Fetal Alcohol Spectrum Disorder: What does Public Awareness Tell Us about Prevention Programming?

The prevalence of Fetal Alcohol Spectrum Disorder (FASD) does not appear to be diminishing over time. Indeed, recent data suggests that the disorder may be more prevalent than previously thought. A variety of public education programs developed over the last 20 years have promoted alcohol abstention during pregnancy, yet FASD remains a serious public health concern. This paper reports on a secondary data analysis of public awareness in one Canadian province looking at possible creative pathways to consider for future prevention efforts. The data indicates that the focus on women of childbearing age continues to make sense. The data also suggests that targeting formal (health care providers for examples) and informal support (partner, spouse, family, and friends) might also be valuable. They are seen as sources of encouragement, so ensuring they understand the risks, as well as effective ways to encourage abstinence or harm reduction, may be beneficial for both the woman and the pregnancy. Educating people who might support a woman in pregnancy may be as important as programs targeted towards women who may become or are pregnant. The data also suggests that there is already a significant level of awareness of FASD, thus highlighting the need to explore the effectiveness and value of current prevention approaches.

A scoping review of evidence-based interventions available to parents of maltreated children ages 0-5 involved with child welfare services.

Parents referred to child welfare services for child maltreatment often struggle against chronic risk factors including violence, substance abuse, mental health concerns, and poverty, which impinge upon their ability to be sensitive caregivers. The first line of intervention within the child welfare context is to modify parenting behavior. This scoping review comprehensively surveyed all available literature to map the extent and range of research activity around the types of interventions available within a child welfare context to parents of infants and toddlers (0-5 years of age), to identify the facilitators and/or barriers to the uptake of interventions, and to check that interventions match the risk factors faced by parents. This scoping review engaged in stringent screening of studies based upon inclusion/exclusion criteria. Sixty-five articles involving forty-two interventions met inclusion criteria. Interventions generally aimed to improve parenting practices, the relationship between parent and child, and/or attachment security, along with reducing child abuse and/or neglect. A notable finding of this scoping review is that at present, interventions for parents of children ages 0-5 involved with the child welfare system are most frequently measured via case study and quasi-experimental designs, with randomized control trials making up 26.2% of included study designs.

Exploring alternate specifications to explain agency-level effects in placement decisions regarding Aboriginal children: Further analysis of the Canadian Incidence Study of Reported Child Abuse and Neglect Part C.

A series of papers using data from the Canadian Incidence Study of Reported Child Abuse and Neglect (CIS) explored the influence of clinical and organizational characteristics on the decision to place Aboriginal children in out-of-home placements at the conclusion of child maltreatment investigations. The purpose of this paper is to further explore a consistent finding of the previous analyses: the proportion of investigations involving Aboriginal children at a child welfare agency is associated with placement for all children in that agency. CIS-2008 data were used in the analysis, which allowed for inclusion of previously unavailable organizational and contextual variables. Multi-level statistical models were developed to analyze the influence of clinical and organizational variables on the placement decision. Final models revealed that the proportion of investigations conducted by the child welfare agency involving Aboriginal children was again a key agency-level predictor of the placement decision for any child served by the agency. Specifically, the higher the proportion of investigations of Aboriginal children, the more likely placement was to occur for any child. Further, this analysis demonstrated that structure of governance, an organizational-level variable not available in previous cycles of the CIS, is an important agency-level predictor of out-of-home placement. Further analysis is needed to fully understand individual and organizational level variables that may influence decisions regarding placement of Aboriginal children.

Differentiating between child protection and family support in the Canadian child welfare system's response to intimate partner violence, corporal punishment, and child neglect.

Rates of reported child maltreatment nearly doubled in Canada over the period 1998-2003, an increase that reflects growing awareness of the harmful effects of an expanding array of parental behaviors, including corporal punishment, lack of supervision, and exposure to intimate partner violence (IPV). Some of these situations may benefit from voluntary family support programs outside of the child welfare system. Analyzing a sample of 11,807 investigations, this paper compares cases where the sole concern is exposure to IPV, or hitting a child, or neglect, or other forms of investigated maltreatment. Situations where exposure to IPV or potentially abusive hitting were the sole reason for investigation presented with fewer risk factors and were less likely to lead to ongoing child welfare interventions compared to other maltreatment investigations. While situations involving alleged neglect presented a higher risk profile and elicited a more intensive child welfare response than did exposure to IPV or hitting, opportunities for alternative services were nevertheless identified. The study also found that visible minority families were overrepresented in cases involving hitting and that Aboriginal families were overrepresented in cases involving neglect. Overall the findings support the development of alternative response programs in Canada.

