| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
ORIGINAL RESEARCH |
From the Alaska Division of Public Health, Anchorage, Alaska.
 |
ABSTRACT |
|---|
TOP
 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
METHODS: An evaluation was conducted among Alaskan females age 10 through 15 years enrolled in Medicaid. Subjects were identified who had experienced reproductive health outcomes. The Medicaid file was linked to a Child Protective Services database and a Juvenile Justice database to identify episodes of abuse by a caretaker and criminal behavior.
RESULTS: Of 21,350 Alaskan females aged 10–15 years enrolled in Medicaid during 1999–2003, 841 (3.9%) presented for reproductive health care, 2,930 (14%) were referred to Child Protective Services and 1,858 (8.7%) were referred to Juvenile Justice for criminal activity. Among the subjects with a reproductive health-related claim, 39% were referred to Child Protective Services while 31% were referred to Juvenile Justice at some point during the study period. Reproductive health care was strongly associated with referral to Child Protective Services (adjusted odds ratio [aOR] 2.9, 95% confidence interval [CI] 2.5–3.4), substantiated sexual abuse (aOR 2.3, 95% CI 1.7–3.2), and referral to Juvenile Justice (aOR 2.9, 95% CI 2.5–3.4). These associations remained regardless of the type of reproductive health care, including contraceptive management.
CONCLUSION: Females aged 10–15 years enrolled in Medicaid who present for any type of reproductive health care are at increased risk of abuse by a caretaker and criminal behavior. Clinicians caring for low-income females should consider routine screening for sexual activity and the experience of violence.
LEVEL OF EVIDENCE: II-2
|
MATERIALS AND METHODS |
|---|
|
TOP
ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
A cross-sectional analysis was performed to evaluate the association between having a reproductive health-related medical claim and having a referral to Child Protective Services or Juvenile Justice. The primary tested hypothesis was that females enrolled in Medicaid who had a claim for reproductive health care would be more likely than those without such a claim to have experienced physical or sexual abuse by a caretaker or a referral to Juvenile Justice.
A master data file was obtained from the Alaska Division of Medical Assistance, which contained information on all females enrolled in Medicaid at any point during January 1999 through December 2003 and who were aged 10 through 15 years on December 31 of any study year. This file contained a unique identifier for each person, social security number, name, residence, race, gender, and date of birth. Nine percent of all enrollees and 17% who experienced one of the evaluated clinical outcomes were enrolled in Medicaid during all 5 study years.
A clinical outcomes database was created by identifying all billing claims for outcomes of interest that occurred for females aged 10 through 15 years at the time of presentation. Clinical outcomes were categorized using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) and included codes V22 and V23 (pregnancy), V24 (postpartum care and examination), V25 (contraceptive management), 630–676 (complications of pregnancy, child birth, and puerperium), 90–99 (syphilis and other venereal diseases), and 42 (human immunodeficiency virus [HIV] infection).
Code V72.4 (pregnancy examination or test) was not included because it would have included an unknown number of subjects tested for reasons other than reproductive health or sexual activity, such as radiological or presurgical evaluation or at a guardian's insistence. This rule excluded 131 subjects who would otherwise have been included. When these 131 subjects were evaluated to determine their risk of Child Protective Services or Juvenile Justice referral, results were almost identical to results for subjects included in final analysis. Thus, this rule did not alter substantially overall results or conclusions.
To determine which study subjects had a live birth and to have information on father's age for these births, the Alaska Bureau of Vital Statistics provided a database of live births that occurred to Alaska residents during January 1999 through June 2004. This database included births to Alaska residents that occurred in another state.
The Alaska Office of Children's Services Child Protective Services unit provided a database of all females aged 10 through 15 years referred during 1999–2003 for evaluation of physical or sexual abuse or neglect perpetrated by a primary caretaker. Abuse committed by noncaretakers, such as boyfriends, was not included because the Office of Children's Services does not have jurisdiction over these cases. The Child Protective Services database did not include a description of the abuse and individual case records were not reviewed.
The Alaska Office of Children's Services provided a database of all females aged 10 through 15 years referred to the Juvenile Justice system during 1999–2003 for evaluation of possible criminal behavior. Of 1,858 referred subjects, 32 (1.7%) had all charges dismissed.
