Child Abuse & Neglect 79 (2018) 22–30

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Child Abuse & Neglect

journal homepage: www.elsevier.com/locate/chiabuneg

The relationship between child protection contact and mental

T
health outcomes among Canadian adults with a child abuse history
⁎
Tracie O. Afifia, , Jill McTavishb, Sarah Turnera, Harriet L. MacMillanc,
C. Nadine Wathend
a
Department of Community Health Sciences and Department of Psychiatry, University of Manitoba, Winnipeg, Canada
b
Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Canada
c
Department of Psychiatry and Behavioural Neurosciences and Department of Pediatrics, McMaster University, Hamilton, Canada
d
Faculty of Information & Media Studies, and Research Scholar, Centre for Research and Education on Violence Against Women and Children,
Western University, London, Canada

AR TI CLE I NF O AB S T R A CT

Keywords: Despite being a primary response to child abuse, it is currently unknown whether contact with
Child abuse child protection services (CPS) does more good than harm. The aim of the current study was to
Mandatory reporting examine whether contact with CPS is associated with improved mental health outcomes among
Child welfare adult respondents who reported experiencing child abuse, after adjusting for sociodemographic
Child protective organizations
factors and abuse severity. The data were drawn from the 2012 Canadian Community Health
Mental health
Survey-Mental Health (CCHS-2012), which used a multistage stratified cluster design (house-
hold-level response rate = 79.8%). Included in this study were individuals aged 18 years and
older living in the 10 Canadian provinces (N = 23,395). Child abuse included physical abuse,
sexual abuse, and exposure to intimate partner violence (IPV). Mental health outcomes included
lifetime mental disorders, lifetime and past year suicidal ideation, plans, and attempts, and
current psychological well-being and functioning and distress. All models were adjusted for so-
ciodemographic factors and severity of child abuse. For the majority of outcomes, there were no
statistically significant differences between adults with a child abuse history who had CPS con-
tact compared to those without CPS contact. However, those with CPS contact were more likely
to report lifetime suicide attempts. These findings suggest that CPS contact is not associated with
improved mental health outcomes. Implications are discussed.

1. Introduction

Child maltreatment is a significant global public health problem, with many physical, emotional, and relationship consequences
across the lifespan (McCrory, De Brito, & Viding, 2012; Miller, Chen, & Parker, 2011; Naughton et al., 2013; Norman et al., 2012;
Veenema, Thornton, & Corley, 2015). Mandatory reporting and provision of subsequent child protection services (CPS) forms the
basis for many countries’ national responses to child maltreatment (Dubowitz, 2014), yet the effectiveness of such processes remains
unclear (Gilbert et al., 2009; McTavish et al., 2017; World Health Organization & International Society for Prevention of Child Abuse
& Neglect, 2006). With origins in the 1960s (American Humane Association, 1977; Mathews et al., 2015), mandatory reporting laws
were enacted in the United States (U.S.), and subsequently in other countries, in an effort to curb professionals’ tendencies to “turn a

⁎
Correspondence to: S113-750 Bannatyne Avenue, Winnipeg, Manitoba, R3E 0W5, Canada.
E-mail addresses: tracie.afifi@umanitoba.ca (T.O. Afifi), mctavisj@mcmaster.ca (J. McTavish), Sarah.Turner@umanitoba.ca (S. Turner),
macmilnh@mcmaster.ca (H.L. MacMillan), nwathen@uwo.ca (C.N. Wathen).

https://doi.org/10.1016/j.chiabu.2018.01.019
Received 2 August 2017; Received in revised form 12 January 2018; Accepted 19 January 2018
0145-2134/ © 2018 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
T.O. Afifi et al. Child Abuse & Neglect 79 (2018) 22–30

