Maltreated Infants: Identifying Factors
Associated with Poorer Outcomes
Anita Scarborough, Ph.D.
Frank Porter Graham Child Development Institute
University of North Carolina
Julie McCrae, MSW, Ph.D.
University of Pittsburgh, School of Social Work
Child Welfare Education and Research Programs
The research for this presentation was funded by the Administration on Children, Youth, and
Families of the U.S. Department of Health and Human Services, Award 90PH0014.
2007 OSEP National Early Childhood Conference
Marriott Crystal Gateway Hotel
Organization of Presentation
1.
2.
3.
4.
Data Source
Research Questions
Findings
Discussion
Implications for Service Provision
2
Source of Information
• The Administration for Children and Families
(ACF), funded the National Survey of Child and
Adolescent Well-Being, the first national
probability study of children and adolescents
investigated by Child Welfare Services.
• Baseline data was collected in 1999 and 2000.
• This session will present the developmental
characteristics of a nationally representative
sub-sample of 1,196 infants, representing
149,398 maltreated infants shortly after
investigation and again, 3 and 4½ years later.
3
Long-term Outcomes of Abused
and Neglected Children
• More likely to be arrested as juveniles, to
become pregnant during adolescence, use
drugs, have lower grade point averages, and
experience mental health problems.
• 16% of males and 57% of females in State
prisons experienced childhood physical or
sexual abuse.
• Research has become quite conclusive
regarding the negative impact of the experience
of child maltreatment on adult outcomes in
cognitive, economic and mental health domains.
4
Growing Public Awareness and Policy Change
• Amendment of the Child Abuse and Prevention
Treatment Act (CAPTA, 2003) “requires referral of a child
under the age of 3 who is involved in a substantiated
case of child abuse or neglect to early intervention
services funded under Part C” (section
106(b)(2)(A)(xxi)).
• The Individuals with Disability Education Act (IDEA,
2004), requires state Part C programs to have a
description of their policy and procedures that require the
referral for early intervention services for children under
the age of 3 who are involved in a substantiated case of
child abuse or neglect. Eligibility requirements for Part C
are determined by individual states.
5
Definition of Substantiation
• Where the allegation of maltreatment was
supported or founded by state law or state
policy (US Department of Health and
Human Services, 2006).
• Each state requires a specific standard of
proof to substantiate maltreatment.
6
Part C Services
• The goal of Part C is to provide services to children from
birth through two years of age with disabilities.
• Children in this age range experiencing developmental
delays, as defined by the individual states, are entitled to
services.
• States vary according to the agency serving as the lead
agency, the eligibility definition for delay, if services are
provided to children “at risk” for developmental delays
(currently 5 states), and in the percentage of children
served.
• Part C services are provided to 2.4% of children between
birth and 2 years of age nationally. The percentage of
children and families served among the individual states
varies, ranging from 1.34 to 6.71% (U.S. Department of
Education, 2006).
7
Basis for the Research
• An under utilization of Part C services among
maltreated infants and toddlers, based on scores
on developmental measure shortly after
investigation by child welfare, has been reported
(Rosenberg et al., 2004; Stahmer et al., 2005;
Zimmer & Panko, 2006),
• Clearly it difficult to determine developmental
delay as an eligibility criteria among infants who
do not have established risk conditions.
• This study is looking at the developmental
characteristics of maltreated infants over time to
stress the need for intervention services, and to
determine factors present in infancy associated
with poorer developmental outcomes.
8
Research Questions
• What are the characteristics of infants, their caregivers
and type of maltreatment shortly after the time of
investigation by Child Welfare Services?
• Are there discernible developmental profiles for
maltreated infants, 3 and 4½ years after investigation?
• What proportion of maltreated infants were reported to
have an IFSP 12 months after investigation and what
proportion had an IEP 4½ years later?
• Are characteristics of maltreated infants, their
caregivers, or maltreatment type related to
developmental outcomes 4½ years later?
• What do those findings suggest about the need for Part
C early intervention services?
