Mental health

Lack of timely and appropriate community-based mental health care probably leads to more hospitalisations during mental health crises

Paul Hotton

The Aboriginal and Torres Strait Islander-developed depressive symptom screening scale that we studied is reliable and valid, and it performs well across multiple Aboriginal and Torres Strait Islander primary care settings

Timothy Skinner · Alex Brown · Armando Teixeira‐Pinto · Sara F Farnbach · Nicholas Glozier · Deborah A Askew · Graham Gee · Alan Cass · Maree L Hackett

Simple training programs for senior physicians can change self-reported behaviour that may support the mental health of their staff

Aimée Gayed · Jessica Strudwick · Nathasha Kugenthiran · Anthony D LaMontagne · Andrew Mackinnon · Helen Christensen · Nicholas Glozier · Samuel Harvey

Improving their social and emotional wellbeing could help reduce the number of Aboriginal people in Australian prisons by reducing recidivism

Pat Dudgeon (Bardi) · Ee Pin Chang · Joan Chan · Carolyn Mascall · Gillian King (Noongar) · Jemma R Collova · Angela Ryder (Noongar)

Richard CJ Bradlow · Ferghal Armstrong

School-based e-health multiple health behaviour change interventions need effective engagement strategies to maximise their effectiveness

Siobhan O'Dean · Matthew Sunderland · Nicola Newton · Lauren Gardner · Maree Teesson · Cath Chapman · Louise Thornton · Tim Slade · Leanne Hides · Nyanda McBride · Frances J Kay‐Lambkin · Steve J Allsop · David Lubans · Belinda Parmenter · Katherine Mills · Bonnie Spring · Bridie Osman · Rhiannon Ellem · Scarlett Smout · Karrah McCann · Emily Hunter · Amra Catakovic · Katrina Champion

There was a marked shift from daily opioid agonist treatments to long-acting depot buprenorphine during 2019–2022

