L E TT ER T O T HE E DI T OR

Documenting Opportunity for records information to prioritize support services for young
Systematic Identification and Mitigation families,6 though such innovations have yet to be system-
of Risk for Child Maltreatment atically incorporated into obstetrical or newborn medical
services of US health systems.
Clinical trial registration information: Study to Understand
Risk and Resilience Opportunity for Newborns After Delivery
(SURROuND); https://clinicaltrials.gov/; NCT04438161. METHOD
Patients in an urban obstetrical service (Washington
To the Editor:
University Department of Obstetrics and Gynecology,
his is a communication of preliminary data as a BJC Health System, St. Louis, Missouri) were recruited

T matter of priority in relation to Clinical Trials

protocol ID 2018110118; NCT 04438161. This
protocol represents, to our knowledge, a first-ever attempt
from prenatal clinics or during hospital stays following the
birth of their infants to participate in a prospective longi-
tudinal study of community supports, which included ef-
to convert an epidemiologic discovery on risk for child forts to help navigate parents to resources for interventions
maltreatment (CM) into a readily deployable modification with known efficacy for the prevention of CM. Parents
of obstetrical practice designed to offset risk for CM and its were compensated for their time spent in research study
psychiatric sequelae. Before1 and during the coronavirus enrollment and data collection but not for participation in
disease 2019 (COVID-19 pandemic),2,3 CM has incurred a interventions. The following 9 birth records risks were
burden of epidemic proportions to US children, with included in the analyses:1) abnormal condition of the
confirmed incidents occurring on the order of 12% of the newborn; 2) low birth weight; 3) absence of private in-
population. Wu et al.4 and Putnam-Hornstein and Needell5 surance; 4) inadequate prenatal care; 5) single parenthood;
previously established that profiles of risk ascertained 6) parenting multiple children; 7) maternal age <25 years;
exclusively from birth records identified specific groups of 8) maternal education less than high school; 9) prior
newborns at highly elevated risk for official-report CM. For abortion. In addition to birth records, which were available
example, infants with the joint characteristics of low birth for all newborns, mothers were screened for depression
weight, more than 2 siblings, and maternal characteristics of (Edinburgh Postnatal Depression Scale [EPDS]), smoking
being unmarried, on Medicaid, and smoking during preg- during pregnancy, and maternal childhood trauma
nancy (ascertained separately) were found to have a 7-fold (Childhood Trauma Questionnaire [CTQ]). Families
risk for maltreatment compared with the population consented to having their individual-level data cross-
average.4 Putnam-Hornstein and Needell showed that referenced with state administrative records to ascertain
newborns with 3 or more risk factors ascertained from birth whether official reports of CM from the State of Missouri
records (including any of the above, delayed prenatal care, Department of Social Services existed for any of the fam-
less than high school maternal education, and/or maternal ilies enrolled in the study as of July 30, 2021. Maltreat-
age less than 24 years) comprised 15% of an epidemiologic ment data could include child emotional, physical, or
birth cohort but accounted for more than half of all the sexual abuse and educational, medical, or general neglect.
children in the cohort who experienced substantiated Following the birth of the children, families participated in
official-report maltreatment by the age of 5 years. This quarterly surveys of utilization of preventive intervention
study explored whether prospective implementation of birth resources about which all families were educated at the
records screening in an urban obstetrical service recapitu- time of enrollment, including home visitation, maternal
lated the association with CM observed in an epidemiologic mental health care, and crisis services. Midway through the
context and whether families in higher echelons of risk study, in-person enrollment procedures were converted to
(ascertained in this manner through birth records) could be virtual contacts owing to the COVID-19 pandemic.
prospectively engaged in supportive interventions of Written consent was obtained at the start of the project as
demonstrated effect in reducing the occurrence of CM. This approved by the Washington University School of Medi-
work follows on promising efforts elsewhere to use birth cine Institutional Review Board.