blind eye” to children presenting with clinical indicators of maltreatment. Proponents of mandatory reporting suggest that reporting
laws both increase identification of children exposed to maltreatment (Lamond, 1989, Besharov, 1990; Mathews, Lee, & Norman,
2016) and increase reporting rates in reluctant reporter groups (Shamley, Kingston, & Smith, 1984; Webberley, 1985). Indeed,
research assessing mandatory reporting tends to focus on rates of reports or rates of maltreatment substantiation (Ho, Gross, &
Bettencourt, 2017; Krase & DeLong-Hamilton, 2015; Palusci & Covington, 2014; Steen & Duran, 2014), even though such approaches
do not address the question of whether mandatory reporting actually improves outcomes for children. Authors offering critiques of
mandatory reporting, alternatively, suggest that simply identifying children exposed to maltreatment is not sufficient to improve the
lives of children (Melton, 2005; Worley & Melton, 2013).
There is a paucity of research available about the effects of mandatory reporting to help practitioners, researchers, and policy
makers understand the benefits and harms of reporting. To date, no studies that prospectively evaluated the impact of mandatory
reporting on child well-being outcomes have been conducted (McTavish et al., 2017). A meta-synthesis of qualitative research across
nine high-income and five middle-income countries identified many accounts of harm to children, families, and reporters resulting
from reporting and especially from associated CPS responses (or lack of responses) (McTavish et al., 2017). Although CPS responses
were designed to improve the lives of vulnerable children (and ultimately their future well-being), the studies included in the meta-
synthesis consistently raised concerns among reporters that indicate that the potential (and unproven) benefits of mandatory re-
porting and CPS contact must be balanced against their potential harms. However, designing contemporaneous studies that can
directly compare CPS and no CPS contact is legally and ethically extremely difficult. Given these challenges, use of retrospective data
to examine the impacts of CPS contact is warranted; this approach is taken in the present analysis to examine current mental health
status among adult respondents who report experiencing child abuse.
It should be noted that “contact” with CPS cannot be directly linked to mandatory reporting legislation as, aside from mandated
professionals, non-professionals (including friends, family members, or neighbours) may file reports (Tonmyr, Li, Williams, Scott, &
Jack, 2010). For instance, according to 2015 U.S. national reporting data (U.S. Department of Health & Human Services,
Administration for Children & Families, Administration on Children, Youth & Families, Children’s Bureau, 2017), the highest per-
centages of referrals to CPS was from education personnel (18%), legal and law enforcement personnel (18%), and social services
personnel (10%); however, non-professionals, such as relatives (6.8%), parents (6.8%), and friends and neighbors (4.2%), make up
about one-fifth of reports. Furthermore, having contact with CPS is a complicated process involving many steps that are removed
from the reporting process. First, professionals (or non-professionals) must contact CPS to report suspected maltreatment, but re-
search suggests that many mandated professionals are hesitant to report for a variety of reasons (e.g., lack of training, previous
negative experiences with CPS, fear of negative consequences for themselves, concern about negative repercussions for their re-
lationships with patients) (Flaherty, Jones, Sege, & Child Abuse Recognition Experience Study Research Group, 2004; Piltz &
Wachtel, 2009; Vulliamy & Sullivan, 2000). Some children experiencing maltreatment may never be reported (Flaherty, Sege, Griffith
et al., 2008) and thus never come into contact with CPS, while other marginalized groups, such as Indigenous peoples (Flaherty et al.,
2008), and Black or Latino populations (Fallon et al., 2013; Lavergne, Dufour, Trocmé, & Larrivée, 2008; Sinha, Trocmé, Fallon, &
MacLaurin, 2013), are subject to over-reporting and/or receive more intrusive service responses from CPS. Second, reports (by
professionals or non-professionals) are typically “screened” by CPS intake workers. Reports that are “screened in” are identified for an
investigation or, where available, a differential response, which allows CPS professionals to respond differently depending on the
type and severity of maltreatment (Fluke, Merkel-Holguin, & Schene, 2013). When reports are “screened out”, children and families
may never be aware of the report or have contact with CPS; however, in these cases, the intake worker may refer the reporter to other
agencies, such as the police (Cross, Goulet, Helton, Lux, & Fuller, 2015). Third, reports that are referred for investigation may be
“substantiated”, “unsubstantiated”, or “indicated”/“inconclusive” and in many cases, only children experiencing substantiated re-
ports will receive services, even though health outcomes of children and recurrence rates do not vary significantly between sub-
stantiated and unsubstantiated groups (Drake et al., 2011; Hussey et al., 2005; Kohl, Jonson-Reid, & Drake, 2009).
As Fluke and Casillas (2015) have argued, “once the screening decision is made, children and families must respond to an array of
possible interventions with both positive and negative consequences that often have little to do with the originator of the report” (p.
444–445). In general, the evidence regarding the effects of CPS contact on children is absent or mixed. Vinnerljung, Sundell, Löfholm,
and Humlesjö, 2006 investigated how use of services provided by CPS influenced outcomes in a representative sample of adults in
Sweden. They compared a group referred to CPS in childhood who did not receive services with another referred group who received
services. In four of the five outcomes assessed, including teenage parenthood, hospitalizations for psychiatric diagnoses, self-support
problems, and criminal offences, the group that received services had higher rates of negative outcomes than the group that did not
receive services (Vinnerljung et al., 2006).
A recent systematic review summarized cohort studies that evaluated the impact of service use in a subsample of children exposed
to maltreatment (White, Hindley, & Jones, 2015). Other than one study that found recurrence rates of abuse were not impacted by
service use, the majority of included studies found that recurrence rates were increased with the provision of services, especially
foster care (White et al., 2015). Finally, studies evaluating differential response processes have mixed results (Drake et al., 2011;
Ellett, 2013; Fluke et al., 2013; Hughes, Rycus, Saunders-Adams, Hughes, & Hughes, 2013). There is, therefore, an urgent need to
examine, in an ethical way, how CPS contact impacts children in the short, and longer, terms.
The present study used retrospective data from the 2012 Canadian Community Health Survey-Mental Health (CCHS-MH, 2012) to
examine whether adults who report exposure to child abuse with CPS contact compared to those with no CPS contact, differed, when
controlling for abuse severity and demographic factors, in their current mental health status.

