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

Hospital admissions and community health service contacts for mental illness following self-reported child maltreatment: Results from the Childhood Adversity and Lifetime Morbidity (CALM) study

BACKGROUND

Child maltreatment (CM) includes neglect, and several types of abuse, including physical, emotional, and sexual. CM has been associated with a wide range of mental illnesses. Literature examining these illnesses in mid-life is scarce, and the impact of these illnesses on mental health service use is currently unknown.

OBJECTIVE

To examine associations between self-reported CM and subsequent hospital admissions for mental illnesses, and/or community mental health service contacts.

SETTING

Birth cohort study data linked to administrative health data, including hospital admissions and community mental health service contacts, up to the age of 40.

METHODS

Associations between hospital admissions for mental health and community mental health contacts and CM subtypes (neglect, physical abuse, emotional abuse and sexual abuse) were examined using multivariate logistic regression.

RESULTS

Adjusted analyses showed that all subtypes of CM were significantly (p < 0.05) associated with admissions to hospital for any type of mental illness (aOR range 1.87-3.61), non-psychotic mental disorders (aOR range 1.98-3.61), alcohol and/or substance use (aOR range 2.83-5.43), and community mental health service contacts (aOR range 2.44-3.13). Hospital admissions for psychotic mental disorders were significantly associated with physical abuse, emotional abuse, and sexual abuse (aOR range 2.14-3.93).

CONCLUSIONS

The results of this study confirm the current knowledge around CM and subsequent mental health illnesses up to the age of 40, and extend this knowledge to hospital and mental health service use.

Intergenerational transmission of childhood maltreatment and offspring behavioral adjustment problems and competence

BACKGROUND

Previous studies have consistently highlighted that exposure to childhood maltreatment adversely affects the developmental domains of subsequent generations. Little, however, is known about the relationship between maternal childhood maltreatment history and adolescent development, as well as the mediator role of offspring childhood maltreatment.

OBJECTIVE

The current study attempts to investigate the mediating role of offspring childhood maltreatment in the relationship between maternal childhood maltreatment history and offspring behavioral adjustment problems and competence.

METHODS

Participants were 1102 adolescents aged 10-15 years (Mage = 12.14, SD = 1.22) and their mothers (Mage = 39.40, SD = 5.31). Participating adolescents filled out self-report instruments assessing their childhood maltreatment by their mothers, self-esteem, academic performance, loneliness, and prosocial and aggressive behaviors between October 2018 and May 2019. In addition, we collected data from mothers on their childhood maltreatment history.

RESULTS

We analyzed the data through a structural equation model. The findings revealed insignificant direct effects of maternal childhood maltreatment history on offspring behavioral adjustment problems and competence. Yet, indirect effects demonstrated that offspring maltreatment by mothers mediated the relationship between maternal childhood maltreatment history and offspring behavioral adjustment problems and competence. Maternal childhood maltreatment history was significantly associated with offspring maltreatment (β = 0.30; p < .001), which in turn was linked to a higher level of behavioral adjustment problems (β = 0.40; p < .001) and a lower level of competence (β = -0.71; p < .001).

CONCLUSION

The research findings extend our understanding of the relationship between maternal childhood maltreatment history and offspring behavioral adjustment problems and competence, identifying the mediating role of offspring maltreatment.

Investigating the impact of Out-of-Home Care on early childhood development

BACKGROUND

Early childhood development is influential for life course capability. Children exposed to child maltreatment and at high risk of harm may be removed for their safety, but the effect on child development is uncertain.

OBJECTIVES

To assess developmental vulnerability at school commencement across five developmental domains to ascertain whether removal of children with substantiated maltreatment to foster/kinship care is likely protective, or not, of developmental vulnerabilities.

METHODS

The study drew on linked-data for a South Australian population birth cohort (2003 to 2014) N = 74,751. For children exposed to substantiated child maltreatment meeting study criteria (N = 2011, mean age = 5.7 years, 50.7 % boys), the effect of placement in foster/kinship care (N = 666) on developmental vulnerability was explored using generalized linear models, adjusted for child and family covariates, maltreatment severity and propensity score.

