Hospitalizations among children involved in the child protection system: A long-term birth cohort study from infancy to adulthood using administrative data

A Meta-Analytic Review of the Impact of Child Maltreatment on Self-Esteem: 1981 to 2021

An increasing number of studies have examined the relationship between child maltreatment and self-esteem. In this study, we assess the magnitude of this association through a meta-analytic approach. Four English databases (PubMed, PsycINFO, PsycARTICLES, and Web of Science), three Chinese databases (China National Knowledge Infrastructure, Wanfang, and Weipu), and grey literature were systematically searched. A total of 254 independent studies, including 550 effect sizes, met the inclusion criteria for this meta-analysis. Child maltreatment was significantly and negatively associated with self-esteem (P C C ¯  = -0.24, p < .001); emotional abuse and neglect were associated with decreased self-esteem (P C C ¯  = -0.23, p < .01; P C C ¯  = -0.22, p < .01, respectively) at a moderate level; and physical abuse, sexual abuse, and physical neglect were negatively associated with self-esteem (P C C ¯  = -0.14, p < .01; P C C ¯  = -0.14, p < .01; P C C ¯  = -0.17, p < .001, respectively) at a small level. Furthermore, the meta-regression results suggested that the aggregated associations between child maltreatment and self-esteem were not inflated by publication bias, but they were moderated by age and culture. General and subtypes of child maltreatment are associated with decreased self-esteem. Evidence-based and culturally sensitive child maltreatment prevention and intervention programs should be developed and implemented as early as possible.

Child protection system involvement in children of incarcerated mothers: A linked data study

BACKGROUND

Women prisoners are a growing portion of the prison population. Health and social outcomes of their children have been studied and found to be poor, but little is known about child protection outcomes.

OBJECTIVES

Ascertain child protection system contact of children exposed to maternal incarceration.

PARTICIPANTS AND SETTING

All children born between 1985 and 2011 exposed to the incarceration of their mothers in a Western Australian correctional facility and a matched comparison group.

METHODS

A matched cohort study using linked administrative data on 2637 mothers entering prison between 1985 and 2015 and their 6680 children. We estimated hazard ratios (HRs) and incidence rate ratios (IRRs) of child protection service (CPS) contact post maternal incarceration (four concern levels), comparing rates for children exposed to maternal incarceration with a matched non-exposed group, adjusting for maternal and child factors.

FINDINGS

Exposure to maternal incarceration increased risk of CPS contact. Unadjusted HRs exposed vs unexposed children were 7.06 (95%CI = 6.49-7.69) for substantiated child maltreatment and 12.89 (95%CI = 11.42-14.55) for out-of-home care (OOHC). Unadjusted IRRs were 6.04 (95%CI = 5.57-6.55) for number of substantiations and 12.47 (95%CI = 10.65-14.59) for number of removals to OOHC. HRs and IRRs were only slightly attenuated in adjusted models.

CONCLUSIONS

Maternal incarceration is a warning flag for a child at high risk of serious child protection concerns. Family-friendly rehabilitative women's prisons, incorporating support for more nurturing mother-child relationships could provide a placed-based public health opportunity for disrupting distressing life trajectories and intergenerational pathways of disadvantage of these vulnerable children and their mothers. This population should be a priority for trauma-informed family support services.

Complex early childhood experiences: Characteristics of Northern Territory children across health, education and child protection data