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2. Methods

2.1. Data and sample

The data were drawn from Statistics Canada’s 2012 Canadian Community Health Survey-Mental Health (CCHS-2012), which used
a multistage stratified cluster design, providing a cross-sectional representative sample of respondents aged 15 years and older living
in the 10 provinces (N = 25,113). Not included in the CCHS were: a) individuals who reside in the three territories, b) those living in
First Nations, Inuit, or Métis communities, c) full-time members of the Canadian Forces, and d) institutionalized populations (col-
lectively less than 3% of the Canadian population) (Statistics Canada, 2013a). Members of Indigenous communities were included in
the CCHS if they lived in cities or rural communities within the sampling areas. A total of 87% of the interviews were conducted in
person by trained lay interviewers using computer-assisted interviewing (Statistics Canada, 2013a). The overall household-level
response rate was 79.8% with a household and person response rate of 68.9% (Statistics Canada, 2013a). Due to the sensitive nature
of the child abuse questions, they were only administered to respondents aged 18 years and older (n = 23,395). All respondents were
informed about privacy, confidentiality, and the voluntary nature of the survey and provided their consent to participate (Statistics
Canada, 2011).

2.2. Measurements

2.2.1. Child abuse

Physical abuse and exposure to IPV were assessed using items from the Childhood Experiences of Violence Questionnaire (CEVQ).
The CEVQ is a valid and reliable assessment tool developed to examine victimization experiences (Walsh, MacMillan, Trocmé,
Jamieson, & Boyle, 2008). Sexual abuse was assessed using two items similar to those previously used in population-representative
surveys. In the CCHS-2012 the child abuse items referred to experiences that occurred prior to the age of 16 years with a reported
frequency of never, 1 or 2 times, 3 to 5 times, 6 to 10 times, and more than 10 times. The CEVQ guidelines define physical abuse as
present if one or more of three variables met the following minimum cut-offs, being: 1) slapped on the face, head or ears or hit or
spanked with something hard 3 times or more; 2) pushed, grabbed, shoved, or having something thrown at the respondent to hurt
them 3 times or more; and 3) kicked, bit, punched, choked, burned, or physically attacked 1 time or more. Exposure to IPV was
defined as having seen or heard parents, step-parents or guardians hitting each other or another adult in the home 3 times or more.
Sexual abuse was categorized as experiencing either of the following 1 time or more: 1) attempts to force or being forced into
unwanted sexual activity by being threatened, held down, or hurt in some way and/or 2) sexually touched, meaning unwanted
touching or grabbing, kissing, or fondling against the respondent’s will. An “any child abuse” variable was computed if the re-
spondent experience physical abuse, sexual abuse, or exposure to IPV (yes or no).
To account for severity of child abuse, several child abuse severity covariates were adjusted for in the models. First, the number of
child abuse types experienced (i.e., 0, 1, 2 or more) were included. Second, we used ordinal variables to measure the frequency of
child abuse with the categories of never, 1 or 2 times, 3–5 times, and 6 or more times. This included individual variables for exposure
to IPV; being slapped on the face, head, or ears, or hit or spanked with something hard; being pushed, grabbed or shoved, or having
something thrown at the respondent to hurt them; being kicked, bit, punched, choked, burned, or physically attacked; being forced
into unwanted sexual activity by being threatened, held down, or hurt in some way; and being sexually touched meaning unwanted
touching or grabbing, kissing, or fondling against the respondent’s will.

