LINKING RECORDS TO ADVANCE CHILD
PROTECTION: A CALIFORNIA CASE STUDY
Emily Putnam-Hornstein, PhDUniversity of Southern California
Barbara Needell, PhDUniversity of California at Berkeley
3rd Annual State of Health Care Conference
BACKGROUND
California Child Welfare Indicators Project longstanding university/agency partnership longitudinal configuration of state’s child protective services data
technical assistance to California counties & state
consultation services to other state child welfare agencies
publicly available website for tracking outcomes and performance indicators (interactive queries)
data available for research…
In 2011, more than 6 million children were referred for possible maltreatment in the United States; nearly 700,000 were substantiated as victims
Estimated lifetime cost of child maltreatment is $124 billion each year (Fang, et al., 2012)
A growing body of research indicates that children who experience abuse or neglect are at heightened risk of adverse health outcomes, including: Obesity, cancer, strokes (Felitti, et al., 1998) Teen pregnancy (Noll & Shenk, 2013) Self-injurious behaviors (Rhodes, et al., 2013)
WHAT WE KNOW (NATIONAL)
WHAT WE KNOW (CALIFORNIA)
010
2030
4050
Rat
e
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Referrals Substantiations Entries to Foster Care
(per 1,000 children)Rates of CPS Involvement in California
WHAT WE DO
Birth
Maltreatment
Referral
Investigation
Services
CPS involvement
A “SNAPSHOT” OF MALTREATED CHILDREN
before CPS Data
after
Children not Reported for Maltreatment
MOVING AWAY FROM DATA SILOS…
birth data
death data
population-based information
child protective
service records
before CPS Data
after
Children not Reported for Maltreatment
RECORD LINKAGES 101
File A File BSSNSSN
First Name
First NameMiddle Name Middle InitialLast Name Last Name
Date of Birth
Date of BirthAddress Zip Code
deterministic match
probabilistic match
LINKED DATASET
birth records
LINKED DATA
birth cps contact birth no cps contact
4.3 million
514,000
cps records
EXPANDED INFORMATION
vital birth
records
population-based information
child protective
service records
California Birth Cohort
Child A
Child B
Child C
Child D
Referral by
Age 5
“Risk factor”: a term used in epidemiology to define a characteristic that is either directly or indirectly associated with risk of disease or other adverse health outcomes Stable / Fixed at birth (e.g., male gender is a risk
factor for injury) Time varying – developing through exposure to
adversities in the social or physical environment
This information can be used to identify individuals/groups/communities particularly vulnerable to a given adverse outcome in order to strategically target prevention and intervention programs and policies
LANGUAGE
sex• female• male
birth weight• 2500g+• <2500g
prenatal care
• 1st trimester• 2nd trimester• 3rd trimester• no care
birth abnormality
• present• none
maternal birth place
• US born• non-US born
race
• Native American• black• Hispanic• white• Asian/Pacific Islander
maternal age
• <=19• 20-24• 25-29• 30+
maternal education
• <high school• high school• some college• college+
pregnancy termination
hx
• prior termination• none reported
named father
• missing• named father
# of children in the family
• one• two• three+
birth payment method
• public/med-cal• other
BIRTH RECORD VARIABLES
SELECTED FINDINGS…
14% of children in birth cohort were reported to CPS by age 5 Lower bound estimate…could not match 16% of CPS records Cumulative rate of CPS involvement 3x higher than single year
estimates suggest
11 of 12 variables were significantly associated with CPS contact Crude risk ratios >2 were observed for 7 variables
Contact with CPS is hardly a rare event for certain groups 34% children without paternity established 25% of children born to teen mothers
missing paternity paternity medi-cal coverage private insurance
34%
12%
21%
9%
Percentage of Children Reported for Maltreatment by Age 5:California's 2002 Birth Cohort, by paternity & birth payment
none third trimester second trimester first trimester
48.9
25.4 22.3
12.3
Percentage of Children Reported for Maltreatment by Age 5:California's 2002 Birth Cohort, by prenatal care
<20 yrs 20-24 yrs 25-29 yrs 30+ yrs
25.719.0
12.6 9.3
Percentage of Children Reported for Maltreatment by Age 5:California's 2002 Birth Cohort, by maternal age at birth
AN EPIDEMIOLOGIC RISK ASSESSMENT TOOL?
(“BACK OF THE ENVELOPE” CALCULATIONS…)
We classified as “high risk” any child with three or more of the following (theoretically modifiable) risk factors at birth:
late prenatal care (after the first trimester) missing paternity <=high school degree 3+ children in the family maternal age <=24 years Medi-Cal birth for a US-born mother
Think of this as a means of “sorting” children – looking for proxy indicators that give us additional information about an infant’s likelihood of referral
RISK ASSESSMENT TOOLS
ADMINISTERED AT BIRTH?
15% 50%
Full Birth Cohort Children Reported to CPS
RECOGNIZING THE RISK ASSOCIATED WITH THE PRESENCE OF MULTIPLE RISK FACTORS…
High Risk on Every Modifiable Risk Factor: 89% probability of CPS reportLow Risk on Every Modifiable Risk Factor: 3% probability of CPS report
CONCLUDING THOUGHTS…
Data that are universally collected at birth can be used to identify those children that are at greatest risk of later CPS involvement
Compared with the demographics of the birth cohort as a whole, these young children are defined by the presence of multiple risk factors
A standardized assessment tool can never replace more comprehensive assessments of a family’s strengths and risks, but against an invariable backdrop of limited resources, the ability to prioritize investigations and adjust levels of case monitoring in order to meet the greater needs of a targeted swath of at-risk children and families has the potential for cost-savings to be realized, while also improving child well-being
“Each person in the world creates a Book of Life. This Book starts with birth and ends with death. Its pages are made up of the records of the principal events in life. Record linkage is the name given to the process of assembling the pages of this Book…” (Dunn, 1946)
RECORD LINKAGES
Government
University Partners
Ongoing Collaboration
Thank you to our colleagues at the Center for Social Services Research and the California Department of Social Services
Ongoing support for research arising from the California Performance Indicators Project and related activities is generously provided by CDSS, the Stuart Foundation, and Casey Family Programs
Record linkages funded by the Harry Frank Guggenheim Foundation, the Conrad N. Hilton Foundation, and First 5 LA
ACKNOWLEDGEMENTS