost 1 in every 100 children in the United States (U.S. Department of Health and Human Services [USDHHS], 2015). One in eight children is identified as a victim of maltreatment during his or her childhood (Wildeman et al., 2014). Many children remaining in the home after maltreatment live with poverty and violence; many caregivers in these homes struggle with parenting challenges, social isolation, and depression (Campbell, Cook, Lafleur, & Keenan, 2010; Campbell, Thomas, Cook, & Keenan, 2012). Persistence of these risks may contribute to poor outcomes for many children with a history of maltreatment, including recurrence of maltreatment, placement in out-of-home care, and poor emotional and physical health (Connell, Bergeron, Katz, Saunders, & Tebes, 2007; Dakil, Sakai, Lin, & Flores, 2011; Flaherty et al., 2006; Hindley, Ramchandani, & Jones, 2006; Horwitz, Hurlburt, Cohen, Zhang, & Landsverk, 2011; Widom, Czaja, Bentley, & Johnson, 2012).

The moment at which CPS becomes involved in a household based on a mandated report of concern for maltreatment represents a unique opportunity to provide services and support to improve child outcomes. Child welfare caseworkers are asked by the state to provide resources to prevent future episodes of maltreatment and to remedy the “conditions that brought the children and their family to the attention of the agency” (USDHHS, 2015). Child welfare response to maltreatment is guided by administrative data describing the demographics (race, age, marital status); social risk indicators (caregiver mental health, substance use or abuse, family violence); and case characteristics (abuse type, severity, chronicity) closely associated with recidivism (Dakil et al., 2011; Drake & Jonson-Reid, 1999; Horwitz et al., 2011; Jonson-Reid, Emery, Drake, & Stahlschmidt, 2010; Shlonsky, 2007; Sledjeski, Dierker, Brigham, & Breslin, 2008). This aggregate data guides critical safety decisions regarding the need for out-of-home placement of a child or for protective orders against a violent caregiver.

Yet the majority of children found to be victims of maltreatment require neither out-of-home placement nor legal intervention. Eight out of ten children remain in the home after maltreatment, and just half of those children remaining in the home receive any ongoing services from child welfare workers (USDHHS, 2015). For children remaining in the home after maltreatment, administrative data maintained by a single agency cannot capture the diversity of circumstances and interactions, both inside and outside the child welfare system, that may influence short and long term outcomes. Although many families benefit from CPS involvement, well-documented persistence of household, caregiver, and child risk factors after CPS involvement suggests that additional information is needed to better understand how an episode of maltreatment may be used to effectively engage with families to address social risks present in the home.

Prior Research

The challenge of improving household conditions through CPS involvement for child maltreatment has stimulated researchers to examine the relationship between parents and child welfare workers. This relationship is most intense when child welfare workers are charged with the task of making the home of origin safe enough for the reunification of a child placed in foster care. Interviews with parents receiving services after placement of at least one child in foster care revealed a parental preoccupation with the perceived power of the child welfare system, described as “limitless” or “unstoppable” (Diorio, 1992). This conceptualization of the “limitless” power of CPS workers was expanded in a subsequent study of 18 parents with ongoing interventions through child protection agencies (Dumbrill, 2006). In these interviews, parents who experienced this power as something that was used “over” or “against” them by caseworkers made the choice to simply “play along with” or actively fight against agency interventions and meaningful change. In contrast, parents who described the power of the child welfare system as leverage to reunite with or improve conditions for children reported acceptance of agency interventions. Understanding parental perceptions of the power of caseworkers allows child welfare workers to recognize how their authority may be used “for” or “against” families during CPS involvement (Altman, 2003, 2008).

Along with identifying the perceived power of CPS workers, previous studies have explored how parental identity may influence parental response to CPS involvement in a household. Mothers of children placed in foster care struggle to preserve closely held constructions of identity as “good mothers” within a child welfare process which demands acceptance of a “bad mother” identity in order to achieve reunification with a child (Kenny, Barrington, & Green, 2015; Nixon, Radtke, & Tutty, 2013; Sykes, 2011). Other parents fight perplexing invisibility within the child welfare system. These “ghost” parents describe feeling unheard and unseen by child welfare caseworkers who are burdened with implicit biases and overwhelmed by protocols and timelines (L. Brown, Callahan, Strega, Walmsley, & Dominelli, 2009; Coady, Hoy, & Cameron, 2012). Researchers have used these findings to recommend caseworker support of the fragile identity of a “good” parent or recognition of the easily overlooked “ghost” parent within a household to promote more effective engagement with vulnerable or defensive parents around issues related to child maltreatment (L. Brown et al., 2009; Coady et al., 2012; Sykes, 2011).

Understanding parents’ perceptions of CPS intervention and the potentially strained relationships between CPS caseworkers and parents may lead to improved effectiveness of child welfare interventions after child maltreatment (Altman, 2003, 2008). All of these studies are limited, however, by a singular focus on the unique relationship between child welfare workers and parents in those cases where children have been removed from the home or where in-home services are in place to prevent removal. This intensive engagement with the child welfare system does not reflect the experiences of the majority of CPS-involved households. Despite the powerful significance of CPS involvement for many parents, interactions with the CPS caseworker may be limited when children remain in the home after a finding of maltreatment. In these cases, experiences outside of the interaction between caseworker and parent provide context for and influence outcomes of a case as much as CPS involvement itself. Community service providers, first responders, educators, health care providers, co-workers, friends, families, and others interacting with CPS-involved families may all shape outcomes for children with a history of abuse. Research exploring the professional and informal relationships and experiences that provide context for CPS involvement in a household is missing. The research presented here addresses this critical gap in understanding by investigating the experiences of mothers with a recent first-time CPS finding of child maltreatment not resulting in out-of-home placement.

Theoretical Framework

Our research is grounded in a biopsychosocial model of child development, developed by Bronfenbrenner and elaborated by many child health advocates over the intervening decades (Bronfenbrenner, 1979; National Research Council and Institute of Medicine [NRC/IOM], 2004; Center on the Developing Child at Harvard University [CDCHU], 2010). The biopsychosocial model conceptualizes child health and well-being as the malleable product of a longitudinal interaction between a child’s biology, behavior, and environment, influenced over time by societal policies and practices. This framework helps to highlight gaps in the current understanding of the experiences of children remaining in the home after maltreatment. Prior research isolating and describing the unique relationship between child welfare caseworkers and caregivers does not account the range of physical, emotional, and environmental changes affecting children after maltreatment. By focusing on the relationship between caseworker and caregivers in out-of-home placement situations, prior research also fails to capture policies and practices outside of the child welfare system that may have far more significant impact over time for children remaining at home after maltreatment. The biopsychosocial model suggests that a holistic approach to improved understanding of the changing child, caregiver, and household circumstances around an episode of child maltreatment may support future practice, policy, and research addressing child health and well-being after maltreatment.

