Developmental Status and Early Intervention Service Needs of Maltreated Children

Major Findings

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Contents

1. Environmental and Biomedical Risk Affecting Development
   1. Finding #1:  Children ages birth to 36 months who have been maltreated are at substantial risk of experiencing subsequent developmental problems.
   2. Finding #2:  Compared to classification at the time of initial contact with Child Welfare Services, over time a higher proportion of children tend to be described as having fewer risks or with a low score on a developmental measure.
   3. Finding #3:  Few infants and toddlers with substantiated cases of maltreatment were reported to have an established risk condition as described in IDEA (e.g., Down syndrome) that would make them eligible for Part C services.
2. Developmental Outcomes
   4. Finding #4:  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.
   5. Finding #5:  Maltreated children between 24 to 36 months of the age have relatively high levels of behavior problems reported by their caregivers.
3. Service Receipt
   6. Finding #6:  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.
   7. Finding #7:  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.
4. Considerations for Successful Interventions
   8. Finding #8:  Part C providers may not be familiar with the unique challenges associated with providing services to maltreated children and their families.
   9. Finding #9:  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.

Footnotes

The major findings are grouped into four areas — environmental and biomedical risk affecting development, developmental outcomes, service receipt, and considerations for successful interventions.  Each section contains a statement of the finding, reference to any previous research included in this project’s literature review, findings from this study, and implications.

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A.  Environmental and Biomedical Risk Affecting Development

Maltreated infants and toddlers are subject to multiple types of risk associated with poorer developmental outcomes, often in conjunction with a measured delay on a developmental measure. Some maltreated children consistently demonstrate developmental concerns over time as evidenced by a low score on a developmental measure. Children with many risk factors at baseline tend to have reduced risk status or subsequent developmental concerns over time. Very few maltreated children are reported to have an established risk condition (i.e., a diagnosed medical condition known to be associated with developmental delay) that would entitle them to Part C services.

Young children who experience child neglect and abuse are at high risk of developmental problems.  Moreover, much research highlights the importance of the early years in both physical and psychosocial development. Specific domains potentially affected include cognitive, social, emotional, and physical health in addition to the potential for subsequent development of psychopathology. Effects are similar to poverty, but may be more severe.

Young children from birth to three years of age are most at risk of experiencing maltreatment. Approximately 3.5 million children are investigated for maltreatment annually. Of that group, nearly 900,000 are eventually substantiated to have experienced maltreatment. Children birth to three years have the highest rate of victimization, 16.1 per 1,000, while infants (children less than one year old) accounted for over 10% of all maltreated children or nearly 90,000 infants per year (U.S. DHHS, 2006). Some research suggests that children with unsubstantiated maltreatment reports may not differ developmentally from those who were substantiated (Hussey et al., 2005). This would place the entire population of children reported for maltreatment at risk for developmental problems.

Using data from the National Survey of Child and Adolescent Well-Being (NSCAW) and the National Early Intervention Longitudinal Study (NEILS), the developmental risk and well-being of maltreated children birth to 36 months of age was investigated. Specific literature relating to the developmental experiences of maltreated infants and young children was reviewed. Using the two longitudinal studies, NSCAW and NEILS, analyses were completed to describe the characteristics and developmental experiences of these children.

Previous Research

Maltreatment places the child at increased risk for problems in any developmental domain. Such domains include cognitive, language, social, and emotional. Moreover, negative developmental effects are typically seen in at least one domain regardless of the type of maltreatment experienced (Hoffman-Plotkin & Twentyman, 1984; Porter, Lawson, & Bigler, 2005).

Cognitive and language development may be markedly affected by maltreatment. Maltreated children have shown poorer performance across an array of cognitive and language sub-domains. Children experiencing emotional maltreatment or neglect often perform the most poorly of maltreated children. These differences persist even after poverty or low socioeconomic status (SES), a risk that commonly co-occurs with maltreatment, is controlled for (Beers & De Bellis, 2002; Eigsti & Cicchetti, 2004; Pears & Fisher, 2005; Yasik, 1998). The cognitive and language effects of maltreatment persist into at least elementary school years (Koenig, Cicchetti, & Rogosch, 2000; Toth & Cicchetti, 1996). Maltreated children have an increased likelihood of being held back in school (Shonk & Chicchetti, 2001).

The social and emotional development of young children is also adversely affected by maltreatment. When infants do not experience responsive relationships; are met with threats or criticism during emotional events; and are exposed to violence, intense anger, and fear, their social-emotional development may be impaired (Edwards, Shipman, & Brown, 2005; Howes, Cicchetti, Toth, & Rogosch, 2000; Shipman & Zeman, 1999).

The negative effects of maltreatment on young children’s development are increasingly defined and understood. However, specific domains of development are often differentially affected according to the type of maltreatment experienced. Neglect seems to more profoundly affect cognitive and social development areas, in particular, but any maltreatment may negatively affect development.

Study Findings

Findings from the NSCAW cohort tend to support what has been found by other researchers. Children from birth to three with substantiated cases of maltreatment experienced numerous factors that place them at risk for developmental problems.  In addition to their risk-laden environmental experiences, these children are also likely to have developmental delays based on the results of developmental screeners administered during the study.

Developmental risk is commonplace among infants and toddlers with substantiated cases of maltreatment. All of these children have at least one risk for developmental problems because of their maltreatment experience. A majority (55%) of children have at least five risk factors associated with developmental problems. Specific risk factors that were examined are shown below, with the percentage of children with that risk factor in parentheses:

Further evidence for the high levels of risk these children are subject to is found in the scores on the Bayley Infant Neurodevelopmental Screener (BINS). The BINS, a developmental screening instrument for children 3 to 24 months of age classified 56% of children in this age range at high risk and an additional 32% at moderate risk for developmental problems.

Risk may change over time. Some risk factors such as having been maltreated or being a member of a racial or ethnic minority group are fixed and permanent in duration. Others are temporary but may be brief or chronic in duration. For example, teen-aged caregiver is necessarily a time-limited risk factor while poverty may be experienced briefly or chronically (or intermittently). The practical consequence is that a child who has eight risk factors (i.e., High Risk using the DRIGs) at baseline may have only four risks at a follow-up because the primary caregiver is now 20 years old (no longer teen-aged), is now married and gainfully employed (no longer single or living in poverty), and has obtained a post-high school vocational certificate (no longer has low educational achievement). Labile risk factors were re-assessed at each time of data collection so a degree of instability in the DRIG high/lower risk classifications is expectable.

In addition to risk, many children had a low score on a developmental measure, a measured delay. Children were screened in the domains of cognitive functioning, communication skills, and adaptive behavior in the area of daily living. The cognitive portion of the Battelle Developmental Inventory (BDI), Kaufman Brief Intelligence Test (K-BIT), and the Pre-School Language Scale 3^rd Edition (PLS-3) were administered, and the daily living skills portion of the Vineland Adaptive Behavior Screener (VABS) were all completed by caregivers.

Results of developmental screening were organized within the DRIGs. Based on these instruments, almost half of the children (49%) had a low score on at least one measure at baseline and were classified in the Measured Delay category of the DRIGs. An additional 28% had five or more risk factors resulting in their classification as High Risk. The remainder (23%) had no delay and four or fewer risk factors, and were categorized as Lower Risk.

Stability of the DRIGs was assessed. At the 18-month follow up when children were approximately 18 to 52 months in age, the disposition of the sub-group of children who had a Measured Delay at baseline was re-assessed. Half were reported to have a Measured Delay while 31% were classified as High Risk, and 18% at Lower Risk. When this same sub-group of children were approximately 3 to 6 years of age at the 36-month follow-up the proportion with a Measured Delay decreased slightly to 44%, but only 13% were classified as High Risk, and 43% were Lower Risk (see Exhibit 1).

