Executive Summary
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Children younger than three years of age are the most likely of all children
to become involved with child welfare services (Wulczyn, Barth, Yuan, Harden,
& Landsverk, 2005). Those with medical or developmental conditions
experience an even higher level of involvement, including more removals from
parental care and longer stays in foster care (Rosenberg & Robinson,
2004).
In 2003, the Federal government amended the Child Abuse and Prevention Treatment
Act (CAPTA) to require that infants and toddlers who are substantiated for
child maltreatment be referred to early intervention services funded under
Part C of the Individuals with Disabilities Education Act (IDEA). The
CAPTA requires each state to develop
provisions and procedures
for referral of a child under the age of three who is involved in a substantiated
case of child abuse or neglect to early intervention services funded under
Part C of the Individuals with Disabilities Education Act (section
106(b)(2)(A)(xxi)) (CAPTA, 2003).
While there is some general agreement that children who experience child
abuse/neglect may experience a range of
developmental delays across developmental
domains, little is known about the true extent of developmental problems
of children substantiated for abuse/neglect, and those subsequently removed
from parental custody and placed in an alternative living environment.
This dearth of information is in part due to the inconsistencies in child
welfare practice across jurisdictions; variability in state and jurisdictional
eligibility criteria for infants and toddlers for Part C services (Shackelford,
2006); differential policies, procedures, and practice competencies of public
child welfare workers; and the differential availability of resources to
serve children once identified. Further complicating the issue is the
requirement under Part C that states must provide services to children
who meet the state criterion for eligibility, but states may also choose
to serve children who are at risk of having substantial developmental
delays if early intervention services are not provided. Only
five states (CA, HI, MA, NM, & WV) currently serve such at risk children.
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This project is funded by the Office of the Assistant Secretary for Planning
and Evaluation (ASPE), U.S. Department of Health and Human Services.
Child maltreatment has been shown to have a significant negative impact on
childrens healthy growth and development. However, national estimates
of the extent and type of need for early intervention services for maltreated
infants and toddlers are lacking. The overarching question guiding
our analysis is: What are the developmental problems among children
receiving Child Welfare Services that suggest a need for Part C early
intervention services?
Implementing CAPTA requirements poses a variety of challenges. A key
challenge is the lack of information on which to begin considering problems
and solutions. Therefore, the Assistant Secretary for Planning and
Evaluation has endeavored to achieve maximum benefit from data already collected
in the National Early Intervention Longitudinal Study (NEILS) and the National
Survey of Child and Adolescent Well-Being (NSCAW) in an effort to provide
some information about maltreated children and early intervention.
This study answers several key questions:
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To what extent do maltreated children have developmental problems or are
subject to factors associated with poor developmental outcomes?
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What services might these maltreated children be eligible for and what services
are they receiving through child welfare systems?
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What child and/or case characteristics (e.g., child
welfare setting) influence developmental service receipt by maltreated
children?
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What barriers to service provision and solutions have experts in the field
identified?
Data from the National Survey of Child and Adolescent Well-Being was used
to describe the developmental characteristics of infants and toddlers in
Child Welfare Services nationally. The National Early Intervention
Longitudinal Study (NEILS) was used to provide comparative national information
on infants and toddlers entering Part C early intervention services.
In addition to these two data sources, we conducted a literature review and
discussions were held with Part C and Child Welfare Service experts.
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Children ages birth to 36 months who have been maltreated are at substantial
risk of experiencing subsequent developmental problems. Fifty-five
percent of children under the age of three with
substantiated cases of maltreatment are
subject to at least five risk factors associated
with poorer developmental outcomes.
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Compared to classification at the time of initial contact with Child Welfare
Services, over time a higher proportion of children are described as having
fewer risks or with a low score on a developmental measure while over time
a smaller proportion of children are described as having more risks.
By 36 months after involvement with Child Welfare Services, the findings
show a large increase (21% to 45%) in children who have shown improvement
by having fewer risks and the percentage of children in the highest risk
classification declined by more than half from 29% to 13%.
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Few infants and toddlers with substantiated cases of maltreatment are
reported to have a diagnosed medical condition (an
established risk condition) as described
in IDEA (e.g., Down syndrome, blindness, cerebral palsy) that would make
them automatically eligible for Part C services. Though not reflected
in eligibility distributions, 38% of infants and toddlers entering Part C
are reported by caregivers or service providers
to have an established risk condition, compared to 3% of infants and toddlers
with a substantiated case of maltreatment. A condition of established
risk is defined as a diagnosed physical or mental condition which has
a high probability of resulting in developmental delay. Children with
these conditions are eligible for Part C services without documentation of
delay.