Purpose of the Study

The purpose of the current study was to explore changes in child, caregiver, and household circumstances occurring within the window of opportunity provided by CPS involvement in a household. We wanted to begin to identify and understand the influential relationships, resources, and experiences for children who remained in the home after experiencing maltreatment and their families. Our study builds on previous explorations of parental experiences with child welfare agencies by describing how mothers perceive the household antecedents of, societal response to, and outcomes attributable to a CPS finding of child maltreatment in a household.

Method

Recruiting

The Utah Division of Child and Family Services mailed four waves of recruitment letters providing a study introduction to mothers of children remaining in the home after a first-time finding of maltreatment. Investigators contacted mothers 6–12 months after the first maltreatment concerns in the home. Exclusion criteria included a primary language other than English or Spanish, primary maltreatment type other than physical abuse or neglect, address outside of Utah, or subjective concern by the Division of Child and Family Services for safety as a result of recontact. The first author, not involved in CPS response, interviewed twenty-two mothers recruited through these letters, reflecting “typical” or “average” case sampling (Patton, 2015).

Preliminary analysis prompted investigators to seek confirmation or disconfirmation of emerging themes, using a process known as “theoretical sampling” (Charmaz, 2000). In order to interview mothers of children who had sustained more severe abusive injuries, investigators mailed recruitment letters to mothers of children with a recent inpatient diagnosis of child physical abuse by a child abuse pediatrician, with a medical record that reflected no prior CPS involvement and discharge home with the biological mother. The second author, not involved with child abuse consultations, interviewed two mothers recruited through this approach.

We limited our study population to maternal caregivers, recognizing that differences reflected by the rare father identified as the “primary caregiver” in this population would be difficult to interpret fairly. Similarly, we chose to include mothers of children with no prior history of CPS involvement, as the moment of first contact with outside agencies may reflect a unique moment for potential change in a family. Finally, we chose to focus on specific types of child maltreatment–physical abuse or neglect–understanding that antecedent conditions and longitudinal outcomes for child sexual abuse may be substantively different than those seen in physical abuse and neglect (Connell et al., 2007; English, Marshall, Brummel, & Orme, 1999; Hussey, Chang, & Kotch, 2006; Stith et al., 2009). This is particularly true in Utah, where any sexual contact involving minors, regardless of the relationship between partners, may be listed as child sexual abuse by the child welfare agency.

The University of Utah IRB and the Utah Department of Human Services IRB approved all research protocols. A certificate of confidentiality was obtained from the National Institutes of Child Health and Human Development. Each participant provided oral and written informed consent prior to beginning the research interview.

Participants

A total of twenty-four primary caregivers of children remaining in the home following a first-time finding of physical abuse or neglect formed the research sample. Twenty-one of the 24 participating mothers were White and non-Hispanic, reflecting the majority race and ethnicity of the region. Three mothers reflected non-majority racial and ethnic perspectives, including two Latina women (interviewed in Spanish) and one Filipina woman (first language Tagalog, interviewed in English). Most were cohabitating with a spouse (14 of 24) or significant other (3 of 24) at the time of CPS involvement in the home. One third (9 of 24) described personal experiences with intimate partner violence. There were one to three children living in each household, ranging from 0 to 15 years of age.

Although official outcomes of CPS investigations were not available to the investigators, all mothers described at least one episode of physical abuse associated with CPS involvement; six mothers described additional concerns for neglect or non-protection. Biological fathers represented the majority of reported perpetrators of maltreatment (16 of 24), while stepfathers and maternal boyfriends made up the next largest group of perpetrators (5 of 24). Mothers self-identified as substantiated perpetrators of physical abuse in one case and in four cases of non-protection in household with ongoing intimate partner violence. Two out-of-home sitters were also identified as perpetrators of physical abuse. Physical abuse was severe enough to require medical attention for fractures and/or head injury in four children. Five women described repeated CPS involvement in the household since the original investigation, and two reported out-of-home placement of their child in the intervening months as a result of CPS involvement for a new concern for maltreatment. At the time of the interview, most children continued to have regular contact with the perpetrator of abuse (15 of 24).

Data Collection

The investigators selected a set of domains to explore circumstances and relationships associated with outcomes of CPS involvement within the existing literature (List 1). Each interview began with an open-ended question: “Tell me how CPS became involved with your family, and what has happened since then.” Probes were used if needed to assure that each domain was covered over the course of the interview. Each 45–90 minute interview was conducted one-on-one and was audio-recorded and transcribed verbatim. Women received a $50 gift certificate for participation in the interview. Investigators recorded personal reflections after each interview to capture potential bias. Reflections were shared with the research team to further contribute to the trustworthiness of the study.

LIST 1
Topics covered within each interview.

Data Analysis

A modified grounded theory approach to data analysis was used to understand and interpret the shared experiences of the mothers. Grounded theory is defined by systematic collection and analysis of qualitative data to allow themes and theories to emerge from the data themselves rather than building from a priori hypotheses (Charmaz, 2000; Creswell, 2013). Transcribed interviews and personal reflections defined the qualitative data set. During initial coding, the first and second authors independently read transcriptions and assigned individual codes to experiences, reactions, and emotions described by the mothers. These authors met to discuss coding of each transcript, achieving consensus through discussion. Related and recurring codes were grouped and tentatively identified as themes, and new interview probes were introduced to gather convergent and divergent perspectives on these themes in subsequent interviews. All four investigators met to review selected transcripts and emerging themes throughout this process. Data collection was halted when investigators no longer identified new themes or unique perspectives on established themes (thematic saturation).

After initial coding of each transcript, the first author re-read interview excerpts within each theme, refining, collapsing, and expanding themes during the process of axial coding. Themes were named using original text fragments that captured the common content of the theme. Investigators then described the relationships among themes and how these relationships were associated with participants’ experiences. A summary of the findings was distributed to interested participants who could be contacted by telephone, email, or postal mail. A brief survey with both closed- and open-ended questions related to the findings was enclosed with the summary. Results of the survey provided a member check and were incorporated into the final analysis (Creswell, 2013). Of ten women contacted during analysis, six member check surveys were returned to the investigators. This iterative process identified common experiences of mothers around CPS involvement.

Results

Initial coding of interviews revealed a shared narrative thread related to longitudinal change (or expectation of change) around child maltreatment and CPS involvement in a household. Seen most clearly among women who described the emergence of a changed child, parent, or household after the experience of maltreatment and CPS involvement, this chronology was also identified in those women who found themselves “lost” despite involvement of multiple agencies around a concern for child maltreatment in the home. Growing from this, themes identified through the coding process were named based on the interview text and then grouped into categories to illustrate the progression of household experiences described by participants (Figure 1). Mothers described similar household risks and ineffective coping strategies, or Roots of maltreatment, prior to CPS involvement. In contrast, mothers reported variable experiences with Recognition of and Response to maltreatment. Growing from these experiences, two divergent Outcomes were seen: I Feel Stronger and We’re No Better.

Figure 1
In the visual representation of the results, pre-existing household risks are represented as tree Roots, with the diverging experiences of Recognition of and Response to abuse reflected as the central growth of the tree. A positive Outcome, I feel stronger ...