Exhibit 1.
Disposition of Children with a Measured Delay at Baseline

Source:  NSCAW

Part of this pattern of change over time is related to the child’s age at the time the case was investigated. At baseline, infants less than 12 months of age with substantiated cases of maltreatment had the highest number of risk factors on average, and the lowest levels of measured delay. This small proportion of infants with a low score on a developmental measure is related to the difficulty using a standardized measure to assess delay in an infant. At baseline, children with substantiated cases of maltreatment investigated during the second or third year of life were more likely to have a low score on a developmental measure, but the proportion with High Risk status was smaller than among infants with substantiated maltreatment. For children in the third year of life, shortly after the time of investigation, the proportions with either High or Lower Risk is smaller than for infants (see Exhibit 2). This finding demonstrates that high levels of risk are associated with maltreated infants being designated as substantiated, compared to toddlers.

Exhibit 2.
Measured Delay and Risk (DRIGs) by Age at Baseline for Children with Substantiated Cases of Maltreatment

Source:  NSCAW.
Note:  These are weighted percentages.

Infants and Toddlers Entering Part C and Risk Status.  Children entering Part C services were found to be at higher risk than children younger than three years of age in the general population (National Household Education Survey [NHES], 1999) in some, but not all areas (Hebbeler, Spiker, Mallik, Scarborough, & Simeonsson, 2003). Approximately 17% of children entering Part C have reasons for eligibility that describe a biomedical or environmental risk factor associated with developmental delay, though almost all of these reasons are biomedical in nature, rather than environmental risk (Scarborough, Hebbeler, & Spiker, 2006). Another indicator of the risk experienced by infants and toddlers with disabilities entering Part C services is reflected in that 7% were in foster care — a rate far in excess of the rates of children in foster care (< 1%) of comparable age in the general population (US DHHS, 2007). Information was available to compare some of the demographic characteristics of substantiated infants and toddlers with children the same age entering Part C, and those in the general population (see Exhibit 3).

When the poverty level of the families of infants and toddlers entering Part C services is compared with infants and toddlers with substantiated cases of maltreatment, several differences are apparent (see Exhibit 4).  Though the proportion of very poor families is similar in the two populations, the proportion between 51% and 100% of poverty is almost three times as large among maltreated children, and the proportion of Part C children above 200% of the poverty level is greater (50% vs. 29%). The most striking difference may be in the receipt of Temporary Assistance for Needy Families (TANF) in that almost twice as many Part C families (42% vs. 23%) are recipients. TANF provides low-income families with financial assistance and work opportunities by offering states block grants to deliver their welfare programs.  Reasons for this difference may be due to TANF eligibility, but it may also be related to families’ voluntary involvement with social services.

Implications

Based on these findings, there is a reason to be concerned that many of these young, maltreated children will continue to lag behind their non-maltreated peers developmentally and will not be school-ready upon entrance to kindergarten or first grade. Risk factors such as poverty and maltreatment are known to have a negative influence on children’s development (English et al., 2005; McLoyd, 1998). The findings here provide additional evidence for the negative developmental effects of the previously discussed risk factors.

However, the effects of risk are not necessarily determinable in infants and toddlers, and become more apparent as age-expected developmental competencies become more complex. As a result, services, such as those provided for by Part C, may help offset these risks if provided in the first year of life. Additional services, such as income assistance and parent training might also reduce risk and likelihood of eventual developmental problems (National Scientific Council on the Developing Child, 2007).

There is movement among children between the DRIGs categories. This may be because some risks are potentially transient (e.g., transitional poverty, single parenthood) while addressing others might raise new issues (e.g., removing an abusive parent from the home may mean a child now has a single caregiver and more exposure to poverty). As a result, children classified as Lower Risk at the 36-month follow-up may have been in the High Risk group or experienced a measured delay at some point.

Information on infants and toddlers from birth to 36 months of age was obtained at baseline, and again 12, 18, and 36 months later. Changes in low scores on developmental measures and risk status when children were older were examined.

Study Findings

Shortly after the time of the initial investigation of child maltreatment 49% of infants and toddlers aged 0 to 36 months were reported to have a Measured Delay (see Exhibit 5). A small proportion (3%) of children in the Measured Delay category had an established risk condition associated with developmental delay, making them eligible for Part C services regardless of documented delay. In almost all cases, these children also had a low score on one or more developmental measure. The remaining children without a measured delay were classified as having 5 or more risk factors associated with poorer developmental outcomes (High Risk, 28%) or having fewer than five risk factors (Lower Risk, 23%).

At the 18-month follow-up when children were approximately 18 to 54 months of age, the distribution of children in these categories remained similar (50%, 29%, and 21% respectively). Approximately half of the children with a Measured Delay (52%), a third of High Risk (36%) and a third of Lower Risk (33%) were still classified as such, as can be seen in Exhibit 5. However many individual children changed classification.  Of those classified as having a Measured Delay at baseline, 31% were described as High Risk and 18% Lower Risk 18 months later.

Looking at High Risk children (28%) at baseline in Exhibit 5, about a third (36%) of them were described that way 18 months later. Forty-three percent of children had moved into the Measured Delay category and 22% were classified as Lower Risk. Likewise only 33% of Lower Risk (23%) at baseline were still classified as such, with more than half (56%) reported to have a Measured Delay, and 11% being classified High Risk 18 months after baseline.

There was substantial movement of children to the Measured Delay category in the first 18 months after entrance into Child Welfare Services. Among the 28% of children who were High Risk at baseline, about twice as many (43%) moved into the Measured Delay category as moved into the Lower Risk (22%) category. Among the 23% of children who started as Lower Risk, 56% moved into the Measured Delay category 18 months after baseline. This was a larger proportion than what remained in the Lower Risk (33%) or became High Risk (11%). Taken together, although there is movement across categories, the proportion of children in the Measured Delay category remains almost unchanged (49% to 50%) as is true of the other categories.

As shown in Exhibit 6, between 18 and 36 months there was somewhat more stability in the DRIG status of children — at least for the Measured Delay and Lower Risk groups. Among children with Measured Delay (50%) at 18 months, 57% of them remained in that status. Among children who were Lower Risk (21%) at 18 months, 72% remained there at 36 months. At the same time, among children who were High Risk (29%) at 18 months, a substantial proportion (37%) had a Measured Delay by 36 months and among those with Lower Risk (21%) at 18 months after baseline, 22% of those were subsequently classified in the Measured Delay category. The proportion of children in the Measured Delay category does decline from 50% of children at 18 months to 42% of children by 36 months. The percentage of children in the High Risk classification declined by more than half from 29% to 13% and children in the Lower Risk category more than doubled from 21% to 45%.

Reasons for change in DRIG status are not directly discernable from these data. Multiple influences may be at play. Change in the number of risk factors may be reflective of changes in who is caring for the child. Children placed into foster care can be expected to have a lowered level of risk. Among children who remained in the home, reduction in the number of risk factors may reflect the effect of intervention services provided to caregivers aimed at reducing developmental risk in the child’s caregiving environment. Changes in classification are also influenced by the challenges inherent in measuring developmental status in young children, particularly infants. A large proportion of the children at baseline classified as having a Measured Delay (38%) were younger than 12 months of age at that time.

The data show no overall change in the proportion of children in the Measured Delay and High Risk categories in the first 18 months after involvement with Child Welfare Services. After 18 months we would expect that some children would be improving, and they do. By 36 months, the findings are more positive and show a modest reduction(50% to 42%) in the proportion of children in the Measured Delay category and a large increase in those who have shown improvement by moving into the Lower Risk group (comprising 45% of all children assessed at 36 months).

