Subsequent Maltreatment in Children With Disabilities After an Unsubstantiated Report for Neglect

Children with disabilities are at increased risk for maltreatment,^1,2 and neglect accounts for the majority of such cases.³ Although most cases of suspected neglect are unsubstantiated at the time of the initial report to child protective services (CPS),⁴ meaning there is insufficient legal evidence of maltreatment, these children are at risk for subsequent maltreatment.⁵

We conducted a retrospective cohort study to examine the incidence and timing of re-referral to CPS, substantiated maltreatment, and foster care placement for any type of maltreatment after an initial unsubstantiated referral for neglect. We compared outcomes between children with and without disabilities.

We analyzed data from the National Child Abuse and Neglect Data System (NCANDS),⁴ which collects data annually on all children reported to state-level CPS agencies in the 50 states, the District of Columbia, and Puerto Rico. The Boston University Medical Campus institutional review board qualified the study as exempt. We included data from states that contributed child-level data to NCANDS for fiscal years 2008 through 2012 and retained unique child identification numbers.

Children were included if they had first-time unsubstantiated referrals for neglect in 2008; they were followed up for 4 years. We excluded reports that occurred within 24 hours of initial referral because these likely represented the index incident.

Children were excluded if the initial report included maltreatment other than neglect or listed prior maltreatment, or if they had previously been reported to CPS, as determined by a search of all available years of NCANDS records (range, 1-10 years). Children were classified as having disabilities if they had conditions included in the Individuals with Disabilities Education Act, and were excluded if his or her disability status was missing.

We conducted the statistical analysis using SAS version 9.3 (SAS Institute Inc). All statistical tests used a 2-sided α level of .05. We evaluated the proportion of children who experienced each outcome, comparing children with and without disabilities. We used Kaplan-Meier statistics to estimate time to event and regression models to estimate adjusted hazard ratios, accounting for clustering by household and adjusting for state, child age, race, ethnicity, and initial referral source.

A total of 489 176 children from 33 states, Puerto Rico, and the District of Columbia were included (12 610 children with disabilities and 476 566 children without disabilities; Table). Children with vs without disabilities were more likely to be re-referred (45% vs 36%, respectively; adjusted risk difference [ARD], 14% [95% CI, 13%-15%]; P < .001), experience substantiated maltreatment (16% vs 10%; ARD, 9% [95% CI, 8%-10%]; P < .001), and be placed in foster care (7% vs 3%; ARD, 4% [95% CI, 4%-5%]; P < .001).

The median time to each outcome was shorter for children with disabilities (Figure). For children with disabilities compared with those without, the adjusted hazard ratio was 1.41 (95% CI, 1.35-1.46) for re-referral, 1.82 (95% CI, 1.72-1.94) for substantiated maltreatment, and 2.71 (95% CI, 2.48-2.96) for foster care placement.

Our data demonstrate that children with disabilities and unsubstantiated referrals for neglect experienced future maltreatment sooner and more often than other children.

Our study has some limitations. Substantiated maltreatment may represent prior or ongoing maltreatment.⁵ Even though we adjusted for referral source, existing data on surveillance bias for child maltreatment are mixed,^1,6 and the observed higher incidence in maltreatment of children with disabilities may have resulted in part from increased interactions with mandated reporters.

Although we included all available data from geographically diverse states (including 65% of 2008 US population), such data may not be nationally representative. In addition, we were not able to identify whether children crossed state lines and were referred in a different state.

Despite these limitations, our findings highlight the significant incidence of maltreatment experienced by children with unsubstantiated referrals for neglect, particularly children with disabilities. Such children may benefit from targeted interventions to prevent subsequent maltreatment.

Corresponding Author: Caroline J. Kistin, MD, MSc, Department of Pediatrics, Boston Medical Center, 89 E Newton St, Vose 3, Boston, MA 02118 (caroline.kistin@bmc.org).

Author Contributions: Dr Kistin had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Kistin, Tompson, Sege.

Acquisition, analysis, or interpretation of data: Kistin, Tompson, Cabral, Winter, Silverstein.

Drafting of the manuscript: Kistin, Silverstein.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Kistin, Cabral.

Obtained funding: Kistin.

Administrative, technical, or material support: Sege.

Study supervision: Kistin, Sege, Silverstein.

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: The study was funded by National Institutes of Health grant K23 HD078503-02 (awarded to Dr Kistin). Funding support for preparing the data for public distribution was provided by contract 90-CA-1370 between the National Center on Child Abuse and Neglect and Cornell University.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: The data used in this report were made available by the National Data Archive on Child Abuse and Neglect at Cornell University in Ithaca, New York.