2.2.2. CPS contact

Contact with CPS was assessed by asking the respondents whether, before the age of 16, they had ever seen or talked to anyone
from a child protection organization about difficulties at home (yes or no).

2.2.3. Sociodemographic covariates

The sociodemographic variables included: age (continuous), sex (male versus female), highest level of education (less than high
school, high school, some post-secondary, trade/ college/ university certificate/ diploma, university degree), household income (less
than $30,000, $30,000 to $49,999, $50,000 to $79,999, $80,000 or more), and marital status (separated/ widowed/ divorced, never
married, married/ common-law).

2.2.4. Mental disorders

Lifetime diagnoses of several disorders were made using the World Health Organization version of the Composite International
Diagnostic Interview (WHO-CIDI) and based on Diagnostic and Statistical Manual of Mental Disorder (DSM-IV) criteria (American
Psychiatric Association, 2000; Statistics Canada, 2013b). The specific mental disorders included depression, bipolar disorder, gen-
eralized anxiety disorder, alcohol abuse/dependence, and drug abuse/dependence (including nonmedical sedatives or tranquilizers,
nonmedical analgesics, nonmedical stimulants, cannabis, cocaine, club drugs such as ecstasy or ketamine, hallucinogens, heroin or
opium, inhalant or solvents, and other drugs). Respondents meeting criteria for one or more of these disorders were classified as
having any mental disorder. Additional mental conditions were assessed using self-reports by asking the respondent if they have a
long-term health condition diagnosed by a health professional that had lasted or was expected to last 6 months or more (including
obsessive-compulsive disorder, post-traumatic stress disorder (PTSD), panic disorder, phobia, a learning disability, attention deficit
disorder, and an eating disorder). Respondents self-reporting one or more of these mental conditions were classified as having any

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self-reported mental disorder.

2.2.5. Suicidal ideation, plans, and attempts

Lifetime suicidal ideation was assessed with a question that asked if the respondent ever seriously thought about committing
suicide or taking his/her own life (yes or no). Lifetime suicide plans were assessed with a question that asked if the respondent made a
plan for committing suicide (yes or no). Lifetime suicide attempts were assessed using a question asking if the respondent had ever
attempted suicide or tried to take one’s own life (yes or no). Past-year suicidal ideation, plans, and attempts were also assessed by
asking respondents if the above occurred in the past year.

2.2.6. Positive functioning and emotional well-being

The 14-item Mental Health Continuum – Short Form (MHC-SF) was used to assess psychological, social, and emotional func-
tioning and well-being (Keyes, 2002; Keyes et al., 2008; Lamers, Westerhof, Bohlmeijer, ten Klooster, & Keyes, 2011; Westerhof &
Keyes, 2010). Based on the algorithms developed for this tool, participants were categorized into one of three mental health status
categories: flourishing mental health (high positive functioning and high emotional well-being), moderate mental health (high po-
sitive functioning and low emotional well-being or low positive functioning and high emotional well-being), and languishing mental
health (low positive functioning and low emotional well-being).

2.2.7. Distress
Distress was measured using the 10-item Kessler Distress Scale developed to measure non-specific psychological distress (Kessler
et al., 2002). Each item was measured on a scale from 1 to 5 ranging from all of the time to none of the time. Responses were then
reverse coded from 4 to 0 and summed to create a continuous scale ranging from 0 to 40. High scores indicate more distress.

2.3. Statistical analysis

Statistical weights were applied in all analyses to ensure that the estimates reflected the general Canadian population.
Bootstrapping was performed as a variance estimation technique to account for the complex survey design. First, descriptive statistics
were used to compute the prevalence of sociodemographic variables, number of types of abuse experienced and frequency of abuse
types stratified by those who experienced child abuse without CPS contact and those who experienced child abuse with CPS contact.
Logistic regression analyses were used to measure the strength of these associations. Second, prevalence estimates were computed for
the mental health outcome variables stratified by those who experienced child abuse without CPS contact and by those who ex-
perienced child abuse with CPS contact. Logistic regression models for dichotomous outcome variables and linear regression for
continuous outcome variables were computed to understand the relationship between CPS contact and mental health outcomes
among adults reporting experiences of child abuse. Models were adjusted for sex, age, marital status, past year household income,
education, number of types of child abuse experienced, and frequency of all child abuse items.