9
Characteristics of Maltreated Infants
•
•
•
•
•
•
Age
Gender
Race
Health Status
Neurodevelopmental risk status as assessed by
the Bayley Neurodevelopmental Screener
Cognitive development as indicated by scores
in the cognitive domain of the Battelle
Developmental Inventory
10
Caregiver Characteristics
•
•
•
•
•
•
•
•
Age
Education
Cognitive impairment
Mental illness/depression
Substance abuse
Domestic violence
Poverty
Poor quality home environment as
measured by the HOME
11
Maltreatment Characteristics
• Prior reports of maltreatment
• Maltreatment type
– Physical abuse
– Sexual abuse
– Physical neglect
– Supervisory neglect
– Other
• Maltreatment case substantiated
• Reported level of harm to the child
• Child placed out of home
12
Developmental Characteristics Examined
3 and 4 ½ Years after Investigation
•
•
•
•
•
Cognitive development
Language skill
Adaptive behavior
Behavioral concerns
Loneliness & social dissatisfaction
13
NSCAW Sample
6,231 children, birth to 14 years of age, who had contact with the Child
Welfare System
Over Sampled on the basis of:
•
Children/Families Receiving Child Welfare Services
•
Infants
•
Sexually Abused Children
Baseline collection from Nov. 1999 to Apr. 2001
•
Follow-Ups at 12, 18, 36, and 54 months after baseline
•
12 month follow-up included only limited data collection
•
54 months follow-up currently available only on infants
at baseline
Measures
Neurodevelopment
Bayley Infant Neurodevelopmental Screener
(BINS; 0-2 years)
Cognitive Domain
Battelle Developmental Inventory – Cognitive
Domain (BDI; 0 – 3 years)
Kaufman Brief Intelligence Test (K-BIT; 4+ years)
Adaptive Behavior Domain
Vineland Adaptive Behavior Scale Screener,
Daily Living Skills sub-domain (VABS)
Communication Domain
Preschool Language Scale-3 (PLS-3)
15
Measures
Behavior Domain
Child Behavior Checklist (CBCL; 2+ years for
parent; 5+ years for teacher)
Socialization
Loneliness and Social Dissatisfaction
Questionnaire for Young Children (self report
5+ years)
Home environment
The Home Observation for Measurement
of the Environment (HOME)
16
Definition of Delay
• Children scoring 1.5 standard deviations or more below
the mean on a developmental measure were considered
to have a delay.
• High Risk for subsequent developmental difficulties
based on the BINS.
Described 3 and 4 ½ years later using:
• PLS – 3
• VABS
• CBCL- parent and teacher
• KBIT
• Loneliness & Social Dissatisfaction
17
Characteristics of Infants Investigated by Child Welfare
Age in months at baseline
%
0-6
45
7-12
55
Male
49
Race/ethnicity
White
44
African-American
30
Hispanic
21
Other
5
Fair/poor health
8
High risk on the BINS
53
18
Caregiver Characteristics
At baseline
%
Less than high school education
37
Cognitive impairment
13
Mental illness/depression
34
Active or history of domestic violence
56
Poverty
45
Low score on HOME
12
High number of risk factors
34
19
Caregiver Characteristics
Female Caregiver age
Education-level
8
32
37
19 to 34
35 and older
68
<HS
HS or GED
College
55
20
Household Characteristics
60
48
Proportion
50
45
40
30
23
20
11
10
0
TANF
recipient
At or below
poverty line
Single
parent
4 or more
children
21
Family Risks
34
Substance abuse
41
Prior reports
61
High stress
31
Low social support
Trouble paying basic
necessities
35
0
10
20
30
40
50
60
70
Proportion with risk present
22
Characteristics of Maltreatment
At baseline
%
Prior report of maltreatment
41
Maltreatment type
Physical abuse
20
Sexual abuse
2
Physical neglect
40
Supervisory neglect
33
Other
5
Severe level of harm
16
Clear evidence of maltreatment
41
Worker reports the child has special needs
14
Maltreatment substantiated
38
Out of home placement
22
23
Low Scores at Baseline by Age in Months
25
0-6 mos.