Roots

The family and community context in which concerns for maltreatment surfaced reflected many social risk factors associated with child maltreatment in prior research, such as substance abuse, depression, financial insecurity, or intimate partner violence. Participants also described pre-existing supports that were perceived to balance out these risk factors. Although these contextual Roots were shared across interviews, maternal interpretation of these factors influenced their subsequent processes of identification of, response to, and outcomes attributed to a finding of maltreatment in the household. We found that mothers attributed household stress to the presence of these risk factors; described efforts to reduce risk of abuse by monitoring and modifying a potentially abusive behavior; highlighted household strengths that modified existing risks; and weighed their own circumstances—usually positively—against the presentations of family violence and dysfunction represented in popular culture.

A stressful time

All but one mother reflected on household stressors that predated CPS involvement. Many reflected on longstanding marital problems associated with a spouse or partner’s mental illness, addiction, financial insecurities, and employment difficulties. One woman shared: “He has depression issues…he’ll rotate jobs and he’ll be unemployed for a while in between.” Frustration with child support and custody was common among divorced mothers, such as one who reported, “I took him to court for child support…and that was when it all started, that it just got worse.” As a way to cope, some mothers struggled to normalize their husbands’ unacceptable behaviors for children: “I’d say, ‘Oh, that’s not his beer in his hand, that’s his friend’s’…I lied to [the children] and hid it for probably a month or two.”

Children with pre-existing health conditions such as ADHD, autism, or developmental delay were another source of stress. Mothers reported their own frustration and empathized with their partners’ struggles in parenting a child with special needs: “He has some delays so he doesn’t speak well. He throws temper tantrums non-stop…It gets old. I’ve gotten to my wit’s end with him, before, too.” One mother of troubled children adopted out of foster care explained, “My husband just gets really frustrated…we don’t know how to do better.”

You mustn’t provoke him

Over half of the mothers recognized a potential for maltreatment prior to CPS involvement, explaining, “He hadn’t really done anything serious up until that point, but I could see the escalation, and I was worried that something could happen.” Some pointed to a personal history of child maltreatment, such as “[His] dad was up in the military, and there was corporal punishment…smack down punishment” and “His dad was abusive….it’s trickling down the line,” as a precursor to current problems. Mothers described efforts to avoid triggering a potential abuser, ranging from delicate negotiation of custodial arrangements, “If I was nice and didn’t do anything he would be nice enough to let me have the kids…I kind of learned that if I’m nice and don’t do anything, then he’s more willing to let me have the kids,” to teaching children to avoid conflict with a violent father, “She was disrespectful to him…He didn’t hit her full blast but enough to turn her face violently with a closed fist. She was in shock and said ‘Mom, why did my dad do that?’ I said, ‘You mustn’t provoke him because he gets worse.’”

It’s really nice, comforting

Although household stress was common, mothers also identified compensating household strengths. Mothers described the comfort associated with longstanding marriages, explaining, “I’ve been married 18 years…on the weekends me and my husband just spend time with the children” or “We’ve been married 30 years. Our relationship is always changing.” A history of time-tested marriage resulted in a balanced view of parenting frustrations. Despite battles with depression and alcoholism, a woman described her husband as “An awesome dad…he spends all his time with [the kids]. If he wants to go do something, they want to come so he takes them.” Although the strength of these established relationships did not protect against maltreatment, they could temper maternal reactions to a finding of maltreatment.

The two Latina mothers interviewed for this project provided a variation on this theme. Each woman described a long history of physical or emotional abuse, yet resolved to stay with her partner for cultural and religious reasons. “It was difficult for me to abandon the marriage for that reason and for what others may say, for my family, our parents, for the oath we made in front of God.” Even in the context of ongoing abuse, the traditional family was considered protective of women and children. Faced with the unraveling of an abusive marriage, the other reported, “I said, ‘My God, what’s going to happen with my life and with my children? I am far away from my country and my family and in another culture’…I felt very unprotected.” For both mothers, culturally embedded beliefs had to be overcome prior to acceptance of CPS involvement in the family.

There’s worse things out there

Women used this “big picture” of their households to distinguish between small episodes of violence present in their homes and the visible cases of child maltreatment reflected in the community or in the media. In their minds, their experiences of household dysfunction paled in comparison to popular images of family violence, with comments such as “It’s not like I feel like our family is constantly beating each other…I wouldn’t call us a typical violent family” or “When you think of abuse, you think of somebody who’s gonna beat up their kids, and that’s not him.” Several women reflected on child abuse fatalities in the news around the time of their interviews, saying, “There are kids out there, you know, babies who end up getting murdered by their parents.” Media portrayals of severe family violence and child abuse blurred the threshold between poor parenting and maltreatment for many women in this study.

Women who described severe, longstanding intimate partner violence provided extreme examples of how pre-existing family violence could be normalized. Two women were surprised to find that a child had witnessed the abuse, reporting, “I didn’t know how many times my son saw me being hit,” believing instead that “He only did it when they were asleep.” Another cited a protective motivation for staying with an abusive spouse, explaining, “It’s best to remain with [the] biological father. I’ve heard stories about stepfathers that are abusive to their children because they are not the biological children.” These women also described limited choices under dangerous circumstances. “It’s really hard when you’re in that situation. It is. If you leave he’s gonna kill ya. If you don’t leave you’re gonna die…something bad’s gonna happen all the time and there’s just not a lot of options.” Of note, CPS caseworkers found all three of the women who described severe intimate partner violence to be non-protective caregivers for their decision to remain with an abusive partner—decisions that the women believed to be protective of their children.

Recognition

For each woman interviewed, there was a moment of change, a point at which she recognized a child’s maltreatment or recognized CPS concern for her child’s maltreatment. Three distinct patterns of recognition were identified. In many cases, the circumstances of recognition colored maternal perceptions of the formal response to concerns of maltreatment in the months after case closure. These moments of recognition included instances in which mothers clearly saw or heard evidence of a child’s maltreatment, others in which mothers understood single events identified as maltreatment by CPS differently within the larger context of the household, and still others in which mothers—even months after CPS involvement ceased—never fully understood the CPS concerns for maltreatment in the household.

My new owie

For some women, recognition represented a “tipping point”–“That’s just when I realized…I’ve got to get these kids out of this situation.” Women in this group frequently initiated the CPS report of maltreatment, actively sought professional help in making a report, or were simply relieved when someone else made the report for them. This experience was most common in the face of clear physical evidence of maltreatment, as when one mother reported, “I’m shaking, because I just can’t believe it’s gotten to that point…I stripped her and you could even see a belt buckle mark on her back.” These moments were often memorialized by the child’s own description of maltreatment. “[He] said, ‘Mom, look at my new owie.’ And I looked at his leg and he had a mark…he had tears in his eyes and he said, ‘Daddy kicked me.’” This tangible evidence left little room for maternal doubt and facilitated recognition of maltreatment.

