Papers by Howard Dubowitz
JAMA network open, 2021
Many children experience abuse, neglect, and other forms of violence, jeopardizing their physical... more Many children experience abuse, neglect, and other forms of violence, jeopardizing their physical and emotional health and their social and cognitive development. The study by Finkelhor and colleagues1 characterizes children and youth evaluated medically following their experience of some type of violence. The nationally representative sample consisted of 8503 children and youth aged 2 to 17 from 2 surveys conducted in 2011 and 2014. Caregivers responded via telephone interviews for children aged 9 years or younger regarding possible exposure to violence, other adversities, and trauma symptoms; the youth aged 10 years and older reported on themselves. There were follow-up probes regarding injury and medical treatment for those with any of the 16 types of violence. As many as 5187 were reported to have been exposed to violence; 3.4% had had a medical visit related to the experience, 1.9% in the past year. Those with a recent medical visit had more trauma symptoms and faced more adver...
Implementation Science Communications
Background Child maltreatment (CM) is a major public health problem, affecting many lives, in the... more Background Child maltreatment (CM) is a major public health problem, affecting many lives, in the short and long term, and costing individuals, families, and society dearly. There is a need for broad implementation of evidence-based preventive interventions, such as the Safe Environment for Every Kid (SEEK) model, developed for pediatric primary care. Primary care offers an excellent opportunity to help address prevalent psychosocial problems (e.g., parental depression) that are risk factors for CM. By addressing such problems, SEEK can strengthen families and support parents; promote children’s health, development, and safety; help prevent CM; and benefit the health of the US population. This study will examine intervention strategies for optimizing SEEK’s adoption, implementation, and sustainment, and its effectiveness in preventing CM. Despite strong evidence from two federally funded randomized controlled trials, SEEK has not been widely adopted. The goal of this study is to exa...
Journal of Child & Adolescent Substance Abuse
Abstract This longitudinal prospective study examined the relationship between child maltreatment... more Abstract This longitudinal prospective study examined the relationship between child maltreatment as per reports to child protective services (CPS) and adolescent self-reported marijuana use, and the association between relationships with mothers and fathers and use of marijuana. The association between relationships with parents early in childhood (ages 6 to 8 years) and during adolescence with adolescent marijuana use were also probed. Another aim examined whether relationships with parents moderated the link between child maltreatment and youth marijuana use. The sample included 702 high-risk adolescents from the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN), a consortium of five studies related to maltreatment. Children were recruited at age 4 or 6 years together with their primary caregiver. Some were recruited due to their risk for child maltreatment, others were already involved with CPS, and children in one site had been placed in foster care. Logistic regression analysis was performed using youth self-report of marijuana use as the criterion variable and child maltreatment and the relationships with parents as predictor variables, controlling for youths’ perceptions of peer substance use and parental monitoring, parental substance use, race/ethnicity, sex, and study site. Approximately half the youths had used marijuana. Most of them described quite positive relationships with their mothers and fathers. Participant marijuana use was associated with a poorer quality of relationship with mother during adolescence, and with peer and parental substance use. A better relationship with father, but not mother, during adolescence attenuated the connection between child maltreatment and youth marijuana use.
International Journal on Child Maltreatment: Research, Policy and Practice
Claims that new science is changing accepted medical opinion about abusive head injury have been ... more Claims that new science is changing accepted medical opinion about abusive head injury have been made frequently in the media, legal publications, and in legal cases involving abusive head trauma (AHT). This review analyzes recently published scientific articles about AHT to determine whether this new information has led to significant changes in the understanding, evaluation, and management of children with suspected AHT. Several specific topics are examined as follows: serious or fatal injuries from short falls, specificity of subdural hematoma for severe trauma, biomechanical explanations for findings, the specificity of retinal hemorrhages, the possibility of cerebral sinus thrombosis presenting with signs similar to AHT, and whether vaccines can produce such findings. We conclude (a) that the overwhelming weight of recent data does not change the fundamental consensus, (b) that abusive head trauma is a significant source of morbidity and mortality in children, (c) that subdural hematomas and severe retinal hemorrhages are commonly the results of severe trauma, (d) that these injuries should prompt an evaluation for abuse when identified in young children without a history of such severe trauma, and (e) that short falls, cerebral sinus thrombosis, and vaccinations are not plausible explanations for findings that raise concern for abusive head trauma.