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LETTER TO THE EDITOR

RESULTS charge within the metropolitan St. Louis community; nurse

This interim communication is a report of the 196 home visitation is a prototypic example of a supportive
participants who were retained in longitudinal follow-up. An parenting intervention, widely (not universally) accepted by
additional 82 women expressed initial interest in partici- young families, that has accrued evidence for efficacy in
pating in the program, representing all strata of birth records reducing the occurrence of official-report CM.7 Among 135
risk, but left the hospital before they could complete consent participants who have been followed for at least 6 months to
for follow-up and were not included in this preliminary date (most in the COVID-19 pandemic era), 36% actively
analysis. The study sample represented a heterogeneous risk pursued this recommendation, and the subset who pursued
distribution for CM and demonstrates the ability to engage the intervention had a higher mean count of birth records
families at high risk in a program of preventive intervention. risk factors than the group who did not pursue the
Based on previous epidemiologic estimates of CM risk recommendation for this intervention (t133 ¼ 2.002,
indexed by birth records data,5 72% of the consecutively p < .047). Figure 1 depicts the respective distributions of
enrolled (unselected) newborns from this urban obstetrical families who did and did not pursue home visitation as a
population had levels of risk for CM that were significantly function of birth records risk count.
elevated in relation to the US population average of 12%; At the time of the match (July 30, 2021), 22 parents had
specifically, 27% of the newborns were at a risk level of 15% not yet given birth, and 4 were missing complete birth in-
(based on 3 birth records risks), 26% had an estimated risk of formation. Of the 170 participants remaining, 17% of the
25% (4 birth records risks), 14% were at 35%-40% risk (5 families were discovered to have had prior official reports of
birth records risks), and 5% were at 60% or higher risk for CM related to older siblings (before the date of birth of the
maltreatment (6 or more birth records risks). The in- index child), and, to date, 9 index newborns (5.3% of 170
tercorrelations between the number of birth records risk in- participants) have been involved in new reports of CM sub-
dicators, summary scores on the EPDS, and ratings of sequent to birth (average age of the entire group of infants at
maternal history of childhood trauma on the CTQ were low the time of cross-referencing with state administrative records
to moderate in magnitude, suggesting the possibility that was 13 months). Five of the 9 (55.5%) CM reports involving
these additional indices might enhance the identification of index newborns were in families with prior reports.
families at risk if jointly implemented with birth records
screening before newborns are discharged home from
the nursery (see Supplement 1 and Table S1, available online). DISCUSSION
As a matter of study protocol, all consented families To our knowledge, this is the first attempt to use birth
were educated about and encouraged to enroll in nurse or records information for the clinical purpose of estimating
paraprofessional home visitation programs available free of risk for (and ultimately deploying targeted intervention to

FIGURE 1 Distribution of Participant Home Visitation Pursuit Based on Birth Record Risk Variables Count

Note: Distribution of the sample (n ¼ 196, mean [SD] ¼ 3.24 [1.49]) in Project SURROuND based on birth record risk variables count. Home visitation is selectively depicted
as a preventive intervention for child maltreatment.

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 LETTER TO THE EDITOR

prevent) CM. The enrichment of this urban obstetrical high rates of retention of the subjects through the period of the
sample for documented cases of official-report CM in a pandemic. It is to our knowledge the first to implement birth
relatively narrow time window (more than double the US records screening for the purpose of predicting CM prospectively
rate for substantiated cases throughout the entirety of in a clinical setting. Limitations of this study are that the data are
childhood) was reflected in an upward shift of the distri- preliminary (the study is ongoing) and that rates of official re-
bution of risk indexed by birth records risk counts in this ports of CM (to be contrasted with the actual occurrence of CM)
sample. Moreover, we were able to show preliminarily that have been attenuated during the pandemic (especially during
families of newborns at substantially elevated risk for CM periods of lockdown), indicating that this method represents
can be specifically and successfully engaged in a program underestimation of the actual occurrence of CM, which (by
promoting evidence-informed community supports other methods) is believed to have increased or intensified.2,3
designed to prevent CM (even in families with prior expe- As a randomized controlled trial involving supplemental
riences with child protective services related to older sib- methods of engagement in intervention is in process, future
lings). These data corroborate findings from an independent communications regarding this work will describe whether
observation of substantial voluntary participation of young tailoring the engagement of young families in clinical and
families with prior official maltreatment reports in evidence- preventive intervention on the basis of specific profiles of
based preventive intervention provided within Early Head risk will improve uptake and reduce rates of CM as
Start programs in Missouri and Illinois.8 measured by state administrative data (official report). It is
The fact that a robust index of CM risk is universally our hope that these findings will inform a migration of
obtained in obstetrical practice and therefore available at the ownership of risk surveillance and prevention—in relation
time of birth for all children in the United States poses an to a US epidemic of child abuse and neglect9—from the
ethical imperative to make targeted clinical and/or evidence- child welfare system to the health system, as has been done
based preventive interventions available to offset higher historically for preventable medical conditions through
echelons of risk, minimally by ensuring access to nurse home newborn screening.
visitation, crisis support services, and the provision of
Mini Tandon, DO
necessary clinical care to parents with unmet mental health Melissa Jonson-Reid, PhD
needs. In this program, a substantial number of families John N. Constantino, MD
readily pursued recommendations for a preventive inter-
vention (home visitation) even during the pandemic. Accepted June 1, 2022.