Nicholas Lintzeris · Victoria Hayes · Adrian J Dunlop

Ben Mathews

Nicole TM Hill · Wai Chen · Jenny Downs

Alain Braillon

Healthy is one of the seven domains outlined in the Future Healthy Countdown 2030 framework on children and young people's health and wellbeing. The Countdown's framework draws on the Nest, a framework of wellbeing developed by the Australian Research Alliance for Children and Youth.1 In the 2021 iteration of the Nest, a new generation of child and youth voices defined healthy children and young people as those who “have their physical, mental, and emotional health needs met” and “receive appropriate health services, including preventative measures to address potential or emerging physical, emotional and mental health concerns”.1 The physical health and mental health of young Australians continue to benefit from advances in public health, modern medicine, preventive interventions such as vaccination, and a strong universal health care system. However, health inequities remain and the social determinants of health (eg, economic, commercial and structural factors) are strongly at play. Differential outcomes in children's and young people's health and wellbeing are recognised to be “unjust, unnecessary, systematic and preventable”.2 For these reasons, attempts to improve health outcomes in Australia and around the world must ensure that children and young people aged 0–24 years — particularly priority groups (eg, those who are Aboriginal and/or Torres Strait Islander and those living in low income households) — are front and centre of policy decisions aimed at reducing inequities. A broad range of indicators can be used to track the health and wellbeing of young populations. Among these, unhealthy weight (overweight and obesity) and mental health problems and disorders are leading examples of health conditions that remain unacceptably high in young populations globally. These conditions are also inequitably distributed and significant risk factors for wider diseases and disorders across the lifespan.3 Weight problems often begin in the developmental years of childhood and adolescence.4,5 Similarly, half of mental health problems emerge by 18 years of age and almost two‐thirds emerge by 24 years of age.6 Addressing these two health priorities alone would reap major benefits, including improved quality of life and reduced risk of physical disease, with implications within and across generations.3 However, intervening to prevent weight and mental health problems early in the life course necessitates accurate population and clinical data on both of these outcomes, around aspects of public health and health services, ideally from early childhood through to young adulthood (ages 0–24 years). Currently, there is no single survey system in Australia that provides these insights. However, Australia does have three survey systems that could be better integrated to regularly provide an epidemiological profile of the developmental years of Australians. These are the National Health Study (NHS; which collects data on Australians aged 2 years or older), the Australian Child and Adolescent Survey of Mental Health and Wellbeing (which collects data on 4–17‐year‐olds) and the National Study of Mental Health and Wellbeing (which collects data on Australians aged 16 years or older). Broader data capture across each survey system (including measures of social determinants and healthy development) has the potential to provide a more comprehensive and sustainable survey system for tracking the health of young populations. Furthermore, triennial administration of each survey could provide the necessary frequency for “state of the nation” reports that could enhance investments in timely, evidence‐based policy and practice decisions that are intended to improve the health of children and young people across our nation. Tracking data on overweight and obesity in young populations Current generations of children and young people are more likely to live with overweight or obesity than people at the same age in previous generations (Box 1).7 This burden is even greater among particular populations, such as those aged 5–14 years who live in the lowest socio‐economic areas (28%) or are of Aboriginal and/or Torres Strait Islander origin (38%).7 The National Obesity Strategy 2022–2032 has set a target of reducing overweight and obesity in 2–17‐year‐olds by at least 5% by 2030.8 If we are serious about reducing overweight and obesity by 5%, we need to reliably measure weight in young populations and its determinants to track progress and evaluate intervention and policy efforts. High quality and frequently collected data on body mass index (BMI; height and weight) of children and young people are available in the NHS, from in‐person objective measurements taken every three to four years (except in 2020–21 due to the coronavirus disease 2019 [COVID‐19] pandemic).9 The most recent NHS data, from 2017–18, estimated that almost one in four 5–14‐year‐old Australians (24%) and two in five 15–24‐year‐old Australians (41%) were either overweight or obese.7 In the 22 years since data were first collected, in 1995, these rates have risen by 20% for those aged 5–14 years and 46% for those aged 15–24 years (Box 1). We also need to regularly measure key risk factors and protective factors for overweight and obesity, such as physical activity, sleep and nutrition. The National Nutrition and Physical Activity Survey was completed during the period 2011–2012 and is being administered again in 2023 — a decade later.10 We suggest that more frequent data on these key factors are needed to better track the results of previous policy and intervention decisions. Beyond individual factors, we need to measure the key social, structural and commercial determinants of obesity, such as community factors. Community differences