Addictive behaviors, Jan 30, 2017
Youth with a history of child maltreatment use substances and develop substance use disorders at ... more Youth with a history of child maltreatment use substances and develop substance use disorders at rates above national averages. Thus far, no research has examined pathways from maltreatment to age of substance use initiation for maltreated youth. We examined the longitudinal impact of maltreatment in early childhood on age of alcohol and marijuana use initiation, and whether internalizing and externalizing behaviors at age 8 mediates the link between maltreatment and age of substance use initiation. Data were drawn from the Longitudinal Studies of Child Abuse and Neglect (LONGSCAN) at ages 4, 8, 12, and 18. Maltreatment was assessed through reviews of administrative records and youth self-reports. Behavior problems were assessed with the Child Behavior Checklist. Age of substance use initiation was assessed with the Young Adult version of the Diagnostic Interview Schedule for Children. Path analyses indicated mediated effects from a history of maltreatment to age at first alcohol an...
Child Abuse & Neglect, 2017
Many children with unsubstantiated reports of child abuse and neglect repeatedly return to the ch... more Many children with unsubstantiated reports of child abuse and neglect repeatedly return to the child protection system, indicating that unsubstantiated reports may represent actual child maltreatment or risk for future maltreatment. Identifying patterns of re-reporting and predictors that may be associated with later substantiated re-reporting could help to identify children who are very likely to be maltreated. This knowledge may guide the development of policies and interventions to prevent further maltreatment and the risk for re-reports. The aims of this study were to: (1) measure the period between the time of the initial reports that were not substantiated and the time of first substantiated re-reports; and (2) identify factors associated with the risk of later substantiated re-reporting. The study analyzed secondary data from the Longitudinal Studies on Child Abuse and Neglect (LONGSCAN) through survival analysis. Of the 378 children with initially unsubstantiated reports, 81% were re-reported, of which almost twothirds were substantiated. Children who were younger, non-white, and had caregivers with more depressive symptoms were at increased risk of a substantiated re-report. Among those that were later substantiated, 20% were substantiated within one year. Findings suggest that targeted preventative services should be developed and provided for families who are reported for the first time, even if not substantiated. During 2014, approximately 2.2 million child maltreatment reports were investigated by child protection services (CPS) workers in the United States. About 20% of the reports were substantiated, but the other four-fifths did not contain sufficient evidence to conclude or suspect under state law that the child was maltreated or at risk of being maltreated (USDHHS, 2014). However, many children who are initially reported but not substantiated continue to return repeatedly to CPS (Fluke, Shusterman, Hollinshead, & Yuan, 2008). Only a few studies have examined the rate of unsubstantiated reports that were later substantiated when re-reported, yielding widely varying estimates ranging from 10 to 15% within 4.5 years (Way, Chung, Jonson-Reid, & Drake, 2001) to 83% within 11-15 years (Thompson & Wiley, 2009). < Child protection workers have a duty to protect children from maltreatment, and one of their major responsibilities is to investigate suspected maltreatment and determine whether reports should be substantiated. Substantiation is a statement about the validity of a report based on state laws, agency guidelines, and the information gathered during the investigation (DePanfilis & Salus, 2003). However, many reports may not be substantiated for several reasons, such as insufficient evidence to conclude maltreatment, and/or circumstances that do not meet the criteria established by CPS policy in accordance with state law (Drake, 1996; Kohl,
Child maltreatment, Jan 24, 2016
Risky sexual behavior is a serious public health problem. Child sexual abuse is an established ri... more Risky sexual behavior is a serious public health problem. Child sexual abuse is an established risk factor, but other forms of maltreatment appear to elevate risky behavior. The mechanisms by which child maltreatment influence risk are not well understood. This study used data from 859 high-risk youth, followed through age 18. Official reports of each form of maltreatment were coded. At age 16, potential mediators (trauma symptoms and substance use) were assessed. At age 18, risky sexual behavior (more than four partners, unprotected sex, unassertiveness in sexual refusal) was assessed. Neglect significantly predicted unprotected sex. Substance use predicted unprotected sex and four or more partners but did not mediate the effects of maltreatment. Trauma symptoms predicted unprotected sex and mediated effects of emotional maltreatment on unprotected sex and on assertiveness in sexual refusal and the effects of sexual abuse on unprotected sex. Both neglect and emotional maltreatment ...
