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Child Abuse & Neglect 122 (2021) 105344

Available online 29 September 2021 0145-2134/© 2021 Elsevier Ltd. All rights reserved.

Childhood psychiatric outcomes in the context of suspected neglect and abuse reports related and unrelated to parental substance use

Kriti D. Gandhi a,c, Magdalena Romanowicz a, Paul E. Croarkin a, Prabin Thapa b, Mara Limbeck a,d, Jinal Desai a,e, Amanda J.M. Benarroch a, Julia Shekunov a,*

a Department of Psychiatry and Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA b Department of Biomedical Statistics and Informatics, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA c Children's, National Takoma Theatre, 6833 4th Street NW, Washington, DC 20012, USA d University of Minnesota, 105 Peters Hall, 1404 Gortner Avenue, St. Paul, MN 55108, USA e University of North Dakota School of Medicine & Health Sciences, Department of Psychiatry & Behavioral Science, 1919 Elm St N, Fargo, ND 58102-2416, USA

A R T I C L E I N F O

Keywords: Child maltreatment Child abuse and neglect Parental substance use Psychiatric diagnoses

A B S T R A C T

Background: Child maltreatment is prevalent in the United States and carries long-term conse- quences. Parental substance use may have associations with child maltreatment. It is unclear whether co-occurring parental substance use aggravates childhood psychiatric outcomes related to suspected maltreatment. Objective: To compare psychiatric and healthcare utilization outcomes in children with suspected abuse reports, with and without documented parental substance use. Participants and setting: Retrospective cohort study (n = 2831) of children with suspected abuse/ neglect (SANC) reports filed in the electronic health record between January 1, 2000 and January 1, 2016. Children who had SANC reports referencing parental substance use (n = 458) were compared with those who had SANC reports that did not reference substance use (n = 2346). Methods: Outcome data included ICD-10 coded medical and psychiatric diagnoses and healthcare utilization. Results: Compared to children who had a SANC report filed without parental substance use, children with parental substance use in a SANC showed significantly lower age-adjusted odds of anxiety disorder, mood disorder and externalizing disorder, and higher odds of a substance use disorder diagnosis. They were also less likely to present to an emergency department visit for any reason in the year prior to the report. Conclusions: Children with exposure to parental substance use in a household where parental abuse or neglect was suspected had lower odds of adverse psychiatric outcomes as compared to children with suspected report of abuse or neglect unrelated to parental substance use. The present findings highlight the complex interplay of psychosocial factors associated with outcomes of childhood maltreatment.

* Corresponding author at: Mayo Clinic, Department of Psychiatry and Psychology, 200 First Street NW, Rochester, MN 55905, USA. E-mail address: [email protected] (J. Shekunov).

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Child Abuse & Neglect

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https://doi.org/10.1016/j.chiabu.2021.105344 Received 13 January 2021; Received in revised form 17 September 2021; Accepted 19 September 2021

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1. Introduction

Child maltreatment is a problem of epidemic proportions in the United States. In 2017, approximately 3.5 million children were subjects of at least one report of maltreatment (U.S. Department of Health and Human Services et al., 2019). Reports include neglect (74.9%), physical abuse (18.3%), sexual abuse (8.6%), and a combination of these (U.S. Department of Health and Human Services et al., 2019). In 2017, an estimated 1720 children died of abuse and neglect, a rate of 2.32 per 100,000 children in the national population of the US. Maltreatment affects many outcomes in childhood and adulthood (Arai et al., 2019). Prior research suggests that childhood abuse and neglect may be risk factors or associated with subsequent mood and anxiety disorders, posttraumatic stress disorder, personality disorders including borderline personality, and substance use disorders (Jaffee, 2017; Lippard & Nemeroff, 2019; Mills et al., 2013; Scott et al., 2010). Studies also report worse social and physical health outcomes in children who have been abused or neglected (McGovern et al., 2018; Mills et al., 2013). There is evidence that the duration, severity, and age of maltreatment mediate the risk for later psychopathology; maltreatment that occurs earlier in life and continues for longer duration is associated with the worst outcomes (Lippard & Nemeroff, 2019).

