Prospective data confirm the lasting effects of maltreatment on children

Child protection services in Australia require fundamental workforce and organisational reform

The numbers of recorded cases of child maltreatment in Australia have risen sharply in recent years, accompanied by a substantial increase in the number of children placed in out‐of‐home care.1 The article by Green and colleagues2 in this issue of the MJA reports a linkage study of prospectively recorded contacts of children with child protection services during early childhood and subsequent mental health service visits between 6 and 13 years of age, based on administrative data for a representative population sample of 74 500 New South Wales children commencing school in 2009.3

Much of the information on the adverse outcomes of child maltreatment is derived from retrospective studies, which are limited by the potential for recall bias and their assessment of clinical rather than population samples. Population‐based longitudinal studies are more rigorous, but relatively few investigations of the consequences of childhood trauma have been published. The contribution by Green and her co‐authors is therefore a welcome addition to the literature.

Their findings extend our knowledge of the mental health of children who have been the subjects of reports to child protection services, and raise additional questions about their numbers and needs. Most remarkable is that there had been child protection service reports for almost one in five children by the time they started school. The implications of this level of potential maltreatment cannot be overstated. Of particular concern is that the subsequent rate of diagnosis with mental health problems was three times as high for these children as for other children, a finding that indicates the urgency of the problem. In addition, the authors found a dose response, with the chance of mental health problems in middle childhood increasing with the level of child protection response that was required. The mental health consequences of child maltreatment included a broad range of diagnoses, including developmental, emotional, conduct, and hyperactivity disorders. These findings are complemented by those from cohort studies in both Australia and New Zealand that have found similar effects on diagnoses of mental disorders during adulthood.4,5,6

The strengths of the study by Green and colleagues include their analysis of administrative data for an entire state, averting the problems of attrition that bedevil follow‐up cohorts recruited at birth or during early childhood. The data on maltreatment are also more recent than information from longer standing cohort studies, which can reflect the reporting practices of 20 to 30 years ago. However, limitations include the use of health service contacts and diagnoses recorded in an administrative database as outcomes, rather than diagnoses with structured psychiatric instruments: in their study, about 70% of children with diagnoses had at least one unspecified diagnosis (F99) rather than a specific emotional, conduct, or behavioural disorder.

Another limitation is that it was not possible to distinguish mental disorders that began prior to notification to child protection services from those first recorded later, or which may have been consequences of the transition to out‐of‐home care. It was therefore not possible to determine whether there were complex interactions between environmental exposures, maltreatment, and psychiatric symptoms rather than simple cause‐and‐effect relationships.

Further, it was not possible to differentiate the effects of different types of maltreatment, nor those of multiple instances or types of maltreatment. Emotional abuse and child neglect are probably the most common forms of child maltreatment;1 they can be at least as harmful as physical and sexual abuse, but do not receive as much attention.5 The lack of information about the demographic and family circumstances of maltreated children in the analysis by Green and colleagues leaves some questions unaddressed; for example, children from single‐parent households and from Indigenous Australian families are generally more likely to come into contact with the child protection system.1

The consequences of child abuse are not confined to mental health problems. Longitudinal analyses have found that maltreatment is associated with a broad range of harms, including victimisation, delinquency, risky sexual behaviours, and adverse pregnancy outcomes.7 In addition, rates of injecting drug and cannabis use disorders are higher among maltreated children.8 Adverse physical health outcomes include stunting of growth, higher fat intake, poorer sleep quality, asthma, and poorer overall quality of life.9,10

The rapid increase in the number of notifications of child maltreatment in Australia and a greater understanding of the likely consequences have caused substantial concern about how protective services should respond.11 Thirty‐two enquiries into child protection services in Australia between 1997 and 2011 found evidence that the system is inadequate and requires fundamental workforce and organisational reform.11 In particular, child protection needs to shift from models focused solely on risk to primary and secondary prevention of harm. The article by Green and her colleagues is an important contribution to the necessary discussions about the consequences of child maltreatment in Australia.