The child welfare system is designed to protect children from harm and to reduce the risk of future harm by supporting families. However, the manner in which the system currently addresses child maltreatment by primary caregivers may not be sufficiently robust as current research suggests that important members of the family – fathers – may not be fully engaged as agents of change in preventing or responding to maltreatment. Evidence suggests that, until recently, fathers were largely overlooked in child welfare. This is beginning to change as child welfare researchers and practitioners are paying increasing attention to fathers and the role that they do and can play in child welfare cases and case outcomes.

In the past decade, child welfare researchers have begun to explore the engagement of fathers, the factors that contribute to a lack of engagement, and the effects of engaging fathers. This literature asserts that fathers are routinely not engaged by the child welfare system, negatively affecting their children, and suggests that caseworker bias against fathers is largely to blame for this problem. However, the extant literature takes a broad-brush approach to fathers with child welfare-involved children, painting them as a homogenous group and father engagement as invariably beneficial for children. Furthermore, the literature has yet to enumerate how many fathers are represented in child welfare cases at any given time, how many fathers are eligible (i.e. not restricted by factors such as incarceration) for engagement in their children’s cases, or among eligible fathers, how many are not being engaged.

Through a review of case records for 507 children from 359 families who entered out-of-home care in one urban county for the first time between October 1, 2013 and September 30, 2015, this mixed method exploratory study re-examines father engagement with a more nuanced lens. Data from the case record review was linked with administrative data to: 1) examine the extent and nature of father engagement in an urban county’s child welfare system; 2) compare levels of father engagement to those of mother engagement; and 3) examine the association, if any, between father engagement and case outcomes.

In this study father engagement is conceptualized as a gradient that encompasses the various points throughout the beginning of a child welfare case during which a father may be included. The gradient begins with attempting to identify fathers and concludes with considering fathers as a potential placement for their children. The gradient is progressive such that each of the later stages cannot occur without the earlier stages.

In aggregate, the 359 families included 420 fathers, most of whom were alleged fathers (75%). A majority of all fathers were identified (95%) located (75%), and contacted (63%). When considering only fathers who were contacted, as these are the fathers who can be engaged in the later stages of the gradient, over half of fathers were offered visitation (58%), offered services (56%), included in the case plan (54%), and considered as a potential placement for their children (53%).

Fathers varied in their eligibility for engagement such that 35% of fathers were found to be ineligible for engagement, largely due to a failure to establish presumed father status. Among fathers eligible for engagement, 90% were found to be eligible for full engagement and 10% for restricted engagement. Fathers eligible for engagement were more likely than ineligible fathers to be resident fathers and to have perpetrated the maltreatment that brought the family to the agency’s attention than fathers ineligible for engagement.

Among fathers who were eligible for full engagement, 40% were not offered services, included in the case plan, or considered as a potential placement. Among these, half were fathers on cases that were being dismissed or that were being transferred to family maintenance. Another quarter were fathers whose whereabouts were unknown.

In comparing father engagement to that of mothers, significant differences were found. On average, mothers had higher rates of engagement than fathers did. However, this difference was attributable to parent’s criminal justice involvement, status as the perpetrator of the maltreatment, and residence in the same home as the child and not to type of parent (i.e. mother vs. father).

In terms of the relationship between levels of father engagement and case outcomes, on average, higher levels of father engagement were associated with decreased case length. However, this difference was attributable to child’s type of primary placement and type of permanency outcome, such that when controlling for these variables, level of father engagement is no longer significantly associated with case length. Increased levels of father engagement were, however, associated with increased likelihood of reunification over adoption or remaining in care but not with likelihood of reunification in comparison to legal guardianship.