Understanding the investigation-stage overrepresentation of First Nations children in the child welfare system: an analysis of the First Nations component of the Canadian Incidence Study of Reported Child Abuse and Neglect 2008.

OBJECTIVES: The overrepresentation of Aboriginal children in child welfare systems in the U.S., Canada, and Australia is well documented, but limited attention has been paid to investigation-stage disproportionality. This paper examines the overrepresentation of First Nations (the largest of three federally recognized Aboriginal groups in Canada) children, focusing on three questions: (1) What is the level/nature of First Nations overrepresentation at the investigation stage? (2) What is known about the source of referrals in child welfare investigations involving First Nations children? (3) What risk factors and child functioning concerns are identified for investigated First Nations children and families? METHODS: The First Nations Component of the Canadian Incidence Study of Reported Child Abuse and Neglect (FNCIS-2008) was designed to address limitations in existing Aboriginal child welfare data: it sampled one quarter of the Aboriginally governed child welfare agencies that conduct investigations in Canada, gathered data on over 3,000 investigations involving First Nations children, and incorporated weights designed for analysis of First Nations data. Bivariate analyses are used to compare investigations involving First Nations and non-Aboriginal children. RESULTS: The rate of investigations for First Nations children living in the areas served by sampled agencies was 4.2 times that for non-Aboriginal children; investigation-stage overrepresentation was compounded by each short term case disposition examined. A higher proportion of First Nations than non-Aboriginal investigations involved non-professional referrals, a pattern consistent with disparities in access to alternative services. Workers expressed concerns about multiple caregiver risk factor concerns for more than ½ of investigated First Nations families and, with the exception of "health issues", identified every caregiver/household risk factor examined in a greater percentage of First Nations than non-Aboriginal households. CONCLUSIONS: It would be extremely difficult to reduce First Nations overrepresentation at later decision points without addressing overrepresentation at the investigation-stage. Despite the serious needs of investigated First Nations families, alternatives to traditional child protection responses may be appropriate in many cases. If First Nations overrepresentation is to be reduced, child welfare agencies must be equipped to provide supports needed to help families address factors such as poverty, substance abuse, domestic violence, and lack of social supports.

Exploring alternate specifications to explain agency-level effects in placement decisions regarding aboriginal children: further analysis of the Canadian Incidence Study of Reported Child Abuse and Neglect Part B.

OBJECTIVE: This paper builds upon the analyses presented in two companion papers (Fluke et al., 2010; Fallon et al., 2013) using data from the 1998 and 2003 cycles of the Canadian Incidence Study of Reported Child Abuse and Neglect (CIS-1998 and CIS-2003) to examine the influence of clinical and organizational characteristics on the decision to place a child in out-of-home care at the conclusion of a child maltreatment investigation. This paper explores various model specifications to explain the effect of an agency-level factor, proportion of Aboriginal reports, which emerged as a stable and significant factor through the two data collection cycles. It addresses the issue of data comparability between the two cycles and explores various re-specifications and descriptive analyses of reported models to evaluate their solidity with regards to the sampling schemes and the precise contribution of a multi-level specification. METHODS: The decision to place a child in out-of-home care was examined using data from the CIS-2003. This child welfare dataset collected information about the results of nearly 12,000 child maltreatment investigations as well as a description of the characteristics of the workers and organization responsible for conducting those investigations. Multi-level statistical models were developed using MPlus software, which can accommodate dichotomous outcome variables and are more reflective of decision-making in child welfare. The models are thus multi-level binary logistic regressions. RESULTS: Final models revealed that two agency-level variables, 'Education degree of majority of workers' and 'Degree of centralization in the agency' clarify the nature of the effect of 'Proportion of Aboriginal reports', a stable, key second level predictor of the placement decision. The comparability of the effect of this agency-level variable across the 1998 and 2003 cycles becomes further evident through this analysis. By using a unified database including both cycles and various specifications of models, the comparability was found to be robust, in addition to clarifying the precise contribution of a multi-level specification. CONCLUSIONS: This third paper in a series establishes the 'Proportion of Aboriginal reports' received by the child welfare agency as an important agency level predictor associated with a child's likelihood of being placed in the Canadian child protection system. While the more complex models give support to the notion that unequal resources subtend those results, more analyses are needed to confirm this hypothesis. Unequal resources for agencies with larger Aboriginal caseloads may explain the persistence of the results. These findings suggest that specific resource constraints related to worker education may be explanatory.