The National Survey on Drug Use and Health estimated that between 2009 and 2014, one in eight children (8.7 million) aged 17 or younger lived with a parent who had a substance use disorder (SUD) (Lipari & Van Horn, 2017). This population of children has elevated rates of public health service utilization, including welfare, mental health, and special education services. Substance use disorders in parents has an important impact on family functioning, parenting roles, and child development (Barnard & McKeganey, 2004). During periods of substance use, parents may be uninvolved and emotionally unavailable to children, with less child monitoring (Kuppens et al., n.d.; Barnard & McKeganey, 2004). These family systems may confer more subtle forms of child abuse or neglect that are less likely to be identified and reported (Wolock & Magura, 1996). Some clinical studies show an association between substance use and one or more types of child maltreatment (De Bellis et al., 2001; Walsh et al., 2003), however findings in this regard have been inconsistent (Widom & Hiller-Sturmhöfel, 2001). Substantial research has been conducted in the area of parental alcohol use disorder (AUD), demonstrating mixed results with regards to its relationship with physical abuse (Widom & Hiller-Sturmhöfel, 2001). Parental illicit drug use and its effects on child maltreatment is less studied. Existing studies are fraught with many methodological limitations, such as some studies listing opioids as an independent risk factor of child abuse (Morris et al., 2019), while other studies are incon- clusive due to methodological challenges and/or conflicting data (Johnson & Rosen, 1982; Suchman & Luthar, 2000).

It is possible that parental substance use exacerbates the effects of childhood trauma (Wells, 2009; Young et al., 2007). To our knowledge, there is no study that compares the outcomes between parental substance use and other types of child maltreatment based on suspected abuse or neglect reports. We aimed to assess the psychiatric morbidity in children of parents with and without substance use where a suspected abuse or neglect (SANC) report was filed. We hypothesized that among all SANC reports filed, children whose reports noted parental substance would have worse psychiatric outcomes and increased healthcare utilization than those without documented parental substance use.

2. Methods

2.1. Data sources

This study was approved by the local institutional review board prior to any research activity. The cohort was obtained using the Advanced Cohort Explorer (ACE) database (Unified Data Platform, Rochester, MN). We initially screened a cohort of 4705 children (2657 girls, 2046 boys) who received care at Mayo Clinic or the Mayo Clinic Health System with a Suspected Abuse and Neglect – Child (SANC) report filed in their medical record prior to age 18 and between January 1, 2000 and January 1, 2016. Definitions of child abuse and neglect in our state can be found in the online supplemental materials.

A total of 2831 subjects met inclusion criteria of having a Mayo Clinic visit date in the year 2016 or later, or being 18 years of age or older at the patient's last recorded visit in the Mayo Clinic electronic health record, Epic (Epic Systems, Verona, WI), as well as a clinical encounter documented a year before and after the SANC was filed. Subjects who were less than one year of age were included if there were available medical records in addition to the SANC. Subjects who did not meet the inclusion criteria (n = 1874) were excluded from the analyses. Subjects ranged in age from 0 to 33 years old at the time of chart review.

2.2. Procedure

Data were collected from ACE about mental health and medical diagnoses, including substance use and intoxication. Any diagnoses that were due to a medical condition or attributed to substances were excluded. Information that could not be retrieved using ACE was manually reviewed by KG, AB, JD, and ML within Epic (Epic Systems, Verona, WI) using a standardized search protocol to maximize fidelity of data collection (see Supplemental Materials). Any discrepancies were resolved by a consulting a third party, JS. Additional details on data collection can be found in the online supplemental materials.