7-12 mos.
21
20
16
14
15
10
10
5
3
1
0
Cognitive
Language
Adaptive Behavior
24
High Risk on BINS by Age at Baseline
80
70
69
Proportion
60
50
39
40
30
20
10
0
0-6 mos
7-12 mos
25
Low Scores 3 Years Later, by Age
at Baseline
Domain
0-6 mos. 7-12 mos.
%
%
Total
%
Cognitive
37
32
34
Language
35
38
37
Adaptive Behavior
25
10
17
At least 1
Problem score
59
57
57
26
Combinations of Low Score Areas
3 Years After Baseline
Developmental areas
%
No problem scores
42
Cognitive
12
Language
14
Adaptive behavior
6
Cognitive & Language
15
Adaptive + Cognitive or
Language
5
All problems
6
Total
100
27
Low Scores 3 Years after Baseline by
Race/ethnicity
50
45
40
35
47 46
Black
White
Hispanic or other
32
30
25
20
19
17
19
14
12
15
10
9
14
8
12
8 7
4
3
5
0
No
problems
p<.10
Cog only
Lang only
Adaptive
Behav only
Cog +
Lang
7
5
Adaptive
Behav +
Cog or
Lang
6
4
7
All
28
Low Scores 3 Years After Baseline by
Gender
60
48
50
40
Boys
Girls
36
30
20
19
20
14
10
10
9
10
8
4
8
3
6
6
0
No
Cog only Lang only Adaptive
problems
Behav
only
Cog +
Lang
Adaptive
Behav +
Cog or
Lang
All
p<.05
29
Infants with an IFSP,
or 4 ½ Years Later an IEP
IFSP in the12 months after baseline
32%
IEP 54 months after baseline
20%
IFSP 12 months, or IEP 54 months after baseline 37%
Those with an IEP who also had an IFSP
54%
30
Teacher Report of Areas of Concern for
Those with an IEP
Category
%
Category
%
Learning disability
24
Speech language delay
66
Autism
18
Traumatic brain injury
5
Emotional disturbance
22
ADHD
25
Mental retardation
15
Developmental disability
26
Multiple disabilities
11
Visual impairment
2
Orthopedic
6
Deafness or hearing
impaired
2
Other/unknown
13
31
Low Score Areas 4 ½ Years Later, by Age
at Baseline
Domain
Cognitive
0-6 mos. 7-12 mos.
%
%
16
11
Total
%
13
Language
27
21
25
Adaptive Behavior
42
28
34
At least 1
Problem score
45
44
55
32
Focus on Low Language Scores 4 ½
Years after Baseline (PLS-3)
• Low language scores associated with:
– Severe level of harm reported at baseline (p<.05)
– High risk rating on the Bayley scales of infant
neurodevelopment at baseline (p<.001)
• No association with:
–
–
–
–
–
Child demographic characteristics
Maltreatment characteristics, including substantiation
Caregiver risks, age, education-level, poverty status
Poor quality home environment
Baseline cognitive delay
33
Low Language Scores
4 ½ Years after Baseline
Regression using child characteristics, R-square: .03
Baseline characteristic
Odds of age 5
language delay
p-value
Age: 0-6 months
1.36
.47
Male
1.41
.24
Black
.67
.42
Hispanic or other
.88
.71
Poor physical health
1.08
.80
High risk BINS
1.46
.28
Cognitive delay
1.52
.19
34
Low Language Scores 4 ½ Years after Baseline
Regression using child & caregiver characteristics, R-square: .17
Baseline characteristic
Odds of age 5 language delay
p-value
Age: 0-6 months
1.12
.80
Male
1.87
.15
Black
.41
.16
Hispanic or other
1.64
.36
High risk BINS
2.34
.11
Poor health
3.00
.03
Cognitive delay
.69
.53
Caregiver age: <35 years
1.20
.80
<HS education
.57
.29
10.59
.01
Mental illness
.22
.05
Substance abuse
1.65
.43
Domestic violence
2.46
.14
Below poverty line
.86
.80
Poor quality home environment
1.08
.87
Caregiver cognitive impairment
35
Low Language Scores 4 ½ Years After Baseline
Regression with child, caregiver & maltreatment characteristics, R-square: .27
Baseline characteristics
related to low language scores
Odds of age 5
language delay
p-value
16.12
.02
Caregiver mental illness
.20
.03
Prior reports
.27
.05
Severe level of harm
7.77
.02
Caregiver cognitive impairment
Statistical trends (p<.10): High risk BINS, domestic violence, “Other” as the
primary type of maltreatment
36
Predictors of IEP 4 ½ After Baseline
Regression with child, caregiver & maltreatment characteristics, R-square: .26