Although a concern in the field of prevention is that effective Drs. Tandon and Constantino are with Washington University School of
Medicine, St. Louis, Missouri. Dr. Jonson-Reid is with Washington University in
intervention may be disproportionately adopted by lower- St. Louis, Missouri.
risk participants, we observed that the families who pur- This work was funded by the Eunice Kennedy Shriver National Institute of Child
sued preventive intervention included many who could Health and Human Development, as part of the Center for Innovation in Child
Maltreatment Policy, Research and Training (P50 HD096719; J.N. Constantino
benefit from it most and that on average the families who project P.I., M. Jonson-Reid center P.I.) Work was completed through the
Department of Psychiatry, Child Division at Washington University School of
pursued recommendations for home visitation were at higher Medicine in St. Louis, in conjunction with the Brown School of Social Work and
risk than families who deferred engagement in this inter- the obstetrical units and clinics of Barnes Jewish Hospital, St. Louis.
vention. Given low to moderate correlations between the Written consent was obtained as approved by the Washington University
School of Medicine Institutional Review Board, HRPO# 201811018.
birth record index and other readily measurable correlates of
A subset of this data was presented at the American Academy of Child and
early life adversity (EPDS, CTQ), supplemental screening Adolescent Psychiatry 68th Annual Meeting; October 25-30, 2021; Virtual. The
for maternal depression and maternal childhood trauma may only prior publication was in the form of a program abstract for this conference
(https://doi.org/10.1016/j.jaac.2021.07.706).
further enhance identification and targeted intervention to
Author Contributions
prevent CM; future analysis of information from larger Conceptualization: Tandon, Jonson-Reid, Constantino
datasets combining medical record information with state Data curation: Tandon, Jonson-Reid
Formal analysis: Tandon, Jonson-Reid
administrative data on CM (this is neither common nor Funding acquisition: Jonson-Reid, Constantino
generally authorized without individual informed consent) Investigation: Tandon, Constantino
Methodology: Tandon, Constantino
would allow exploration of whether specific combinations of Project administration: Tandon, Constantino
Resources: Tandon, Constantino
electronic health record variables, when integrated with in- Supervision: Tandon, Constantino
formation from birth records, would afford opportunity for Validation: Tandon, Jonson-Reid, Constantino
Visualization: Constantino Visualization: Constantino
higher-precision prediction. Writing e original draft: Tandon
The study had a number of strengths, including ascertain- Writing e review and editing: Jonson-Reid, Constantino

ment of a heterogeneous sample, enriched for risk for CM, and

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LETTER TO THE EDITOR

The authors would like to acknowledge the efforts of Yi Zhang, MS, of Dr. Constantino has reported receipt of royalties from Western Psychological
Washington University, for data management; Kyria Brown, MSW, MPH, of Services for the commercial distribution of the Social Responsiveness Scale,
Washington University, for her input on a previous draft of this manuscript; which was not used in this work.
Shannon Lenze, PhD, of Washington University, for input on study design; and
Claire Karlen, PhD, of Ranken Jordan, and Hannah Jeffries, MAC, of Covenant Correspondence to Mini Tandon, DO, Division of Child Psychiatry, Department
Theological Seminary, for recruitment and enrollment of the participants. of Psychiatry, Washington University School of Medicine, 660 S. Euclid Avenue,
Campus Box 8504, St. Louis, MO 63110; e-mail: [email protected]
Disclosure: Dr. Tandon has reported royalties from AuthorHouse for a chil-
dren’s book series on mental health. Dr. Jonson-Reid has reported receipt of 0890-8567/$36.00/ª2022 American Academy of Child and Adolescent
royalties from Oxford University Press for a book on child maltreatment and Psychiatry
Pearson Publishing for a textbook, neither of which was used in this work. https://doi.org/10.1016/j.jaac.2022.05.008

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