2.3. Statistical analysis

Continuous variables are reported with mean (SD) or median (IQR) and compared using t-tests; categorical variables reported as frequencies and percentages and compared with Chi-square or Fisher's exact tests. Association between psychiatric outcomes and substance as a risk factor were evaluated using univariate/multivariate logistic regression with odds ratios (OR) reported. General

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linear model were used to access association between substance use and hospital visits. Statistical analysis were performed using SAS® (version 9.4) and R (version R-3.6.2) with 2-sided p < 0.05 considered statistically significant. We controlled for age given the increased likelihood of most psychiatric diagnoses and healthcare utilization with older age in children and adolescents.

3. Results

3.1. Cohort characteristics

Table 1 illustrates the demographic characteristics of 2829 children who had parental substance use noted in a SANC (n = 485) compared to children who had a SANC report filed without note of parental substance use (n = 2344). The racial makeup of the sample was 78% Caucasian, 6.8% African American/African, 1.7% Asian, 0.7% American Indian/Native American, and 11% other races. Thirty-nine percent were living in a single parent household at the time of the first SANC report.

Based on the univariate and multivariate logistic regression analysis adjusting for age, children who had parental substance use noted in a SANC report were significantly more likely to be living in a single parent household at the time of the SANC report filing (odds ratio [OR]: 1.38; 95% confidence interval [CI]:1.13–1.70; p = 0.0021).

Children who had parental substance use noted in a SANC report showed significantly higher odds of being exposed to THC in utero in both univariate and multivariate analyses, consistent with the finding that 90% (n = 153) of children who had THC in their meconium had a SANC filed at the time of their birth (OR: 26.33, 95% CI: 15.9–43.5; p = 0.001).

3.2. Psychiatric outcomes

Table 2 shows the comparison of psychiatric outcomes between the two groups. Unadjusted for age, compared to children who had a SANC filed without note of parental substance use, children who had parental substance use noted in a SANC showed significantly lower odds of multiple psychiatric outcomes including diagnoses of mood disorder (OR: 0.39, 95% CI: 0.31–0.49; p < 0.0001), anxiety disorder (OR: 0.43, 95% CI: 0.34–0.54; p < 0.0001), externalizing disorder (OR: 0.32, 95% CI: 0.25–0.42; p < 0.0001), trauma di- agnoses (OR: 0.61, 95% CI: 0.45–0.83; p = 0.0015), autism spectrum disorder (OR: 0.51, 95% CI: 0.29–0.89; p = 0.0187), and sub- stance use disorder in the child (OR: 0.73, 95% CI: 0.57–0.93; p = 0.0099), as well as suicide attempts (OR: 0.60, 95% CI: 0.46–0.78; p = 0.0002) and non-suicidal self-injury (OR: 0.59, 95% CI: 0.46–0.74; p < 0.0001) (see Table 2). Adjusted for age (Fig. 1), diagnoses of anxiety disorder, mood disorder and externalizing disorder demonstrated significantly lower odds in the parental substance use group (OR: 0.68, 95% CI: 0.52–0.89; p = 0.0045, OR: 0.74, 95% CI: 0.54–0.99; p = 0.0479, and OR: 0.44, 95% CI: 0.33–0.57; p = 0.0001 respectively), and this group had significantly higher odds of a substance use disorder diagnosis in the child (OR: 1.45, 95% CI: 1.08–1.94; p = 0.0135). Compared to children who had a SANC report filed without note of parental substance use, children who had parental substance use noted in a SANC report showed significantly lower odds of psychiatric hospitalization and rehospitalization (OR: 0.44, 95% CI: 0.35–0.56; p < 0.0001 and OR: 0.46, 95% CI: 0.34–0.63; p < 0.0001 respectively), with these findings no longer significant when age-adjusted.

Table 3 shows that children who had parental substance use noted in a SANC report had significantly fewer Emergency Medicine Department (ED) visits (for both any chief complaint and psychiatric symptoms) in the year before the SANC (parameter estimate [PE]: − 0.54, 95% CI: − 0.71, − 0.38; p < 0.0001 and OR: − 0.12, 95% CI: − 0.20, − 0.04; p = 0.0039 respectively). Age-adjusted (Fig. 2), the psychiatric ED visits in the year before SANC remained significantly less frequent in the substance use SANC group (PE: − 0.45, 95% CI: − 0.61, − 0.28; p < 0.0001).