3. Results

Sociodemographic characteristics of those who experienced any child abuse with and without CPS contact are presented in
Table 1. Sociodemographic characteristics that increase the likelihood of CPS contact are being female compared to male, being
separated, widowed or divorced or being never married compared to married, experiencing more than one type of child abuse, and
increased frequency of experiencing each child abuse type. Notably, a dose-response trend is suggested with increasing frequency of
experience of each child abuse type corresponding with higher odds of contact with CPS. Sociodemographic characteristics that are
associated with decreased odds of CPS contact were older age and higher education attainment and household income. The pre-
valence and adjusted odds ratios of all mental health outcomes by adults reporting a child abuse history with and without CPS contact
are presented in Table 2. After adjusting for sociodemographic factors and the severity of child abuse, the findings indicated that CPS
contact was not associated with a statistically significant improvement in outcomes for any mental disorder, any self-reported mental
disorder, lifetime or past year suicidal ideation, lifetime or past year suicide plans, past year suicide attempts, positive functioning
and emotional well-being or current distress. However, those with CPS contact compared to those without CPS contact were more
likely to report lifetime suicide attempts (AOR = 1.52; 95% CI = 1.0, 2.3).

4. Discussion

These study findings suggest that among adults with a childhood history of abuse, CPS contact is not associated with improvement
in mental health outcomes after adjusting for sociodemographic factors and severity of abuse. Furthermore, in some cases, adults with
CPS contact as a child had worse mental health outcomes (i.e., lifetime suicide attempts) compared to those without such contact.
Several conclusions have been offered by researchers regarding the contradictory finding that increased CPS contact are associated
with poorer health outcomes. For example, some authors have suggested that service use is a proxy for severity of maltreatment
exposures (i.e., that children who receive services are experiencing greater maltreatment severity and chronicity, and as such have
poorer outcomes) (White et al., 2015). However, in this study, efforts were made to control for maltreatment severity. While we
recognize that using frequency of abusive acts, regardless of type, as a proxy for severity, lacks nuance, we were limited by the
available data and reporting categories used by Statistics Canada in the CCHS. The approach is, however, conservative, and we apply

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Table 1
Sociodemographic characteristics of those who experienced any child abuse with and without CPS contact.

Any Child Abuse and No CPS Any Child Abuse and CPS OR (95% CI)
Contact % (95% CI) Contact % (95% CI)