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Among children who have substantiated maltreatment, the proportion with
a low score on a developmental measure does not differ markedly from those
of children investigated but not found to have substantiated
maltreatment. Children with substantiated maltreatment have been
found to be quite similar to those children with
unsubstantiated maltreatment (Drake,
1995), but different in that unsubstantiated cases receive fewer services
(Drake et al., 2003). This has recently been reconfirmed in the NSCAW
data (NSCAW Research Group, 2002), for the general population of children
and, now, again for very young children in this study. The current
study adds important information in showing that developmental outcomes do
not differ by substantiation status. This evidence suggests that children
involved in child welfare even those who have not had their
maltreatment substantiated have an increased likelihood of being
Part C eligible.
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Maltreated children between 24 to 36 months of age have relatively high
levels of behavior problems reported by their caregivers. These
behavior problems are quite constant. About 70% of children who were
reported by caregivers as having behavior problems at
baseline were still having behavior problems
at the 36-month follow-up. It is not clear whether maltreating caregivers
experience their childrens age-expected behavior as more problematic
or whether the children have, in fact, more problematic behavior. Recent
evidence that compares the ratings of maltreating parents to those of independent
observers suggests that maltreating parents are more harsh raters of their
childrens behavior (Lau, Valeri, McCarty, & Weisz, 2006).
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A sizeable proportion of infants and toddlers with substantiated maltreatment
were reported to have an Individualized Family Service Plan (IFSP), reflecting
eligibility for Part C services. About 12 months after the
investigation of maltreatment, 28% of children still younger than 36 months
of age were reported by caseworkers to have an IFSP.
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Families are receiving parent training and family counseling services
through Child Welfare Services or by referral. It is unclear the extent
to which these services provide interventions focused on enhancing child
development. Approximately 39% to 67% of the families of infants
and toddlers with substantiated cases of maltreatment received parent training
or family counseling through child welfare systems in the period of time
prior to the 18-month follow-up. Between 18 months and 36 months after
baseline, the percentage of families reported to still be receiving parent
training or family counseling decreased, ranging from 9% to 31%, suggesting
that for some children and families the needs for these services was no longer
critical or they may have completed a time-limited or structured intervention.
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Part C providers may not be familiar with the unique challenges associated
with providing services to maltreated children and their families.
First, many Part C providers are speech language therapists, occupational
therapists and physical therapists. They may not be well prepared to
address the special considerations required when working with maltreated
children. Second, receipt of Part C services is voluntary, so court-ordered
services are not part of the culture for early intervention service
providers. Court-ordered involvement may cause parents or caregivers
to view a service provider as an intrusion rather than as a source of
assistance. They may be suspicious of, or hostile towards, service
providers. Third, the focus of Child Welfare Services is on protecting
the childs safety and dealing with the perpetrator and Part Cs
focus is providing services to children with disabilities and their
families.
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Increased training and collaboration of Child Welfare and Part C service
providers may be a useful approach to facilitate CAPTA compliance and enhance
developmental outcomes for children. Experts we spoke with were
concerned about service providers being able to manage high-risk families
in the Part C service environment. According to the experts, very few
Part C providers have both early intervention and social work training and
knowledge. The experts suggest cross-training, better developmental
education for Child Welfare workers, and specialized case coordination.
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The new and reviewed findings presented suggest several potentially important
directions for future research. New research can help inform how service
providers for Child Welfare and Part C early intervention interact with clients
as well as each other. Some areas are:
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Intervention research. Matching level of service with the needs
of children and their families is important only if the services are effective.
Intervention research to demonstrate methods, test the impact of variation
of the intensity and duration of service, and present results to the field
is needed. Very little information is available to show which methods
have the greatest impact on the development of maltreated children or on
the development of children served under Part C.
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Characteristics of families. Research is needed to better understand
certain sub-groups of families who receive Child Welfare and Part C
Services. One expert mentioned that we should improve our understanding
of effective services for older mothers who often have several children,
a history of domestic violence, substance abuse, or repeatedly have children
entering into Child Welfare Services. Another sub-group of interest
is caregivers with disabilities.
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Substantiation as a criterion for CAPTA-mandated referrals.
Another area requiring further investigation is the extent to which
substantiation status is the optimal indicator of which children reported
to Child Welfare Services may need developmental assistance. Taken
in combination with prior findings (e.g., Hussey et al., 2005), this research
suggests children who are not substantiated for maltreatment are at similar
developmental risk as those who are. This study provides information
suggesting that the count of environmental and biomedical risk factors may
be a robust indicator of future developmental delay and may be a useful indicator
of which children should be referred for Part C early intervention
services. A more precise calculation of which risks and what count
of risks are the best indicators of poorer developmental outcomes would likely
result in referrals with a more empirical basis than the current reliance
on substantiation status.