4. Discussion

This retrospective cohort study examined comparative outcomes of children depending on the presence or absence of parental

Table 1 Cohort characteristics

No parental substance use in SANC Parental substance use in SANC Total

(N = 2344) (N = 485) (N = 2829)

Race Caucasian 1831 (78.1%) 375 (77.3%) 2206 (78.0%) African American/African 160 (6.8%) 48 (9.9%) 191 (6.8%) American Indian/Native American 13 (0.6%) 6 (1.2%) 19 (0.7%) Asian 46 (2.0%) 3 (0.6%) 49 (1.7%) Other 268 (11.4%) 42 (8.7%) 310 (11.0%) Unknown 11 (0.5%) 3 (0.6%) 14 (0.5%) Missing 15 (0.6%) 8 (1.6%) 23 (0.8%)

Single parent household at the time of first SANC 849 (37.3%) 214 (45.1%) 1063 (38.7%) Missing 69 (2.9%) 11 (2.3%) 80 (2.8%)

In utero to THC exposure 20 (1.5%) 150 (39.3%) 170 (9.7%) Missing 978 (41.7%) 103 (21.2%) 1081 (38.2%)

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substance use documented in a suspected abuse/neglect report, when compared to a suspected abuse/neglect report filed without note of parental substance use. The present findings suggest that family environments with child abuse/neglect reports related to parental substance use have lower odds of adverse psychiatric outcomes in children compared to environments with child abuse/neglect reports and no documented parental substance use. However, there are likely more complexities to consider in future studies. It is important to note that we did not perform comparisons with a healthy control group of children with no history of SANC reports but rather aimed to identify differences in specific ways abuse or neglect might manifest.

Recent studies showed that mothers with SUD are more likely to be single parents (Brady & Ashley, 2005; Greenfield et al., 2007). It

Table 2 Psychiatric outcomes in children with parental substance use noted in a SANC compared to children who had a SANC report without note of parental substance use

Outcomes Unadjusted Age-adjusted

Odds ratio estimate p Value Odds ratio estimate p Value

Anxiety disorder 0.43 (0.34, 0.54) <0.0001 0.68(0.52,0.89) 0.0045 Autism spectrum disorder 0.51 (0.29, 0.89) 0.0187 0.58(0.33,1.03) 0.0611 Trauma disorder 0.61 (0.45, 0.83) 0.0015 0.94(0.69,1.30) 0.7268 Mood disorder 0.39 (0.31, 0.49) <0.0001 0.74(0.54,0.99) 0.0479 Psychotic disorder 0.99 (0.59, 1.66) 0.964 1.64(0.96,2.80) 0.07 Externalizing disorder 0.32 (0.25, 0.42) <0.0001 0.44(0.33,0.57) 0.0001 Suicide attempts 0.60 (0.46, 0.78) 0.0002 1.12(0.81,1.54) 0.503 Nonsuicidal self-injury 0.59 (0.46, 0.74) <0.0001 1.11(0.83,1.46) 0.4945 Substance use disorder 0.73 (0.57, 0.93) 0.0099 1.45(1.08,1.94) 0.0135 Psychiatric hospitalization 0.44 (0.35, 0.56) <0.0001 0.81(0.60,1.09) 0.1583 Psychiatric rehospitalization 0.46 (0.34, 0.63) <0.0001 0.76(0.55,1.06) 0.1092 In utero THC exposure 43.51 (26.7, 70.8) <0.0001 26.33(15.9,43.5) 0.0001 Single parent household at the time of first SANC 1.38 (1.13, 1.69) 0.0015 1.38(1.13,1.70) 0.0021

Fig. 1. Psychiatric outcomes in children with parental substance use noted in a SANC compared to children who had a SANC report without note of parental substance use, adjusted for age.