RESULTS

Children placed in care had a reduced risk of developmental vulnerability on the Physical Health and Wellbeing (aRR = 0.73 [0.64, 0.84]), Language and Cognitive Skills (school based) (aRR = 0.79 [0.68, 0.92]), and Communication Skills and General Knowledge (aRR = 0.81 [0.70, 0.94]) domains, compared to children who were not removed. However, these children had increased risk of vulnerability on Social Competence (aRR = 1.14 [1.01, 1.29]) and Emotional Maturity (aRR = 1.20 [1.05, 1.37]) domains.

CONCLUSIONS

These findings suggest placement in out-of-home care supported physical health and wellbeing, communication and cognitive but not social and emotional early childhood development. These results highlighting the need for professional therapeutic support for children in care and better attending to the physical development, communication and cognitive skills in maltreated children remaining at home.

Diffusion tensor imaging of white-matter structural features of maltreating mothers and their associations with intergenerational chain of childhood abuse

Child abuse causes lifelong adverse outcomes for both physical and mental health, although many are resilient. Efforts to prevent this issue from the parental side require an understanding of the neurobiological basis that leads abusive parents to perpetrate abuse and the influence of the intergenerational chain of childhood abuse. Therefore, this study was conducted to compare the brain white-matter fiber structures between 11 maltreating mothers who had been recognized as having conducted child abuse prior to the intervention and 40 age-matched control mothers using tract-based spatial statistics. There was a significantly reduced axial diffusivity (AD) and a similar trend in fractional anisotropy (FA) in the right corticospinal tract in maltreating mothers compared to control mothers. Therefore, maltreating mothers may have excessive control over the forcefulness of voluntary movements. These features also decreased as the number of childhood abuse experiences increased, suggesting that an intergenerational chain of child abuse may also be involved. Other aspects observed were that the higher the current depressive symptoms, the lower the AD and FA values; however, they were not related to parental practice or empathy. These results corroborate the neurobiological features that perpetrate behaviors in abusive mothers.

Breaking the cycle: Effect of a multi-agency maternity service redesign on reducing the over-representation of Aboriginal and Torres Strait Islander newborns in out-of-home care: A prospective, non-randomised, intervention study in urban Australia

BACKGROUND

Strategies to reduce over-representation of Indigenous children in out-of-home care must start in pregnancy given Indigenous babies are 6 % of infants (<1 year), yet 43 % of infants in out-of-home care.

OBJECTIVE

To determine if an Indigenous-led, multi-agency, partnership redesign of maternity services decreases the likelihood of babies being removed at birth.

PARTICIPANTS AND SETTING

Women carrying an Indigenous baby/babies who gave birth at the Mater Mothers' Public Hospital, Brisbane (2013-2019).

METHODS

A prospective, non-randomised, intervention trial evaluated a multi-agency service redesign. Women pregnant with an Indigenous baby birthing at a tertiary hospital were offered standard care or Birthing in Our Community (BiOC) service. We compared likelihood of babies being removed by Child Protection Services (CPS) at birth by model of care. Inverse probability of treatment propensity score weighting controlled baseline confounders and calculated treatment effect. Standardized differences were calculated to assess balance of risk factors for each copy of multiple imputation. Australian New Zealand Clinical Trial Registry, ACTRN12618001365257.

RESULTS

In 2013-2019, 1988 women gave birth to 2044 Indigenous babies, with 40 women having babies removed at birth (9 BiOC, 31 standard care). Adjusted odds of baby removal were significantly lower for mothers in BiOC compared to standard care (AOR 0.37, 95 % CI 0.16, 0.84). In total, 2.0 % of Indigenous babies were removed by CPS; eight times higher than non-Indigenous babies at the same hospital (0.25 %).

CONCLUSIONS

BiOC reduced removals of newborn Indigenous babies likely disrupting generational cycles of CPS contact, trauma, and maltreatment, and contributing to short and long-term health and wellbeing benefits for mothers and babies.

A comparative effectiveness study of the breaking the cycle and Maxxine Wright intervention programs for substance-involved mothers and their children: study protocol

BACKGROUND

Children of substance-involved mothers are at especially high risk for exposure to adverse childhood experiences (ACEs) and poor mental health and development. Early interventions that support mothers, children, and the mother-child relationship have the greatest potential to reduce exposure to early adversity and the mental health problems associated with these exposures. Currently, there is a lack of evidence from the real-world setting demonstrating effectiveness and return on investment for intervention programs that focus on the mother-child relationship in children of substance-involved mothers.