Sex
Male 95.2 (94.2, 96.1) 4.8 (3.9, 5.8) 1.00
Female 89.4 (87.3, 91.3) 10.6 (8.7, 12.7) 2.36 (1.7, 3.2)***
Age
Mean age 48.3 (47.8, 48.8) 39.3 (37.8, 40.8) 0.96 (0.95,
0.97)***
Marital Status
Married/common law 94.3 (93.2, 95.2) 5.7 (4.8, 6.8) 1.00
Separated/ Widowed Divorced 89.9 (83.3, 94.1) 10.1 (5.9, 16.7) 1.85 (0.9, 3.7)
Never Married 88.4 (86.3, 90.2) 11.6 (9.8, 13.7) 2.18 (1.7, 2.8)***
Education
Less than high school 89.1 (86.0, 91.5) 10.9 (8.5, 14.0) 1.00
High school 91.7 (89.2, 93.7) 8.3 (6.3, 10.8) 0.73 (0.5, 1.1)
Some post-secondary 94.0 (91.2, 95.9) 6.0 (4.1, 8.8) 0.52 (0.3, 0.9)*
Trade/ college/ university certificate 92.6 (90.8, 94.1) 7.4 (5.9, 9.2) 0.65 (0.4, 0.95)*
University degree 94.0 (90.2, 96.3) 6.0 (3.7, 9.8) 0.52 (0.3, 0.97)*
Income
Less than $30,000 87.7 (85.2, 89.9) 12.3 (10.1, 14.8) 1.00
$30,000 to $49,999 93.5 (90.5, 95.5) 6.5 (4.5, 9.5) 0.50 (0.3, 0.8)**
$50,000 to $79,999 92.5 (88.6, 95.1) 7.5 (4.9, 11.4) 0.58 (0.3, 0.98)*
$80,000 or more 93.9 (92.3, 95.2) 6.1 (4.8, 7.7) 0.47 (0.3, 0.7)***
Number of Types of Abuse
One 95.8 (94.8, 96.6) 4.2 (3.4, 5.2) 1.00
Two or more 84.9 (81.8, 87.6) 15.1 (12.4, 18.2) 4.02 (2.9, 5.5)***
Severity of Abuse
Exposure to Intimate Partner Violence
Never 95.8 (94.7, 96.6) 4.2 (3.4, 5.3) 1.00
1 or 2 times 93.7 (91.5, 95.3) 6.3 (4.7, 8.5) 1.52 (1.0, 2.3)*
3 to 5 times 89.7 (86.4, 92.3) 10.3 (7.7, 13.6) 2.60 (1.7, 3.9)***
6 time or more 80.3 (75.0, 84.7) 19.7 (15.3, 25.0) 5.55 (3.8, 8.2)***
Slapped on the face, head or ears or hit or spanked with
something hard
Never 95.8 (94.6, 96.8) 4.2 (3.2, 5.4) 1.00
1 or 2 times 94.1 (91.8, 95.7) 5.9 (4.3, 8.2) 1.45 (0.9, 2.3)
3 to 5 times 94.1 (91.6, 95.9) 5.9 (4.1, 8.4) 1.44 (0.9, 2.3)
6 times or more 89.9 (87.8, 91.7) 10.1 (8.3, 12.2) 2.58 (1.8, 3.7)***
Pushed, grabbed, shoved or something thrown at
Never 96.6 (95.7, 97.4) 3.4 (2.6, 4.3) 1.00
1 or 2 times 93.7 (92.0, 95.0) 6.3 (5.0, 8.0) 1.95 (1.3, 2.8)***
3 to 5 times 89.5 (84.7, 93.0) 10.5 (7.0, 15.3) 3.37 (2.0, 5.6)***
6 times or more 83.3 (79.1, 86.8) 16.7 (13.2, 20.9) 5.78 (4.0, 8.4)***
Kicked, bit, punched, chocked, burned or physically attacked
Never 95.5 (94.6, 96.3) 4.5 (3.7, 5.4) 1.00
1 or 2 times 91.8 (89.0, 94.0) 8.2 (6.0, 11.0) 1.89 (1.3, 2.8)**
3 to 5 times 87.5 (83.3, 90.7) 12.5 (9.3, 16.7) 3.05 (2.0, 4.6)***
6 times or more 76.0 (68.7, 82.0) 24.0 (18.0, 31.3) 6.72 (4.4, 10.2)***
Forced into unwanted sexual activity by being threatened, held
down, or hurt in some way
Never 93.9 (92.6, 95.0) 6.1 (5.0, 7.4) 1.00
1 or 2 times 91.5 (88.9, 93.6) 8.5 (6.4, 11.1) 1.42 (0.99, 2.1)
3 to 5 times 82.6 (71.0, 90.2) 17.4 (9.8, 29.0) 3.23 (1.6, 6.7)**
6 times or more 79.5 (72.4, 85.1) 20.5 (14.9, 27.6) 3.96 (2.5, 6.2)***
Unwanted touching or grabbing, kissing, or fondling
Never 93.9 (92.4, 95.1) 6.1 (4.9, 7.6) 1.00
1 or 2 times 92.4 (90.2, 94.2) 7.6 (5.8, 9.8) 1.26 (0.9, 1.8)
3 to 5 times 85.7 (77.4, 91.3) 14.3 (8.7, 22.6) 2.57 (1.4, 4.8)**
6 times or more 83.2 (78.0, 87.4) 16.8 (12.6, 22.0) 3.11 (2.1, 4.7)***

* p < .05.
** p < .01.
*** p < .001.

the suggestion of Litrownik et al. (2005) to preserve ratings within, rather than across, abuse types. Future studies should examine
more carefully factors contributing to abuse severity, including differential impact of specific acts (for example, the relative fre-
quency/severity of one type of physical abuse, e.g., “slap”, versus a type of sexual abuse, e.g., “rape”). These are discussions that must
continue, as the field grapples with how best to assess severity across abusive acts, but also as uniquely experienced by individuals.

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Table 2
Relationship between Contact with Child Protection Services (CPS) and Mental Health Outcomes Among Those Who Experienced Any Child Abuse.

Any Child Abuse and No CPS Contact Any Child Abuse and CPS Contact % AOR (95% CI)
% (95% CI) (95% CI)

Any mental disorder 50.6 (48.6, 52.7) 62.2 (53.5, 70.2) 1.11 (0.8, 1.6)
Any self-reported mental disorder 12.7 (11.5, 14.0) 27.3 (22.1, 33.2) 1.20 (0.9, 1.7)
Lifetime suicidal ideation 21.1 (19.7, 22.5) 39.5 (32.8, 46.7) 1.19 (0.9, 1.6)
Lifetime suicide plans __Not reported __Not reported 1.44 (0.99, 2.1)
Lifetime suicide attempts 5.8 (5.0, 6.7) 20.3 (15.2, 26.4) 1.52 (1.0, 2.3)*
Past-year suicide ideation 5.4 (4.6, 6.4) 13.5 (9.6, 18.6) 1.18 (0.8, 1.8)
Past-year suicide plans 2.1 (1.5, 2.9) 5.5 (3.6, 8.3) 1.16 (0.6, 2.4)
Past-year suicide attempts 1.0 (0.6, 1.8) 3.4 (1.3, 8.7) 0.86 (0.3, 2.3)
Languishing & moderate mental health vs flourishing 69.7 (67.9, 71.5) 65.7 (58.5, 72.1) 1.21 (0.9, 1.7)
mental health