Table 3 Utilization of emergency department in children with parental substance use noted in a SANC compared to children who had a SANC report without note of parental substance use.

Outcomes Unadjusted Age-adjusted

Parameter estimate p Value Parameter estimate p Value

Psychiatric ED visit year before SANC − 0.54(− 0.71, − 0.38) <0.0001 (− 0.45(− 0.61, − 0.28) <0.0001 Psychiatric ED visit year after SANC 0.09(− 0.08, 0.25) 0.3089 (0.08(− 0.10, 0.25) 0.39 Any ED visit year before SANC − 0.12(− 0.20, − 0.04) 0.0039 (0.06(− 0.02, 0.13) 0.16 Any ED visit year after SANC − 0.08(− 0.14, − 0.01) 0.0273 (0.06(− 0.01, 0.13) 0.073

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is therefore of no surprise that in our study children who had parental substance use noted in a SANC report showed higher odds of living in a single parent household. This finding is important as previous research demonstrates that single parent household status is linked to other risk factors, including difficulties finding appropriate child care while in treatment, economic hardships, limited social support as well as higher likelihood of stigma attached to parental substance use disorder and therefore less motivation for change and seeking treatment (Stringer & Baker, 2018). The latter might also contribute to the finding that children who had parental substance use noted in a SANC report showed significantly lower odds of an ED visit both for any reason and specifically for a psychiatric reason, in the year before the SANC. It is possible that parents with SUD were ashamed of their issues and did not want medical professionals to “discover them” via examining their children. Another hypothesis is based on observational studies of mothers on methadone maintenance treatment, which shows they appear disinterested and ambivalent towards their children, suggesting they could miss signs of illness in their child (Romanowicz et al., 2019).

It is important to consider the limitations of the present study in the context of the complexities of how family and community environments impact a child's neurodevelopment and risk for psychiatric illness. While we noted that at the time of the first SANC, 39% of the subjects in our sample were in a single parent home, there are many potential unknown factors to consider. It is possible that in some instances a positive adult relationship was present (e.g. a neighbor or parental significant other) to buffer the stress of parental substance use or provide a role model of resilience. Recent clinical and translational research efforts focus on the positive effects of maternal buffering in the context of early life stress (Callaghan et al., 2019; Garner, 2013; Tottenham, 2020). Communities or other adult caregivers may provide similar effects. It is also possible that the substance using parent is not the primary caregiver in the home and so we may be seeing a protective effect on the children if this is the case in the current study. Capturing this information was beyond the scope of this initial study. In the future it would be valuable to examine the gender and in-out of home status of the substance using parent.

Notably, a SANC report related to substance use was associated with significantly lower odds of multiple psychiatric outcomes including diagnoses of mood disorder, anxiety disorder, externalizing disorder, trauma diagnoses, autism spectrum disorder, and substance use disorder in the child, as well as suicide attempts and non-suicidal self-injury, though when age-adjusted, only the lower odds of mood disorder, anxiety disorder and externalizing disorder remained significant. Not surprisingly, when adjusted for age children who had parental substance use noted in a SANC had significantly higher odds of a substance use disorder diagnosis. Numerous studies show that children of parents with substance use are at higher risk to develop SUD themselves in comparison with the general population (Johnson & Leff, 1999; Kerr et al., 2020; Marino et al., 2018; Rusby et al., 2018). A large registry study conducted in Finland showed that parental SUD predicted mental disorders in school aged children in a bivariate model, though the association disappeared in a multivariate model; in the same study, risk of childhood SUD was also stronger for mothers with SUD as compared to fathers with SUD (Jääskeläinen et al., 2016). In our study, we were not able to present separate results for mothers and fathers. It is also possible that our cohort of children of parents with suspected SUD utilized not only the ED but also regular visits with their pediatrician significantly less than the comparison group, and as a result they were underdiagnosed, which would require further studies. It is worth noting that in this study we are comparing to children who experienced other forms of abuse. This may account for the finding of lower odds of adverse psychiatric outcomes in children where abuse or neglect was suspected related to parental substance use, compared to children with suspected other kinds of abuse or neglect, which may be more severe. Further research is needed on this topic.