The master Medicaid file was linked to the Medicaid file of clinical outcomes using a unique Medicaid identifier. This database was linked to birth certificate data by matching on mother's name and date of birth using a computerized program followed by a hand linkage to identify obvious transcription errors.
This database was then linked to the Child Protective Services and Juvenile Justice databases using an exact computer match of social security number or, since this information was frequently missing, subject's last name and date of birth. Of 21,350 subjects enrolled in Medicaid, 2,081 (9.7%) matched to the Child Protective Services database by social security number and 849 (4.0%) matched by name and date of birth; 1,080 (5.1%) matched to the Juvenile Justice database by social security number and 778 (3.6%) matched by name and date of birth.
Case definitions are as follows:
Juvenile Justice referral categories are as follows:
To evaluate the association between reproductive health care and either Child Protective Services or Juvenile Justice referral, cross-sectional analyses were performed and odds ratios were calculated. Logistic regression models were created that adjusted for age at Medicaid enrollment, the number of days enrolled in Medicaid, Alaska Native status (as defined by the Medicaid file), and Anchorage residence. The number of days enrolled in Medicaid determined the at-risk period for reproductive health outcomes. Despite the small number of outcomes included in some analyses, adjusted results using logistic regression differed little from bivariate analyses.
In theory, analyses could be influenced if some subjects were enrolled in Medicaid too briefly to allow some outcomes to occur. However, when analyses were repeated and limited to persons enrolled in Medicaid for at least 365 days, virtually identical results were obtained. Because of this and because small sample sizes for some outcomes prevented analysis using the restricted dataset, results are presented only for analyses performed on the entire dataset. All analyses were conducted with SPSS 11.0 (SPSS Inc., Chicago, IL).
This evaluation used existing public health databases housed within the Alaska Department of Health and Social Services. No additional information from subjects was obtained and no subjects were contacted. As an evaluation of routine public health surveillance databases by a legally empowered governmental authority for the development of public health recommendations, no institutional review board approval was sought or obtained. After the decision to publish results, approval was obtained from the University of Alaska, Anchorage Institutional Review Board. The Alaska Department of Health and Social Services has a commitment to patient confidentiality including formal confidentiality procedures and training, password-encrypted data files, password-protected computer log-on, and a firewall specific to the Section of Epidemiology server where final data files were housed.
|
RESULTS |
|---|
|
TOP
ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
|
Among all subjects, 317 (1.5%) had a billing code for pregnancy, including 178 (56%) with a live birth, 63 (20%) with documented pregnancy termination, and 76 (24%) with no evidence of a live birth and that were considered to have had a pregnancy termination. There were 575 (2.7%) that had an approved billing code for contraceptive management, 23 (0.11%) for a sexually transmitted infection evaluation, and none for HIV evaluation. A total of 841 (3.9%) subjects had one or more approved claims for one of the evaluated medical outcomes. For live births, pregnancy terminations, and any reproductive health-related approved claim, the incidences were 3.7, 2.7, and 16 per 1,000 subjects per year, respectively. Among subjects with a reproductive health claims, most were 14 or 15 years of age at the time of the first claim (Fig. 1).
Among all subjects, 2,930 (14%) had a Child Protective Services referral including 1,996 (9.3%) for physical or sexual abuse. There were 870 (4.1%) with substantiated physical or sexual abuse, including 375 (1.8%) with substantiated sexual and 538 (2.5%) with substantiated physical abuse; respective incidences were 17, 7.2, and 10 per 1,000 per year. Among subjects with substantiated physical or sexual abuse, the age at first documented abuse was relatively evenly divided by year of age (Fig. 1).
Among all subjects, 1,858 (8.7%) were referred to the Juvenile Justice system. Three percent of those referred had a first referral before their 11th birthday, increasing to 10% by 12 years of age, 23% by 13 years, and 48% by 14 years. Among the 1,858 referred subjects, 1,115 (60%) were referred for theft, 562 (30%) for a violent offense, and 223 (12%) for drug or alcohol offenses, while 224 (12%) had a referral for an offense other than these three.
