Linking Records to Advance Child Protection: A California Case Study

1. Linking Records to Advance Child Protection: A California Case Study 3rd Annual State of Health Care Conference Emily Putnam-Hornstein, PhD University of Southern California Barbara Needell, PhD University of California at Berkeley

2. 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…

3. What we know (National) • 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)

4. What we know (California)

5. What we do CPS involvement Birth Maltreatment Referral Investigation Services

6. a “snapshot” of Maltreated Children after before CPS Data Children not Reported for Maltreatment

7. Moving away from data silos… child protective service records birth data death data after before CPS Data Children not Reported for Maltreatment population-based information

8. record linkages 101 File B File A SSN SSN deterministic match First Name First Name Middle Initial Middle Name Last Name Last Name probabilistic match Date of Birth Date of Birth Zip Code Address

9. linked dataset cps records 514,000 LINKED DATA birth cps contact birthno cps contact birth records 4.3 million

10. expanded information vital birth records child protective service records California Birth Cohort Child A Child B Child C Child D Referral by Age 5 population-based information

11. Language • “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

12. birth record variables

13. 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

17. 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

18. Risk assessment tools

19. administered at birth? Children Reported to CPS Full Birth Cohort

20. recognizing the risk associated with the presence of multiple risk factors… High Risk on Every Modifiable Risk Factor: 89% probability of CPS report Low Risk on Every Modifiable Risk Factor: 3% probability of CPS report

21. 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 Astandardized 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

22. Record Linkages “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) Government University Partners Ongoing Collaboration

23. Questions?ehornste@usc.edubneedell@berkeley.eduhttp://cssr.berkeley.edu/ucb_childwelfare/

24. Acknowledgements 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