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Development of intervention practices. For many Part C providers,
working with children and families involved with Child Welfare Services is
an unfamiliar experience. Conversely, for many Child Welfare workers,
experience with services designed to address a childs developmental
needs may be limited. It is not clear to what extent Child Welfare
and Part C practices can be adapted and when new methods will have to be
developed. We expect that considerable advances in parent engagement
and training approaches employed by Child Welfare Services and Part C will
be necessary for the provision of effective services. In particular,
this research highlights the need for new expertise and interventions for
infants (i.e., the first year of life).
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Best practices on collaboration models. Central to identification
of eligible children and effective service delivery is collaboration between
Child Welfare and Part C professionals. Experts often pointed out that
service providers often do not have a basic competency in each others
knowledge base or practice methods. As a consequence, research on
best practices in collaboration could help to identify innovations
in referrals, screening, assessment, communications between Part C and Child
Welfare Services and Part C and the courts, and interactions between Child
Welfare Services, Early Head Start, and Part C and, later, school-based
services. These innovations could help ensure that children had the
level of service that was most commensurate with their developmental needs.
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Funding models and services receipt. An area which might benefit
from additional research is the issue of funding sources for services and
types of services provided. State-run childrens health insurance
programs, Medicaid, Part C, private insurers, and other payment sources have
an important role in determining what services will be received. The
effects of eligibility criteria, compensation systems, and payment amounts
on services should be investigated. The extent to which providers and
case coordinators are knowledgeable of these issues may also play a role.
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School readiness. Additional NSCAW research would be helpful
in understanding the longer-term developmental implications of early maltreatment
and early intervention on childrens development. Of particular
interest would be the school-readiness of the NSCAW sample of children.
This research found them to be at-risk and often measurably delayed in one
or more developmental domains. Recently, a 66 month follow-up was completed
with children in NSCAW who were 0 to 12 months old at baseline (i.e., the
infants). Ranging in age from approximately 5 ½ to 6 ½ these
children are now entering the educational system through kindergarten or
first grade. It remains to be seen if their problems have persisted
and what factors might have promoted developmental recovery (e.g., interventions
from child welfare or others).
Opportunities for new research exist at all levels of Child Welfare and Part
C programming. A better understanding of the effects of maternal age,
substance abuse, and other child, family and case characteristics is necessary
for the development of new developmental intervention strategies. In
addition, further research is needed to help practitioners from both Child
Welfare and Part C systems communicate with each other and collaborate more
effectively. Finally, new research may help enhance understanding the
role that local, state, and federal funding plays in service delivery to
maltreated children with developmental needs. Because resources are
limited in both Part C and Child Welfare systems, it is important that services
be delivered in the most effective and efficient manner possible. Obtaining
the knowledge to achieve this goal requires more investigation.
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CAPTA and IDEA recognize that child maltreatment signals a substantial risk
to the development of children. Their requirements call for action
to address the developmental problems of children substantiated for
maltreatment. Together, these Acts generate a clear expectation for
efforts to mitigate the developmental harms of maltreatment.
This study confirms that the level of risk for developmental delay is high
for maltreated children and that it remains high, years after the initial
maltreatment. The rates of developmental and behavioral problems are
well above those in the general population and the rates of environmental
risk and serious problems within the dyadic relationship between child and
caregiver are above those of children typically encountered by Part C service
providers.
The majority of these infants and toddlers are subject to risk factors known
to predict academic difficulties (Lee & Burkam, 2002). These high
rates of developmental concern are similar among children judged to have
experienced substantiated maltreatment as well as those who have had the
child maltreatment investigation closed with no finding of maltreatment.
Because these factors are apparent among infants, it is clear they require
intervention services as early as possible to avoid developmental problems,
rather than waiting for delays to become intractable or trying to remediate
academic failure. CAPTA and IDEA reforms offer the opportunity to markedly
address and reduce developmental delay among maltreated children.
Much work can be done to better achieve the goals of CAPTA and IDEA.
The implementation of successful services for maltreated infants is clearly
complicated. The findings of this report call for further review of
effective strategies and consideration of new efforts, and related research,
to implement these innovative policies. This research should involve
rigorously conducted evaluations of best practice models so that the knowledge
gained from these evaluations can add measurably to the information provided
by the surveys upon which this study was based.
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