Developmental Status and Early Intervention Service Needs of
Maltreated Children Early Childhood Comprehensive Systems Partners Meeting
The Radisson Plaza Lord Baltimore March 14, 2008
Anita A. Scarborough, University of North CarolinaRichard P. Barth, University of Maryland
E. Christopher Lloyd, University of Arkansas Jan Losby, ISED Solutions
Tammy Mann, ZERO TO THREE
This research was funded by the Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services, under contract 233-03-0099 to ISED Solutions. Points of view or opinions in this presentation do not necessarily represent the official position or policies of the U.S. DHHS.
Organization of Presentation
1. Data Sources2. Research Questions3. Part C Eligibility4. Findings5. Areas for Future Research6. Project Summary
Sources: NSCAW, NEILS, Experts, Literature Review
• NSCAW– National Survey of Child and Adolescent Well-Being, the first national
probability study of children and adolescents investigated by Child Welfare Services (’99 – present)
– Sub-sample of 980 maltreated (substantiated/high risk) children ages birth to thirty-six months
• NEILS– National Early Intervention Longitudinal Study, the first national probability
study of children entering Part C Services (’97-’98-2005)– 3,338 participants, birth to thirty-one months, entering Part C
• Experts– Identified for policy, service, and developmental domains related to Part C services and Child Welfare Services
• Literature Review– Identified and summarized literature addressing developmental risk of
children ages 0 to 3 and Early Intervention services
NEILS & NSCAW Samples
• 3,338 Participants ages 0-31 months• Entry to Part C in
1997-1998• 20 States• Follow-up every year
in Part C, at age 3, & kindergarten school year
• 1,845 Participants ages 0–36 months
• 950 Substantiated or High Risk Participants
• 36 States• Baseline was 1999-2001• Follow-up data collection
12, 18, 36 months after baseline
NEILSNEILS NSCAWNSCAW
Both studies are nationally representative of their respective populations when special
analytic methods are employed
Research Questions
• What are the developmental characteristics of infants and toddlers receiving Child Welfare Services?
• What do those characteristics suggest about the need for Part C early intervention services?
• How might these services be best delivered to maltreated children?
Goal: Facilitating CAPTA’s intent by informing the CWSand Part C communities about the developmental status of maltreated children
Part C EligibilityFor children with disabilities birth through two years of age –
1. Developmental Delay: Criterion for delay established by individual
states.
2. Conditions of Established Risk: a diagnosed physical or mental
condition having a high probability of resulting in developmental
delay
3. Optional category of “at-risk” of substantial delay if early
intervention is not provided, based on presence of
biological/medical or environmental risksbiological/medical or environmental risks. (4 states recognize
environmental risk)
Finding #1
Children birth to 36 months of age who have been maltreated are at substantial risk of experiencing
developmental problems.
NSCAW Developmental MeasuresCommunication: The Pre-School Language Scales –
3rd Edition. Because of questionable reliability of scores for infants it was used for children 12 months of age and older.
Adaptive Behavior: The daily living skills portion of the Vineland Adaptive Behavior Screener was completed by the caregiver. Because of questionable reliability of scores for infants it was used for children 10 months of age and older.
Cognitive: The cognitive subscale of the Battelle Developmental Inventory. For children 4 years and older, the Kaufman Brief Intelligence Test was used.
*DRIGs = Delay and Risk Indicators Groups (3 mutually exclusive groups)
(1) Measured Delay: – At least 1.5 SD below the mean on any
measure or 1 SD below on any 2, or;– An Established Risk condition associated with
delay & Part C eligible (3%)(2) High Risk: Five or more risk factors, no
measured delay(3) Lower Risk: Less than five risk factors, no
measured delay
* DRIGs were devised and defined for this study.