Mean (95% CI) Mean (95% CI) Linear Regression

Kessler K10 distress 6.5 (6.3, 6.8) 9.7 (8.9, 10.5) 0.74 (−0.04, 1.5)

AOR – adjusted odds ratio, adjusted for: sex, age, marital status, income, education, number of types of abuse (1 or 2 or more), and frequency of exposure to IPV, being
slapped on face, head, ears, or hit or spanked with something hard, being pushed, grabbed or shoved, or having something thrown at the respondent to hurt them,
being kicked, bit, punched, choked, burned, or physically attacked, being forced into unwanted sexual activity by being threatened, held down, or hurt in some way,
being sexually touched meaning unwanted touching or grabbing, kissing, or fondling against the respondent’s will (never, 1 or 2 times, 3–5 times, or 6 times or more).
Due to reporting restrictions and rules set by Statistics Canada Research Data Centre, the prevalence for lifetime suicide plans was not released.
* p = .05.

Other authors have commented on additional factors that may impact the relationship between service use and health outcomes,
such as a) the imprecision of substantiation processes (that some children and families who need services are not receiving them,
while others not in need of services are receiving them) (Vinnerljung et al., 2006), b) poor training and support allotted to some child
protection workers (McFadden, Campbell, & Taylor, 2014; White et al., 2015), c) the lack of evidence-based services available to
children exposed to maltreatment (Fraser et al., 2013; Lipien & Forthofer, 2004; MacMillan et al., 2009; Vinnerljung et al., 2006), and
d) a lack of engagement by families with services provided (Fluke, Shusterman, Hollinshead, & Yuan, 2008). Many of these con-
clusions speak to the greater need for training in the response to child maltreatment and for increased research about evidence-based
responses for children exposed to abuse and/or neglect.
The findings of worse outcomes with regard to lifetime suicide attempts are particularly concerning, but are consistent with the
study by Vinnerljung et al. (2006) who found that among adults in Sweden with histories of CPS contact, increased service use was
associated with poorer outcomes for four of the five outcomes they assessed, including hospitalizations for psychiatric diagnoses and
self-support problems. A recent systematic review about the relationship between child maltreatment and suicidality suggested that
childhood physical abuse and sexual abuse – two of the three maltreatment exposures assessed in this study – were linked with
suicide ideation and attempts in adolescents (Miller, Esposito-Smythers, Weismoore, & Renshaw, 2013). The authors of this review
found that the risk was especially great for boys with certain risk factors, such as greater number of abuse experiences, specifically
invasive/physically painful experiences, lack of support when disclosing abuse experiences, and a closer relationship with the per-
petrator (Miller et al., 2013). We know of no evidence-based interventions for children exposed to maltreatment that have assessed
impact on suicide ideation/behaviour; this is an urgent research and practice gap.
As noted above, services offered to children following contact with CPS are varied (Fluke & Casillas, 2015) and children will not
necessarily receive or even have access to evidence-based interventions. Lack of engagement by caregivers has been cited as another
potential factor that may lessen the CPS’ benefits (Fluke et al., 2008), further reinforcing the potential harm of inappropriate or
ineffective CPS responses. While there are very few evidence-based approaches specifically for children and their families that show
effectiveness in improving mental health outcomes following exposure to maltreatment, the following are worth noting. There is
some evidence for the use of cognitive behavioural therapy (CBT) with a trauma focus for children who have been exposed to sexual
abuse with symptoms of depression, anxiety, or PTSD (de Arellano et al., 2014), but it is first important to determine whether
children have mental health symptoms that could benefit from such treatment. Parent-child interaction therapy (PCIT) has been
shown effective for children exposed to physical abuse or neglect with externalizing problems (or those whose caregivers have been
found to have concerning stressors/behaviours, such as harsh discipline practices) (Cooley, Veldorale-Griffin, Petren, & Mullis, 2014),
but again assessment is required in determining who should be referred for such programs. There is a major gap for children who
have been maltreated to access assessments to determine their mental health needs. Maltreatment is an exposure, not a disorder, and
as outlined above, children may experience a wide range of symptoms and problems following exposure to child abuse and/or neglect
(MacMillan et al., 2009). CPS professionals may have some training in mental health, but are not typically trained to assess children
for mental health problems.
Lack of response from CPS following a report and lack of faith in the ability of CPS to respond effectively to children exposed to
maltreatment are two related reasons why mandated reporters hesitate to report children (Flaherty et al., 2004; Kenny, 2001; Piltz &
Wachtel, 2009; Vulliamy & Sullivan, 2000). Also, mental health professionals may not become involved with children with mal-
treatment experiences while child protection investigations are occurring, leaving children and families with limited options. In-
creased training, collaboration, consultation, and communication have all been cited as much needed remedies for poor responses to