One of those fluke things

Other mothers expressed doubts over the concerns of maltreatment in the household. Boundaries between justifiable displays of emotions, corporal punishment, and physical abuse were a common source of confusion and frustration in these cases. “I guess something happened and [my boyfriend] grabbed him by the face and it left a mark, but the next day the mark was gone…He’s never left a mark on him before or did any kind of abuse to him, and first thing happens and it gets blown out of proportion.” In contrast to children who showed physical or emotional signs of maltreatment, these mothers described children who appeared almost indifferent to a recognized episode of violence. “She got on the bus and had told a little friend of hers what had happened, you know, ‘My dad smacked me because he’s just being mean and punched holes in my mom’s wall because he was mad.’…It sounded a lot worse than it was…after that, she came home and was fine and happy.” Women in this group were unlikely to make a CPS referral independently, and they more commonly felt that these referrals were out of context—“I think if they had known a little bit more about our situation they might not have reported”—or even set-backs to ongoing interventions to improve household stress—“We don’t really feel like it is an abusive situation. It’s just a not good situation between my husband and the boys and we are working on that.”

In the dark

In the third identified pattern of recognition, a lack of clarity around events subsequently described as maltreatment created confusion that persisted even after CPS involvement ended. Many times, the women had not witnessed the event: “I’m not really sure what happened because I wasn’t there. From what my husband has told me, [my son] was flipping out. I don’t know if he was pushing on my husband or trying to push by him or what. But my husband put him in a headlock. I don’t know if he was…they were by the stairs, and [my son] nearly took them both down the stairs, you know?” To try to better understand events that they either had not witnessed or did not understand what had happened, women often triangulated stories between the different children in the home. “I asked them, ‘What happened? Can you show Mommy what happened?’ And they did; and my oldest, she said she didn’t know….I just sat [my youngest] down and I asked her, I said, ‘Do you think daddy hurt you?’ And she goes, ‘No, daddy didn’t hurt me.’ So” Another woman who initially held doubts about her husband’s claim of accidental injury explained, “I asked all the kids, you know, and they all had the same story [of accidental injury], so I didn’t doubt it. You know, if it was just coming from [my husband], I might have doubted it.” As in all cases where clear evidence of abuse was lacking, these women never initiated a CPS report. Unfortunately, their doubts were not always resolved with CPS involvement. Even caseworkers seemed, at times, unsure of how to manage these cases. After the investigating caseworker told one mother that her son’s black eye was “probably a pure accident,”…“[he] said that any time there’s a parent-child collision of some kind, they have to list it as abuse.” For these women, persistent confusion made recognition of maltreatment almost impossible despite the recognition that CPS had made a finding of maltreatment.

Response

The response to maltreatment within each household reflected varying involvement of state agencies (CPS, police, and legal agencies); community service providers (child advocacy centers, victim advocates, and parenting resource agencies); health providers (mental health and medical); and informal support structures (family, friends, and workplace). Mothers’ perspectives on this response to maltreatment included mixed feelings about a loss of control related to outsider interventions in the household; feelings of gratitude for the actions and individuals that responded to perceived needs; and feelings of loss, frustration, or anger over responses that seemed inadequate or inappropriate for the needs that mothers identified in their households.

Out of your hands

Women described both hope and fear in response to the loss of control associated with entry of outside agencies into the household. Fear of child removal from the home was common: “[It’s] a fear in the back of your mind, ‘Am I perfect enough to be able to keep my children?’” This fear was supported by recalled histories of friends or family who had children in foster care. Several women described safety concerns: “I was scared that….if we called the police or something, he would become more aggressive with me” or long-term consequences of CPS involvement: “[I was] a little bit concerned, because, you know, I need the child support and alimony to live…there was a risk that, you know, he might lose his job over this.” In contrast, others welcomed outside involvement with a sense of hope: “I was hoping it would be good and that things would change and we could all just get along better” or relief: “I started thinking to myself, ‘Okay, this is now out of your hands’…. I could have tried to hide it or whatever, but I just kind of thought to myself, ‘You know what? I’m so tired of the violence.’”

The best help

Women identified specific aspects of the professional response to maltreatment from CPS caseworkers, law enforcement, victim’s advocates, educators, and health care workers that made a lasting, positive impact. What women described as “the best help” came from many directions and was often contrast with less effective interventions. Efforts to assure family safety were described as helpful, even among women who had not previously considered themselves at risk of harm. One woman who did not report prior experience with intimate partner violence described a conversation that helped her to understand the pre-existing risk in her home: “The victim’s advocate, she said… ‘Have you ever tried [getting a protective order]? Would you consider this? We’re so concerned. He has all of the signs of [an] abusive domestic violence person that’s going to snap. He’s escalating.’” Community-based family violence programs were also identified as supportive both emotionally and materially, as in the case of one woman who recalled, “The people at the [Child Advocacy] Center were definitely the most helpful…they got us a list of resources to begin with. They gave us paperwork for the Crime Victim’s Reparations and they actually mailed it in for us that day because they knew it would take a while.”

Women expressed gratitude for simple expressions of empathy from responding professionals: “I just will never forget when I was sitting there, and I was just crying my eyes out, and we were talking about, like, what had gone on and his injuries; and somebody from [CPS] said, ‘Tell me what you’re—what are you feeling right now?’ Just that question, just the personal how are doing, are you okay…that goes so far.” A Latina woman ostracized from her community after leaving an abusive spouse drew strength from a CPS caseworker who was able to support her identity as a “good mother” even as her friends and family questioned her choices: “He told me one or two things that I have to tell you…, ‘First of all, I congratulate you in your decision…That is a very controlling man, very possessive, and it’s going to require a lot of hard work from you to get rid of him…I hope,’ the social worker said, ‘for your sake and the sake of your daughters, that you continue firm in your decision.’…It made me feel more certain…it gave me strength to continue forward in my decision.”

Although several mothers described interactions with health care providers in documentation of injuries and reporting of abuse concerns, none identified a primary health care provider as a source of support in the response to child abuse without direct probes from the interviewer. One woman did describe a supportive and empathic interaction when following up with her son’s physician, “I didn’t think of saying anything to the pediatrician, but he just started to talk to my son; and…he just very plainly said to my son, ‘You know, just like you get to make choices, mom and dad get to make choices and sometimes they don’t make good choices and it sounds like dad didn’t make a very good choice—but that doesn’t mean he doesn’t love you’; and so, yeah, I think his pediatrician was very, very helpful in just being plain and simple.” This experience was unique among the women interviewed. Most seemed surprised by the idea of discussing abuse concerns with their child’s pediatrician: “I try not to mention all the negative things going on…I wouldn’t go in and tell her [about the abuse]….I mean, I just don’t think that that’s anybody’s business. I don’t know. It doesn’t really seem to relate to what she needs to know from a doctor’s standpoint. You know, unless, I mean, if we were coming in there and he had an injury.”