Defining RiskRisk Factor %Maltreatment 100Poor Parenting Skills 61Minority Race/Ethnicity 58Single Caregiver 48Poverty 46Domestic Violence 40Substance Abuse 39Caregiver MH Problems 30Low Caregiver Education 29Biological/Medical Risk 22Four or More Children 14Teenaged Caregiver 19
• 56% have 5 or more risk factors
• 82% had at least 4 risk factors
• Virtually all had at least 2 risk factors (99%)
• Maltreatment co-occurs with other problems placing children at-risk for developmental delay & later school difficulties
DRIGs Distribution at Baseline
Half of all infants and toddlers had a low score on a developmental measure
• Measured Delay = 49%
• High Risk = 28% (5 or more risk factors)
• Lower Risk = 23% (< 5 risk factors)
DRIGs by Age at Baseline
0
10
20
30
40
50
60
70
80
0 - 3 Months 4 - 6 Months 7 - 9 Months 10 - 12Months
13 - 24Months
25 - 36Months
Wei
ghed
Per
cent
Measured Delay High Risk Lower Risk
• Percentage with a Measured Delay higher among cases investigated as toddlers
• Percentage with High Risk lower among cases investigated as toddlers
• Children with more risk factors are more likely substantiated at younger ages
Finding #2
Finding #2
Compared to classification at the time of initial contact with child protective services, over time a
higher proportion of children tend to be described as having
fewer risks or having a low score on a developmental measure.
Baseline (0-36 months in age)
Approximately 18 months after Baseline
(18-54 months in age)
Measured Delay(50%)
High Risk
(29%)
Lower Risk (21%)
Measured Delay (49%)
52 31 18
High Risk (28%)
4343 36 22
Lower Risk (23%)
5656 11 33Diagonal = Percent unchanged
DRIGs 18 Months After Baseline• Similar distribution,
however change in classification of individual children:
• Measured Delay: 52% still have a Measured Delay
• High Risk: 36% remain HR, with 43% now with a Measured Delay
• Lower Risk: 33% remain LR, but 56% now with a Measured Delay
Approximately 36 months after Baseline
(3-6 years of age)
18 months after Baseline(18-54 months in age)
Measured Delay(42%)
High Risk
(13%)
Lower Risk
(45%)
Measured Delay (50%)
57 10 33
High Risk (29%)
3737 28 35
Lower Risk (29%)
2222 6 72 Diagonal = Percent unchanged
DRIGs 36 Months After Baseline Compared To 18 Month Follow-up
• 36 months after baseline only 13% High Risk; 42% Measured Delay, 45% Lower Risk
• 72% LR remain the same, 22% now with a Measured Delay
• Only 28% of HR classified the same, 37% now with Measured Delay
DRIGs 36 months After Baseline (at 3-6 years of age)
49
28
23Measured Delay
High Risk
Lower Risk
44% remain in Measured Delay Category
57% remain Lower Risk
23% remain High Risk
Baseline
• Children in the Lower Risk category show more stability in classification
• High risk children tend not to stay there
Cumulative Risk and Measured Delay at Baseline
5
18
44
76
9299
0102030405060708090
100
Up to 2 3 4 5 6 7
Number of risks
Perc
enta
ge w
ith m
easu
red
dela
y
At baseline the relationship between risk and measured delay is clear
DRIGs and Child Welfare Placement at Baseline
65
15
21
51
29
20
38
25
37
22
58
20
0
10
20
30
40
50
60
70
Measured Delay High Risk Lower Risk
Percen
t
In Home no CWS (30%)
In Home CWS (40%)
Foster Care (18%)
Kinship (9%)
• A higher proportion of Measured Delay among children receiving NO ongoing CWS
• Risk is distributed more evenly among placement options
Finding #3
Few infants and toddlers with substantiated cases of
maltreatment are reported to have an established risk
condition (e.g., Down syndrome), as described in IDEA, that would
make them eligible for Part C services.
Eligibility For Part C Services Based On Diagnosis Of An Established Risk Condition
3% of total population; N=50
Birth Defect26% Epilepsy
6%Cerebral Palsy
5%
Spina Bifida5%
Fetal Alcohol Syndrome
23%
Blood Disorder5%
Traumatic Brain Injury18%
Sickle Cell Anemia
12%
Only 3% of young maltreated children are reported to have an Established Risk condition which would make them eligible for Part C services, compared to 38% of children entering Part C.
Finding #4
The proportion of children with a measured delay who have
substantiated maltreatment reports does not differ markedly
from children investigated for maltreatment (but not
substantiated).
Substantiation: A Distinction Without a Developmental Difference?
49
2328
49
34
18
0
10
20
30
40
50
60
Measured Delay High Risk Lower Risk
Percent
Unsubstantiated Substantiated
Identical percentage with a Measured Delay
Higher percentage of Lower Risk cases among unsubstantiated
No statistically significant differences between the groups
Finding #5
Maltreated children between 24 to 36 months of age have relatively high levels of behavior problems
reported by their caregivers.