Early identification of vulnerable children to protect them from harm and support them in achieving their long-term potential is a community priority. This is particularly important in the Northern Territory (NT) of Australia, where Aboriginal children are about 40% of all children, and for whom the trauma and disadvantage experienced by Aboriginal Australians has ongoing intergenerational impacts. Given that shared social determinants influence child outcomes across the domains of health, education and welfare, there is growing interest in collaborative interventions that simultaneously respond to outcomes in all domains. There is increasing recognition that many children receive services from multiple NT government agencies, however there is limited understanding of the pattern and scale of overlap of these services. In this paper, NT health, education, child protection and perinatal datasets have been linked for the first time. The records of 8,267 children born in the NT in 2006-2009 were analysed using a person-centred analytic approach. Unsupervised machine learning techniques were used to discover clusters of NT children who experience different patterns of risk. Modelling revealed four or five distinct clusters including a cluster of children who are predominantly ill and experience some neglect, a cluster who predominantly experience abuse and a cluster who predominantly experience neglect. These three, high risk clusters all have low school attendance and together comprise 10-15% of the population. There is a large group of thriving children, with low health needs, high school attendance and low CPS contact. Finally, an unexpected cluster is a modestly sized group of non-attendees, mostly Aboriginal children, who have low school attendance but are otherwise thriving. The high risk groups experience vulnerability in all three domains of health, education and child protection, supporting the need for a flexible, rather than strictly differentiated response. Interagency cooperation would be valuable to provide a suitably collective and coordinated response for the most vulnerable children.

Excess hospital costs incurred by individuals with child abuse and neglect history in South Australia: A birth-cohort study

Child abuse and neglect is a serious public health issue across the globe, with documented impacts on health, but the impact on hospital costs, at the population level, is unknown. We aimed to estimate the additional public hospital costs for emergency department visits and admitted patient hospitalizations, for persons with reported child protection concerns, from birth to 31 years and modelled to age 65. Using linked hospital data from 2003 to 2017 for a population birth-cohort of all individuals born in South Australia from 1986 to 2017, we estimated costs of public hospital care. Mean cost and cost differences (adjusted and unadjusted) in 2018 Australian dollars (AU$) were calculated for persons with child protection contact vs none, per person and at the population level. Persons with child protection contact had higher annualized mean hospital costs than those with no contact, with cost differentials increasing with age. Unadjusted differential cost per person was AU$338 (95% CI AU$204-AU$473) from birth to 12 years; increasing to AU$2242 (AU$2074-AU$2411) at ages 25 to 31 years, equating to an additional AU$124 (US$100) million for public hospital services from birth to 31 years, an 18% cost penalty (33% from 13 to 31 years). Modelled to age 65 years, excess costs were estimated at AU$415 (US$337, adjusted: AU$365 and US$296) million, a 27% cost impost. There is a considerable hospital cost penalty associated with persons with reported child protection concerns, especially from adolescence into adulthood, highlighting an opportunity for cost savings by preventive investment in effective early-in-life interventions.

Physical health of care-experienced young children in high-income countries: a scoping review protocol

INTRODUCTION

Care-experienced children have poorer health, developmental, and quality of life outcomes across the lifespan compared to children who are not in care. These inequities begin to manifest in the early years. The purpose of the proposed scoping review is to collate and synthesise studies of the physical health of young care-experienced children. The results of the review will help map the distribution of health outcomes, identify potential targets for intervention, and assess gaps in the literature relating to this group.

METHODS AND ANALYSIS

We will carry out a scoping review of the literature to identify studies of physical health outcomes in care-experienced children. Systematic literature searches will be carried out on the MEDLINE, CINAHL and Web of Science Core Collection databases for items indexed on or before 31 August 2022. Studies will be included where the participants are aged 3 months or greater and less than 6 years. Data elements extracted from included studies will include study objectives, health outcomes, participant demographics, care setting characteristics and bibliographic information. The results of the review will be synthesised and reported using a critical narrative approach. Comparisons between care and non-care populations will be reported if sufficient studies are identified.

ETHICS AND DISSEMINATION

Data will be extracted from publicly available sources, so no additional ethical approval is required. Results will be published in a peer-reviewed journal article. Furthermore, they will be shared in summary reports and presented to local authorities, care organisations and other relevant stakeholders that can influence healthcare policy and procedure relating to young children in care.

Child maltreatment and emergency department visits: a longitudinal birth cohort study from infancy to early adulthood

BACKGROUND

Child maltreatment (CM) is a serious global public health issue, with documented impacts on health.