Comparing the classification of children investigated by Child Welfare Services longitudinally reveals that about half of the children move from being classified as having a Measured Delay to not having one. Conversely, about half of the children are indicated to have a Measured Delay in at least one area at two time points over an 18-month interval.

This pattern of findings highlight the potential value of providing these children with a formal screening and intervention process prior to three years of age to determine the nature of their delays and their possible eligibility for Part C services and their ongoing risk of developing developmental delays. It is apparent that many of these children with low scores on a developmental measure who might not meet the local criterion for Part C services or who have multiple risk factors might benefit from child care services or home visiting programs focused on providing a stimulating environment to enhance their developmental outcomes and social-emotional well-being (National Scientific Council on the Developing Child, 2007). 

On a positive note, it seems likely that the reduction of the proportion of High Risk children might be credited to the intervention of child welfare services. This pattern suggests that the reduced risk in some of the children’s caregiving environments would contribute to supporting more optimal outcomes for children maltreated as infants and toddlers.

Examining the relationship of multiple risks to developmental scores at baseline demonstrates a direct connection. When substantiated infants and toddlers are grouped according to the number of risk factors they were reported subject to, a linear relationship can be observed (see Exhibit 7). Only 5% of children exposed to a single risk factor in addition to maltreatment have a measured delay, whereas the percentage of infants and toddlers reported to have a measured delay ranges from 76% to 99% for children subject to 5, 6, or 7 risks.

Exhibit 7.
Percentage of Infants and Toddlers with a Measured Delay by the Number of Risk Factors Present at Baseline

Source:  NSCAW.

It has been demonstrated that a single risk factor such as poverty (Duncan, Brooks-Gunn, Klebanov, 1994) or maternal mental health (Laucht, Esser, & Schmidt, 2001) can be associated with poorer developmental outcomes for infants and toddlers. The least positive developmental outcomes are, however, associated with the cumulative effect of a range of multiple risk factors (Rutter, 1979; Sameroff, Seifer, Zax, & Barocas, 1987; Sameroff, 1998). Infants and toddlers may be at risk for poorer outcomes by having been the victims of maltreatment; however the clustering of multiple risks has been shown to be strongly associated with increases in the likelihood of poorer developmental outcomes.

Setting and measured delay and risk.  At baseline, 40% of infants and toddlers were in home care receiving Child Welfare Services, 30% were in home care not receiving Child Welfare Services, 18% were in foster care, and 9% were in kinship care (see legend in Exhibit 8).

Of the children in home and not receiving Child Welfare Services, 65% had a Measured Delay.  Fifty-one percent of those in home care receiving Child Welfare Services had a Measured Delay.  Of children in foster homes, 38% had a Measured Delay as well as 22% of those in kinship care.

Those in kinship care were the most highly represented in the High Risk category (58%). Children remaining at home without Child Welfare Services had higher rates, overall, of a Measured Delay (65%).

Exhibit 8.
DRIGs According to Setting at Baseline

Source:  NSCAW.

Implications

Reduction in the number of risk factors would be hypothesized to positively affect child outcomes. Brooks-Gunn and colleagues (1992) found among preschoolers that the number of years a child lived in poverty, not the current economic status of the family, was a stronger predictor of developmental status. Similarly for maltreated infants and toddlers, it could be that those who continue to be reared in a caregiving environment subject to multiple risks would be anticipated to have poorer outcomes than children who have a significant reduction or elimination of contextual risk. Research is becoming conclusive regarding the negative impact of such experiences on adult outcomes in cognitive, economic and mental health domains (Anda et al., 2006; Knudsen, Heckman, Cameron & Shonkoff, 2006; Shonkoff & Phillips, 2000). As found in this study, of the 28% of children in the High Risk category shortly after the initial investigation 79% were High Risk or had a Measured Delay approximately 18 months later. Eighteen months later, of the 29% classified as High Risk 18 months after baseline, 28% remain High Risk, and 37% have a Measured Delay.  Hence, concern regarding the occurrence of abuse and other commonly co-occurring problems (e.g., poverty) on infants and toddlers is well justified.  These findings provide an even stronger basis for assessing the level of environmental risk to children and making referrals for Part C early intervention services based on the assessment of those risks.  Information from risk assessment instruments, used in virtually every state during routine child welfare practices, could be used to generate developmental risk scores that would indicate the approximate risk of experiencing a measured developmental delay.

The Individuals with Disabilities Education Act (IDEA) presents a framework for eligibility for Part C early intervention services based on the presence of developmental delay or physical or mental conditions associated with developmental delay. Children with a medical diagnosis of a physical or mental condition associated with a high probability of developmental delay are eligible regardless of their developmental status. A chromosomal abnormality such as Down syndrome is an example of an established risk condition associated with a high probability of delay. Children with such disorders typically enter Part C services at a younger age by virtue of a medical diagnosis (Scarborough, Hebbeler & Schuster, 2008), rather than waiting until delays in development are measurable on standardized assessments.

IDEA provides guidelines regarding the specific conditions of established risk, but some states have added additional conditions to their eligibility criteria (Shackelford, 2006). States may choose to provide services to children in a third category described as at risk, based on the presence of biomedical (e.g., prematurity and low birthweight) or environmental conditions placing children at risk of having substantial delay. Currently five states provide Part C services to children at risk.

In the context of NSCAW analysis, children reported to have an established risk condition were included in the Measured Delay category. They represent a special group in that they have a condition known to be associated with developmental delay and, hence, are eligible for Part C services regardless of delay status. This group of children is not large enough to analyze separately.

The presence of certain recognized biomedical conditions place children at increased risk for developmental problems. In NSCAW, caregivers reported what, if any, biomedical risks the participating child has. If the child had at least one such condition, it was counted as a risk factor (see page 10 for the risk factors considered). The biomedical risk conditions included in NSCAW are listed at the bottom of page 21.

Study Findings

In all, infants and toddlers entering Part C services nationally are markedly more likely to have an established risk condition reported by caregivers or service providers than maltreated infants and toddlers (38% vs. 3%). A large proportion (22%) of maltreated infants and toddlers are, however, subject to biomedical risks in addition to maltreatment, placing them at high risk for poor developmental outcomes. 

Based on caregiver or caseworker report, 3% of infants and toddlers with substantiated cases of maltreatment were indicated to have an established risk condition that would entitle them to Part C services in all states, regardless of the presence of measured delay. The majority of these children also had a measured delay in at least one domain. Of the established risk conditions reported about one quarter were birth defects (26%) and another quarter (23%) were Fetal Alcohol Syndrome (see Exhibit 9).

Exhibit 9.
Types of Established Risk Conditions Reported Among Substantiated Infants and Toddlers at Baseline

Source:  NSCAW.
Note:  This exhibit shows the diagnoses of the 3% of infants and toddlers that have an established risk condition at baseline (unweighted N = 50).

There are also biomedical conditions that place infants and toddlers at risk for developmental delay, though these risks do not inevitably result in developmental delay, they are often associated with poorer developmental outcomes, but individually they do not typically convey Part C eligibility. In order to describe the risk status of substantiated infants and toddlers, any biomedical condition associated with poorer developmental outcomes that was reported by caregivers was classified as a biomedical risk factor. Biomedical conditions that were reported include: HIV/AIDS, low birthweight, anemia, arthritis or joint problems, chronic cardiac condition, dental problems, hernia, high blood pressure, lead poisoning, obesity, other respiratory problems, persistent bowel problems, physical deformities, repeated ear infections, severe allergies, orthopedic impairment, and other health problems. Regardless of the number of biomedical conditions a participating child was reported to have, it was only counted as a single risk factor for the purposes of assigning them to the High Risk or Lower Risk DRIG grouping. Of the substantiated cases, 22% were reported to have at least one of the aforementioned biomedical risks, in addition to the risk associated with maltreatment.