The distribution of evaluated factors was not uniform by Alaska Native status or residence. The occurrence of reproductive health care, Child Protective Services referrals, and Juvenile Justice referrals was highest among Alaska Natives residing in Anchorage and lowest among Alaska Natives residing outside of Anchorage (Table 1).
|
Of 841 subjects with a reproductive health claim, 326 (39%) had one or more referrals to Child Protective Services during the study period (range 1 to 8, mean 1.9), 49 (5.8%) were referred for substantiated sexual abuse (range 1 to 3, mean 1.2), and 49 (5.8%) were referred for substantiated physical abuse (range 1 to 3, mean 1.3). There was a strong association between having a reproductive health claim and experiencing substantiated abuse by a caretaker (Table 2). The association with having a Child Protective Services referral was similar for all categories of reproductive health related claims.
|
A subject's age had an inconsistent effect on the likelihood of referral for abuse. Among subjects aged 10 to 11, 12 to 13, and 14 to 15 years when they experienced their first reproductive health-related claim, 16% (4 of 25), 52% (85 of 165), and 36% (237 of 651), respectively, received a Child Protective Services referral and 4.0% (1 of 25), 16% (27 of 165), and 10% (68 of 651) had substantiation of abuse.
While 326 (39%) of the 841 subjects with a reproductive health claim had a referral for abuse, many of these referrals occurred months before or after the claim. Among these 326 subjects, 82 (25%) received a referral within 1 month (before or after) of their first claim date, 139 (43%) within 3 months, and 194 (60%) within 6 months. A referral on or after the claim date occurred for 120 (37%) subjects (Fig. 2).
|
Of 841 subjects with a reproductive health claim, 258 (31%) had one or more referrals to Juvenile Justice during the study period (range 1 to 103, mean 6.0) including 102 (12%) with a first referral for a violent offense (range 1 to 18, mean 3.1), and 147 (18%) for with a first referral for theft (range 1 to 65, mean 4.8). A strong association existed between reproductive health-related claims and Juvenile Justice referrals (Table 3). This was true for all evaluated categories of Juvenile Justice referral and reproductive health-related claims.
|
The youngest subjects were least likely to have a Juvenile Justice referral. Among subjects aged 10–11, 12–13, and 14–15 years when they experienced their first reproductive health-related claim, 4.0% (1 of 25), 33% (55 of 165), and 31% (202 of 651), respectively, received a referral and 0% (0 of 25), 15% (25 of 165), and 12% (77 of 651) received a referral for a violent offense.
As with Child Protective Services referrals, Juvenile Justice referrals often occurred many months before or after the reproductive health-related claim (Fig. 2). Of the 258 subjects that had a reproductive health-related claim and a referral to Juvenile Justice, 18 (7.0%) had their first referral within 1 month of their first medical claim, 64 (25%) within 3 months, and 163 (63%) within 12 months.
|
DISCUSSION |
|---|
|
TOP
ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
Effective screening tools for the identification of violence have been developed including a 3-question tool from the American College of Obstetricians and Gynecologists (Website: http://www.acog.org/departments/dept_notice.cfm?recno=17&bulletin=585; retrieved December 20, 2005). The American Academy of Pediatrics recommends that questions related to domestic violence become part of routine anticipatory guidance (Website: http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3b101/6/1091; retrieved December 20, 2005). Several recent reviews, however, have emphasized that data are lacking on the effectiveness of screening or other interventions in improving health outcomes among persons experiencing abuse or neglect.6,7,9 In the case of minors, a lack of documented effectiveness generally does not alter clinical management because a legal reporting requirement exists once abuse is suspected or confirmed. Nevertheless, data on intervention effectiveness would bolster the case for routine screening of lower income adolescents and younger females for sexual activity and the experience of abuse.
Criminal behavior and the experience of abuse often occurred well before or after seeking reproductive health care, indicating that sexual activity in this cohort often occurred within a general context of ongoing social disruption. Thus, prevention of abuse likely will require a comprehensive approach that addresses underlying issues such as violence,10,11 drug abuse, family disintegration,14,15 and mental health,16,17 including intervening during childhood.18 Clinicians serving the Medicaid-eligible population may have a role in this process by prospectively determining whether patients younger than 16 years are engaged in sexual activity and if so, initiating screening and referral (see recommendations below).