This study has multiple implications for research, practice, and policy. In research, there is a need for increased specificity around which populations are being studied, as fathers do not represent a homogenous group. Future studies should consider eligibility for engagement and control for factors, namely incarceration and residence in the same home as the child, that are predictive of levels of engagement. Future studies should also further examine the association between levels of engagement and case outcomes and explore best practices for engaging fathers. Turning to practice and policy, there is a need to re-examine policies around paternity and to work to align the various federal, state, and county policies relating to defining and establishing paternity. There is also a need to explore the ways in which the child welfare system can facilitate the continued engagement of parents while they are incarcerated. Lastly, the findings suggest that there is much nuance to consider when making decisions about if, when, and how to engage fathers, nuance that until now has largely been overlooked.

As awareness has grown regarding the co-occurrence of domestic violence and child maltreatment, and the potential deleterious outcomes associated with children's exposure to domestic violence, some public child welfare agencies are expanding their reach to include domestic violence as a form of maltreatment warranting protective intervention. Research to date has not fully determined how or whether cases referred for domestic violence exposure differ from traditional cases of maltreatment. If appropriate policies and interventions are to be developed and implemented for these cases, clearer information is needed to explicate how these cases are currently being processed in the child welfare system, and what their unique features are compared to cases involving other forms of abuse and neglect.

Using baseline data from the second National Survey of Child and Adolescent Well-Being II, a nationally representative longitudinal child welfare survey, this study uses a retrospective case comparison design to produce descriptive findings on cases referred to child welfare agencies for domestic violence. This analysis compares three groups of cases: those in which domestic violence was the sole maltreatment allegation reported to child welfare, those in which domestic violence was alleged concurrently with other types of maltreatment, those in which only other maltreatment was reported. Using bivariate analyses and multivariate logistic regression analyses, this study addresses two research questions: 1) What are the differential demographics, risk factors, and outcomes of CPS cases reported for domestic violence (alone or with other allegations) compared to cases reported for other maltreatment types? and 2) Is the presence of domestic violence as a maltreatment allegation an independent predictor of key child welfare outcomes after controlling for demographic and risk variables?

Results of this analysis indicate that child welfare cases alleging domestic violence as a maltreatment allegation have unique profiles of risk, demographics, and outcomes that distinguish them from cases alleging other maltreatment types. In the aggregate, cases reported for domestic violence have higher likelihood of substantiation than other cases, but despite higher substantiation rates, they are no more likely to receive child welfare services, and they are much less likely to result in out-of-home placement. These findings suggest that for many cases that come to the attention of child welfare agencies due to child domestic violence exposure, substantiated findings of maltreatment do not result in more intensive CPS interventions. In addition, these data show that, though cases alleging only domestic violence do not represent a substantial portion of the national child welfare caseload, they involve much lower levels of risk yet a much higher rate of substantiation than cases reported for other maltreatment. In sum, the findings from this study suggest that some lower-risk cases reported to child welfare agencies for domestic violence exposure could be appropriately targeted for alternative, non-investigative service approaches.

This dissertation is based on a unique dataset constructed by probabilistically linking records across three independent sources of data from California: 1) vital birth records, 2) administrative child protective service records, and 3) vital death records. The final dataset captures 4.3 million children born in California between 1999 - 2006 and includes maltreatment allegation information for over 500,000 children who were reported to child protective services (CPS), as well as death reports on 2,000 children who were fatally injured before age five. Three research questions were examined in the context of a prospective birth cohort analysis: 1) Is a referral to child protective services an independent risk factor for injury mortality? 2) Is allegation disposition associated with injury fatality risk? 3) Does injury fatality risk vary across maltreatment allegation types? To answer these three questions, a series of multivariate survival models were specified. Separate models were estimated for overall risk of injury death, risk of unintentional injury death, and risk of intentional injury death.