The NEILS research team constructed a system for categorizing terms provided by Part C services providers to describe the reasons why children were eligible for Part C early intervention. Terms describing a developmental delay were used as the primary classification. For example if the service provider described a child’s eligibility because of global delay and Down syndrome, the child was classified as having a developmental delay. This hierarchical classification resulted in 62% of children eligible for service because of a developmental delay, 22% eligible because of an established risk condition, and 17% at risk for developmental delay, with the at-risk reasons primarily associated with biomedical risk (e.g., prematurity), rather than environmental risk (Scarborough et al., 2006). 

The NEILS research team also examined information from Part C service providers on why the child was receiving services coupled with information from interviews with caregivers describing their child’s developmental and health problems. Using both sources of information revealed that 38% of the infants and toddlers entering Part C services had an established risk condition, with or without a measured developmental delay (Scarborough et al., 2007).

Implications

Comparing findings from two nationally representative studies demonstrates that 38% of infants and toddlers entering Part C are reported to have an established risk condition regardless of reason for eligibility, compared to 3% of infants and toddlers with a substantiated case of maltreatment. Clearly, maltreated infants and toddlers will need to be identified in a manner other than a medical diagnosis in order to receive Part C services. About half of substantiated children do not have a measured delay, implying that they are developing skills in the manner and timing expected. Nevertheless, almost all of the children without measured delay were subject to numerous risk factors associated with poorer academic outcomes as demonstrated in the U.S. Department of Education’s Early Childhood Longitudinal Study (Lee & Burkam, 2002). The majority of maltreated infants and toddlers are at high risk for school failure, regardless of their developmental status as indicated on a developmental measure.  Those with a measured delay not only are subject to risks associated with school failure, but also have as infants and toddlers, given signs of aberrant development in one or more domains, putting them at additional risk for various types of learning difficulties and cognitive impairments.

For maltreated infants and toddlers, unless they reside in one of the four states that provides Part C early intervention based on environmental risk status or in a location where unique provisions are available for maltreated infants, some will not receive Part C services until they are old enough to demonstrate a significant delay. Typically, documented developmental delay is not measurable until a child is approximately 18 months of age. In states with more rigorous criterion for delay, such as 50% delay, children may never meet eligibility requirements for Part C, despite having a low score on a developmental measure and multiple risk factors. A 50% delay in an 18-month old means that s/he would not have the skills expected in a 9-month old in order to be deemed eligible for Part C services because of a documented developmental delay.    

Maltreated infants and toddlers who are subject to multiple risks associated with poor developmental outcomes could benefit from intervention services aimed at both reducing risk factors and in enhancing the caregiving environment. Proactive interventions that begin when children are at younger ages can help prevent or address developmental delay.

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B.  Developmental Outcomes

Significant problems in the caregiving environment of infants and toddlers are evidenced in the act of maltreating children. Study findings support reason to be concerned about the developmental status of maltreated children regardless of substantiation status. Likewise, problems in the caregiving relationship with the potential to affect developmental outcomes are also indicated in the increased rate of behavioral problems reported by caregivers of young maltreated children.

Previous Research

CAPTA makes a critical distinction between children with substantiated abuse or neglect and those without. Because of the expectations of negative developmental outcomes for maltreated infants and toddlers, the 2003 revision to CAPTA (PL. No. 108-36 § 106(2) (A) (xxi)), mandated that children birth to three years of age with substantiated cases of child maltreatment be referred to Part C early intervention services as described in the Individuals with Disabilities Education Act (IDEA). Part C service providers, or their designee, are required to screen these children and to provide services to those found eligible.

Yet previous research generally shows that children with substantiated cases have more similar case outcomes, over time, to those whose cases are not substantiated. Research does show that children with substantiated cases are more likely to be sexually or physically abused than neglected (US DHHS, 2006; Wolock et al., 2001) and are more likely to have been reported by mandated reporters (Giovannoni, 1995; US DHHS, 2006). Other factors associated with substantiation include the presence of observable injuries and multiple types of maltreatment (Giovannoni, 1989; U.S. DHHS, 2006), and a more complete investigation report. Thus, although some of these indicators could be associated with greater developmental harms, there is not an obvious and direct relationship between substantiation status and developmental well-being of children.

As a result of child welfare policies and practices, children with substantiated cases of maltreatment are more likely to have a child welfare case opened (NSCAW Research Group, 2002). However, in another study among children 4 to 8 years of age who were investigated, though not necessarily substantiated for maltreatment, behavioral and developmental outcomes were not associated with whether the case was substantiated (Hussey et al., 2005). An official determination of maltreatment was not related to the child’s developmental and behavioral outcomes. Determining factors that lead to substantiation of child maltreatment in very young children and understanding how their developmental outcomes compare to unsubstantiated cases will help policy makers understand the experiences and needs of these children who are, on legal grounds, quite distinct.

Study Findings

Exhibit 10 shows that there was an identical (49%) proportion of substantiated and unsubstantiated cases with a Measured Delay, but a lower proportion in the High Risk category in the unsubstantiated group (23 % vs. 34%) and a higher proportion of children in the Lower Risk category in the unsubstantiated group (28% vs. 18%).

Exhibit 10.
Percentage of Substantiated and Unsubstantiated Cases by DRIGs

Source:  NSCAW.

Implications

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. 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.

Previous Research

Maltreated children between 24 to 36 months of the age appear to have an increased occurrence of behavior problems as reported by their caregivers using the Child Behavior Checklist (CBCL) (Achenbach, 1991; Stahmer et al., 2005).  It is not clear whether maltreating caregivers experience their children’s 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 children’s behavior (Lau, Valeri, McCarty, & Weisz, 2006).

Despite the high frequency of temperamental or behavioral concerns in children with developmental delay of various etiologies, behavioral difficulties are rarely used to describe eligibility for Part C services (Hebbeler et al., 2001).  An elevated frequency of behavior problems associated with developmental delay has been described.  Studies found that over 40% of children between 4 and 18 years of age with mild intellectual disability could be classified as having severe emotional or behavioral disorders (Einfeld & Tonge, 1996; Gillberg, Perrson, Grufman, & Themner, 1986; Rutter, Tizard, & Whitmore, 1970).^[3]

A child’s behavior and development are strongly related.  The transactional model of development (Sameroff, 1995) illustrates how the child and the caregiving environment are mutually affected by interaction, e.g. the developing child is influenced by stimuli from the environment and, in turn, provides feedback to the environment that partly determines what future stimuli he or she will receive.  As a result, the child’s behavior and development play a reciprocal role.  For example, a baby quick to smile and respond to caregivers may receive more positive, developmentally important stimuli than a child who is more withdrawn or less responsive.  The transactional model recognizes difficulties that caregivers experience with children as a disturbance in the relationship, not as a problem within the child.

Prior research specific to occurrence of behavior problems in young, maltreated children is relatively scarce.  NSCAW research on children entering the study found that 27% of 2- and 3-year-olds had behavior problems reported by their caregivers compared to 5% of the general population (Administration for Children and Families, 2006). Stahmer et al. (2005), also using NSCAW data, found that 26% of 2-year-olds and 32% of 3- to 5-year-olds had serious behavior problems as assessed by the CBCL. Other research on young children entering out-of-home care indicates that this rate could be between 33% and 39% for children entering foster care (Reams, 1999; Urquiza, Wirtz, Peterson, & Singer, 1994). In sum, among maltreated toddlers, behavior problems seem more common than in the general population. These findings provide a basis for further analysis pertaining to young children substantiated for maltreatment.