Placement decisions and disparities among Aboriginal children: further analysis of the Canadian incidence study of reported child abuse and neglect part A: comparisons of the 1998 and 2003 surveys.

OBJECTIVE: Fluke et al. (2010) analyzed Canadian Incidence Study on Reported Child Abuse and Neglect (CIS) data collected in 1998 to explore the influence of clinical and organizational characteristics on the decision to place Aboriginal children in an out-of-home placement at the conclusion of a child maltreatment investigation. This study explores this same question using CIS data collected in 2003 which included a larger sample of Aboriginal children and First Nations child and family service agencies. METHODS: The decision to place a child in an out-of-home placement was examined using data from the Canadian Incidence Study of Reported Child Abuse and Neglect-2003 and a reanalysis of CIS-1998 data (Fluke et al., 2010). The CIS-2003 dataset includes information on nearly 12,000 child maltreatment investigations from the time of report to case disposition. The CIS-2003 also captures information on the characteristics of investigating workers and the child welfare organizations for which they work. Multi-level statistical models were developed to analyze the influence of clinical and organizational variables using MPlus software. MPlus allows the use of dichotomous outcome variables, which are more reflective of decision-making in child welfare and facilitates the specific case of the logistic link function for binary outcome variables under maximum likelihood estimation. RESULTS: Final models revealed the proportion of investigations conducted by the child welfare agency involving Aboriginal children was a key single agency level predictor of the placement decision. Specifically, the higher the proportion of investigations of Aboriginal children, the more likely placement was to occur. Contrary to the findings in the first paper (Fluke et al., 2010), individual Aboriginal status also remained significant in the final model at the first level. CONCLUSIONS: Further analysis needs to be conducted to further understand individual and organizational level variables that may influence decisions regarding placement of Aboriginal children. There is also a need for research that is sensitive to differences among, and between, Métis, First Nations and Inuit communities. Results are not generalizable to Québec because data from this province were excluded.

Shifting definitions of emotional maltreatment: an analysis child welfare investigation laws and practices in Canada.

OBJECTIVE: Although there is growing evidence that the emotional dimensions of child maltreatment are particularly damaging, the feasibility and appropriateness of including emotional maltreatment (EM) in child welfare statutes continues to be questioned. Unlike physical and sexual abuse where investigations focus on discreet incidents of maltreatment, EM is not as easily defined and delimited. Through a review of legislation and child welfare investigation practices in Canada, this paper examines (1) whether Canadian child welfare services respond to EM with the same level of perseverance as with other forms of maltreatment and (2) the extent to which the introduction in 2008 of a more specific EM taxonomy distinguishes between EM and family problems that could lead to EM. METHOD: Following an analysis of the legislative framework for EM across Canada, investigations practices in Canada are examined using data from the 1998, 2003 and 2008 cycles of the Canadian Incidence Study of Reported Child Abuse and Neglect (CIS). Using data from the 2008 cycle, EM investigations are compared to other maltreatment investigations for all of Canada (N=15,980). Changes in EM investigations over time are then compared using data from the three cycles of the study, excluding Québec because of limited data availability in 2003 (N=5,360 in 1998, 11,562 in 2003 and 14,050 in 2008). RESULTS: EM is included as a form of reportable maltreatment in all provincial and territorial statutes in Canada. Over 11,000 cases of EM were substantiated in Canada in 2008, at a rate of 1.86 cases per 1,000 children. While EM investigations were substantiated at a lower rate as other forms of maltreatment, a higher proportion of EM cases were referred for specialized services, kept open for on-going child welfare services, lead to an out of home placement, and lead to an application to child welfare court. Using a broad definition of EM the number of investigations classified as EM in Canada, excluding Québec, nearly tripled from 1998 to 2003. In 2008, using more specific definitions focusing on caregiver definitions, the number of investigations classified as EM nearly returned to their 1998 level, with nearly twice as many cases being classified as risk of future maltreatment. CONCLUSION: EM is a well established category for child welfare intervention in Canada, however, more emphasis should be given to distinguishing between EM and family problems that place children at risk of EM.

Should child protection services respond differently to maltreatment, risk of maltreatment, and risk of harm?