Findings indicate that an earlier report to CPS is the strongest predictor of a child's injury death during the first five years of life. Children previously reported for maltreatment died from accidental injuries at twice the rate of their unreported, demographically similar peers, and from intentional injuries at five times the rate. After adjusting for other characteristics, children whose report of maltreatment was evaluated out without an in-person investigation by CPS died of injuries at significantly higher rates than children who had never been reported. Children with a substantiated allegation of maltreatment and no foster care placement died of intentional injuries at over 10 times the rate of children who had not been reported. Placement in foster care for even a single day was protective. Children with a prior allegation of physical abuse died from injuries at rates that were notably higher than not only unreported children, but also children reported for reasons of sexual abuse, neglect, or other forms of maltreatment. When only intentional injury fatalities were modeled, a prior allegation of physical abuse was associated with a rate of death that was 38 times that of children who had not been reported.

This study represents the most rigorous longitudinal analysis of mortality outcomes following a report to CPS to date, with several key implications for practice and policy emerging. First, these data underscore that a child's report to CPS is not random, nor is it simply a function of poverty. Rather, a report to CPS signals a level of risk, including a risk of death, that is greater than sociodemographic factors would alone predict. A second and related point is that children evaluated out after a CPS hotline call reflect a group whose risk of injury death is far greater than their unreported sociodemographic peers. The decision to screen these children out without an investigation, under the logic that these children were assessed to be at no greater risk of harm than other demographically similar children, is not supported by the empirical evidence generated from this study. Third, these data highlight that although there has been a recent emphasis on the unmet service needs of children reported for neglect, it is young children reported for physical abuse who face the greatest risk of death. Given that physical abuse allegations represent a minority of reports received by CPS, these data suggest that a different protocol for investigating and intervening in cases in which physical abuse is alleged may be justified. Finally, the finding that a prior allegation of maltreatment is the single greatest predictor of not just intentional injury death, but also unintentional injury death, lends support to calls that have been made for child welfare services to be pursued under a broader, public health-oriented agenda, focused on the prevention of all manners of injury death.

This dissertation examines the children’s public mental health Full Service Partnership (FSP) program established by the California’s Mental Health Services Act of 2004 in order to provide mental health and social services and supports not otherwise available to the underserved. Utilizing a California statewide dataset of all public county mental health system provisions linked from two sources of data, including FSP program exposure data (Data Collection and Report dataset) and mental health service data (Client Services Information dataset) from the California Department of Health Care Services (CDHCS), analyses compare the FSP program to usual care within county mental health systems. Synthesizing records summarizing each month a child was served, the final dataset encompasses 36 counties (61%) inclusive of 623,031 (70%) children (ages 6<18) served within county mental health systems over 102 months between July 1, 2004 and December 31, 2012, reflecting 15,723 children served by the FSP program. To evaluate whether the FSP program was meeting its goals as established in statute and guidelines, three research questions were addressed: 1) Do FSP programs reach underserved children, as intended? 2) Do FSP programs provide a different array of services as compared to usual care, as intended? 3) Does participation in the FSP program result in positive outcomes as intended, measured by a decrease in the use of mental health emergency service? Adjusting for demographics, indicators of clinical severity, and county of residence, three respective analytical models were developed to compare FSP served children to those in usual care including: 1) hierarchical logistic regression modeling for the odds of a child enrolling into an FSP versus remaining in the pool of those served by usual care in each county, 2) t-tests contrasting service provision arrays for FSP served children as compared to those in intensive (service on >= four days per month) usual care, and 3) longitudinal hierarchical Poisson regression modeling the pre-post matched change in incidence rate of mental health emergency services use before, after and without FSP enrollment.

