Preventable Injury Deaths:A Population-Based Proxy of Child Maltreatment Risk

Emily Putnam-Hornstein, PhDCenter for Social Services ResearchUniversity of California, Berkeley

background

Maltreated children not known to child protective services

Maltreated children known to child protective services

motivation

• CPS: a racially biased sample of maltreated children?

• a population-based metric of child maltreatment risk / child welfare service needs

• implications for how and where we intervene to reduce racial disparities…as well as what our short-term expectations should be

this study• uses data from two public surveillance systems as

a means of assessing bias in one source (CPS data), using the more complete data found in the other (vital injury death records)

• exploits variations in injury fatality rates as a means of quantifying bias in the racial distribution of maltreatment victims identified by CPS

• hypothesized that racial variability in excess injury death would be observed, but absent widespread bias on the part of CPS, consistent counts of substantiations for each excess death

child injury deaths

A mortality-based standard for evaluating parental behavior may be the closest we can get to “culture-free” definitions of neglect and abuse. (S.R. Johannson, 1987)

why all injury fatalities?• maltreatment-related, inflicted injuries are

severely undercounted in death records– cannot capture racial bias in one data source, using

another source potentially corrupted by the same bias

• unintentional and intentional child injury fatalities are falsely dichotomized – the outcome is the same – unintentional injury fatalities are largely preventable,

occur in the home, frequently reflect inadequate caregiving and supervision (i.e., neglect), accompanied by the same risk factors as intentional injury deaths

data

injury mortality rates

maltreatment rates

population estimates

death statistical master files

substantiation records

bridged-race postcensal est.

year, age, race/ethnicity, manner/mechanism of death

year, age, race/ethnicity, maltreatment substantiations

year, age, race/ethnicity

maltreatment rates (per 1,000) &injury death rates (per 100,000)

020

4060

020

4060

0 1 2 3 4 0 1 2 3 4

White

Black

Hispanic

Asian/PI

Death Rate Substantiation Rate

Ra

te

Age

* Native American children excluded due to small cell sizes.

21.6 per 1,00018.8 per 100,000

20.7 per 1,00016.9 per 100,000

62.8 per 1,00045.5 per

100,0007.0 per 1,00012.3 per 100,000

excess injury deaths

• rates of excess (or preventable) injury mortality were derived based on the difference between each racial group’s rate of injury death and that of an achievable baseline

semi-arbitrary achievable death rate

excess deaths

??

Since, by its very definition, the “achievable death rate” is the upper bound estimate of some unknown fraction of injury deaths that were actually unavoidable…two other baselines were also considered.

4.5

18.5

14.9

4.0

4.0

8.2

0 10 20 30

All

Native American

Black

White

Hispanic

Asian/PI

Achievable Death Rate Excess Death Rate

excess injury deaths

substantiations per excess death

• it was posited that in the absence of widespread substantiation bias on the part of CPS, consistent numbers of substantiated cases for each excess death would be observed across racial groups

• differences in the number of substantiations per excess death were treated as an indication that CPS had substantiated a racially biased sample of the full population of children at risk of maltreatment / in need of child welfare services

definition:the number of substantiated cases of maltreatment for every injury death in excess of a specified baseline rate

substantiations per excess death

0 100 200 300 400

Asian/PINative American

HispanicBlackWhite

Asian/PINative American

HispanicBlackWhite

* Asian/PINative American

HispanicBlackWhite

Excess Death defined as > 4 injury deaths per 100,000

Excess Death defined as > 6 injury deaths per 100,000

Excess Death defined as > 8.2 injury deaths per 100 000

Number of Substantiations per Excess Death

* Excess death rate is equal to 0.

summary

• established an “achievable” baseline rate of injury death– computed rates of excess death– alternative baselines set at 50% and 75% of

this rate

• computed the corresponding number of substantiated allegations of maltreatment associated with each excess death

findings

• findings from this population-level analysis align with other recent research suggesting that racial disparities in rates of substantiated maltreatment arise from real group-level differences in risk

• per excess death, Black and Native American children had rates of substantiated maltreatment that were equivalent to or lower than White children

qualifications and limitations

• ecological analysis – racial bias unlikely to operate on such a large scale as to explain

observed disparities

• method for determining how many injury deaths are preventable– relied on a rate of death that was achieved, findings held under

alternative specifications

• baseline rates of random deaths may differ due to non-parental risk factors– excluded transportation-related deaths, findings held

• variation in the timeliness and/or quality of medical interventions to prevent death– research suggests most injury fatality victims are declared dead

prior to arrival at ER/hospital

conclusions?

• to date, efforts to reduce racial disparities have been oriented around an understanding that the overrepresentation of Black and Native American children among victims of maltreatment originated from CPS system and worker bias

• efforts to reduce racial disparities will continue to fall short if intervention strategies ignore the social and economic factors that place some children at far greater risk of abuse and neglect than others

eputnamhornstein@berkeley.eduhttp://cssr.berkeley.edu/

cwscmsreports/Thank you to my colleagues at the

Center for Social Services Research and the California

Department of Social ServicesSupport for this and other child

maltreatment/mortality research was provided by the HF Guggenheim Foundation. Ongoing support

for research arising from the California Performance Indicators Project is generously provided by the California Department of Social Services and the

Stuart Foundation.