Study Findings

Using the CBCL,^[4] behavior problems are classified into one of two categories. First, behavior problems may be externalizing which are difficult behaviors such as physical aggression. Behavior may also be classified as internalizing. These behaviors include less interpersonal problems such as depressive or anxious symptoms. The behavioral characteristics are not mutually exclusive so a child may have both.

Children with behavior problems emerge as a relatively common phenomenon among this group (see Exhibit 11). Almost one in three children 2- to 3-years-old at the time of initial baseline data collection was reported to have a behavior problem. This is much higher than would be expected in the general population, which would have about 8% with an externalizing or internalizing score. This number drops slightly to about 1 in 4 by the 36-month follow-up, by which time all children in NSCAW would have exited the Part C system.

Exhibit 11.
Internalizing, Externalizing, and Any Behavior Problems in Maltreated Children 2 Years of Age and Older
at Baseline and 18- and 36-Month Follow-Up

Source:  NSCAW.  Caregiver completes the CBCL.

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.

Children with behavior problems were not found to be different from children without behavior problems in several areas. For example, children with behavior problems were placed into out-of-home living arrangements no more often than those without behavior problems. Similarly, the distribution of risk and measured delay was similar among children with and without behavior problems.

A key finding is that very young maltreated children were commonly reported by their caregivers to have both internalizing and externalizing problems (as seen in Exhibit 11).

Implications

Young, maltreated children are commonly reported by their caregivers to demonstrate behavior problems. Children at least two years of age are typically reported to have both internalizing and externalizing behavior problems. As a result, child welfare and Part C providers may find these families challenging to work with unless efforts are made to help caregivers learn how to manage problem behaviors. The ratings may suggest serious family dysfunction in which the children are the identified symptom of a troubled family system. The ratings of child behavior may indicate unreasonable behavioral expectations or inability to provide appropriate limits to their children, or to reflect chaos and strife in the life of the caregivers of maltreated toddlers (Scarborough & Poon, 2004). Harrington, Black, Starr and Dubowitz (1998) posit that caregivers living in poverty who ascribe behavior problems to their neglected children may be asking for help, particularly with child-rearing and family functioning. Child-centered interventions will likely be inadequate to remediate these behavioral ratings. Service providers will need to address problems in the aversive caregiver–to-child interaction to effect a positive change. Part C providers specifically need tools for responding to the individual behavioral needs of these children and families (Scarborough, Hebbeler, Spiker, & Simeonsson, 2007).

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C.  Service Receipt

Prior to CAPTA amendments requiring procedures for referring young children to Part C services, a sizable proportion of infants and toddlers were reported to be receiving Part C services. An even larger proportion of families were receiving parent training or family counseling.

Previous Research

Little information is available on the use of Part C services by children involved with Child Welfare Services. A notable exception is a demonstration project implemented by The Massachusetts Early Childhood Linkage Initiative (MECLI, 2005). This project attempted to refer all children younger than three years of age involved in substantiated cases of maltreatment to Part C early intervention at three pilot sites in Massachusetts between November 2002 and December 2004. Over the course of the project, 540 children were offered a referral to early intervention.^[5]  The majority (82%) of parents or guardians accepted the referral. Of those offered a referral, 40% (218 children) were eventually evaluated to determine eligibility for services (Lippitt, 2007). Of those evaluated, 74% were deemed eligible (see Exhibit 12).  Interpretation of the findings in terms of the proportion of children eligible for services are complicated by the fact that a sizable proportion of families were not offered a referral based on the discretion of the local child welfare workers (Mills, 2007). Although these data are from only one state, they provide a rare glimpse at the patterns of referral, service acceptance by parents, and eligibility. Additional information is now available based on our analyses of NSCAW and NEILS data.

Part C early intervention services are provided to infants and toddlers with disabilities to maximize the child’s developmental potential. Eligibility for Part C services extends from birth to 36 months of age. The types of Part C services received nationally by infants and toddlers with disabilities can be seen in Exhibit 13.

Study Findings

An Individualized Family Service Plan (IFSP) is a formal document designating eligibility for Part C services and an agreement between service providers and caregivers regarding the type and amount of services to be provided. In the NSCAW data we examined the proportion of substantiated infants and toddlers reported to have received Part C services. Twelve months after baseline, when maltreated infants and toddlers ranged in age from approximately 12 to 48 months of age, 28% of children still younger than 36 months of age were reported by caseworkers to have an IFSP (see Exhibit 14). This proportion of substantiated infants and toddlers receiving Part C services is prior to implementation of the CAPTA requirement of referral of substantiated cases. Information regarding the type of Part C services children and families received was not available.

Among children reported to have an IFSP 12 months after baseline, the largest proportions were among those who were between 0 to 12 months (29%) and 25 to 36 months (27%) of age at baseline (Exhibit 14). Eighteen months after baseline, when children were approximately 18 to 42 months of age, the proportion with an IFSP was slightly less (20%). At this time point the proportion with an IFSP among children 0 to 12 months at baseline dropped from 29% to 22%, whereas the proportion of those with an IFSP who were between 13 to 24 months at baseline remains fairly stable at 19% compared to 20%, at the 12-month follow-up.

By the 36-month follow-up only children who were between 0-12 months of age at baseline were still age eligible for Part C, and 13%, down from 29% and 22% at earlier time points, were reported to have an IFSP. (Because of study procedures, some of the interviews from the 36-month wave occurred after children were three years of age — this could have resulted in a lower estimate of the proportion of children who were identified as having an IFSP in the 18 months prior to data collection 36 months after baseline.)

Exhibit 14.
Percentage of Children Reported to Have an IFSP by Age
at Baseline, 12, 18 and 36 Months Later

Source:  NSCAW.  Child Welfare providers supply information regarding the IFSP.

Overall, these findings suggest that the reduction in the proportion of children with an IFSP among those investigated as infants 0 to 12 months of age may be attributable to loss of Part C eligibility. Loss of eligibility can be due to no longer needing or qualifying for services or the parent’s choice to no longer participate in services. NEILS found that 16% of children entering Part C in 1997/98 left Part C prior to 36 months of age when Part C eligibility ends (Hebbeler et al., 2007). Data reported by individual states in 2002/03 showed 20% of children who received services left Part C prior to 36 months of age because they no longer required services (U.S. Department of Education, 2004).^[6]

The more stable proportion of children 13 to 24 months of age at baseline with an IFSP over time suggests the possibility that a higher proportion of these children were deemed eligible for Part C because of a documented delay, rather than risk status. Children eligible because of risk factors are often deemed eligible shortly after birth, whereas children with developmental delays have to be old enough to demonstrate the required discrepancy between their developmental status and their chronological age. Often developmental delays due to chromosomal or neurological disorders are not remediable. Many of these children remain eligible and receive special education services when they become school age.^[7]  Some will receive special education services until they age out of the special education system at 21 years of age. In NEILS 58% of children who entered Part C services in 1997/98, had an Individualized Education Program in kindergarten, indicating the receipt of special education services. Another 10% had a disability, but were not receiving special education services (Hebbeler et al., 2007).

NEILS found that 63% of the children who entered Part C services went on to receive preschool special education services (Hebbeler et al., 2007). Numbers from the individual states indicate that 43% of children who received Part C services were Part B eligible (U.S. Department of Education, 2005).