OBJECTIVE: To examine evidence available in large-scale North American datasets on child abuse and neglect that can assist in understanding the complexities of child protection case classifications. METHODS: A review of child abuse and neglect data from large North American epidemiological studies including the Canadian Incidence Study of Reported Child Abuse and Neglect (CIS), the National Child Abuse and Neglect Data System (NCANDS), and the National Incidence Studies of Reported Child Abuse and Neglect (NIS). RESULTS: The authors of this paper argue that recent evidence from large North American epidemiological studies examining the incidence of child abuse and neglect demonstrate that children and families identified as being at risk of maltreatment present with as many household and caregiver concerns as investigations that are substantiated. CONCLUSIONS: In order to continue to develop appropriate services and policies for vulnerable children the authors urge continue definitional clarity for research in child maltreatment that considers the exemplars or indicators of categories, in tandem with parental and child characteristics which can provide one source of evidence-basis to meaningful child protection case classifications. Continued monitoring, refined by the dilemmas faced in practice, are critical for a continued public health investment in children's well-being, predicated upon upholding children's rights.

Methodological challenges in measuring child maltreatment.

OBJECTIVE: This article reviewed the different surveillance systems used to monitor the extent of reported child maltreatment in North America. METHODS: Key measurement and definitional differences between the surveillance systems are detailed and their potential impact on the measurement of the rate of victimization. The infrastructure requirements, quality of information, timely access to data and the usefulness for child welfare policy are compared and contrasted and a summary table of the type of information by each system is presented. RESULTS: Two studies collect data regarding the extent and nature of child maltreatment using survey methodology reported to professionals: the United States National Incidence Study of Child Abuse and Neglect (NIS) and the Canadian Incidence Study of Reported Child Abuse and Neglect (CIS), and the United States National Child Abuse and Neglect Data System (NCANDS) uses administrative data methods to collect annual case-level and state data. PRACTICE IMPLICATIONS: The purpose of this comparison is to assist researchers and policy analysts with interpreting data from these studies as well as to help officials from other countries in developing surveillance systems that are appropriately adapted to their needs.

Placement decisions and disparities among aboriginal groups: an application of the decision making ecology through multi-level analysis.

OBJECTIVE: This paper examined the relative influence of clinical and organizational characteristics on the decision to place a child in out-of-home care at the conclusion of a child maltreatment investigation. It tested the hypothesis that extraneous factors, specifically, organizational characteristics, impact the decision to place a child in out-of-home care. A secondary aim was to identify possible decision making influences related to disparities in placement decisions tied to Aboriginal children. Research suggests that the Aboriginal status of the child and structural risk factors affecting the family, such as poverty and poor housing, substantially account for this overrepresentation. METHODS: The decision to place a child in out-of-home care was examined using data from the Canadian Incidence Study of Reported Child Abuse and Neglect. This child welfare dataset collected information about the results of nearly 5,000 child maltreatment investigations as well as a description of the characteristics of the workers and organization responsible for conducting those investigations. Multi-level statistical models were developed using MPlus software, which can accommodate dichotomous outcome variables, which are more reflective of decision making in child welfare. MPlus allows the specific case of the logistic link function for binary outcome variables under maximum likelihood estimation. RESULTS: Final models revealed the importance of the number of Aboriginal reports to an organization as a key second level predictor of the placement decision. It is the only second level factor that remains in the final model. This finding was very stable when tested over several different levels of proportionate caseload representation ranging from greater than 50% to 20% of the caseload. CONCLUSIONS: Disparities among Aboriginal children in child welfare decision making were identified at the agency level. PRACTICE IMPLICATIONS: The study provides additional evidence supporting the possibility that one source of overrepresentation of Aboriginal children in the Canadian foster care system is a lack of appropriate resources at the agency or community level.

Level of street involvement and health and health services use of Calgary street youth.

OBJECTIVES: To examine differences in health risks, health outcomes and health services use of Calgary street-involved youth by level of street involvement to inform services planning. METHOD: 355 street-involved youth (61% male, 26% Aboriginal) completed surveys at a variety of outdoor and agency locations: 46% currently lived on the street, 33% had lived on the street in the past, and 20% were street-involved but had not lived on the street. Odds Ratios (OR) adjusted for sex, ethnocultural group, and age group were calculated for each health/health risk and health service factor by level of street involvement. RESULTS: With the exception of condom use, significant health and health risk outcome differences were seen by level of street involvement. Use of hospitals and walk-in clinics did not differ significantly by level of street involvement; however, youth living on the street were less likely (OR 0.2) than those who had not lived on the street to use a physician during office hours, and those who had lived on the street were more likely (OR 10.1) to use mobile clinics, services that are targeted to street-involved people. CONCLUSION: Street-involved youth who had not lived on the street showed better health/health risk outcomes than those who currently or had lived on the street, and health services use showed some differences by level of street involvement. Public health and other service providers need to be cognizant of their role in providing prevention, safety or stabilization services for youth at different stages of street life.

Differentiating between substantiated, suspected, and unsubstantiated maltreatment in Canada.