Many women identified non-professional supports that were likely invisible to the professional responders. Family members and friends provided support and advice for women overwhelmed by the recognition of child maltreatment and the professional response to this. One woman defined specific roles for different members of her social support network after her ex-husband abused their young son: “[My grandma] was more of a listening board, sounding board, so she gave me ideas; and whatever I thought I could use I would take that and use it. [My boyfriend] was more of a moral support; and he took over when I wasn’t able to go on any further….[The rest of my family], they’re just a drama in a bucket.” Three women aligned themselves with retired CPS caseworkers as trusted guides of a complex system: “[My CPS caseworker] had a couple of names of places to call…but I wasn’t really listening. I just had it in my head that I would call T., because I knew he would tell me who I could talk to….he’s a great person, T. is. He’s retired [from CPS] now.” Several others developed friendships within their communities based, in part, on a shared history of family violence and child abuse. One mother reflected on her weeks in an intimate partner violence shelter, “You would meet the girls there that was in a similar situation. CPS, they had CPS as well, and they had perpetrators, and they had lost their children as well because of violence or drugs or whatever. And it was just a place where you could talk, and it was safe.” These friendships provided more global perspectives on family violence, agency response, and outcomes of abuse than women could access on their own as they moved through this process. “A friend of mine…her husband beat her kids, like, left marks, and she’s like, ‘You need to leave. You need to call [CPS]… You need to take care of this now because it’s not going to get better unless something changes.’” Friends with these shared histories acted as mentors during CPS involvement: “I think her experience may actually help mine be a little better, and that’s why I [thought], ‘I’m calling her. I’ll just call and ask her.’” These alliances persisted even after CPS involvement ended: “We were kind of acquaintance friends but since this has happened we’re like best friends…I call her quite often and we chat at church every Sunday about what’s happened that week and what I’m struggling with… I’m the same with her.”

Women defined the characteristics of support that contributed to feelings of security or self-sufficiency. Well-intentioned but proscriptive interventions were rarely welcomed. One woman shared a colorful quote from the therapist who was a sole source of support after a bitter CPS investigation, “’You know,’ he says, ‘When somebody’s drowning, you don’t yell at them and say, “Hey idiot, you shouldn’t have got in the water!” and you don’t tell them, “Hey, do it this way!’” Professionals who tried to expand rather than narrow available options were typically perceived to be most successful. One woman identified her Department of Workforce Services counselor as her most supportive contact: “She kinda helped me decide what I needed to do, you know? She was very open to whichever path I chose.” Several women described positive outcomes for children who had the opportunity to make choices after maltreatment. “They gave my daughter this list…of ‘what do you want to happen to him?’ So we went down the list. I explained to her what each thing was and I said to her, ‘So what do you want?’ She goes ‘I want anger management classes for him.’…and he went to the counseling classes and they actually helped.” Providing choice, within safe boundaries, was almost always well received.

It would have been nice

Although all women described supportive encounters related to CPS involvement in the household, all also described a lack of communication or contact during the investigation. Mothers were able to identify simple steps that would have been supportive and helpful in guiding them through this process, at times prefacing these statements with, “It would have been nice if ….” Women clearly identified steps that might have improved outcomes during these professional contacts. In the early stages of investigation, this information gap compounded maternal anxiety. After being picked up from work by police investigators, one woman reported, “I kept asking, ‘Can I see my kids?’ You know, ‘If it’s so bad, let me see. Please let me see’…they wouldn’t show me. They wouldn’t let me see my kids and they just kept going around.” Another woman who noted a dramatic change in her son’s behavior after his interview with CPS repeated the theme, “I don’t know what happened [in the interview], so I can’t help my son.” Without key information about the interview of her son by CPS caseworkers, she could not help him.

The majority of women interviewed recalled only one or two brief interactions with a CPS caseworker. This minimal involvement resulted in frustration. One woman explained, “I saw her maybe 10 minutes…I realize that they’re busy, I realize that they have a large caseload, but…this is a kind of negative thing in life, I would expect follow-up. ‘Hey, we closed the case…We didn’t find anything.’” In cases involving potentially violent partners, a lack of communication left women feeling unsafe or vulnerable. Even in cases with substantial initial CPS involvement, ongoing communication was lacking. The mother of a young infant found to have abusive head trauma inflicted by the father reflected, “Nobody has tried to talk to me about it. I got a call from a cop, like, three months after the incident and he just—he made me feel like he was accusing me of something…he’s like ‘Okay, we’ll follow up with you,’ and I never heard anything from him, ever. Not [CPS], not the police, not [the hospital], nobody.”

These limited contacts contributed to disappointment for mothers who had initial hope for improvements based on CPS involvement. “I didn’t feel like [the caseworker] listened to me at all…I tried to be really honest and say there are some things that I want changed at my house, but she didn’t take any notes. She didn’t ask me questions, she just…went back to her office and wrote it up.” At times, limited contact with investigating agencies contributed to a feeling of being judged or misunderstood by the system. “I didn’t really like the fact that they had already passed their judgment on [my husband]. I mean, that was very unsettling to me.”

Outcomes

We identified two themes reflecting distinct outcomes after abuse—We’re Not Better and I Feel Stronger. Subthemes emerged within each of these topics to expand the meaning of these outcomes for families with a history of child maltreatment.

We’re not better

The subthemes that follow reflect disappointment or frustration that recognition of and response to maltreatment had not improved the root causes of maltreatment and, in some cases, may have increased risks in the household.

Swept under the rug

The lack of close contact with investigating agencies contributed to a common perception that the system was driven more by efforts to follow protocol than to achieve change for affected families: “I felt like they were just doing their policies and their procedures and they didn’t really give a crap about me or my kid.” A formal letter substantiating the finding of maltreatment that women received months after final contact with CPS seemed to confirm this impression: “The only reason I found out the case was closed was because of the letter he got. Otherwise, it was just a mystery. And I realized that our case wasn’t severe like some of them that they see, but it was severe for us.” Although women recognized that brief CPS involvement was unlikely to solve significant problems in the home, they expressed regret that so little effort was made to link families with prevention and treatment services. “It was a very violent incident that happened, so I guess you could say that I’m pretty appalled that there wasn’t, ‘Here’s these resources if you feel like you need the help.’” A number of women wished that CPS might check in after case closure as a means of addressing household stresses that had contributed to abuse and remained unchanged despite a finding of abuse: “In a way, it would be good if CPS came back and said, ‘Well, are you really better?’” Although women with more severe cases of maltreatment described more contact with investigating agencies than many, there was still a shared sense of being “dropped” by CPS too quickly. A woman who left her boyfriend after a severe episode of child physical abuse explained, “People that still have abuse in their families seem to get all this help from [CPS]… I hear that from my friends all the time. ‘[CPS] checks up on us for this, [CPS] checks up on us for that.’ Well, what about the families where there is no abuse left? I mean, sometimes they need help too. Even though there’s no physical abuse left, they still need resources and stuff to hold them…Sometimes you’re not ready when you’re right there, fresh wounds at the hospital….”