25
1412
24
11
19
31
18
24
0
10
20
30
40
Baseline 18 Months 36 Months
Perc
ent
Internal (I)External (E)Any (I or E)
Behavior Problems in Children 2 Years of Age and Older as
Reported by Caregivers
About 70% with a problem at baseline also had problem at 36 month follow-up
Specific interventions needed for these
children and families
Finding #6
A sizeable proportion of substantiated infants and toddlers are
reported to have an Individualized Family Service Plan (IFSP), reflecting
eligibility for Part C services.
Part C - Individualized Family Service Plan (IFSP)
Eligibility for Part C services ends at 36 months of age
28
20
13
29
22
13
20 19
27
0
5
10
15
20
25
30
35
12 months 18 months 36 months
Perc
ent
All ages0-12 mos13-24 mos25-36 mos
• An IFSP is a mandated component of Part C services
• Families participated in Part C voluntarily
• Proportion of children receiving Part C services, as indicated by IFSP, decreases over time
IFSP by Baseline Age at Follow-Ups
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.
Services Received Between Baseline and 18 Months
Parent Training
Family Counseling
Vision Hearing Therapeutic Nursery
Head Start
Age at baseline
% % % % % %
0-12 64 39 18 14 <1 3413-24 66 51 16 8 <1 5025-36 67 54 10 6 <1 45
Services Received Between 18 and 36 Months0-12 14 16 9 15 <1 3913-24 30 31 13 11 3 5625-36 9 20 6 6 0 36
39% - 67% of families
received parent training or family
counseling in the period 18 months after investigation
As children age, fewer children
get family-focused services
Impressions of Experts We Spoke with for this Study
• CWS and Part C personnel agree that many maltreated children need Part C as well as other early intervention services
• Experts believe several obstacles exist to fulfilling vision set forth in CAPTA and IDEA legislation– Policies– Service Delivery– Training & Cooperation
Finding #8
Part C providers may not be familiar with the unique
challenges associated with providing services to maltreated
children and their families.
Impressions of Experts We Spoke with for this Study
• Part C and CWS personnel often have little knowledge of each others’ areas of expertise
• Differing theoretical and service orientations• Part C provider potential frustration and burnout
in working with complex CWS cases• Service – Need mismatch may result in
ineffectual services• CWS-involved families may be difficult to
engage and/or maintain in Part C services– Hostile, overwhelmed, or chaotic families
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.
Impressions of Experts We Spoke with for This Study
• Lack of centralized oversight of both systems’ accountability
• CWS/Part C providers may not be aware of obligations
• Part C referral may not be a priority for CWS• Development of a rapid screening tool for
CWS to use prior to Part C referral to better utilize scarce resources: – For example, in rural areas Part C providers
may need to travel great distances to screen a child who clearly has no developmental problems
Promising Options for Improving Services– Impressions of Experts We Spoke With
• Cross-training workers from CWS and Part C
• Developing multi-disciplinary Part C teams that include a child welfare worker
• High-level oversight and facilitation of implementation of CAPTA/IDEA vision
• Increase resources by leveraging other systems (e.g., Medicaid, Early Head Start)
• Development of a rapid screener for use by CWS to determine need for referral
Areas for Future Research
• Intervention. Matching levels and types of services with child and family needs
• Types of families. Understanding characteristics of sub-groups of families who receive Child Welfare and Part C Services
• Substantiation as a criterion for referral. Number of risk factors as an indicator of likelihood for poor developmental outcomes may be a more useful indicator of which children to refer to Part C
• Engaging in intervention. Parent engagement and training approaches employed by Child Welfare Services and Part C may need considerable development
Future Research [continued]
• Best practices on collaboration. Central to effective service delivery is the development of collaborative work models between Child Welfare and Part C
• Funding models and services receipt. Services provided depend on what funding authorities support. Additional research of potential funding sources is needed
• School readiness. Understanding the longer-term developmental implications of early maltreatment and early intervention on children’s development
Project Summary• Based on Measured Delay and/or High Risk, 79% of
CWS investigated children were identified as having a measured delay or high risk status
• High risk children are at higher likelihood for poor developmental outcomes, including school-age problems.
• Those with a low score on a developmental measure are demonstrating an additional marker associated with academic and cognitive difficulties.
• Children with more than 5 recognized risk factors are likely to persist in that category or develop measured delays.