in the number of child development risk factors (eg, neighbourhood alcohol availability, school suspension, family conflict and peer bullying) predict significant increases in child weight status (eg, four or more risk factors increase the odds of a child being overweight by 50%) and other outcomes such as poor mental health.11 Broader structural factors offer policy targets that can have far reaching consequences. For example, a tax on sugary sweetened beverages alone is estimated to help reduce obesity rates at the population level by at least 2%.12 To be maximally effective in supporting evidence‐based decision making, we need to find ways of capturing macro level policy settings to help reduce obesogenic environments. Tracking data on mental health difficulties and disorders in young populations Young Australians continue to rate mental health concerns as a major challenge for their generation,13 with some groups dealing with greater burden than others (eg, LGBQTI+ and Aboriginal and Torres Strait Islander children and young people).14,15 Despite this, nationally representative and community data on mental health are collected too infrequently to develop the coherent picture of developmental years that is needed to evaluate current policies and inform approaches to mental health promotion in young populations. Like the NHS, the Australian Child and Adolescent Survey of Mental Health and Wellbeing and the National Study of Mental Health and Wellbeing have the potential to provide a continuous picture of mental health difficulties and disorders across the developmental years. These population representative mental health survey systems collect data on mental health difficulties (distress) and mental disorders (clinical conditions). In the most recent Australian Child and Adolescent Survey of Mental Health and Wellbeing, which was administered a decade ago (during the period 2013–2014), one in five 11–17‐year‐olds (20%) reported high or very high levels of psychological distress using the Kessler 10 Psychological Distress Scale (K10)16 (no equivalent data are available for children younger than 11 years). This compares to almost one in seven 4–17‐year‐olds (14%) who were classified as having a diagnosable mental disorder in the previous 12 months using the Diagnostic Interview Schedule for Children version IV (DISC‐IV).16 The absence of a more recent survey means that there is a striking gap in data for one of the most important public health and health service priorities for children and young people.17 More recent estimates of mental health difficulties are available for those aged 16 years or older in the larger national cohort (2020–2021). However, estimates of psychological distress are presented within wide age bands (16–34 years) which are not likely to represent those aged 16–24 years.18 Tighter age disaggregation is available for mental disorders (rather than mental health distress), with two in five 16–24‐year‐olds (40%) classified as having a mental disorder in the previous 12 months using the Composite International Diagnostic Interview (CIDI).19 In this age group, anxiety and affective disorders have steadily increased since national data were first collected in 1997 (Box 2), while substance use disorders have substantially declined.19,20,21 Driving responsive and accountable action for physical and mental health An important picture of physical health (overweight and obesity) and mental health (distress and disorder) in young populations can be assembled by bringing together data from the NHS, the Australian Child and Adolescent Survey of Mental Health and Wellbeing, and the National Study of Mental Health and Wellbeing. However, these important and high quality survey systems are not currently designed to “talk with each other” and thereby fail to provide a single, coherent picture of health and development in young populations at regular intervals. In addition, there is an important gap in data relating to early childhood and there is no tracking of positive health and developmental outcomes, including good general health, pro‐social behaviour and pro‐environmental behaviour. Yet, measuring the development of these positive types of behaviour has the potential to provide a crucial read on the key attitudes and behaviours that we need to nurture in young populations to ensure kinder, more peaceful societies and a healthier planet into the future. Similarly, the broader social determinants of both positive and problematic outcomes are not assessed. Beyond tracking mental health outcomes, tracking modifiable risk factors and protective factors provides specific targets for public health investments in preventive interventions in addition to health services. For this Countdown series, we suggest connecting these three important Australian survey systems to assemble an early life course national data system capable of providing continuous developmental data (up to age 24 years) on indicators of both physical and mental health. We also suggest more frequent administration of surveys (eg, triennially) with particular attention to measuring the primary social determinants of health and wellbeing and positive measures. Capitalising on the strengths of these national survey systems would address a major gap in data using expertise and infrastructure already in place within a nationally funded system. This could be done in a way that builds on existing assets (adding brief and reliable measures) but does not interfere with the core elements of these surveys which enable international comparisons. Beyond these potential data capture extensions, there is a broader question of data utilisation, particularly concerns about how effectively population data are used. One important barrier to data utilisation relates to the ease with which non‐scientific audiences can make sense of complex, multidimensional data, in ways that lead to clarity about how and when to invest for maximum impact. With this in mind, we further suggest investment in a centralised data visualisation capability that places data on a single platform, to create a single “point of truth” that can be accessed by a broad range of end users. A leading example of this has been developed by the Institute for Health Metrics and Evaluation to visualise Global Burden of Disease estimates. Summary and recommendations The current state of play is summarised in Box 3. We make the following three recommendations around strengthening existing surveillance platforms and building new surveillance capabilities to help improve physical and mental health of young Australians. 