It was hard

The professional response to child maltreatment was perceived, at times, to place an unfair burden on the non-perpetrating parent. “The second [caseworker], she was really adamant that I needed to do something about the situation. Which was true, but there wasn’t really any help offered, you know? She didn’t send us any resources, either.” Safety plans often failed to account for the realities of split work schedules or cars that could not carry all the children in the family. Even when there was no explicit expectation for the non-perpetrating parent from CPS, women frequently shouldered additional parenting roles: “I have to be the bad person and the good person all in one, and I don’t like being both at the same time.” Women who lost financial stability after separation from an abusive spouse, left a job to stay home with children, or entered the job force to support the family described material hardships after a finding of abuse: “Half my income just walked out the door….I’m behind on my mortgage, like four months, so I would have appreciated more concern into that end of it. It was nice that they wanted to make sure…that my kids were physically safe in the immediate, but looking at the long-term repercussions of what happened, I think that should have been a higher priority.”

I am very cautious

Finally, women described the emotional strain of moving forward after child maltreatment. Several women described persistent fears of having children “taken” for minor problems after an investigation. Others reported fears of leaving their child with a spouse or a sitter in the future. Similarly, women who left abusive relationships noted that it would be difficult to trust a new partner or an estranged spouse: “I’m very wary of having to send them with their dad on his days that he has them. I still get butterflies and kind of sick to my stomach when I have to send them.” For the many women who continued to live with the alleged perpetrator, this struggle was perhaps most difficult. “Ever since then,” explained one mother, “I’ve been more cautious. I pay more attention to the stupid little things…His parents have a running joke. It’s like, ‘Oh, don’t touch her, you might bruise her.’ It’s a big old joke. They just laugh about it, [and] I try and laugh, but I take everything a little more seriously. So I am very cautious.”

I feel stronger

In contrast to We’re No Better, the subthemes below captured changes contributing to new security or strength growing from the recognition of and response to abuse.

No yelling, no hitting

More than half of the women interviewed felt that the formal response to child maltreatment in the home contributed to meaningful changes to high-risk parenting behaviors such as less yelling, shouting, and spanking. Although some changes were rooted in fear, “I think it really put the fear of God into my husband…you know, people are going to watch out for [our] family,” other changes were attributed to positive intervention. For example, a woman who described previous failed efforts to keep her husband from losing his temper with the children reported positive changes in his parenting after taking step-parenting classes required by CPS:“A lot of people are just like, ‘Whatever, I’m not going to go, it’s just a class,’ but he took it for what it was and, you know, he came out of there learning things. I saw it.” She returned to the impact of the training, explaining, “Even now, just stepping back and watching…I can see him using some of the [parenting] techniques without him even realizing he’s using them.” Mothers who originally dismissed CPS involvement later acknowledged changing their parenting behaviors as a result, “Because of [CPS’s] involvement… I had to take a long look at how I discipline my children. I was raised with spanking, and so I was spanking my children. I had to learn that even an open hand is considered a weapon.”

We’ll protect you

Mothers described increased confidence in their own ability to protect children from the psychological sequelae of child maltreatment and family violence. For some, this was relatively uncomplicated: “We just don’t bring it up anymore. It was in the past, it was something that had happened.” Others managed more difficult symptoms from children after abuse, such as the perseverative fears described by one mother: “M.’s a bad guy, Mom, what if M. comes here?’…And I always tell him, ‘It’s ok, M.’s not going to hurt you. He can’t come here. He can’t, [or] he’ll go to jail.’” Many women were able to identify and access mental health resources for their children and reported positive benefits when these resources were accessed. One woman with children who had significant health concerns attributed to long-standing violence explained, “The therapy has helped so much. They’re expressing their feelings more and want to do more.” Although few mothers described referrals resulting from CPS involvement, many others sought out services through any and all means—victim’s advocates, trusted friends, and internet searches— in order to find the “best fit” for their children. “I wanted somebody for my daughter that has studied and deals more with the 0–2 year olds…I talked to them both before they did an intake on both of my kids and just felt like they would both work.”

Sure of myself

Many women identified new strengths in themselves and their families that had emerged from recognition of and response to maltreatment. One woman described newfound confidence after a child’s disclosure of maltreatment by her ex-husband: “[Before], he was always putting me down, making me feel small; and I retreated to my shell. I’m able to come out of that, and so that’s definitely changed things….I’ve come to realize, you know, that none of it was my fault. None of it was my children’s fault, and so everything I did was in the best interest of them.” Another attributed similar changes to the CPS caseworker involved in her case: “There was the encouragement from the social worker that I will never forget…That is what helped me most to maintain that decision not to hurt my daughters, and that’s why I stayed [away from him].” Even for women who viewed an episode of abuse as a “fluke” event, CPS intervention offered opportunity for positive change: “I think things have worked out the way they’re supposed to…It was a very unfortunate incident that happened in our life; however, we are taking the approach of, we need to learn from it and move forward.” Other women reiterated the belief that outside intervention had improved family communication around critical parenting issues: “[CPS] made our family stronger in a way…We can talk more, and we can trust each other more. There’s a thing that says, ‘When there’s …, ’ I don’t have the quote exactly, but with some traumatic event, it strangely brings things back together. It makes something stronger.”

Discussion

Mothers of children remaining in the home following CPS substantiation of maltreatment hold unique insight into the pre-existing conditions in the household, recognition of maltreatment, responses to maltreatment, and outcomes attributed to these experiences. From the contextual roots of child maltreatment, through recognition by mothers of the problem, responses by both professional agencies and individual acquaintances, and finally to divergent outcomes, we found that mothers reflected different experiences within a shared pathway. Although no mother in our study described a uniformly positive or negative outcome following an episode of child maltreatment, each woman linked particular elements of her personal experiences to the positive or negative outcomes she identified. Our analysis identified those shared paths, from pre-existing roots to post-investigation outcomes, which may inform professional response to child maltreatment.

This shared pathway through an episode of child maltreatment investigated by CPS serves as a small-scale model for the biopsychosocial theory within which this research is framed. The roots of child maltreatment described by mothers reflected the biological, behavioral, and environmental risk factors described in earlier child maltreatment research (J. Brown, Cohen, Johnson, & Salzinger, 1998; Sidebotham, Heron, & Team, 2006). Almost all women described pre-existing stress related to reordered families, intimate partner violence, parenting difficulties, mental illness, substance abuse, financial strain, and child vulnerabilities. The moment of recognition of maltreatment—or of the concern for maltreatment—offered the potential for accelerated longitudinal change in these circumstances and represented the first point of differentiation for many women. We found that women who saw or heard clear evidence of maltreatment did not struggle as much to understand concerns for maltreatment when compared to women who remained “in the dark” regarding events substantiated as maltreatment through CPS investigation. The experience of a “tipping point” in the recognition of maltreatment allowed women to progress forward and engage more constructively in responding to maltreatment in the household.