Baseline characteristics
related to Special
Education 4 ½ years later
Odds of having an IEP
p-value
Male
5.00
.01
Child cognitive problem
.21
.02
13.21
.002
.30
.03
Caregiver cognitive
impairment
Caregiver mental illness
Statistical trends (p<.10): Age 0-6 months at baseline, Hispanic, low level of
child harm
37
Emotional-behavioral Problems
Reported 4 ½ Years Later
% with clinical-level score
Teacher report Parent report
Problem type
Total problems
Internalizing
Externalizing
9
9
13
21
7
20
38
Self-report of Loneliness and Social
Dissatisfaction 4 ½ Years Later
Age at baseline
0 – 6 months
7 – 12 months
Total
% 1 SD or greater
above the mean
16%
11%
13%
39
Summary
• More than half of maltreated infants are at high risk for
poor developmental outcomes, based on the presence of
multiple risk factors such as high family stress (61%),
single parent (48%), and domestic violence (56%),
coupled with a low score on a measure of cognition,
language or neurodevelopmental risk status (BINS).
• 32% of maltreated infants were reported to have an IFSP
in the period of time 12 months after baseline.
• Three years after baseline more than half are reported to
have a delay in at least one of the domains measured,
with cognitive (12%) and language delays (14%) being
the most common.
• Three years after baseline 74% of boys were reported to
have a low score in at least one domain.
40
Summary
• Using language as a global marker of
development revealed infant & caregiver
characteristics associated with low scores 4 ½
years later:
– Poor infant health
– Caregivers with a cognitive impairment
– Caregiver mental illness was associated with reduced likelihood
of language delay
• Likely due to the self-report, laptop computer method used to have
caregivers describe their mental health/depression
• Adding maltreatment characteristics, infant
health was no longer predictive, but reported
severity of harm was.
• Prior report of maltreatment was negatively
related to language delay.
41
Summary continued
• When infants were 5 years of age, 1/5 of
them were reported to have an IEP, but
only about half of those children were
reported to have had an IFSP.
• Factors associated with having an IEP 4 ½
years later:
– Male infants
– Caregiver cognitive impairment
– Infant cognitive problem (-)
– Caregiver mental illness (-)
42
Summary continued
• Maltreated infants at five years of age:
–
–
–
–
–
25% low score on a language measure
20% IEP
13-20% reported to have clinical level externalizing problems
7-9% reported to have clinical level internalizing problems
13% of the children report loneliness or social dissatisfaction
• Factors in infancy found to be associated:
– Infant poor health
– Caregiver cognitive impairment
– Severe level of harm
• Maltreatment characteristics not found to be associated:
– Substantiation
– Poverty - though these children are disproportionately poor
– Out of home placement
43
Discussion Points
• Have Part C services been adapted to meet the needs of
these children and families?
• Many maltreated infants have multiple risk factors,
recognized as a Part C eligibility in only a few states, yet
these findings support the increased likelihood of poor
outcomes for these children.
– What can be done to help meet the needs of these children and
families and to help children get services earlier?
• Has the CAPTA requirement to refer substantiated
infants and toddlers resulted in more children being
served?
• Substantiation is the criteria for referral, yet these
findings show that this is not significantly related to
outcomes.
44
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Visit Project Website for updates:
http://www.fpg.unc.edu/~promise/
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