Family Planning Can Help Curb Maltreatment Mortality

In my previous column, I quoted Sarah Brown, founder of the National Campaign to Prevent Teen and Unplanned Pregnancy, who said that groups focusing on child and family well-being rarely propose interventions that begin before conception.

Nowhere is this more true than in the field of child welfare. So it is not surprising that the draft recommendations of the Committee to Eliminate Child Abuse and Neglect Fatalities (CECANF) do not include family planning.

But anyone who has worked with children in foster care knows that more of these youth come from larger, closely spaced sibling groups than one would expect in the general population. Indeed, research shows a strong relationship between larger families and child maltreatment.

A study of the 2002 birth cohort in California showed that babies born to mothers who already had two or more children were more than twice as likely to have CPS contact than firstborn babies.

Using earlier data from California, Barbara Needell and Richard Barth found that 59 percent of infants entering foster care between 1989 and 1994 were the third or later child born to their mother, compared to only 29 percent of the general population of infants.

Federal data from the Fourth National Incidence Study of Child Abuse and Neglect shows that one in 48 children in households with four or more children were likely to suffer abuse or neglect. This is double the rate of children in households with two children, which had the lowest rate.

Unfortunately, we don’t know what proportion of child fatalities come from large families. But at least one expert has noticed a pattern. Angela Diaz, who directs New York’s Mount Sinai Adolescent Health Center, testified that during her tenure on a panel that reviewed child fatalities in New York City, the mother of the dead child often had had a child in adolescence, followed by more children in short order.

The correlation between larger families and child maltreatment is not surprising. Parents of larger families undergo more stress due to both the difficulty of supervising more children and the financial burden.

Financial strain can also lead to neglect in the form of lack of supervision when the parent must work, inadequate housing, etc. Moreover, both child maltreatment and larger families may be related to underlying social factors such as poverty and low education levels.

Of course, many people raise large families with no difficulties, and many adults from large families treasure their upbringing and their strong support system. In the past, larger families were more practical for all income levels.

Today, I’d submit that a very large family is financially risky to most adults without a serious cash reserve or income in the top percentile. For parents already involved with child welfare, especially those struggling to make ends meet, it is hard to dispute the benefits of postponing further children.

In the last few years, advances in contraception have led to the availability of Long Acting Reversible Contraceptives (LARCs). But the availability of LARCs and knowledge of their safety and efficacy have not yet caught up.

As I recommended in an earlier column, system-involved mothers could be offered the opportunity to get a LARC immediately. Judges, attorneys and social workers could provide information about LARCs and explain the importance of avoiding further births as a mother tries to regain her children and get the agency out of her life.

CECANF should add to its recommendations that future data collection about child deaths include family size. But the correlation between family size and child maltreatment is compelling enough for immediate action. CECANF should suggest that states explore the possibility of integrating pregnancy prevention with child welfare services.

On a policy level, it is time to discuss ways to limit childbearing by women who lack the financial means to handle more kids. A grant program might even be created in order to encourage states to experiment with different approaches.

Such proposals are difficult to bring up in America, thanks in part to our country’s shameful history of attempting to restrict childbearing by women of color through means including forced sterilization and the promotion of birth control methods like Norplant. But the welfare of children should take precedence over the reluctance to offend adults.

This column was published in the Chronicle of Social Change on December 16, 2015.

Teen Pregnancy Prevention: An Overlooked Weapon Against Child Maltreatment Fatalities

The Commission for the Elimination of Child Abuse and Neglect Fatalities (CECANF) has developed a long list of draft recommendations. One overarching recommendation is to “ensure access to high-quality prevention and intervention services for children and families at risk.”

Many prevention services are mentioned, but one was left out in my opinion: services to prevent teen and unplanned pregnancies.

It is not surprising that pregnancy prevention was not often recommended to CECANF as a strategy to prevent child abuse and neglect fatalities, and that this recommendation did not make its way into CECANF’s draft.

As National Campaign to Prevent Teen Pregnancy co-founder Sarah Brown recently pointed out, groups that focus on child and family well-being rarely propose interventions that begin before conception of a child. CECANF could begin to rectify this omission by including teen pregnancy prevention in its recommendations for reducing child abuse and neglect fatalities.

In her testimony before CECANF, Angela Diaz, director of New York’s Mount Sinai Adolescent Health Center, discussed the connection between teenage parenthood and child maltreatment fatalities. In serving for many years on a child fatality review panel, she noticed that in many of these cases, the mother began childbearing in adolescence, and had more closely spaced children thereafter.

Dr. Diaz cited a national study of deaths of infants born between 1983 and 1991, which showed that “childbearing at an early age was strongly associated with infant homicide, particularly if the mother had given birth previously.”

A second or subsequent infant born to a mother younger than 17 years old was 11 times more likely to be a homicide victim than the first child of a mother 25 or older. A second or subsequent infant born to a mother age 17 to 19 was over nine times more likely to be a homicide victim.

Based on her observations and the research, Dr. Diaz recommended ensuring that adolescents have access to comprehensive sexuality education and reliable family planning methods. I hope the Commission will add this to its recommendations.