METHODS

One hundred substance-involved pregnant and/or parenting women with children between the ages of 0-6 years old will be recruited through the Breaking the Cycle and Maxxine Wright intervention programs, in Toronto, Ontario, Canada and Surrey, British Columbia, Canada, respectively. Children's socioemotional development and exposure to risk and protective factors, mothers' mental health and history of ACEs, and mother-child relationship quality will be assessed in both intervention programs. Assessments will occur at three time points: pre-intervention, 12-, and 24-months after engagement in the intervention program.

DISCUSSION

There is a pressing need to identify interventions that promote the mental health of infants and young children exposed to early adversity. Bringing together an inter-disciplinary research team and community partners, this study aligns with national strategies to establish strong evidence for infant mental health interventions that reduce child exposure to ACEs and support the mother-child relationship. This study was registered with clinicaltrials.gov (NCT05768815) on March 14, 2023.

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.

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.

Traumatic head injury due to child maltreatment: epidemiology, cost analysis, and impact of prevention

BACKGROUND

Traumatic head injury due to child maltreatment (THI-CM), also known as abusive head trauma (AHT), is a significant public health problem due to the wide array of consequences affecting multiple domains of a child's health and development. Several studies have evaluated its cost on healthcare systems, families, and societies. Many jurisdictions have implemented caregiver education programs to prevent THI-CM.

OBJECTIVES

This paper aims to provide a brief overview of the epidemiology and cost analysis of THI-CM and discuss its prevention and the intergenerational transmission of child maltreatment.

METHODS

Although not systematic, a literature search of original articles published from 2000 to 2022 in English and French was undertaken using the following databases: PubMed, EMBASE (Ovid), and PsycINFO (OVID). The search combined terms related to traumatic head injury and child maltreatment, with terms related to its cost and prevention. Studies of children aged 0-5 years old were included. The authors completed a screen of the titles and abstracts to determine relevance with respect to this article.

RESULTS

Globally, although THI-CM accounts for a small proportion of cases of child maltreatment, there is a high incidence of death and neurological sequelae compared to other causes of head trauma.The incidence of THI-CM is likely underestimated due to the lack of standardized definitions, differences in reporting, and challenges in identifying less severe cases. Cost analysis studies reveal the significant short- and long-term costs associated with THI-CM. Caregiver education programs have been studied and implemented in many centers and have shown varying but promising results.

CONCLUSION

A multi-pronged approach to prevention efforts should be considered to support families and help to prevent THI-CM and maltreatment throughout childhood.

Intergenerational Transmission of Peer Aggression

It is plausible that peer aggression—like general forms of aggression—is transmitted from one generation to the next. As such, parental behavior in childhood and adolescence may be associated with offspring aggressive behavior against peers. This study used 1970 British Cohort Study data to test intergenerational transmission of peer aggression. The baseline sample consisted of 13,135 participants. At the first assessment that was used in this study, participants were on average 4.95 years old (SD = 0.79; 48.20% female). At the last assessment, participants were on average 33.88 years old (SD = 0.36; 52.1% female). Models were computed for early and middle childhood, and adolescence. Significant associations between parents’ and offspring peer aggression were found in most models – especially when correlating aggression in similar developmental periods for parents and children. Other transmission mechanisms such as genetic transmission may be relevant and should be taken into account in future studies.

Longitudinal Association Between Child Psychological Abuse and Neglect and Academic Achievement in Chinese Primary School Children: A Moderated Mediation Model

To investigate the relationships among child psychological abuse and neglect (CPAN), children’s learning engagement, family socioeconomic status (family SES), and children’s academic achievement, 271 children (M_age = 9.41 ± 0.81 years old) and their parents participated in this study with a longitudinal design. Results revealed that learning engagement at T1 mediated the relationship between CPAN at T1 and academic achievement at T2 when gender, age, grade, and academic achievement at T1 were under control. Family SES at T1 moderated the relationship between children’s learning engagement at T1 and academic achievement at T2. The association between learning engagement and academic achievement was stronger among children from lower family SES. Our findings highlighted the negative impact of CPAN and the critical role of learning engagement in children’s academic achievement, especially for those from low SES families.