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children involved with CPS following exposure to maltreatment (Flaherty, Sege, & Hurley, 2008; Horwath & Morrison, 2007; Kenny,
2015). Continued research about the effectiveness of reporting and associated responses is also needed (McTavish et al., 2017).
This study has some important limitations. First, the data are cross-sectional and retrospective, meaning we cannot infer causation
or determine underlying mechanisms in the relationship between CPS contact and mental health. Retrospective inquiry of re-
spondents about CPS contacts is an important limitation and should be carefully considered when interpreting the study (Afifi et al.,
2015). Some respondents may not recall contact with CPS. Others may not have been aware that CPS contact occurred. It is possible
that “contact with CPS” represents a group of individuals who remembered contact only because they were contacted by CPS more
times (or in later childhood) and that “no contact with CPS” represents a group who both a) had contact with CPS (and did not
remember) and b) did not have contact with CPS. Future prospective research is needed to further clarify the meaning of “contact
with CPS” and how contact impacts children and families. Second, some may question the accurate recall of traumatic memories in
this type of retrospective survey. However, evidence does indicate that valid and reliable retrospective recall of adverse childhood
events is possible in surveys (Hardt & Rutter, 2004; Hardt, Sidor, Bracko, & Egle, 2006; Hardt, Vellaisamy, & Schoon, 2010). Third,
although three of the major types of child abuse were assessed, measures of neglect and emotional abuse were not included in the
survey, and, as discussed above, the issue of how to assess and control for abuse severity is problematic. The inclusion of these child
maltreatment types is necessary in future Canadian surveys. Fourth, although several mental conditions were assessed in the survey,
this list of disorders did not include all conditions (e.g., personality disorders) and several disorders were assessed using self-reported
diagnoses. It should be noted, however, that other studies have used self-report data to determine prevalence of mental conditions
(Afifi et al., 2014; Sareen et al., 2007). Although there are limitations with this method, it is considered a reliable approach in
community samples (Keski-Rahkonen et al., 2006). Importantly, the self-reported mental conditions included were based on self-
reported health professional diagnoses, which may reduce bias. Fifth, age of onset for mental health disorders was not asked about in
the survey. Therefore, the temporal relationship of occurrence of child abuse in relation to mental disorders could not be assessed.
Sixth, only contact with CPS was assessed in the survey; no additional information regarding this contact was collected. It was not
known if resources or treatment was provided due to the CPS contact. Finally, the data did not include Northern Indigenous com-
munities in the three Canadian territories, or those on Reserve. This is a limitation since Indigenous people have been found to be
over-represented in child welfare (Barker, Alfred, & Kerr, 2014; Sinha et al., 2013).
These study findings highlight the importance of examining the impact of CPS contact by developing systematic approaches to
collecting information about children’s contact with CPS that can be used in national surveys. In addition, it is clear that more
knowledge is needed about evidence-based strategies for responding to children exposed to maltreatment and their families, with a
strong emphasis on children having access to assessments to determine their mental health needs. Fortunately, several countries – and
the World Health Organization – are currently engaged in national processes to improve knowledge and guidance related to responses
to child maltreatment (National Institute for Health & Care Excellence, 2017; World Health Organization, 2017). Cross-sectoral
involvement of CPS and health and social service providers to ensure comprehensive mental health care for children and families
involved with the child welfare system remains a priority.

Funding

Preparation of this article was supported by a Canadian Institutes of Health Research (CIHR)New Investigator Award (Afifi) and a
CIHR Foundation Scheme Award (Afifi). H. MacMillan is supported by the Chedoke Health Chair in Child Psychiatry.

Financial disclosure

None to declare by any author.

Conflicts of interest

None to declare by any author.

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