1. Track BMI and mental health difficulties and disorders in young populations every three years Continue regular ongoing reporting of physical health, including overweight and obesity (BMI) from the NHS (measured from 2 years of age onward). Integrate child, adolescent and adult mental health and wellbeing survey data to provide a single, coherent picture of the early life course (up to age 24 years). Increase the frequency of mental health survey administration to match the triennial frequency of the NHS to ensure best practice coverage of major shifts in population health. 2. Extend and enrich surveys to assess modifiable developmental determinants Lower the starting age of the Australian Child and Adolescent Survey of Mental Health and Wellbeing to match that of the NHS (from two years of age onward, parent report up to age ten years) to ensure better coverage of young children. Extend the scope of mental health assessment to include brief high level indicators of positive development, including pro‐social and pro‐environmental behaviour. Enrich monitoring with regular population reads on common, modifiable determinants (individual, relational and contextual risk factors, protective factors and structural influences). Continue to ensure oversampling of priority groups and communities to drive more equitable health outcomes based on proportionate universalism.22 3. Invest in platforms that developmentally connect and visualise data Ensure that data can be visualised easily and developmentally (eg, use fine‐grained age disaggregation and community profiles) to ensure optimal data utilisation by governments, researchers and community leaders. Ensure that data on modifiable determinants of positive and problematic health outcomes are likewise easily accessible to optimise intervention planning. Ensure that all data collected are aligned with FAIR (findable, accessible, interoperable and reusable) and Open Science principles for data access and utilisation. We believe that such improvements would build a foundation for responsive and accountable actions towards improving the physical and mental health of young Australians. Box 1 – Proportion of children, adolescents and young adults aged 5–24 years living with overweight or obesity, by birth cohort and age group (measured in 1995, 2007–08 and 2017–18) Source: Adapted from the Australian Institute of Health and Welfare.7 Box 2 – Prevalence of 12‐month mental disorders in young people aged 16–24 years, by time (1997, 2007, 2020–21)* * Original figure produced using the data sources below. Data from 1997 are not directly comparable to data from 2007 and 2020–21 because the 1997 data are based on sampling of Australians aged 18–24 years old (not 16–17 years old) using an earlier version of the Composite International Diagnostic Interview (CIDI). Source: ABS National Study of Mental Health and Wellbeing, measured in 1997, 2007 and 2020–21.19,20,21 Box 3 – Pressing issues and key indicators of physical and mental health of Australians aged 0–24 years What are the two most pressing issues where change could make a real difference by 2030 and why? • Overweight and obesity and common mental health problems (distress and clinical disorders) remain persistently high in young populations, are inequitably distributed, and have major implications both now and for future health and wellbeing. • However, we lack developmental data on these health priorities from early childhood to young adulthood (0–24 years of age), which limits evidence‐informed approaches to prevention and treatment across the early life course. • We suggest connecting three important Australian survey systems to assemble an early life course data system capable of providing continuous developmental data on indicators of both physical and mental health up to age 24 years. What are some of the key indicator measures available and what is lacking? • Key indicators: ‣ prevalence of overweight and obesity in children and young people; ‣ prevalence of mental health difficulties (distress) in children and young people; and ‣ prevalence of mental disorders in children and young people. What is lacking? ‣ data on mental health difficulties (distress) and diagnosable mental disorders in children and adolescents aged 0–24 years (the most recent survey of 4–17‐year‐olds was completed a decade ago in the period 2013–2014); ‣ data on positive development indicators (eg, pro‐social and pro‐environmental behaviour); ‣ data on common, modifiable, social determinants of mental health difficulties and disorders; and ‣ clearly visualised and easily understandable data on weight and mental health across the developmental years. What are the key baseline data on these indicator measures that are available? • Almost one in four 5–14‐year‐olds (24%) and two in five 15–24‐year‐olds (41%) are affected by overweight or obesity (29% in regional and remote areas) (source: National Health Study, 2017–18 financial year).7 • Two in five 16–24‐year‐olds (40%) meet the criteria for a mental disorder (source: National Study of Mental Health and Wellbeing, 2020–21).19