OBJECTIVE

To examine the association between different levels of CM concern, and Emergency Department (ED) visits from infancy to early adulthood.

PARTICIPANTS AND SETTING

Individuals born in Adelaide, South Australia from January 1986 to June 2017 (N = 443,754).

METHODS

Using linked administrative data, we examined frequency and adjusted rate ratios for all-cause and cause specific ED visits among individuals with varying levels of CM concern.

RESULTS

Cumulative mean ED visits to age 14.5 years were higher for individuals with any CM concern, ranging from 10.2 to 14.8, compared with 6.4 in persons with no recorded CM concern. Adjusted rate ratios for ED visits varied from 1.26 (95% CI: 1.23-1.30) to 1.54 (1.48-1.60) in children (birth to 12 years), 1.98 (CI: 1.92-2.04) to 4.34 (CI: 4.09-4.60) in adolescence and 2.22 (CI: 2.14-3.48) to 3.48 (3.27-3.72) in young adults, increasing with severity of maltreatment concerns. ED visits coded as self-harm or poisoning, injuries, substance use or mental illness were particularly high, with incidence rate ratios mostly 3 to 15 times for mental health/substance related visits and 1.5 to 3.2 for other accidents or injury for individuals with any CM concern versus none.

CONCLUSIONS

The high rate ratios for ED visits in children with CM concern, especially for self-harm, substance use and mental health during adolescence and adulthood highlights the enduring mental health needs of victims of child maltreatment, providing further impetus for prevention.

Educational strengths and functional resilience at the start of primary school following child maltreatment

BACKGROUND AND OBJECTIVE

This study explored the associations between child maltreatment and functional resilience at school commencement, and investigated factors related to resilience separately for boys and girls.

PARTICIPANTS AND SETTING

Children were part of a birth cohort of all children born in South Australia between 1986 and 2017 who had completed the Early Australian Development Census (AEDC) at about age 5-6 years when starting primary school (N = 65,083).

METHODS

Multivariable logistic regression analysis was conducted with a subsample of 3414 high-risk children who had a maltreatment substantiation or investigation, with resilience defined as having well or highly developed strengths on the Multiple Strength Indicator of the AEDC.

RESULTS

CPS involvement was strongly associated with poorer functioning at school commencement. Among high-risk children, 51.2% demonstrated resilience. Predictors of resilience in the multivariable model were being older, not having an emotional condition, and being read to at home. Risk factors were being male, living in rural or remote areas, having a physical or sensory disability, or having a learning disability. Boys who had been maltreated demonstrated few strengths and had less resilience than girls. Boys and girls who were read to regularly at home had more than three times the odds of showing resilience than children who were not read to at home.

CONCLUSIONS

The early learning environment provides an ideal opportunity to identify and intervene to help those children who are struggling with school adjustment following familial maltreatment. Boys are likely to need additional help.

Association of Child Maltreatment With Risk of Death During Childhood in South Australia

IMPORTANCE

Child maltreatment is a prominent public health concern affecting 20% to 50% of children worldwide. Consequences for mental and physical health have been reported, but population-level estimates of risk of death during childhood that are adjusted for confounders have not been published to date.

OBJECTIVE

To estimate the association of documented child protection concerns regarding maltreatment with risk of death from infancy to 16 years of age.

DESIGN, SETTING, AND PARTICIPANTS

This case-control study was nested in a population birth cohort of 608 547 persons born in South Australia, Australia. Case children were those who died between 1 month and 16 years of age (with the death registered by May 31, 2019). Control children were randomly selected individuals from the same population who were alive at the age at which the case child died, matched 5:1 for age, sex, and Aboriginal status. Data were analyzed from January 2019 to March 2021.