Results from the current study cannot be extrapolated to the non-Medicaid population. Poverty may increase the risk of criminal behavior and experiencing abuse19,20 and the age at initiation of sexual activity.21 Additionally, children and young teens may enroll in Medicaid because of intervention by a social services case manager whose original contact with the subject occurred after a referral for abuse, criminal behavior, or other social issues. Approximately 56% of study subjects were enrolled at ages older than 10 years (ie, rather than having a long previous history of enrollment), suggesting that this phenomenon may have occurred frequently. To the extent that this is true, it will increase the prevalence of adverse outcomes among the Medicaid population relative to the non-Medicaid population.
The current study had several other limitations. Abuse by noncaretakers (such as an intimate partner) was not evaluated because the Alaska Office of Children's Services has jurisdiction only over abuse by a caretaker. Previous studies have found that adolescents frequently experience noncaretaker abuse but there is no readily available data source for these occurrences. Abuse may also have been underestimated because of failure of providers to screen, identify, and refer patients; lack of sufficient evidence to substantiate abuse; and insufficient resources to conduct investigations. Consequently, abuse rates presented here will substantially underestimate the overall experience of abuse in this population.
Racial and geographic differences in outcomes may reflect differences in diagnosis, referral, and access to care rather than true differences in occurrence. For example, Anchorage residents may have higher prevalences of Juvenile Justice outcomes because of the decreased availability of criminal justice system components in many rural Alaskan villages. Similarly, Alaska Natives may have higher rates of abuse outcomes because of improved diagnosis and referral among persons providing care and other services to the Alaska Native community.
The generalizability of results to areas other than Alaska will depend on whether these areas have similar populations and service implementation. For example, much of Alaska's population is rural and lives in areas with relatively poor access to law enforcement and State services. More urban locations might have fewer problems with this potential source for underestimating the true size of the association between reproductive health care and abuse or criminal behavior. In contrast, Alaska has a relatively well-funded State government; poorer rural states with less well-funded social services agencies might have more problems documenting the true size of associations. Finally, the size of associations might truly vary between Alaska and other areas based on such factors as Medicaid income eligibility limits (which vary by state) and differences in the behavior of unique subpopulations such as Alaska Natives.
Alaskan females aged 10 through 15 years enrolled in Medicaid who present for reproductive health services have a high risk of experiencing abuse by a caretaker and of engaging in criminal activity. Clinicians providing care to this population should consider routine screening for sexual activity and experience of violence and should adhere to mandatory reporting laws when child maltreatment is suspected or identified. Data documenting intervention effectiveness would substantially bolster the case for routine screening. Results were presented at mandatory reporter training and in a public health bulletin given to clinicians throughout the state. Recommendations included consideration of screening all Medicaid-eligible adolescent females for initiation of sexual activity, screening those who have initiated sexual activity for abuse using previously developed tools (http://www.acog.org/departments/dept_notice.cfm?recno=17&bulletin=585; retrieved March 14, 2006), and becoming familiar with community and other resources for intervening when abuse is identified, such as those provided by the American Academy of Pediatrics (http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3b101/6/1091; retrieved March 14, 2006).
|
Footnotes |
|---|
The author thanks Phillip Mitchell of the Alaska Bureau of Vital Statistics for creation and linking of various data files and Jonathon Nelson of the Alaska Department of Health and Social Services for assistance with database manipulation.
Corresponding author: Bradford D. Gessner, MD, MPH, Alaska Division of Public Health, P.O. Box 240249, 3601 C Street Suite 576, Anchorage, AK 99524; e-mail: Brad_Gessner{at}health.state.ak.us.
doi:10.1097/01.AOG.0000223873.03115.c9
|
REFERENCES |
|---|
|
TOP
ABSTRACTMATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
|---|
2. Anda RF, Chapman DP, Felitti VJ, Edwards V, Williamson DF, Croft JB, et al. Adverse childhood experiences and risk of paternity in teen pregnancy. Obstet Gynecol 2002;100:37–45.
