Child, caregiver, and family characteristics associated with emergency department use by children who remain at home after a child protective services investigation☆
Introduction
In 2007, child protective/child welfare services (CPS) agencies in the US received approximately 3.2 million referrals for alleged maltreatment involving about 5.8 million children; 900,000 of the investigations determined that the child was a victim of maltreatment and 269,000 children were removed from their homes and placed in foster care (US Department of Health and Human Services, 2008). In September of 2007, there were approximately 496,000 children in foster care (US Department of Health and Human Services, Administration for Children and Families, 2008) but the vast majority of children served by CPS agencies remain in their homes and never enter foster care. In a US midwestern sample of low income families, 47.1% of children who had an initial maltreatment investigation had a report of child maltreatment after three years, thus CPS agencies in the US often serve the same children repeatedly (Drake, Jonson-Reid & Sapokaite, 2006). Studies have consistently found that children in foster care have higher rates of physical health problems (Rubin, Halfon, Raghavan, & Rosenbaum, 2005) and chronic health conditions (Jee, Barth, Szilagyi, & Szilagyi, 2006) compared to US children who are Medicaid-eligible (Hansen, Mawjee, Barton, Metcalf, & Joye, 2004). Recent evidence indicates that children who remain at home following contact with child welfare have rates of health problems comparable to those of children in foster care, particularly children ages 5 and under (Leslie et al., 2005, Ringeisen et al., 2008). However, unlike children who are placed in foster care, very little research on the use of health services has included the in-home population served by CPS. This study examines emergency department (ED) use of children who remain at home after a maltreatment investigation and explores the relationship of ED use to child, caregiver, and family variables and receipt of CPS services.
ED use has increasingly become the safety net for children who have difficulty accessing health services. In 1997, 19.9% of children in the US ages 0–18 years old had at least 1 visit to the ED (National Center for Health Statistics, 2011). In 2009, the percentage of children using the ED at least 1 time increased to 20.8% (National Center for Health Statistics, 2011). Use of EDs often occurs for routine and nonemergent care resulting in a burden on hospitals to provide services, collect commensurate payment for services, and to pay for uncompensated care for the uninsured (Derlet & Richards, 2000). For children, lack of primary health care access and poor continuity of care are related to more ED use for nonurgent conditions (Berry et al., 2008, Gregor et al., 2009). Increased ED use and ED recidivism for children is related to race (African-American and Hispanic), young age, and presence of a chronic health problem (Jee et al., 2005, LeDuc et al., 2006, Rhodes and Iwashyna, 2007, Zandieh et al., 2009). In addition, parental factors affecting home safety such as maternal depression and, exposure to domestic violence (Blumberg and O’Connor, 2004, Rhodes and Iwashyna, 2007) may decrease family attention to preventive activities.
Some evidence suggests that the high prevalence of chronic and acute health problems of many children in foster care, and the difficulties around providing health services to children in foster care, contribute to unusually high levels of ED use in the foster care population. Jee et al. (2005) found that 31% of children in long term foster care (out-of-home placement for at least one year) in a national sample used the ED or urgent care centers (hereafter called ED use) over the last year. In a sample of young maltreated children, home visiting by nurses decreased ED visits by 38% compared to maltreated children who did not receive home visiting (Olds, Henderson, Kitzman, & Cole, 1995). The challenges of accessing health services, though, may be greater for children remaining at home after a CPS investigation for a number of reasons. First, the majority of youth are reported to CPS for neglect, which often includes inadequate health care (American Humane Association, 2001, CCANAAP, 2007). Second, many of their caregivers are involved with CPS due to substance use problems, domestic violence, or mental health issues and effective organization of primary care for their child(ren) may be more difficult to manage (Barth, 2009, Casanueva et al., 2009, Ornelas et al., 2007). Third, these families are not uniformly covered by Medicaid (Allen, 2008). Last, for those youth with Medicaid coverage, identification of a primary care or pediatric subspecialist can be problematic (Berman, Dolins, Tang, & Yudkowsky, 2002). Therefore identifying risk factors of ED use for the in-home population is important to allow for targeted interventions by CPS caseworkers.
This paper uses data from the National Survey of Child and Adolescent Wellbeing (NSCAW) to broaden our understanding of ED use among children in contact with child welfare but who were not placed in foster care at the time of the initial interview. First, we examined rates of ED use in the much larger segment of children who remain at home following contact with child welfare, and compare use rates with those of children in long term foster care and with relevant national data in the discussion of the findings. We hypothesized that ED use among children remaining at home following contact with child welfare would be high and that key variables, including receipt of CPS services, presence of a child's chronic health problem, child age, and insurance, would be associated with ED use. We also hypothesized that psychosocial variables such as caregiver depression, domestic violence, and a constellation of family risk factors that would likely increase the risk for future child abuse and neglect would be related to ED use. Identifying family risk by counting the number of risks present in vulnerable families who have contact with CPS has been shown to be predictive of future placement changes (Horwitz, Hurlburt, Cohen, Zhang, & Landsverk, 2011), thus this risk assessment may also be predictive of ED use. We also examined rates of repeated ED use, which may be more indicative of ineffective health care utilization.
Section snippets
Population and sampling
NSCAW, the first national probability study of families and children involved with CPS, sampled 5,501 children reported for abuse and neglect from birth to 14 years old who had contact with CPS between October, 1999 and December, 2000. Of the 5,501 children, 4,001 children remained at home after the maltreatment investigation, had information on ED use and therefore constituted the sample for this study. Of the entire NSCAW sample, 11.3% of children resided in foster care at Wave 1, 24% of
Sample characteristics
A majority of the children in the in-home sample were White (non-Hispanic) and 6 years old or older. There were an equal proportion of females to males in the child population. Eighty-eight percent of the children in the sample had health insurance. A majority of the caregivers were White (non-Hispanic), female, and under 35 years old. Thirty percent of the caregivers had exposure to intimate partner violence and 23% caregivers scored positively for depression. Half the families had a low
Discussion
Although the emphasis in the extant literature has been on health care service use by children in foster care, our results demonstrate that children who remain at home after a CPS evaluation are also at high risk for ED use. Children in the NSCAW sample who remained in their homes following a CPS investigation used the ED more than the long term foster care population in Jee et al.’s (2005) study. Also, children in this study used the ED more compared to all US children for the year 1997,
Conclusion
Children who remain at home after an investigation for maltreatment use the ED more than children in long-term foster care, yet the health care needs of this portion of the CPS population have been largely uninvestigated. Presently, children in foster care may have better access to primary care, and thus less ED use, as a result of the federal Fostering Connections to Success and Reducing Adoptions Act of 2008 (P.L. 110-351), which requires foster children's case plans to include the health
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Cited by (0)
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(1) Eunice Kennedy Shriver National Institute of Child Health & Human Development (K01-HD057987; PI: Schneiderman). (2) National Institute of Mental Health (P30-MH074678; PI: Landsverk). (3) W.T. Grant Foundation (#9443; PI: Leslie).