Archives of Pediatrics Adolescent Medicine, 2002
Child Welfare, 1970
The number of children in out-of-home placements is increasing exponentially. In 1992, 243,000 ch... more The number of children in out-of-home placements is increasing exponentially. In 1992, 243,000 children were in one of several forms of out-of-home care; by 1992 this figure had grown to 429,000, and it is expected to exceed 840,000 by 1995 [National Commission on Foster Family Care 1991]. In the majority of states, kinship care is the preferred option for out-of-home placements [Gleeson and Craig 1994]. The percentage of children placed in kinship care grew from 18% in 1986 to 31% in 1990 in the 25 states responding to a national survey [Kusserow 1992a]. In Illinois and New York City, approximately half the children placed into out-of-home care by child protective services (CPS) are in kinship care [Illinois Department of Children and Family Services 1990; Meyer and Link 1990].Despite its widespread use, little research has been done on kinship care. Instead, there are deeply felt ideological beliefs, illustrated by the comment, "I'd rather my child be placed with my worst relative than with a stranger." Although it is clear that some issues, such as the extent of families' responsibilities to care for their kin, are not amenable to empirical research, both public policy and clinical practice should be guided by the best available knowledge and theory, not by personal or ideological preferences.Kinship care offers several potential benefits to children who must be placed. Placement with strangers in an unknown environment is avoided. Relatives may have a special investment in one of their kin (i.e., "blood is thicker than water"). In contrast to nonrelative family foster care, children in kinship care are more likely to maintain contact with their biological parents [Duerr-Berrick et al. 1994], relative caregivers appear more invested in working with biological parents toward family reunification [Le Prohn 1994], and children's racial and ethnic identity may be more likely to be preserved. Children placed with relatives move less frequently and enjoy great stability [Duerr-Berrick et al. 1994; Iglehart 1994]. Duerr-Berrick et al. [1994] found significantly more large sibling groups placed together in kinship than in nonrelative family foster homes. Kinship care is also congruent with family preservation with its emphasis on maintaining biological ties and avoiding out-of-home care [Spar 1993]. Most professionals appear to agree that efforts to preserve families are valuable, and that priority consideration of relatives for out-of-home placements is reasonable.Kinship care, however, has also raised several concerns. A number of studies have found that children in kinship care typically remain there longer than those in nonrelative family foster care [e.g., Duerr-Berrick et al. 1994]. Although it may be unfair to assume guilt by association, some studies question the wisdom of placing children with relatives (usually grandmothers) who raised the parents now deemed unable to care for their children.It is also thought that kinship providers are inadequately screened by public child welfare agencies and that the services provided to kinship families are often fewer compared to those provided nonrelative foster families [e.g., Duerr-Berrick et al. 1994]. This is worrisome given that foster children have far more than average health and educational problems [e.g., Kavaler and Swire 1983; Halfon and Klee 1991] and children in kinship care face similar difficulties [Dubowitz et al. 1994]. Two studies comparing children in kinship and those in nonrelative family foster care found both groups had similarly high levels of mental illness and educational problems [Duerr-Berrick et al. 1994; Iglehart 1994]. Furthermore, kinship providers appear eager for services to help them care for these children [Duerr-Berrick et al. 1994]; many are low-income, minority grandmothers struggling to care for young children with serious problems [Minkler et al. 1992].Some argue that public agencies should not be intrusive and should instead allow kinship families to lead "normal lives. …
Pediatric Clinics of North America, 2014
There is no doubt that child abuse and neglect are serious problems in every country. They are fa... more There is no doubt that child abuse and neglect are serious problems in every country. They are far too prevalent and often lead to a variety of adverse outcomes, some fatal and some lifelong. Pediatricians and other child health professionals are wellpositioned to play a valuable role in helping to address this problem. But child maltreatment is inherently complex, posing difficult challenges for those on the frontlines caring for children. The goal of this volume is to effectively support pediatricians and other professionals in their roles. A priority is to offer practical information and guidance that many will find useful. Pediatric primary care provides a unique opportunity to tackle child abuse and neglect. In the United States in particular, primary care is a well-established system, andmost children havemultiple visits, especially in the first few years. There is typically a very good relationship between parents and health professionals, who are respected experts on children. The interested pediatrician, thus, has a remarkable entrée into the workings of a family, its shortcomings, and its strengths. With some knowledge and skill, pediatricians can play a pivotal role, even in a few strategic minutes. We know, however, that some professionals feel very uncomfortable becoming involved in this unpleasant area and may be deterred from taking any action. Understandable as this may be, it can jeopardize a child’s health and safety. Hopefully, this issue of Pediatric Clinics of North America will help make this work a bit easier, albeit not easy. With training and support, pediatricians can equip themselves to be competent and more comfortable addressing child maltreatment. Aside from the possible forensic implications, the heart of this work is primarily about helping families take adequate or good care of their children. Indeed, helping address child abuse and neglect also