The decision to substantiate is a key factor in determining eligibility for services and decisions to press criminal charges or to remove a child, and it is frequently the basis for selecting samples of maltreated children or to measure recidivism or intervention effectiveness. Although there is a growing body of research on case substantiation in the United States, few studies have examined this decision in other jurisdictions. Using data from the 2003 Canadian Incidence Study of Reported Child Abuse and Neglect, this study examines the profiles of a national sample of 10,010 investigations. Multivariate analyses reveal that substantiation decisions are generally made in a fashion that is relatively consistent with the clinical characteristics of cases. Along with severity of harm, parent risk factors, and housing risk factors, police referrals are among the most important predictors of case substantiation. Cases involving multiple forms of maltreatment are also more likely to be substantiated.

The Canadian child welfare system response to exposure to domestic violence investigations.

OBJECTIVE: While child welfare policy and legislation reflects that children who are exposed to domestic violence are in need of protection because they are at risk of emotional and physical harm, little is known about the profile of families and children identified to the child welfare system and the system's response. The objective of this study was to examine the child welfare system's response to child maltreatment investigations substantiated for exposure to domestic violence (EDV). METHODS: This study is based on a secondary analysis of data collected in the 2003 Canadian Incidence Study of Reported Child Abuse and Neglect (CIS-2003). Bivariate analyses were conducted on substantiated investigations. A binary logistic regression was also conducted to attempt to predict child welfare placements for investigations involving EDV. RESULTS: What emerges from this study is that the child welfare system's response to EDV largely depends on whether it occurs in isolation or with another substantiated form of child maltreatment. For example, children involved in substantiated investigations that involve EDV with another form of substantiated maltreatment are almost four times more likely than investigations involving only EDV to be placed in a child welfare setting (Adjusted Odds Ratio=3.87, p<.001). CONCLUSIONS: These findings suggest that the involvement of child welfare has not resulted in the widespread placement of children exposed to domestic violence. The Canadian child welfare system is substantiating EDV at a high rate but is concluding that these families do not require child protection services. PRACTICE IMPLICATIONS: There is debate in the literature about how the child welfare sector should respond to cases involving exposure to domestic violence. Contrary to conventional wisdom, this study finds that children who are the subject of investigations involving substantiated exposure to domestic violence are less likely to be removed from their home than children experiencing other forms of maltreatment. Strategies need to be developed to counter misperceptions about the intrusiveness of child welfare, and discussions need to take place about when it is appropriate for child welfare to become involved when children are exposed to domestic violence.

What is driving increasing child welfare caseloads in Ontario? Analysis of the 1993 and 1998 Ontario incidence studies.

Rates of substantiated maltreatment documented by the 1993 and 1998 Ontario Incidence Studies of Reported Child Abuse and Neglect doubled between 1993 and 1998. Although increasing public awareness and changes in investigation procedures appear to account for part of this change, the increase also reflects a significant shift in the types of maltreatment agencies are investigating and substantiating. Exposure to spousal violence has increased eightfold, and the proportion of neglect cases has more than doubled, whereas cases of sexual abuse are decreasing. The field requires a differentiated response to address the maltreatment-specific challenges underlying child welfare caseload increases in Canada.

Major findings from the Canadian incidence study of reported child abuse and neglect.

OBJECTIVE: To present key findings from the Canadian Incidence Study of Reported Child Maltreatment (CIS) in sufficient detail to provide a basis for international comparisons in terms of forms and severity of maltreatment and the age and sex of victims. METHOD: A survey conducted in a random sample of 51 child welfare service areas across Canada tracked child maltreatment investigations conducted during the months of October to December 1998, produced a national sample of 7672 child maltreatment investigations. Information was collected directly from investigating workers on child and family background, perpetrator characteristics, severity and types of maltreatment and service and court outcomes of investigations. RESULTS: Forty-five percent of investigations were substantiated and in a further 22% of investigations maltreatment remained suspected. Primary reasons for investigation were physical abuse (31%), sexual abuse (11%), neglect (40%), and emotional maltreatment (19%). A larger proportion of physical abuse cases are isolated incidents involving older children and are more likely to lead to injuries. Sexual abuse, neglect and emotional maltreatment involve more chronic situations with children showing signs of emotional harm. Rates of investigated and substantiated maltreatment are lower in Canada compared to the United States, but are higher than rates reported in Australia. CONCLUSIONS: The CIS provides much needed information for developing a better understanding of the profile and needs of children and families investigated by child welfare authorities in Canada. The study also serves as a point from which international comparisons can be made.