Mothers made associations between the response to suspicions of child maltreatment, both professional and informal, and the outcomes for their children and families. Women associated minimal engagement with CPS and other professionals, abandonment by family and friends, or isolation and stigmatization during the investigative process with more negative outcomes. Without adequate support along the pathway of CPS involvement for child maltreatment, women described frustration with broken promises and fear of unknown consequences that persisted in the months after case closure. Women who had more sustained contact with professional response systems, even hostile contact, typically described more positive outcomes. Ironically, women who expressed anger and frustration towards the caseworkers, judges, counselors, and others who set high expectations were often those women who expressed the most gratitude for tangible changes in their families. Women were unlikely to identify medical providers as part of this professional response system. Women who had minimal contact with the professional response systems but who identified strong informal supports to help them recognize and respond to maltreatment were also likely to describe positive outcomes. Regardless of the intensity or outcome of professional involvement in the household, women frequently identified this period as an opportunity to address existing stress or dysfunction.

As in prior research, opportunities for mothers to define priorities for their households contributed to positive outcomes for interventions around an episode of child maltreatment (Altman, 2003). Offering mothers the chance to make reasonable choices for themselves and their children recognized and supported the self-identity of the “good mother” which can be threatened by CPS involvement around an episode of child maltreatment (Sykes, 2011). This threat to identity was reflected by those mothers who recounted stories of friends and family who had children removed by CPS and questioned, “Am I perfect enough to be able to keep my children?” By expanding our perspective beyond the caseworker-parent relationship, we were able to understand that mothers in our study often relied upon informal supports within their communities to identify choices and guide decisions. Mothers maintained this “good mother” identity during CPS involvement in the household or reclaimed this identity once CPS involvement ceased through connections with retired CPS caseworkers, local storeowners, trusted educators, or church acquaintances. For women who could identify neither professional nor informal supports, efforts to re-establish the “good mother” identity were difficult. These women shouldered additional parenting responsibilities (“it was hard”) to compensate for persistently dangerous or apathetic partners—who served as continuing reminders of unresolved risks within the household.

Our study focused on mothers of children who remained in the home after a finding of maltreatment, and our findings can be contrasted with prior research with mothers of children placed in out-of-home care or receiving ongoing services after maltreatment. Similar to previous studies, many mothers hinted at the imbalance of power present in interactions between CPS caseworkers and parents (Diorio, 1992; Dumbrill, 2006). The “gut response” to CPS involvement voiced by many of the women in our study—a fear of child removal or loss of household autonomy—reflected the real and perceived power of CPS that colors almost all interactions between caseworkers and clients. In our study, however, only those two mothers with children who subsequently entered foster care described persistent concerns about the power exercised by CPS. For mothers with less CPS involvement, concerns about agency power were typically fleeting or abstract, reflected in worries about the impact of a CPS finding of abuse on employment, foster and adoption opportunities, or future CPS involvement in the home. Informal community supports commonly served as a primary source of information related to agency power. These experiences highlighted again the important but often unrecognized role of other professionals and community members in defining experiences and shaping outcomes for households after CPS involvement for child maltreatment.

Limitations

Our findings must be considered in light of limitations specific to the study. The experiences of our participants may reflect specific characteristics of a single state and may not reflect demographic/cultural concerns or system responses in other regions of the United States. In addition, due to legal and ethical protections of CPS-involved families, we relied upon first contact by interested mothers who received recruiting letters from CPS or from medical providers. It is likely that different experiences with CPS or with medical providers may have influenced an eligible mother’s decision to contact the research team. Investigator bias is a potential limitation in all research, but is considered a particular challenge to qualitative methodology. By relying on a systematic, team-based approach to data collection and analysis, introduction of bias was identified and reduced. Integration of responses of six participants to preliminary results gives additional validation to the findings reported. As researchers, we would like to have been able to pinpoint exactly what roots, recognitions, and responses led to divergent outcomes. While there were shared pathways, as portrayed in Figure 1, we cannot know that if these patterns might alter a child’s trajectory from abuse to outcomes. However, participants’ narratives were rich with what was helpful and supportive as well as what was potentially harmful or unhelpful. It is these perspectives that we believe may inform future research, practice, and policy with this population.

Implications

Our prior research using large-sample survey data identified minimal change in household risk factors after CPS involvement for child maltreatment (Campbell et al., 2010; Campbell et al., 2012). Findings from the current study support these earlier findings and suggest opportunities to improve engagement with mothers within these households. Women frequently saw CPS involvement in the household as an opportunity to address long-standing risks and expressed frustration when professionals failed to identify risks present in the household during an investigation for maltreatment. Lack of initial transparency or subsequent contact during the course of the investigation created distrust in the systems involved. Transparency and communication, as allowed by safety, helped women understand and respond protectively for children in the household.

CPS workers, responding investigators, health care providers, and educators may improve outcomes by treating non-perpetrating parents as collaborators rather than informants. Providing parents with sufficient information to support decision-making is critical to the longitudinal well-being of these households. Although not always possible, providing clarity around specific concerns of maltreatment to a protective parent may increase her engagement with offered services. Collaborating with parents to develop a multi-disciplinary plan to address existing household risks as well as acute child safety may improve long-term outcomes. Finally, professionals responding to child abuse or neglect should recognize the importance that informal supports serve for women as they move through an investigation. Mothers may rely on community contacts—particularly retired professionals or community members with shared experience with family violence and child welfare—as key resources and advisors during CPS involvement in the home. These same mothers may become mentors for future women in similar circumstances. Better understanding of the role of these informal support systems in shaping outcomes for families after maltreatment is needed.

Our findings reinforce efforts to expand support for families with recent CPS involvement through child welfare and/or appropriate community resources. Recognizing the unique opportunity presented by CPS involvement in the home, these findings should encourage broader assessment of strengths and needs during an investigation rather than a narrow focus on risk and safety. Providing mothers with opportunities for growth by connecting families with local resources to address self-identified household needs may improve acceptance of requirements or restrictions needed to assure safety. Health care providers should recognize that violence and abuse may be an unrecognized presence in the lives of children seen in their clinics and that parents may welcome outreach to children affected by these issues. Further, health care professionals—particularly pediatricians–can improve communication by educating patients’ parents about the relevance of reporting issues related to the psychological, as well as physical, wellbeing of their children. Finally, all professionals who respond to concerns of child maltreatment should recognize that their difficult work with high-risk families is often appreciated, despite initial anger and resistance of families. Mothers in these households experience reverberations long after CPS involvement has ceased, and the impact of meaningful words and actions for these mothers may persist long after shock or anger related to the investigation has faded.

Acknowledgments

The authors thank the Utah Division of Child and Family Services, which helped to contact women eligible for these interviews, and the participating women, who shared their stories with us.

Funding acknowledgment: Research reported in this manuscript was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health under award number K23HD059850. The content is solely the responsibility of the authors and does not represent official views of the National Institutes of Health.