Fig. 2. Utilization of Emergency Department in children with parental substance use noted in a SANC compared to children who had a SANC report without note of parental substance use, adjusted for age.

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Our study did have some limitations. We did not include healthy controls or an age and gender matched comparison group with no child abuse/neglect reports. The average age of our cohort was relatively young, and so there may be a length of time bias in the outcomes recorded that leads to an underestimation of outcome risk. The retrospective nature of this study limits our ability to collect data on covariates, as well as the time period over which data can be collected. Though racial disparities exist in child maltreatment, our sample was predominantly Caucasian and did not capture the higher numbers of minorities in the child protection system (Dakil et al., 2011). Diagnoses were retrieved using a database therefore we did not have access to information about how diagnoses were made, by whom, whether diagnoses changed over time, and inter-observer agreement about diagnoses. We do not have data to assess correlation between diagnoses and numbers of visits. We also do not have data regarding medications, for example prevalence of pharmacologic treatment of the child compared to substance use of the parent. We were unable to reliably ascertain all the substances parents may have been using, and how the type of substance may impact diagnoses and number of visits, which may be an important future area of study. With legalization of recreational cannabis, increasing use of medical cannabis and popularity of cannabidiol, future research is needed on the relationship between parental cannabis use and the effect on the child. We were also unable to preclude the presence of other types of abuse/neglect in the cases where parental substance use was detailed in the SANC report, as well as to differentiate between cases of suspected abuse versus neglect, and their combinations. Additionally, we do not have in- formation as to whether the information submitted by a mandated reporter (typically a social worker or prescriber) was substantiated. One strength of our database is that in our health system, all children in whom abuse or neglect is suspected by the healthcare provider must have a report filed both within the Mayo Clinic electronic health record and with the child's county of residence. This reduces the risk of missed reports due to incomplete documentation or lack of communication with the county, thereby increasing the fidelity of the data. Despite a rather robust system for reporting, it remains possible that abuse or neglect were missed by providers and thus not reported.

5. Conclusions

Child maltreatment and parental substance use are both of significant concern in the United States. This is of particular importance now during COVID-19 pandemic as a growing body of research suggests that there may be an increase in risk factors associated with both childhood maltreatment and SUD (Brooks et al., 2020; Campbell, 2020; Frank et al., 2014; Humphreys et al., 2020; Stith et al., 2009). However, the intersection between these two concerns is not fully understood. In this study, children with suspected abuse or neglect in a household with parental substance use had lower odds of adverse psychiatric outcomes than children with suspected report of abuse or neglect unrelated to parental substance use. Given the long-ranging potential consequences of adverse childhood events, more research is needed on the role of specific adverse experiences which may help better target interventions for children and parents experiencing those events. Furthermore, this work may also allow us to better understand children's resilience, in order to create and refine interventions that give children the best chance of leading healthy lives.

Declaration of competing interest

This publication was made possible by the Mayo Clinic Clinical Translational Science Award (CTSA) to Dr. Shekunov through grant number UL1TR002377 from the National Center for Advancing Translational Sciences (NCATS), a component of the National In- stitutes of Health (NIH). The content of this publication is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Dr. Croarkin has received research grant support from Pfizer Inc.; equipment support from Neuronetics, Inc.; and supplies and genotyping services from Assurex Health, Inc. for investigator-initiated studies. He is the primary investigator for a multicenter study funded by Neuronetics, Inc. and a site primary investigator for a study funded by NeoSync, Inc. Dr. Croarkin is a consultant for Procter & Gamble Company and Myriad Neuroscience. Dr. Romanowicz receives grant funding from the Mayo Foun- dation Departmental Small Grant Program and the Palix Foundation. The other authors report no declarations of interest.

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