Association between maternal perceived capacity in life and physical punishment of teenage children: a longitudinal analysis of a population-based cohort in Tokyo, Japan

OBJECTIVES

Perceived capacity denotes a subjective sense of having resources to cope with strains and hardships, and hence maternal perceived capacity may be protective against risk factors for child maltreatment. This study investigated the longitudinal association between maternal perceived capacity in life and child maltreatment.

DESIGN

This population-based longitudinal study used self-reported questionnaires from the Tokyo Teen Cohort study (TTC), a large community-based cohort study conducted in Japan between 2014 and 2019.

SETTING

Mother-child pairs were randomly recruited from the resident registries of three municipalities in Tokyo, Japan.

METHODS

A total of 2515 mothers participated. Mothers' perceived capacity in life was evaluated using the self-reported TTC wave 2 survey when their children were 12 years old. Mothers rated the extent to which they had capacity in terms of time, finance, physical well-being, mental well-being and life in general. Physical punishment, which is linked to more severe childhood maltreatment, was assessed using a question about the use of physical punishment at the wave 3 survey when children were 14 years old.

RESULTS

After controlling for baseline covariates (including maternal social support, age, marital status, annual household income, educational attainment, child's age, gender, sibling and birth order, and behavioural difficulties), higher perceived capacity in finance (OR 0.95, 95% CI 0.90 to 0.99, p=0.026) and mental well-being (OR 0.93, 95% CI 0.88 to 0.98, p=0.005) were associated with less frequent use of physical punishment with 14-year-old children.

CONCLUSIONS

Maternal perceived capacity in finance and mental well-being may decrease the risk of frequent use of physical punishment at the 2-year follow-up. Child maltreatment prevention strategies should aim to empower mothers and promote their perceived capacity in financial management and mental health.

Where Is the Village? Care Leaver Early Parenting, Social Isolation and Surveillance Bias

Young people transitioning from out-of-home care (termed care leavers) are known to be a relatively vulnerable group. One example is their over-representation in early pregnancy and parenting. This paper presents findings from a study of care leaver early parenting in the Australian state of Victoria. Sixteen service provider staff working with care leavers who had become young parents were asked, via focus groups and interviews, for their perspectives on the factors that influence the high prevalence of early parenting amongst care leavers, and the key support services that are available and necessary to assist both care leavers and their children. Service providers raised multiple issues common to the existing leaving care literature concerning the lack of support provided to young people being exited from state care as potentially leading to both early parenting and parenting challenges. Service providers also expressed concern about what many studies of care leaver early parenting have termed 'surveillance bias'. There was a clear consensus that young people transitioning from care face unique challenges and social isolation due to their difficult experiences pre-care, in-care and post-care. Those experiences place them at risk of disadvantages that impede their ability to demonstrate the practical, physical and financial means to safely raise children. At the same time, they are under greater scrutiny than other parents by being known to child protection already. Service providers argued in favour of greater support for young care leaver parents to prevent their children's engagement with child protection systems.

Intergenerational transmission of out-of-home care and the role of mental health problems: Findings from Stockholm birth cohort multigenerational study

Out-of-home care (OHC) experiences are associated with poor long-term outcomes throughout life. However, the continuity of OHC over generations is not fully explored, and the influence of mental health problems (MHP) and socioeconomic conditions on such transmission is still unclear. We therefore assessed the extent to which MHP affect the intergenerational transmissions of OHC as well as whether there are differential patterns depending on the socioeconomic conditions of the family of origin. We used a prospective data from the Stockholm Birth Cohort Multigenerational Study (SBC Multigen) on 11,333 cohort members (Generation 1; G1), their parents (Generation 0; G0), and 24,905 children (Generation 2; G2). Multivariate regressions and path models were used to examine the associations between OHC and MHP across generations; stratified analysis by occupational class in G0 was performed to explore potentially differential patterns. Our findings support the existence of an intergenerational transmission of OHC, particularly in the working class group (OR 4.70); MHP was only transmitted across generations in this group (OR 1.51). While the results indicated a stronger role of MHP among the middle/upper class (OR 5.59) compared to working class (OR 3.52) in part of the pathway (MHP G1→OHC G2), this patter was not consistent throughout the whole pathway (e.g. OHC G1→MHP G1). We conclude that there is a tendency for OHC and MHP experiences to continue across generations, particularly among families with more disadvantageous socioeconomic conditions. MHP seem to play an important role in the transmission of OHC irrespective of socioeconomic conditions.

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.