References

  • Altman JC. A Qualitative Examination of Client Participation in Agency-Initiated Services. Families in Society: The Journal of Contemporary Social Services. 2003;84(4):471–479.
  • Altman JC. Engaging families in child welfare services: Worker versus client perspectives. Child Welfare. 2008;87(3):41–61. [PubMed]
  • Bronfenbrenner U. The ecology of human development: Experiments by nature and design. Cambridge, MA: Harvard University Press; 1979.
  • Brown J, Cohen P, Johnson JG, Salzinger S. A longitudinal analysis of risk factors for child maltreatment: findings of a 17-year prospective study of officially recorded and self-reported child abuse and neglect. Child Abuse & Neglect. 1998;22(11):1065–1078. [PubMed]
  • Brown L, Callahan M, Strega S, Walmsley C, Dominelli L. Manufacturing ghost fathers: the paradox of father presence and absence in child welfare. Child & Family Social Work. 2009;14(1):25–34.
  • Campbell KA, Cook LJ, Lafleur BJ, Keenan HT. Household, family, and child risk factors after an investigation for suspected child maltreatment: a missed opportunity for prevention. Archives of Pediatrics & Adolescent Medicine. 2010;164(10):943–949. [PMC free article] [PubMed]
  • Campbell KA, Thomas AM, Cook LJ, Keenan HT. Longitudinal experiences of children remaining at home after a first-time investigation for suspected maltreatment. Journal of Pediatrics. 2012;161(2):340–347. [PMC free article] [PubMed]
  • Center on the Developing Child at Harvard University. The Foundations of Lifelong Health Are Built in Early Childhood. 2010 http://www.developingchild.harvard.edu.
  • Charmaz K. Grounded theory: Objectivist and constructivist methods. In: Denzin NK, Lincoln YS, editors. Handbook of Qualitative Research. Second. Thousand Oaks, CA: Sage Publications; 2000. pp. 509–535.
  • Coady N, Hoy SL, Cameron G. Father’s experiences with child welfare services. Child & Family Social Work. 2012;18(3):275–284.
  • Connell CM, Bergeron N, Katz KH, Saunders L, Tebes JK. Re-referral to child protective services: the influence of child, family, and case characteristics on risk status. Child Abuse & Neglect. 2007;31(5):573–588. [PubMed]
  • Creswell JW, editor. Qualitative inquiry and research design: Choosing among five approaches. 3rd. SAGE Publications; 2013.
  • Dakil SR, Sakai C, Lin H, Flores G. Recidivism in the child protection system: identifying children at greatest risk of reabuse among those remaining in the home. Archives of Pediatrics & Adolescent Medicine. 2011;165(11):1006–1012. [PubMed]
  • Diorio W. Parental perceptions of the authority of public child welfare caseworkers. Families in Society. 1992;73(4):222–235.
  • Drake B, Jonson-Reid M. Some thought on the increasing use of administrative data in child maltreatment research. Child Maltreatment. 1999;4(4):308.
  • Dumbrill GC. Parental experience of child protection intervention: a qualitative study. Child Abuse & Neglect. 2006;30(1):27–37. [PubMed]
  • English D, Marshall DB, Brummel S, Orme M. Characteristics of repeated referrals to child protective services in Washington state. Child Maltreatment. 1999;4(4):297–307.
  • Flaherty EG, Thompson R, Litrownik AJ, Theodore A, English DJ, Black MM, Dubowitz H. Effect of early childhood adversity on child health. Archives of Pediatrics & Adolescent Medicine. 2006;160(12):1232–1238. [PubMed]
  • Hindley N, Ramchandani PG, Jones DP. Risk factors for recurrence of maltreatment: a systematic review. Archives of Diseases in Childhood. 2006;91(9):744–752. [PMC free article] [PubMed]
  • Horwitz SM, Hurlburt MS, Cohen SD, Zhang J, Landsverk J. Predictors of placement for children who initially remained in their homes after an investigation for abuse or neglect. Child Abuse & Neglect. 2011;35(3):188–198. [PMC free article] [PubMed]
  • Hussey JM, Chang JJ, Kotch JB. Child maltreatment in the United States: prevalence, risk factors, and adolescent health consequences. Pediatrics. 2006;118(3):933–942. [PubMed]
  • Jonson-Reid M, Emery CR, Drake B, Stahlschmidt MJ. Understanding chronically reported families. Child Maltreatment. 2010;15(4):271–281. [PMC free article] [PubMed]
  • Kenny KS, Barrington C, Green SL. “I felt for a long time like everything beautiful in me had been taken out”: Women’s suffering, remembering, and survival following the loss of child custody. International Journal of Drug Policy. 2015;26(11):1158–66. [PubMed]
  • National Research Counciland Institute of Medicine. Committee on Evaluation of Children’s Health Board on Children, Youth, and Families, Division of Behavioral and Social Sciences and Education. Washington, DC: The National Academies Press; 2004. Children’s Health, the Nation’s Wealth: Assessing and Improving Child Health.
  • Nixon KL, Radtke HL, Tutty LM. “Every Day It Takes a Piece of You Away”: Experiences of Grief and Loss Among Abused Mothers Involved With Child Protective Services. Journal of Public Child Welfare. 2013;7(2):172–193.
  • Patton MQ. Qualitative research and methods: Integrating theory and practice. Fourth. Thousand Oaks, CA: SAGE Publications, Inc; 2015.
  • Shlonsky A. Initial construction of an actuarial risk assessment measure using the National Survey of Child and Adolescent Well-Being. In: Haskins R, Wulczyn F, Webb MB, editors. Child protection: Using research to improve policy and protection. Washington, D.C.: The Brookings Institute; 2007. pp. 62–80.
  • Sidebotham P, Heron J, Team AS. Child maltreatment in the “Children of the Nineties”: A cohort study of risk factors. Child Abuse & Neglect. 2006;30(5):497–522. [PubMed]
  • Sledjeski EM, Dierker LC, Brigham R, Breslin E. The use of risk assessment to predict recurrent maltreatment: A Classification and Regression Tree Analysis (CART) Prevention Science. 2008;9(1):28–37. [PMC free article] [PubMed]
  • Stith SM, Liu T, Davies LC, Boykin EL, Alder MC, Harris JM, Dees JEMEG. Risk factors in child maltreatment: A meta-analytic review of the literature. Aggression & Violent Behavior. 2009;14(1):13–29.
  • Sykes J. Negotiating stigma: Understanding mothers’ responses to accusations of child neglect. Children & Youth Services Review. 2011;33(3):448–456.
  • U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau. Child Maltreatment 2013. 2015 Available from http://www.acf.hhs.gov/programs/cb/research-data-technology/statistics-research/child-maltreatment.
  • Widom CS, Czaja SJ, Bentley T, Johnson MS. A prospective investigation of physical health outcomes in abused and neglected children: New findings from a 30-year follow-up. American Journal of Public Health. 2012;102(6):1135–1144. [PubMed]
  • Wildeman C, Emanuel N, Leventhal JM, Putnam-Hornstein E, Waldfogel J, Lee H. The prevalence of confirmed maltreatment among U.S. children, 2004 to 2011. JAMA Pediatrics. 2014;168(8):706–713. [PMC free article] [PubMed]