The proportion of maltreated infants and toddlers with an IFSP suggest that many came to the attention of Part C agencies prior to CAPTA reforms that now require the referral of substantiated cases. A high percentage of maltreated infants and toddlers (28% at 12 months after baseline) were reported to have an IFSP, indicating eligibility for Part C services compared to the percentage of children (2.4%) the same age receiving Part C services in the U.S. (U.S. Department of Education, 2005).

Some similarities can be seen in examining the proportions of infants and toddlers by age at entry to Part C services in NEILS. Of children entering Part C nationally 38% are less than 12 months of age, 28% are 12 to 24 months, and 34% are older than 24 months of age. The higher representation among children younger than 12 months and older than 24 months is similar to maltreated infants and toddlers with an IFSP. Children younger than 12 months of age tend to enter Part C because of biomedical or environmental risk factors or established risk conditions rather than developmental delays whereas children 24 months of age and older tend to enter Part C because of documented developmental delay (Scarborough et al., 2004).

The number of maltreated infants and toddlers who received Part C services prior to CAPTA was not officially recorded. The information presented is based on data collected as part of a survey of maltreated children, and portrays a national picture of the receipt of Part C services among substantiated cases of maltreatment of infants and toddlers investigated in 1999 and 2000. Since the implementation of CAPTA, a few states have begun to keep records on the number of referrals from child welfare and the children deemed eligible for services; that information is not currently available.

Implications

The Massachusetts Early Childhood Linkage Initiative (MECLI) demonstration project referring families to Part C resulted in rates of substantiated cases being found eligible for services that were higher than those found in NSCAW.  The differences could be partially attributable to different data collection methods at different points in time. The differences may, however, result from the efforts in Massachusetts to refer all substantiated cases of maltreated infants and toddlers to Part C early intervention services and, more generally, to respond to the needs of children at high risk for developmental delay. Massachusetts is one of the five states providing services to at-risk children. This is accomplished through funds available from public health insurance for children that is used to help pay for Part C services. MECLI findings show that a larger proportion of substantiated cases of maltreated infants and toddlers with families willing to pursue a Part C evaluation were found eligible for Part C services, than those reported to have an IFSP in NSCAW. MECLI also found that some child welfare workers used their own discretion as to who should be referred. Some of this unofficial ‘screening’ and family self-selection likely served to increase the proportion of assessed children found eligible (74%). Though the capacity of child welfare workers to screen for referral may be arguable, this process is supported by some Part C providers because it enables them to expend limited resources to determine the eligibility of children who may have a developmental delay, rather than on those who clearly do not.

In 2003, the federal government amended CAPTA, which required states to have provisions and procedures in place for the referral of children younger than the age of three years with substantiated maltreatment. CAPTA does not require that every child younger than the age of three who is involved in a substantiated case of child abuse or neglect be referred to Part C services. States have the discretion to refer every such child younger than the age of three for Part C early intervention services or to use a screening process to determine whether a referral is needed.

The 2004 reauthorization of IDEA included similar changes in Part C child find practices by requiring states to have a description of the policies and procedures that require the referral for early intervention services of a child under the age of three who is involved in a substantiated case of child abuse or neglect. To receive Part C federal funds, states must have child find efforts in place to locate eligible children. Part C requires that infants and toddlers with substantiated cases of maltreatment be screened by a Part C provider or designated primary referral source to determine whether a referral for an evaluation for early intervention services under Part C is warranted. If the screening indicates the need for a referral, a referral is expected to be made. IDEA specifies that this provision is not intended to require that every child involved in a substantiated case of child abuse or neglect receive an evaluation or early intervention services under Part C.

The numbers of children that might be referred to Part C is dependent on many factors including the number of substantiated cases of maltreatment. Variation in the rates of substantiation ranges from less than 2% to over 40% among states (U.S. DHHS, 2007). This variation coupled with differences in eligibility criteria among individual states, limits the ability to make inferences regarding the extent to which CAPTA legislation might affect the number of referrals to Part C. In many states, the number of infants and toddlers involved in Child Welfare Services outstrips the numbers being provided with Part C services. Child Welfare Services is usually unable to determine the proportion of substantiated cases that subsequently receive Part C services. This is often unknown because Child Welfare Services can only verify that the referral process is explained to the family, but has no court-ordered justification to determine whether services are received. This is the case because much of the information regarding eligibility for Part C is confidential and except in a few states is not related to maltreatment status. In some states, evidence of participation in Part C services may help caregivers fulfill their court-ordered service plans. This area of coordination needs additional research and analysis to determine typical and best practices (Stahmer, et al, 2008).

Additionally there are substantial challenges in verification of what happens after referrals are made. States in which Child Welfare Services and Part C services are housed within the same agency have information systems that are configured to allow for better coordination of information and accountability. During expert interviews, some practitioners reported that a shared database was in the process of being developed. Substantiated cases of maltreatment that can be identified in case record systems will improve the efficiency of referrals, and likely improve knowledge of whether Part C services were received.

In order to expedite referrals some states have initiated joint training. This involves training sessions in the screening and referral procedure included in orientation sessions of all new child welfare workers. Training in using a simple screening instrument is included. The Utah Part C agency developed a book and curriculum to train child welfare workers. In Utah, children substantiated for abuse must be interviewed by Child Welfare Services. For infants and toddlers this interview, which utilizes a screening tool, constitutes screening for referral. Utah uses the Nipissing Developmental screen, a normed checklist developed in Canada, derived from Ages and Stages Questionnaires (ASQ):  A Parent-Completed, Child-Monitoring System (Bricker & Squires, 1999). The ASQ is one instrument that is frequently used for screening young children for developmental problems, as is the Battelle Developmental Inventory Screener (Newborg, 2004). New Mexico Part C trains guardian ad litem, judges, and child welfare personnel, but acknowledges the challenges involved in repeated training because of changing personnel. The positive aspect of training sessions is the result of contributing to the formation of county teams to address the needs and referrals of maltreated infants and toddlers.

Study Findings

Seven services were reported in NSCAW.  This included vision services, hearing services, therapeutic nursery, parenting training (including use of a case aide), family counseling, receipt of special educational services (e.g., IFSP), and receipt of developmental child care (e.g., Head Start or other).  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 (see Exhibit 15). 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.  A small proportion of children had vision or hearing services, in the same time period, with slightly more infants (18% and 14%, respectively) receiving services than toddlers.  The percentage of children with vision and hearing services between 18 and 36 months after baseline also was slightly less ranging from 6% to 15% across ages at baseline.

One-third of infants 0 to 12 months of age at baseline (34%) were in a child care setting in the time period between baseline and the 18 months follow-up. Half of children 13 to 24 months of age (50%) and 45% of those 25 months and older at baseline were reported to be in Head Start or a similar child care setting, in the same time period. It would be expected that the proportion in child care would be smaller for the youngest children. In the period of time between 18 and 36 months after baseline the proportion of children in Head Start was similar, with the children 25 months of age and older at baseline decreasing from 45% to 36%, reflecting that the oldest children were school-aged and no longer age appropriate for Head Start. The percentage of children in therapeutic nursery of all ages, at all time points was small, ranging from 3% to less than 1%.

These seven services were combined to indicate whether the child or family received any services during their child welfare case duration. A statistical analysis was conducted to examine the association of gender, race, maltreatment type, child welfare setting, prior contact with child welfare, number of children in the home, and whether the child and family lived in an urban setting with the receipt of any of the services. This analysis indicated that living in a non-urban area was associated with not receiving services, whereas neglected children were more likely to receive services compared to children whose maltreatment was described as abuse. These analyses showed no other significant differences between children who did or did not receive any of the services.