3. Blinn-Pike L, Berger T, Dixon D, Kuschel D, Kaplan M. Is there a causal link between maltreatment and adolescent pregnancy? A literature review. Perspect Sex Reprod Health 2002;34:68–75.[Medline]
4. Fergusson DM, Horwood LJ, Lynskey MT. Childhood sexual abuse, adolescent sexual behaviors and sexual revictimization. Child Abuse Negl 1997;21:789–803.[Medline]
5. Raj A, Silverman JG, Amaro H. The relationship between sexual abuse and sexual risk among high school students: findings from the 1997 Massachusetts Youth Risk Behavior Survey. Matern Child Health J 2000;4:125–34.[Medline]
6. Wathen CN, MacMillan HL. Interventions for violence against women: scientific review. JAMA 2003;289:589–600.
7. Ramsay J, Richardson J, Carter YH, Davidson L, Feder G. Should health professionals screen women for domestic violence? Systematic review. BMJ 2002;325:314.
8. Groves BM, Augustyn M, Lee D, Sawires P. Identifying and responding to domestic violence: consensus recommendations for child and adolescent health. Family Violence Prevention Fund, San Francisco, CA, August 2004. Website: http://endabuse.org/programs/healthcare/files/Pediatric.pdf. Retrieved July 22, 2005.
9. Allin H, Wathen CN, MacMillan H. Treatment of child neglect: a systematic review. Can J Psychiatry 2005;50:497–504.[Medline]
10. Wiemann CM, Agurcia CA, Berenson AB, Volk RJ, Rickert VI. Pregnant adolescents: experiences and behaviors associated with physical assault by an intimate partner. Matern Child Health J 2000;4:93–101.[Medline]
11. Valois RF, Oeltmann JE, Waller J, Hussey JR. Relationship between number of sexual intercourse partners and selected health risk behaviors among public high school adolescents. J Adolesc Health 1999;25:328–35.[Medline]
12. Silverman JG, Raj A, Mucci LA, Hathaway JE. Dating violence against adolescent girls and associated substance use, unhealthy weight control, sexual risk behavior, pregnancy, and suicidality. JAMA 2001;286:572–9.
13. Melzer-Lange MD. Violence and associated high-risk health behavior in adolescents. Substance abuse, sexually transmitted diseases, and pregnancy of adolescents. Pediatr Clin North Am 1998;45:307–17.[Medline]
14. Resnick MD, Bearman PS, Blum RW, Bauman KE, Harris KM, Jones J, et al. Protecting adolescents from harm. Findings from the National Longitudinal Study on Adolescent Health. JAMA 1997;278:823–32.[Abstract]
15. Sieving RE, McNeely CS, Blum RW. Maternal expectations, mother-child connectedness, and adolescent sexual debut. Arch Pediatr Adolesc Med 2000;154:809–16.
16. Hallfors DD, Waller MW, Ford CA, Halpern CT, Brodish PH, Iritani B. Adolescent depression and suicide risk: association with sex and drug behavior. Am J Prev Med 2004;27:224–31.[Medline]
17. Orr DP, Beiter M, Ingersoll G. Premature sexual activity as an indicator of psychosocial risk. Pediatrics 1991;87:141–7.
18. Hawkins JD, Catalano RF, Kosterman R, Abbott R, Hill KG. Preventing adolescent health-risk behaviors by strengthening protection during childhood. Arch Pediatr Adolesc Med 1999;153:226–34.
19. Dearwater SR, Coben JH, Campbell JC, Nah G, Glass N, McLoughlin E, et al. Prevalence of intimate partner abuse in women treated at community hospital emergency departments. JAMA 1998;280:433–8.
20. Vest JR, Catlin TK, Chen JJ, Brownson RC. Multistate analysis of factors associated with intimate partner violence. Am J Prev Med 2002;22:156–64.[Medline]
21. Blum RW, Buehring T, Shew ML, Bearinger LH, Sieving RE, Resnick MD. The effects of race, ethnicity, income, and family structure on adolescent risk behaviors. Am J Public Health 2000;90:1879–84.
22. Ellickson PL, Collins RL, Bogart LM, Klein DJ, Taylor SL. Scope of HIV risk and co-occurring psychosocial health problems among young adults: violence, victimization, and substance use. J Adolesc Health 2005;36:401–9.[Medline]
23. Roberts TA, Auinger P, Klein JD. Intimate partner abuse and the reproductive health of sexually active female adolescents. J Adolesc Health 2005;36:380–5.[Medline]
24. Rickert VI, Wiemann CM, Vaughan RD, White JW. Rates and risk factors for sexual violence among an ethnically diverse sample of adolescents. Arch Pediatr Adolesc Med 2004;158:1132–9.
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
