Using Child Protection Decision-Making to Promote Prevention in Public Systems of Care: A Study of Mediating and Protective Factors Among Caretakers with Mental Illness

Introduction: Preventing and addressing child maltreatment is a priority in public systems of care. Maltreated children whose parents suffer from mental illness face triple the odds of serious child protection involvement (Park, Solomon, & Mandell, 2006). However, the factors that mediate this effect, and protect against it, have not been targets of scholarly inquiry. Analysis of safety threats identified during child protection assessment clarifies the mechanisms by which caretakers with mental illness become involved in the child welfare system, and knowledge of relevant protective factors can inform targeted prevention strategies.

Methods: Maltreatment referrals were merged with safety assessments in one urban county in a large western state from 2007 to 2015. Assessments were administered using the Structured Decision Making^® (SDM) model for child protection, and pertained to 11,174 households investigated for maltreatment. Sixteen safety threats and 10 protective factors were analyzed as possible mediators and moderators, respectively, of the effects of primary caretaker mental health status (PCMHS) on child protection decisions using multiple logistic regression.

Results: Of all households reported since 2007, 50% were screened in and receive a safety assessment. Fourteen percent of assessments resulted in the decision that children were unsafe in the home. Households with primary caretakers with mental illness represented 13% of households that received assessments. The unconditional odds of being assessed as unsafe in the home were four times higher in households with mentally-ill caretakers (OR=4.20, p<0.001). Forty percent of caretakers with mental illness also had co-occurring substance use. Forty-eight percent of the effect of PCMHS on the safety decision was explained by serious caretaker impairment due to emotional stability, developmental status, or cognitive deficiency, and an additional 10% was explained by serious substance use impairment. Among others, a primary caretaker’s supportive relationships, willingness to accept intervention, and ability to access resources were significant protective factors.

Conclusions: This study sheds light on why children of caretakers with mental illness are deemed unsafe in the home, and what keeps them safe. Results have critical implications for public sector health practitioners. Child welfare workers should stress referral to mental health and substance abuse resources, and emphasis should be placed on strengthening caretaker relationships with relevant supports. Timely and specific preventive interventions for families with a mentally-ill caretaker may guard against more serious child protection involvement, and foster recovery and healthy development among maltreated children.