Child Maltreatment, 2012
The 1962 paper on the "battered child" by Kempe and colleagues in a prestigious medical journal t... more The 1962 paper on the "battered child" by Kempe and colleagues in a prestigious medical journal triggered a crucial turning point in US awareness of how children may be maltreated (Kempe et al. 1962). Child abuse had been previously noted in the medical literature, particularly by radiologists speculating about unexplained injuries (Caffey 1946). It was the paper by Kempe et al., however, that evoked a strong response by both clinicians and legislators. Within a few years, all 50 US states passed laws aimed at protecting children from abuse. The battered child paper was important in another respect. Given how little was known about child maltreatment at that time, the paper is remarkable for its rich insights into the problem. The authors accurately identi fi ed important barriers, such as physicians' reluctance to become involved in these cases. While notable progress has been achieved, these issues remain relevant 50 years later (Lane and Dubowitz 2009). Similarly, Kempe and colleagues quickly recognized the need for an "evaluation of psychological and social factors." There is no doubt that this seminal paper has in fl uenced the fi eld of child maltreatment over the years. This chapter will focus on its role with regard to child neglect, now known to be by far the most prevalent form of identi fi ed child maltreatment (USDHHS 2011). With regard to how the paper directly addresses neglect, it is naturally necessary to recognize the thinking and limited knowledge base at the time. In this historical context, it is interesting to have a peek into how neglect was then viewed. In terms of its subsequent in fl uence, there are inevitably many factors that shape a developing
Handbook for Child Protection Practice, 2000
Encyclopedia of Interpersonal Violence, 2008
NCHS growth chart or if it crosses two major percentile lines. 3 Recent research has validated th... more NCHS growth chart or if it crosses two major percentile lines. 3 Recent research has validated that the weight-forage approach is the simplest and most reasonable marker for FTT. 4 Other growth parameters that can assist in making the diagnosis of FTT are weight for height and height for age. FTT is diagnosed if a child falls below the 10th percentile for either of these measurements. Etiology and Differential Diagnosis Historically, FTT has been classified as organic or nonorganic. Usually, this distinction is not useful because most children have mixed etiologies. 5 For example, a child may have a medical disorder that causes feeding problems and family stress. The stress can compound the feeding problem and aggravate FTT. A more useful classification system is based on pathophysiology-inadequate caloric intake, inadequate absorption, excess metabolic demand, or defective utilization. This classification leads to a logical organization of the many conditions that cause or contribute to FTT (Table 1).
International Journal of Child Health and Nutrition, 2014
Background: Food insecure children are at increased risk for medical and developmental problems. ... more Background: Food insecure children are at increased risk for medical and developmental problems. Effective screening and intervention are needed. Methods: Our purpose was to (1) evaluate the validity and stability of a single item food insecurity (FI) screen. (2) Assess whether use may lead to decreased FI. Part of a larger cluster randomized controlled trial, pediatric residents were assigned to SEEK or control groups. A single FI question (part of a larger questionnaire) was used on SEEK days. SEEK residents learned to screen, assess, and address FI. A subset of SEEK and control clinic parents was recruited for the evaluation. Parents completed the USDA Food Security Scale ("gold standard"), upon recruitment and 6-months later. Validity, positive and negative predictive values (PPV, NPV) was calculated. The proportion of screened families with initial and subsequent FI was measured. Screening effectiveness was evaluated by comparing SEEK and control screening rates and receipt of Supplemental Nutrition Assistance Program (SNAP) benefits between initial and 6-month assessments. Results: FI screen stability indicated substantial agreement (Cohen's kappa =0.69). Sensitivity and specificity was 59% and 87%, respectively. The PPV was 70%; NPV was 81%. SEEK families had a larger increase in screening rates than control families (24% vs. 4.1%, p<0.01). SEEK families were more likely to maintain SNAP enrollment (97% vs. 81%, p=0.05). FI rates remained stable at approximately 30% for both groups. Conclusions: A single question screen can identify many families with FI, and may help maintain food program enrollment. Screening may not be adequate to alleviate FI.
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Papers by Howard Dubowitz