Implications

Receipt of Child Welfare Services suggests that as children get older there may be less perceived need for parent training. The proportion of families reported to receive family counseling also declines in this time period. Receipt of services appears to be related temporally to the time of initial investigation. This reduction in services may be associated with the effectiveness of services in reducing risk factors, particularly those associated with conditions in the home directly associated with substantiation of maltreatment.  Alternatively, this reduction may indicate a declining ability of services to engage families. Analyses of child welfare parent training services provided under the auspices of Child Welfare Services suggest that only a fraction are evidence-based and that there are relatively few models that have been developed that are appropriate for younger children (Barth et al., 2005; Hurlburt et al., in press).

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D.  Considerations for Successful Interventions

Discussions with experts revealed concerns that Part C providers may be unprepared to provide effective services to maltreated children and their families. Successful implementation of CAPTA may require structured collaboration between Child Welfare Services, Part C, including procedures for accessing needed services and strategies to provide needed interventions.

Recent CAPTA legislation mandated that all substantiated cases of maltreatment of infants and toddlers be referred to early intervention services to determine eligibility.  Given the elevated levels of risk and delays reported, getting eligible maltreated children, ages birth through two years of age into Part C services seems an important task, perhaps more so because of the importance of this time period in child development. Part C service providers, however, may need new strategies to engage and work with maltreated children and their families. In addition to the negative consequences of maltreatment on children’s behavior and development, children’s families may be disorganized, suspicious of providers’ motives, overwhelmed by multiple services and providers, coping with substance abuse or early sobriety, or coping with other difficult problems. As a result, these children and their caretakers may not respond to routine early intervention practices.

Previous Research

Children coming to services from maltreatment backgrounds bring a new set of challenges to many early intervention practitioners. In addition to their developmental problems, maltreated infants and children may bring severe behavior problems (e.g., attachment disordered behaviors), problems in the family of origin, substitute caregivers who may not be knowledgeable about the child (e.g., a new foster family), multiple service providers and payment sources, and other challenges for interventionists to resolve (Vig, Chinitz & Shulman, 2005).

In particular, intervention with maltreated children, whether the child is in foster care or remaining with their family of origin, requires the active participation of family members. Part C services are by definition supposed to be directed to both children and families, in that the goal is to help caregivers incorporate intervention activities into the child’s daily routines. Because behavioral and mental health disorders are related to maltreatment, Child Welfare Services interventions are often recommended to include parent training and other family-centered components because of the enormous influence parents’ have on their children’s outcomes, developmental or otherwise (Vig et al., 2005).  Recent developments in parenting of maltreated children have focused on helping the caregivers to be more responsive to the variations in the child’s response and to stay positively involved with their care, even if the children are initially unresponsive (Fisher, Burraston, & Pears, 2005).

Many Part C early intervention providers may not be well prepared to address the special considerations required when working with maltreated children. Many Part C providers are speech language therapists, occupational therapists and physical therapists. As Vig et al. (2005) point out; increasing interventionists’ knowledge will improve services and outcomes. In addition to developing new skills, early interventionists may use, or collaborate with others who are using specific treatment regimens designed to improve maltreated children’s behavior, address mental health problems including attachment problems, and promote development.

Study Findings

Discussions with Part C early intervention experts supported the concern that early intervention providers do not have extensive experience or training to work with children and particularly adults with mental health issues. Even for service providers experienced with such families, service provision can be difficult. Providing Part C providers with knowledge and professional support can greatly increase the likelihood of effective service provision with the end result of better child outcomes.

A major concern expressed by experts was that Part C early intervention primarily provides therapeutic services that are child-focused. Family-focused services in Part C are centered on family involvement in supporting child development. Part C does not typically provide services that include services for other family members, though Part C services may be adult focused; it is generally in the form of training for the parent to work with the child. In most cases, Child Welfare Services emphasize providing family-centered services because research, past experience, and theory suggest this will be the most effective intervention model for resolving behavior and mental health problems in the child and promoting a strong sense of ‘connectedness’ among family members.

Part C services are based on the child’s eligibility for services, predicated on developmental delay not maltreatment. The vast majority of services provided are speech-language therapy, physical therapy, occupational therapy, or home-based services from a developmental specialist or early interventionist. It is unusual for infants or toddlers to be eligible for Part C services because of behavior, though behavior is a concern for many parents of children with disabilities (Scarborough et al., 2007).

Families involved in child welfare may also present with problems that inhibit service provision. They may be suspicious of, or hostile towards, service providers. In the MECLI Study in Massachusetts, it is estimated that in addition to the 18% who refused referral that another 19% of families who accepted the referral did not engage with Part C (Lippitt, 2007).  Court-ordered involvement may cause parents or caregivers to view a service provider as an intrusion rather than as a source of assistance. Home environments may be chaotic or, in the case of homelessness or residence in a shelter, non-existent.

Receipt of Part C services is voluntary, so court-ordered services are not part of the service culture, and for most, an unwelcome notion. Delivering court-ordered Part C services would require the development of procedural guidelines. A national survey of state Part C providers indicated that in regards to this matter there needs to be a determination of when to challenge caregivers’ decision to decline services. Specifically the differences in Part C and child welfare agency culture regarding mandating services should be resolved at the state and local level (Stahmer, et al, 2008).

Implications

In sum, three major challenges often need to be addressed by Part C early intervention providers. First, the focus of service should address the child’s needs within the context of the family. Second, special strategies and techniques are often needed to engage, retain, and successfully serve child welfare families in Part C early intervention services. Finally, when possible, the intensity of services should be matched to the needs of children and families in order to facilitate a positive outcome.

Individualized Part C early intervention services as typically delivered to infants and toddlers with disabilities are unlikely to be of sufficient intensity, nor are they designed to be effective in addressing the root causes of maltreatment and severe family dysfunction. The effectiveness of Part C is generally predicated on the intervention that occurs as part of the child’s daily routine between therapeutic sessions, rather than during sessions. Budget constraints or practitioner schedules may limit visits to as few as once a month. When missed and canceled appointments are factored in, visits may be even less frequent. Yet, maltreated children are often behind their peers developmentally, have behavior problems, and continue to experience poorly functioning home environments. These multiple needs call for intensive services to make a meaningful impact. Both families and providers may quickly become frustrated when low-intensity (infrequent or brief) services fail to provide a noticeable developmental benefit to cases in which higher intensity services are probably necessary.

Some immediate assistance for Part C providers, and their child welfare and mental health collaborators, in being able to refer children and families to specific treatment regimens designed for maltreated children or with direct applicability to them could be useful. Early Intervention Foster Care (Fisher et al., 2005) and The Incredible Years Parenting Program (Bauer & Webster-Stratton, 2006) are two examples of evidence-based interventions that have shown success with pre-school aged maltreated children.  Specific issues have been laid out for interventionists, but it is not known to what degree Part C providers have begun to address these concerns.

There are clear differences between the Part C and Child Welfare systems in their general approaches or philosophy and clients served.  For example, the focus of Child Welfare Services is on protecting the child’s safety and dealing with the perpetrator and Part C’s focus is providing services to children with disabilities and their families.  Also, maltreated children and their families may present new challenges to Part C practitioners. These differences create a gap between staff hired to serve child welfare population who are now being asked to recognize the developmental needs of children, and Part C practitioners trained to work with children with disabilities and their families. Our discussions with experts have identified ways to possibly address this issue.

