How Is Parental Mental Health a Risk for Child Maltreatment? Free

The placement of a child into out-of-home care (OHC) by child protective services can be considered an indicator of child maltreatment, be it abuse or neglect. Children who experience abuse or neglect have a significantly increased risk for long-term medical and mental health complications from living with toxic stress; advances in developmental sciences point out a public health imperative of securing a consistently safe, stable, and nurturing environment for every child.¹ Globally, studies from high-income countries reveal high and increasing rates of placement of children into OHC. These trends are worse in children from historically marginalized backgrounds. However, there are no clear data to support that placement into OHC is actually an effective long-term intervention for child maltreatment.² 

In this issue of Pediatrics, Dr Nevriana and colleagues³ describe the likelihood that a child who has a parent with a mental health condition is placed in OHC. Using linked administrative records from across several Swedish national registers, the investigators identified and followed a cohort of >1 000 000 children born in Sweden and their parents. The authors found that depending on the child’s age, parental education, and type of mental health condition, some children are up to 15 times more likely to be placed in OHC than children whose parents do not have a mental health condition. This is a massive increase in risk. Many of us who work with children in the foster care system and their families are not surprised that there is an increased risk, but the degree of additional risk is eye-opening.

This study exemplifies the rigorous use of standardized tracking of linked administrative data. Some caution in the interpretation of the data should be noted. For example, parental mental health conditions were identified through International Classification of Diseases codes, which are not always accurate. In addition, as we know, there are cases in which substance misuse, intellectual disability, or behavioral health conditions in the parent are suspected but have not been formally diagnosed or classified. Therefore, this study may represent an undercount of the prevalence, which would suggest that the differential risk of OHC placement of the child may be overestimated. Even so, the findings are sobering.

The term “wicked problem” refers to a complex issue that is difficult to define and solve because of its interconnected and multifaceted nature.⁵ In many ways, child maltreatment and the challenge of identifying interventions that both protect the child and meet the needs of the family indeed qualify as such a problem for which any attempt to address requires a systemic, collaborative approach and which may not have a clear solution.⁶ For child welfare, this approach involves local and state government agencies, behavioral health providers, economic assistance organizations and other nonprofit organizations, and insurers and managed care organizations, and this is where pediatric providers are on the front line to both intervene and to advocate for the children in their care.

Providers of pre- or perinatal and infant care have an opportunity to identify potential familial risk factors, such as mental health disorders, substance abuse, family violence, social isolation, or economic instability. Early detection allows for timely and holistic interagency interventions. Some screening tools, such as Safe Environment for Every Kid, ask about caregiver depression and substance use disorders and help identify areas in which support is needed.⁷ Screening is only the first step, and as experts in their communities, pediatricians should have ready access to needed referrals once concerns are identified. As part of a system-based approach, pediatricians who can observe the real-world implications of social inequity are also uniquely situated to advocate with child welfare and state lawmakers to reshape practices and policies to better support these families.

Finally, the concern for the overreporting and disparate removal rates for minorities needs to be considered. Children from historically marginalized communities are reported and removed at much greater rates than White children in the United States.⁸ This is likely related to bias in reporting by professionals to child protective services but also to the unfortunate historical racist practices that place minoritized youth at a higher risk of living in poverty and violence and, therefore, at a higher risk of having parents with mental health concerns.^3,4,9 

We applaud Dr Nevriana and colleagues for their innovative contribution to the literature. A methodologically robust analysis of linked administrative data offers a range of benefits that are especially important in areas of inquiry, such as social drivers of health, in which multiple factors interact in complex ways. Future research should include validation studies on the detailed causes of OHC placement.

OHC

out-of-home care