As intended by policy, results indicate that FSPs reach the underserved, provide a different array of service intensity and result in reductions of crisis care for the children and families it served. Compared to others concomitantly served in usual care, FSP enrollees had more clinical indicators of severe disorder and had encountered the mental health system at younger ages (OR=.94, P<.001), but had received fewer total lifetime months of services before enrolling into FSP (OR=.99, P<.001), especially in the six months before beginning an FSP program (OR=.19, P<.001). FSP served children also received an array of services generally more intensive than usual care, even when considering only those children served at least four days per month in usual care. The comparison of service types suggested that the FSP program followed policy guidelines which direct FSPs to offer a heightened focus on linkages to community resources (+80%, P<.001) and to support needs of caregivers and other family members (+60%, P<.001). Improved outcomes were evidenced by changes in emergency service use rates for FSP served children, given that before enrolling in the FSP program, these children showed increasing rates of mental health emergency service use over time which were then reduced or reversed after enrolling in FSP programming and throughout the remainder of the study period – a pattern unlike what was experienced by similar children in usual care. After enrollment, the older groups of FSP served children showed significant improvement in contrast to their mental health emergency service use rates before treatment and to rates of all other comparable children in usual care (ages 11<15 IRR=.83 , P<.001; and 15<18 IRR=.79, P<.001).

FSPs are customized programs which address, at least in part, two significant challenges in children’s mental health: (1) outreach and engagement of underserved populations and (2) provision of community-based stabilizing care for children at high risk for psychiatric crises. There is evidence that FSP programs might have benefits for children by (a) more effectively enrolling into care some of the 2/3 of the population with need who are unserved or underserved; (b) providing an intensive array of services inclusive of family care and linkages to external resources; and (c) resulting in improved crisis-related outcomes for children and families. FSP programs incorporate a variety of innovate components, any of which could contribute to increased success in identifying, enrolling and engaging underserved children; improving the availability of an appropriate intensity of services; or delivering positive outcomes across a lasting developmental trajectory.

Left unserved and underserved, children with severe mental disorders and their families may lack the appropriate tools to manage or improve symptoms of the disorder leading toward a progression into mental illness in adulthood. A key aspect of FSP programs is their ability to provide a combination of social and mental health services, likely helping underserved families living in poverty to overcome prior barriers to treatment. Supported by the existing infrastructure built around the FSP program, research in California is poised to make a significant contribution toward evidencing methods which increase successful treatment of undertreated children’s mental disorders potentially altering their progression. Results from this dissertation provide justification for putting effort forth toward further evaluation to identify the FSP program components which result in these program successes.

Excessive alcohol consumption is a worldwide social problem that has greatly contributed to the global burden of disease, disability and death. Overall volume of alcohol consumption and prevalence of alcohol-related problems in China have remained relatively low in comparison to many western countries until recent years. Since the liberal economic reforms of the early 1980s, China has witnessed an alarmingly increasing rate of alcohol consumption, and as a result, increasing incidence of alcohol-related injuries and morbidity. However, comprehensive alcohol policy and public health infrastructure to address the problems associated with these changes have not yet been established. Using data from the China Health and Nutrition Survey, this dissertation - comprised of three papers - utilizes quantitative methods to examine alcohol consumption behaviors in China, in order to identify alcohol policies and interventions that are both applicable to and appropriate for the Chinese context and to recommend next steps for alcohol control policy and intervention areas in China. The first paper explores the socio-demographic and other factors that are associated with alcohol consumption behaviors in order to identify populations that are at risk for problem alcohol use and that may be targeted for prevention/public health education programs. The second paper establishes evidence regarding alcohol consumption behaviors and its association with community-level alcohol access characteristics, such as proximity of alcohol outlets and price of different types of alcohol. The third examines the association between alcohol consumption and healthcare utilization, in order to identify health policy needs for persons at risk for the development of costly chronic diseases. The three principal conclusions from the three papers are: (1) there is strong evidence of a closing gender gap in problematic alcohol consumption behaviors between men and women - although men are still more likely to consume more alcohol and be frequent and heavy drinkers than women, alcohol consumption levels and rates of heavy drinking among women are significantly increasing; (2) absence of alcohol vendor availability is associated with decreased alcohol consumption, and cost of beer and aged liquor is inversely associated amount of alcohol consumed and heavy drinking; and (3) problematic drinkers in China appear to under-utilize preventive healthcare services and possibly formal medical care in general.