Child abuse and premature mortality: disrupting the harm cascade

In this issue of the MJA,1 Papalia and colleagues report extremely high age‐ and sex‐standardised rates of death before age 50 years among people who had experienced medically confirmed sexual abuse in Victoria before the age of 16 years. The all‐cause mortality incidence rate was more than eight times as high for this cohort as for the general population (incidence rate ratio [IRR], 8.25; 95% confidence interval [CI], 5.92–11.5); the difference with regard to external cause deaths (suicide, accidents, assaults) was greater following penetrative (IRR, 14.9; 95% CI, 10.9–20.5) than non‐penetrative sexual abuse (IRR, 8.92; 95% CI, 5.35–14.9).1 The reported risk ratios are higher than those reported for outcomes in other studies; for example, we found that the mortality risk (between the ages of 16 and 33 years) was 5.77 times as high for people removed to out‐of‐home care after the age of three years as for people who had no contact with child protection services.2 However, the magnitude of the reported IRRs are consistent with other studies; for instance, that the risk of attempted suicide by boys subjected to familial child sexual abuse is fifteen times the population level.3

Similar to Papalia and colleagues, we found that excess mortality among people abused or neglected during childhood was higher for men than women. The only other significant factor associated with early death was having a health problem that resulted in the infant still being in hospital 28 days after their birth. In our multivariable model, no socio‐economic characteristics (including having a young or unmarried mother, area‐based socio‐economic status) were statistically significant.2

The mechanisms of harm associated with child abuse and neglect, apart from the direct effect of the assault, include changes to the developing brain,4 the inflammatory and other physiological effects of long term stress,5 and threat‐based relational patterning as a response to ongoing abuse.6 Higher risks of mental and physical illness and related health problems are consistent with these mechanisms, compounded by the substance use and risky behaviour and self‐harm that are frequent during adolescence in people maltreated during childhood.

The public health significance of child abuse and neglect is crystal clear.7 The described mechanisms support a causal relationship, as does the availability of successful interventions that can prevent abuse and the cascade of subsequent harms. Young adulthood is a period of especially high risk,1 but waiting until the first psychotic episode, self‐harm incident, or drug overdose before intervening does not make sense, as people at risk are in contact with health and other government services from infancy.

Therapeutic interventions for children who have suffered abuse or neglect include attachment and trauma‐based programs that support the parent–child relationship and child development, trauma‐informed infant home visiting, high quality intensive early childhood education and care, intensive therapeutic family re‐unification, and attachment‐based parenting programs. A therapeutic response undertaken in an interdisciplinary framework and with sufficient flexibility to deal with the range of adversities experienced by troubled families would be ideal.8

Disrupting the inter‐generational transmission of trauma — whereby a parent who has suffered serious child abuse does not provide a safe and nurturing environment for their own child, despite their desperate wish to be a good parent — is critical.9 Therapeutic care for children who have been abused, to reduce current high levels of distress, potentially averting mental illness and substance misuse during adolescence and adulthood, and preventing abuse and neglect in the next generation, must be a priority. However, a recent study found that just 19% of Australian children aged 4–14 years with moderate to high level mental health symptoms had received care meeting even “minimally adequate treatment”; almost half had received no mental health care at all.10 Given the close relationship between serious abuse during childhood and mental illness,11 this is highly concerning.

To interrupt the cascade of harms, we need enough skilled practitioners in trauma and attachment care who can work in a compassionate and responsive way in a well resourced and supportive environment. Recognising the dearth of mental health services for infants and children, the Australian government, in partnership with the states, is establishing a number of mental health Head to Health hubs, but, disappointingly, without providing resources for therapeutic care.12 The Victorian government has promised a small number of Family hubs to assist families at risk, adopting an interdisciplinary model incorporating community‐based care (primary medical care, various allied health disciplines, social support services) in partnership with secondary and tertiary health care providers.13 Such models have promise, but secure funding commensurate with need will be vital.

System‐level changes which promote a bio‐psychosocial approach to health that encourages inter‐agency and interdisciplinary engagement are crucial for mitigating the effects of child abuse and neglect. For decades, health economists have discussed single fundholding models to deliver a more responsive approach to health care by removing jurisdictional and portfolio boundaries. Such a model could take the form of a regionally defined family hub (similar to the Victorian model) but jointly funded by the federal and state governments, pooling money from health, human services, child protection, education, justice, and housing departments, according to a needs‐based formula. A governance group would be drawn from the participating agencies and the people they assist. A regional family hub could also provide a platform for improving the skills and capacity of health, education, justice, and social care workers and facilitate a whatever‐it‐takes service response, driven by a deep understanding of complex trauma to meeting the needs of distressed families in a timely fashion.

While such a model may seem radical, something has to change. The terrible health, social, and monetary costs of child abuse and neglect are indefensible on ethical, medical, and financial grounds.