Kate Lycett · Georgie Frykberg · Peter S Azzopardi · Joyce Cleary · Susan M Sawyer · John W Toumbourou · Tim Slade · Craig A Olsson

As highlighted by the recent World Health Organization–UNICEF–Lancet Commission on children wellbeing, our children face an uncertain future.1 As stated in the Commission's report, “Climate change, ecological degradation, migrating populations, conflict, pervasive inequalities, and predatory commercial practices threaten the health and future of children in every country”.1 The welfare of Australia's children, young people and future generations is certainly under threat (Box). Ensuring all children and young people have the right to clean, healthy and sustainable environments has recently been adopted within the United Nations Rights of the Child (General comment no. 26).2 “Environments and sustainable futures” is also one of the seven domains considered in the MJA supplement on the Future Healthy Countdown 2030, which aims to track key indicators of children's and young people's wellbeing and outline policy areas where change could make a real difference by 2030. Australia is doing badly on climate and sustainability issues Two recent reports highlighted just how badly Australia is doing and how lowly it ranks on climate and sustainability issues.1,3 The premise here is that although high income countries may rank well on conventional statistics that favour survival and flourishing, they are doing so at the expense of compromising a sustainable future for their children. However, total country data hide significant inequalities across diverse groups and locations within the country (see below). The WHO–UNICEF–Lancet Commission created a sustainability rank based on carbon emissions exceeding 2030 targets.1 Using this method, Australia ranked 174 out of 180 countries, with excess emission of 524%. Only Qatar, Trinidad and Tobago, Kuwait, the United Arab Emirates, Bahrain and Saudi Arabia, which are all oil and gas producing nations, ranked lower.1 UNICEF recently released the 17th Innocenti Report Card, a series designed to monitor and compare the performance of economically advanced countries in securing the rights of their children.3 The report, titled Places and spaces: environments and children's wellbeing, focused on three questions: How do environmental factors affect children's wellbeing? How are many of the world's richest countries faring in terms of providing a healthy environment in which children can live, develop and thrive? What actions can these countries take to improve the environments in which children live? There are also three cross‐cutting themes that will guide how to respond to this report. These illustrate interlinkages, suggesting the need for whole‐of‐government and whole‐of‐society responses; demonstrate the considerable inequalities in these environments and, therefore, the variability in children's responses (thus the causes of poverty in our nations need to be seriously addressed); and identify how powerless children are with respect to influencing policies (with good examples of how to engage young people in the solutions to improving these environments). The report was a damning indictment for most wealthy countries but particularly so for Australia. Unhealthy living conditions can irreversibly harm children's mental and physical wellbeing, their cognitive development and, hence, their prospects for a happy and healthy life. A life that enables their full participation as citizens. High density traffic, air pollution and limited urban green spaces mean that many children find it hard to avoid such dangers. Children are most vulnerable to these environments as they have a longer lifetime of exposure and are more immature in their ability to mitigate the effects.3,4,5 The UNICEF report card is quite different from its predecessors in two main ways: it focuses on environments that are either positive or negative for childhoods, rather than on measuring and ranking outcomes; and it used high quality data that in many cases did not depend on the nations to provide it. This independently collected information is comparable across time and between geographic locations. The data are used to rank countries across expanding sets of environments: those close to the child such as air, noise and light pollution, water quality, heat and cold, toxicants and pesticides. The next level of environments are community spaces — the area of green spaces and play facilities, housing quality, public transport, walkability and traffic. The overarching global influences include emissions, waste and recycling, management of the natural environment, climate change and natural disasters, renewable energy and housing, transport, and food policies. If the rest of the world behaved like Australia, we would need five planets Earth to ensure survival for us and our children Australia performs very badly in the broader category of the world at large, both historically and currently. Australia had very low rankings on areas that should guide our climate and environmental policies.1,3 We produced 21.7kg of electronic waste per person per year, ranking 38 out of 43. Our consumption‐based carbon dioxide (CO2) emissions since the Kyoto protocol was adopted in 1997 were 14.8 tonnes per person per year, ranking 39 out of 43 (with the United States and Canada). Australia, the US and Canada emitted more metric tonnes of CO2 per capita than any other Organisation for Economic Co‐operation and Development (OECD) country. Yet you still hear arguments that we are so small that our emissions contribute very little. If the rest of the world behaved like Australia, we would need five planets Earth to ensure survival for us and our children. Thus, as global citizens we perform very badly indeed. Despite recent changes in government rhetoric, there are still large sections of politics and industry wedded to coal‐fired electricity generation. In addition, gas developments are still being approved, even on sacred Indigenous lands. In the overall league table, 43 OECD countries are ranked in these three environmental domains. Australia ranks at 30 with Canada (28), Latvia (29) Israel (34) and the US (37). Spain is ranked 1 and clearly performs better than most in all three environmental domains. But no country does well overall and there is obviously substantial room for improvement in all countries. The report highlights how these analyses link to both the UN Convention on the Rights of the Child and the Sustainable Development Goals. So why do we rank so low? Australia ranks well on current air pollution from particulate matter 2.5 (exposure in parts per million), not so well in water‐related morbidity of children aged less than 15 years (maybe influenced by our poor regional and remote water quality),6,7,8,9 too many of our children have high levels of lead compared with children from other OECD countries and more of our