EXPOSURE

Children were assigned to 1 of 4 child protection concern categories (child protection system notification[s] only, investigation[s] [not substantiated], substantiated maltreatment, and ever placed in out-of-home care) based on administrative data from the South Australia Department for Child Protection or were classified as unexposed.

MAIN OUTCOMES AND MEASURES

Mortality rate ratios for death before 16 years of age, by child protection concern category, were estimated using conditional logistic regression, adjusted for birth outcomes, maternal attributes, and area-based socioeconomic status. Patterns of cause of death were compared for children with vs without child protection concerns.

RESULTS

Of 606 665 children included in the study, 1635 were case children (57.9% male [when sex was known]; mean [SD] age, 3.59 [4.56] years) and 8175 were control children (57.7% male; mean [SD] age, 3.59 [4.56] years [age censored at the time of death of the matched control child]). Compared with children with no child protection system contact, adjusted mortality rate ratios among children who died before 16 years of age were 2.69 (95% CI, 2.05-3.54) for children with child protection system notification(s) only; 3.16 (95% CI, 2.25-4.43) for children with investigation(s) (not substantiated); 2.93 (95% CI, 1.95-4.40) with substantiated maltreatment; and 3.79 (95% CI, 2.46-5.85) for children ever placed in out-of-home care. External causes represented 136 of 314 deaths (43.3%) among children with a documented child protection concern and 288 of 1306 deaths (22.1%) among other children. Deaths from assault or self-harm were most overrepresented, accounting for 11.1% of deaths in children with child protection concerns but just 0.8% of deaths among other children.

CONCLUSIONS AND RELEVANCE

In this case-control study, children with documented child protection concerns, who were known to child protection agencies and were typically seen by clinicians and other service providers, had a higher risk of death compared with children with no child protection service contact. These findings suggest the need for a more comprehensive service response for children with protection concerns.

Intergenerational transmission of child maltreatment in South Australia, 1986-2017: a retrospective cohort study

BACKGROUND

The extent of intergenerational transmission of child maltreatment is unclear due to methodological limitations in previous studies. In this study, we aimed to examine factors associated with intergenerational transmission of child maltreatment and quantify its extent in a population sample over a 30-year period in South Australia.

METHODS

In this retrospective cohort study, we used linked administrative data from the South Australian Birth Registry to identify dyads of mothers and their children both born in South Australia between July 1, 1986, and June 30, 2017. Three child protection system (CPS) outcomes (any CPS involvement, substantiated maltreatment, and time spent in out-of-home care) were computed from data obtained from the South Australian Department for Child Protection. Multivariable Cox regression models were used to estimate hazard ratios (HRs) for child CPS outcomes according to their mother's CPS exposure.

FINDINGS

38 556 unique mother-child dyads were included. 458 (2·0%) of 23 437 children whose mothers had no CPS involvement in childhood had a substantiated report of maltreatment and 127 (0·5%) spent time in out-of-home care. By comparison, 970 (22·1%) of 4382 children whose mothers experienced substantiated maltreatment in childhood had substantiated maltreatment and 469 (10·7%) spent time in out-of-home care. After adjusting for potential confounders, children of mothers with any CPS involvement in childhood had an increased risk of CPS contact compared with children whose mothers had no CPS involvement; this risk was greatest for children of mothers who had both substantiated maltreatment and spent time in out-of-home care (HR 6·25 [95% CI 5·59-6·98] for any CPS involvement, 13·69 [10·08-16·92] for substantiated maltreatment, and 25·78 [18·23-36·45] for any time in out-of-home care). Risks of child CPS outcomes were substantially increased for children of mothers who had a first CPS notification under the age of 1 year or who had any CPS notification at age 13-17 years.

INTERPRETATION

Children are at high risk of maltreatment if their mother experienced maltreatment as a child. Assisting survivors of childhood maltreatment, particularly female survivors, provides a crucial intervention opportunity to help prevent further child abuse and neglect.

FUNDING

Australian National Health and Medical Research Council; Channel 7 Children's Research Foundation.