Child maltreatment is well recognized as one of the most significant contributors to pediatric morbidity and mortality throughout the world.1,2 The effect of child maltreatment on morbidity and mortality in older adults has been documented for >20 years as demonstrated by the Adverse Childhood Experiences (ACEs) study.3 The impact of maltreatment on teenage suicide and other mental health diagnoses is also well known.4,5 To date, however, a direct relationship between maltreatment specifically, rather than the broader risk of ACES, and mortality in teenagers and young adults had not been reported.
In this issue of Pediatrics, Segal et al6 evaluated this potential relationship by linking >50 administrative data sets from South Australia that included data from >300 000 children born between 1986 and 2003 who survived to age 16. The authors examined the relationship among multiple demographic factors, Child Protective Services (CPS) involvement, and mortality from 1990 to 2019. For the 20% of children with CPS contact before age 16, the nature of the contact was divided into 7 categories, which included “investigation only,” “substantiation,” and “removal to out-of-home care.” The primary outcome was mortality across various levels of CPS involvement.
The results were striking. All-cause mortality rate was more than twofold higher among those with CPS involvement compared with those without. The highest adjusted mortality rate was almost fivefold higher among those who entered out-of-home care after age 3. “Poisoning, alcohol, drugs, mental illness,” “suicide,” and “natural causes” all contributed to the increase in all-cause mortality, although the most significant association was with “poisoning, alcohol, drugs, mental illness.” The ability to link these contemporaneous data sets minimizes one of the significant limitations of the ACEs study: recall bias.
Consistent with the research of Putnam-Hornstein and Needell,7 the authors found that a report to CPS, whether there was a substantiation, conferred an increased risk for all-cause mortality. The growing data that a report to CPS is in and of itself associated with risk for mortality should challenge the CPS system to approach each report as an opportunity to address potentially modifiable factors that may mitigate long-term morbidity and mortality rather than the current approach, which is often short-term and laser-focused on determining if an allegation should be substantiated.8,9 That is, although a case may not be substantiated, such reports should prompt greater effort to connect families to additional supports and services. Closing a CPS investigation ought not be seen as the end, but rather as the start of the process of making warm hand-offs to other services that can provide an ongoing safety net to families. Children and families currently fall through the proverbial cracks because we have not invested in using evidence-based practice10,11 to improve how CPS hands-off information to pediatricians, teachers, mental health providers, and others who then have the responsibility to keep children safe.
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