Previous Research

As stated earlier, maltreated children receiving services bring a new set of challenges to many Part C service providers.  In addition to their developmental problems, maltreated infants and children may bring behavior problems, problems in the family of origin, substitute caregivers who may not be knowledgeable about the child, multiple service providers and payment sources, and other challenges for interventionists to resolve (Vig et al., 2005).  Previous research also supports the idea that increasing interventionists’ knowledge will improve services and outcomes.  Vig et al. argue that early intervention providers may not be well prepared to address these special considerations when working with maltreated children.

The training, collaboration, and knowledge of child welfare staff could have important ramifications.  There is evidence to suggest that Part C and other early intervention programs may be underutilized (Horwitz, Owens, & Simms, 2000; Robinson & Rosenberg, 2004). This underutilization is associated with the inability of some child welfare professionals to recognize potential developmental problems (which result in low referral rates), as well as low intervention participation (and high attrition) among parents and caregivers (Giardino, Hudson, & Marsh, 2003; Hurlburt et al., 2004).  Having better trained staff could potentially improve referral rates. 

Among agencies providing services for maltreated children there is a gap between advances in basic science (what we believe works) and what is provided (Barth et al., 2005; Wolfe & Wekerle, 1993).  Although most practitioners who work with maltreated children and their families want to provide the best treatment possible, they do not have the opportunity, financial resources, knowledge, training, or incentives to provide best practices.  Experts consulted have suggested the following strategies for closing the gap:  (a) financial changes and incentives (e.g., increased programmatic funding for education and direct costs for hiring more educated workers, higher reimbursement for empirically-based treatments, only paying for empirically-based treatments), and (b) a variety of dissemination plans including providing materials, training, supervision and consultation opportunities from universities, research society conferences, and in-house training facilities (Brown, Zaslow, Weitzman, 2006; Mahler et al., 2002; Malone, McKinsey, Thyer, & Straka, 2000). 

Study Findings

During discussions with Part C and Child Welfare experts, an issue raised was that increased training and collaboration of Child Welfare and Part C service providers could be a useful approach to facilitate CAPTA compliance and enhance developmental outcomes for children.

Experts we spoke with were concerned about both Part C and Child Welfare workers 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.  Many states hire BA-level Child Welfare front-line workers who do not have a social work, psychology, or human services background.  At the most basic level, Child Welfare workers may not be able to identify infants and toddlers who need developmental services and will need more training to know which children to refer.  Referring based on substantiation is likely to result in many false positives (substantiated cases with no need for developmental services) and many false negatives (unsubstantiated cases with a need for developmental services).  Therefore, the experts suggest that additional training is needed for these workers.

The experts suggest cross-training, better developmental education for front-line Child Welfare workers, and specialized case coordination.  Specific topical areas for training for Child Welfare workers include:

• Basic infant development
• How and when to make referrals

The experts suggest training for both Child Welfare Services and Part C workers in these areas:   

• Infant mental health problems and interventions
• Understanding of the specific roles and functions of Part C and Child Welfare Services

The experts made a point to emphasize that both Part C and Child Welfare front-line workers and supervisors need to be trained.  According to the experts, supervisors have an important role in helping front-line staff understand the collaborative system between Part C and Child Welfare Services.  Supervisors need to understand the specific roles and functions of Part C and Child Welfare Services and to be able to train their own staff on these issues.

In addition to training, enhanced collaboration could also facilitate CAPTA compliance and improve child outcomes.  Experts expressed concern over the lack of centralized authority or responsibility for implementation of the CAPTA requirements.  In the majority of jurisdictions, the lead agency for Part C is not the department of social services.  Thus, coordination between Part C and Child Welfare Services can be challenging.

An added element to the coordination mix is that the court system may be involved. One of many issues that does require a coordinated response involves the handling of court-ordered services — quite common in cases in which child maltreatment is substantiated — but not familiar to Part C providers, because Part C services are voluntary.  When family involvement in Part C services is mandated by the courts, this creates many new issues to be resolved regarding confidentiality, reporting back to the courts, protocol for noncompliance by the family, and the unfamiliarity and likely discomfort of the Part C provider with the role of mandated service provider. 

Ideally, states need to have effective collaborative service plans.  While this project did not conduct a comprehensive analysis of existing models across the nation, during conversations with experts, Delaware and Utah were identified as states that have successful collaborative models.  Alaska has acted to bring all prevention services together under Child Welfare Services. Colorado has also just moved their lead Part C services agency from education to health services.  Potentially, other states could look at the work in these four states to determine if any promising practices could be implemented in their own state.

Implications

Of course, any implementation of a training curriculum or enhanced collaboration model may have cost implications.  Training needs vary by state.  A few states have negotiated agreements between Part C and Child Welfare agencies, so that child welfare workers become a designated referral source responsible for screening prior to referral, with training provided by Part C agencies. States already providing Part C services to children at-risk seemed to need less procedural change to serve maltreated infants and toddlers. Screening does not seem to be a problematic issue for these states. States that have a tradition of working with at-risk children are likely better prepared to provide services to maltreated infants and toddlers.

However, the majority of states do not have a tradition of working with at-risk children or a collaborative working relationship between Child Welfare Services and Part C, nor does there appear to be a system of accountability, except perhaps in those states where the same lead agency is responsible for both systems. Opportunities for joint Part C and Child Welfare Services trainings would enable staff and supervisors from both systems to better understand their specific roles and functions.

As our findings demonstrate, Part C professionals are somewhat familiar with maltreating and very high-risk families, as demonstrated by the 28% of infants and toddlers with an IFSP 12 months after baseline. However, those children were receiving services prior to the CAPTA mandate and as such likely represent voluntary participation in Part C. Part C service providers (e.g., physical therapists, speech therapists, developmental specialists) are typically not trained to work with infant and particularly not adult mental health issues. To meet the needs of child developmental problems rooted in dysfunctional child/caregiver interactions will require Part C or Child Welfare Services to access Infant Mental Health services in behalf of these children.

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Footnotes

[3] The report, Literature Review: Developmental Problems of Maltreated Children and Early Intervention Options for Maltreated Children, available at http://aspe.hhs.gov/hsp/07/Children-CPS/litrev/index.htm, provides additional information on this topic.

[4] The CBCL version used in NSCAW has two scales. The first is for children 2- to 3-years old and the second is for children 4 years and older.

[5] 27% of the referrals were not received by Part C:  18% refused the referral, 19% accepted the referral but for various reasons did not engage with Part C.

[6] Eligibility can be lost in several ways. For example, in some states children deemed eligible because of clinical opinion must be evaluated within 6 months. At that time the child must meet eligibility criteria for services to continue. Similarly, children are periodically reevaluated while receiving Part C services. If the degree of delay no longer meets criteria or if the child has met IFSP objectives the child will no longer be eligible for services. In states that designate eligibility based on risk status, if the number of required risks is no longer evident the child will lose eligibility. Infants with an IFSP based on risk may lose eligibility, after a period of time, if no delay is apparent.  Another likely source of decline in IFSP rates is family choice not to continue receiving services.

[7] As children approach age 3, the local education agency (LEA) determines eligibility for Part B Section 619 preschool services. Section 619 services are provided through Part B of IDEA. Eligibility for Section 619 services is different than Part C. Risk status does not influence eligibility for Part B services. Section 619 services are for children with a disability including: mental retardation, hearing impairments (including deafness), speech or language impairments, visual impairments (including blindness), serious emotional disturbance, orthopedic impairments, autism, traumatic brain injury, other health impairments, or specific learning disabilities who need special education and related services. There is an optional category of developmental delay for children ages 3 through 9, at the discretion of the state and the LEA, for children experiencing developmental delays in one or more of these areas:  physical development, cognitive development, communication development, social or emotional development, or adaptive development (Danaher, 2005).

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