It is true that teen pregnancy has been decreasing rapidly. But there were still 249,067 birthsto teenage girls in the United States in 2014, or 24 births for every 1,000 girls. Estimates from 2013 data show that 11 percent of adolescent girls in the United States will give birth by their 20th  birthday.

And rates are still higher among Blacks and Hispanics, girls in poor neighborhoods, and teenagers in foster care. Nearly one third of teenage girls in foster care have at least one child.

Most teens in foster care have been abused or neglected, which makes them statistically more likely to abuse or neglect their children. A large study in California found that 40 percent of children born to teen mothers involved in the child welfare system will be reported for child abuse by age five.

We need to know what proportion of child fatalities involve children who were born when their mothers were teens, as well as those born to mothers who began having kids as teenagers. CECANF should recommend that Congress require the collection of these data.

Even without knowing the proportion of child maltreatment deaths occurring to children of teen mothers, we already know that teen motherhood is a risk factor for child abuse and neglect. CECANF should recommend increased emphasis on teen pregnancy prevention, especially for young women in high poverty areas and those in foster care.

The Commission should recommend that all teens, especially those at higher risk of pregnancy, have access to contraceptive methods and education. Clinics in low income areas and those serving youth in foster care and juvenile justice should provide the full array of contraceptive options including the long-lasting methods that are most effective, along with education and counseling.

Special attention should be devoted to preventing a second birth to a teenage mother by ensuring that she is provided with a contraceptive method at the time of the first birth. The federal Teen Pregnancy Prevention Program, which has been under attack in Congress, should be fully funded or expanded.

 This column was published in the Chronicle of Social Change on December 9, 2015.

Birth Match, Tool to Prevent Abuse and Neglect, Slow to Spread in U.S.

The Commission to Eliminate Child Abuse and Neglect Fatalities (CECANF) has heard from experts and stakeholders around the country and has prepared a draft of its recommendations. Among them is the suggestion that states expand a practice called “birth match,” which can identify at birth children who are at risk of child abuse and neglect.

This recommendation should be highlighted and strengthened.

Richard Barth, a highly regarded child welfare scholar, discussed Maryland’s birth match law in testimony during a CECANF hearing in July of 2014. This law was adopted after several children were killed by parents whose parental rights had been terminated for previous children.

Infants born to parents with a prior termination of parental rights (TPR) are not an insignificant group. Barth found that they made up over 10 percent of entries into foster care in Maryland in 2013.

Maryland’s law requires that birth records be matched against a list of parents who had their parental rights terminated within the last five years due to abuse or neglect. The families thus identified receive a visit from a social worker to assess for safety and risk to the infant.

States have a choice in how to intervene with the families they identify through birth match. In Maryland, these families receive a visit from a social worker to assess the family. If the parent refuses the visit, a case can be opened “only if abuse or neglect is suspected.”

Michigan is more aggressive in dealing with high-risk families. Identification of these families results in the opening of a case unless there is a waiver. That seems a more effective way to ensure a child’s safety than allowing families to opt out of the screening.

Identifying only parents with prior TPRs is a very conservative strategy that does not even capture all parents who lost a child permanently due to abuse or neglect. To identify all of those parents, a state would have to include parents who lost a child to guardianship as well as adoption.

To target a broader swath of parents at risk of harming a child, a state could identify all parents who had a prior finding of child abuse or neglect or a child placed in foster care. It could also target teenage mothers who themselves were victims of child abuse and neglect. One study found that 40 percent of children of California teen mothers who were found to be the victims of abuse or neglect as children will be reported for child maltreatment by age five.

Birth records could also be matched with data other than child welfare administrative records. A groundbreaking study of all 2002 births in California shows that “objective data collected at birth can be used to identify those children in a given birth cohort who are at greatest risk of future CPS contact.”

Among the most important risk factors were a mother’s low education level, a mother’s young age, three or more children in the family, and for U.S. born mothers, Medicaid coverage of the birth.

Despite the promise of this approach, few systems have embraced it. Barth told CECANF that “virtually all states have the option to share birth records with child welfare agencies,” but very few states do; to his knowledge, the only states that do are Minnesota, Maryland and Michigan.

According to Barth, the main obstacle to implementing birth match in other states is the reluctance to trigger CPS involvement with families that may not be maltreating their children.

Clearly, it would be distressing for a family to be contacted by CPS when they have not done anything wrong. And by no means am I suggesting that all, or even most, of the parents identified through birth match are incapable of caring for a child.

However, the opportunity to save a child from serious abuse or neglect should take precedence over the inconvenience to families of undergoing an assessment.

We need more research on birth match programs to identify the outcomes of intervening early in families identified as high-risk. How many families are identified and what is the result? Do child fatalities decrease after the adoption of such a policy?

CECANF’s recommendation that states “expand birth match programs such as those operated in Michigan” should be strengthened and elevated to the federal level. The commission might recommend that the federal government establish a pilot program providing grants to states that adopt and evaluate birth match programs.

Information from this pilot could be used to develop a federal requirement for all the states to match birth and child welfare records.

This column was published in the Chronicle of Social Change on November 30, 2015.