children are exposed to pesticide and other chemical pollution. Although Australia rated well on air pollution at the population level, the report did not measure the main pollutant from vehicle emissions (nitrogen dioxide), which we know is poor in certain parts of the country (eg, Melbourne's Inner West).10 Similarly, although water sustainability rated well, access to fresh drinkable water is poor in many rural and remote communities, especially those housing Indigenous children.6,7,8,9 Even though there were no analyses by subpopulation, the data clearly showed that people who are poorer and marginalised (eg, Aboriginal and Torres Strait Islander people) are more likely to have less capacity to cope with the stresses and environmental conditions outlined in this report. Much data collected in Australia relevant to child wellbeing are not categorised by subpopulations,8,11 making meaningful examinations of disadvantage impossible. There are a number of climate and sustainability issues that are highly relevant to our children. Australia is experiencing unprecedented and extreme floods, fires, major heatwaves, and drought. These events lead to major changes in land use, population displacement, and disruption to children's schooling. The impacts of such events on mental health are being recognised, but perhaps less evident is an increase in child anxiety.12 A global survey of 10000 children and young people conducted in mid‐2021 reported that 82% of Australian children were at least moderately worried about climate change, with 32% reporting their anxiety negatively affected their functioning.12 Similar data were reported in the UNICEF report, with just over 40% of Australian young people stating they would be hesitant about having children due to climate change and a staggering 60% reporting beliefs that their government was betraying them and their future due to inadequate climate policies.3 Our children are subjected to predatory marketing One of the sustainability issues highlighted by the WHO–UNICEF–Lancet Commission report affecting children's future was predatory marketing.1 Children are specifically targeted by marketing of unhealthy and unsafe products, especially related to cigarettes and electronic cigarettes, junk food (high in calories, fat, sugar and salt), gambling, and sexualisation of children. Much attention has been paid to junk food and to sexualisation of children, and although these remain problems for Australian children, more attention needs to be paid to electronic cigarettes and gambling. Despite officially not available to Australian children, electronic cigarettes are becoming a growing problem, increasing exposure to toxic chemicals and nicotine, even in those claiming not to include nicotine.13,14 A major problem facing Australia's children is the enormous penetration of the gambling industry into their lives. It is not possible to watch sport without being bombarded by gambling advertising. Children readily recognise logos of gambling companies and are gaining the impression that gambling is harmless — after all if you lose you get your money back.15,16 What is perhaps more disturbing are the political donations from the gambling industry that are currently attracting media attention, which is reminiscent of the past behaviour of the tobacco industry.17,18 We encourage UNICEF to include measures of predatory marketing practices in their next report card. There are glimmers of hope on the horizon, with a public backlash against gambling advertising during televised sport. Very recently, a public push has emerged for the government to implement a comprehensive ban on sports gambling advertising following the release of the report from the Parliamentary Inquiry on Online Gambling and its Impacts on Those Experiencing Harm.19 Support is increasing among players of some sporting teams for their clubs to reduce reliance on gambling revenue. So, how can we improve the future of Australia's children and young people? Several groups, including an offshoot from the WHO–UNICEF–Lancet Commission known as CAP‐2030 (Children in All Policies 2030; https://cap‐2030.org/), have suggested viewing all government policy through a child's lens. This would see the responsible Minister explain to Cabinet how the new policy being promoted would affect children if adopted. This would advance several important goals; for example, the impacts on children would be actively considered, the natural government silos would be opened, and governments would be forced to think beyond the next election when framing policy. In addition, publicising the UNICEF Innocenti report widely and making Australia's ranking an instrument by which politicians can be held accountable would improve our children's future. Turning things around in the environment and sustainability domain is crucial to all living beings, as the goal of keeping global warming within 2°C is slipping further and further out of sight. Key indicators that can help us track our progress in this domain and ensure we can make a difference in this area for children, young people and future generations by 2030 include consumption‐based CO2 emissions, metric tonnes per capita; and the ratio of a country's ecological footprint to its biocapacity. In addition, we call for indicators of predatory marketing practices, such as electronic cigarettes, gambling and junk food. Our children are our future, but their future is under threat. A concerted effort is required to change this situation and putting children at the centre of all policy decisions would be a good start. Box – Environments and sustainable futures under threat for our young What are the most pressing issues where change could make a real difference by 2030 and why? Climate change, ecological degradation, migrating populations, conflict, pervasive inequalities, and predatory commercial practices threaten the health and future of children in every country. The welfare of our young is certainly under threat. What are some of the key indicator measures available and what is lacking? Key indicators: ‣ consumption‐based carbon dioxide (CO2) emissions, metric tonnes per capita; and ‣ the ratio of a country's ecological footprint to its biocapacity. What is lacking? ‣ Measures of predatory marketing practices (eg, junk food advertising, electronic cigarettes and gambling). What are the key baseline data on these indicator measures that are available? Australia's consumption‐based CO2 emissions since the Kyoto protocol was adopted in 1997 were 14.8 tonnes per person per year, ranking 39/43 (with the United States and Canada). If the rest of the world behaved like Australia, we would need five planets Earth to ensure survival for us and our children.

Peter D Sly · Fiona J Stanley

The health, social, and monetary costs of child abuse and neglect are indefensible on ethical, medical, and financial grounds

Leonie Segal · Harriet Hiscock