Child Maltreatment Determinations for Cases Involving Illicit Drug Exposure

Purpose/Objectives: To detect and address variability in determinations by child abuse experts in cases of suspected child exposure to illicit substances.

Design/Methods: The Forensic Assessment Center Network (FACN) is a coordinated group of pediatric practitioners from 6 academic centers in Texas who provide expert consultation to state-wide child protection workers in cases of suspected abuse and neglect. Each of Texas’ 256 counties is assigned to one of the centers. Providers use a proscribed list of terms (“determinations”) to describe their findings for each case that closely match those used by Texas Child Protective Services. In cases involving illicit substances, the case for child endangerment is often clear, but assigning a determination of abuse or neglect can be challenging. A baseline study of 197 cases in the previous 6 months of FACN provider determinations heightened our suspicion that providers were applying determinations in illicit drug cases inconsistently.

All cases had to have the descriptor “exposure to illicit drug or illicit drug environment” and/or “ingestion / poisoning” to be included in the study, based on one or more of the following: the child had a positive drug screen; the child had signs or symptoms of drug exposure; and/or a caregiver reported concern that the child was exposed to an illicit drug. We included only new cases that were created during each QI cycle month.

Eight board-certified child abuse pediatricians and 2 general pediatricians (all FACN providers) participated in the study. For each of the 3 quality improvement cycles, participants were instructed to keep a list of their determinations in cases involving illicit drugs, and to send each case to other participants (preferably two) for review. Participants were also asked to document any factors, such as child age or caregiver factors, that influenced their determination choices. Authors collected the data for each cycle, and participants discussed findings in monthly telephone meetings. Agreement for each case was categorized as either “complete”, “minor disagreement”, or “substantive disagreement”.

Results: There were 14 cases with a total of 35 opinions in Cycle 1, 17 cases with 37 opinions in Cycle 2, and 15 cases with 36 opinions in Cycle 3. Agreement was better at the start of the project than our baseline data suggested it would be. Participants most often chose supervisory neglect at baseline and in every cycle.

Conclusion/Discussion: We eliminated substantive differences of opinion through iterative group discussions and literature review, though minor variations in determination choice persisted throughout the project. We developed a form letter to standardize the information that we provide to CPS that participants found helpful. A systematic approach for future quality improvement projects was developed using the state-wide network.