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.Leonie Segal, James Doidge, Jason M. Armfield, Emmanuel S. Gnanamanickam, David B. Preen, Derek S. Brown, Ha Nguye

Predictors of dental avoidance among Australian adults with different levels of dental anxiety

Objectives: It has been proposed that avoidance of dental visits might be the main determinant of poor oral health outcomes in people with high dental anxiety (HDA). This study aimed to determine the predictors of dental avoidance among people with HDA and also whether these predictors differed from those found in people with lower dental anxiety (LDA). Method: Study participants (n = 596; response rate = 41.1%) comprised a random cross-sectional sample of the Australian adult population who completed a mailed self-complete questionnaire containing items relating to the use and accessibility of dental services, trust in dental professionals, dental anxiety, dental experiences, self-perceived oral health, vulnerability-related perceptions of visiting the dentist, and psychological health. Multiple imputation was used to replace missing values and statistically significant variables in bivariate analyses were entered into a multivariable logistic generalized linear model. Results: More than two-thirds of participants with HDA were currently avoiding or delaying a dental visit. Among people with HDA, dental avoidance was independently and significantly predicted by difficulty paying a $300 dental bill, having no or only little trust in the last-visited dentist, perceived treatment need and dental anxiety. Among people with LDA, only perceived treatment need and dental anxiety predicted avoidance. Conclusions: In addition to their high anxiety, a number of additional barriers to dental visiting were found for people with HDA. These barriers, especially cost and communication issues with dentists, need to be addressed to assist people with HDA obtain necessary, regular dental care

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$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.Emmanuel S. Gnanamanickam, Derek S. Brown, Jason M. Armfield, Leonie Sega

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 highrisk 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.Jason M. Armfield, Lesley-Anne Ey, Carole Zufferey, Emmanuel S. Gnanamanickam, Leonie Sega

Temporomandibular dysfunction experience is associated with oral health-related quality of life: an Australian national study

Background: There are very few studies of the association between temporomandibular dysfunction (TMD) and oral health-related quality of life (OHRQoL) in a representative sample from the Asia–Pacifc region. Accordingly, we aimed to quantify the association of TMD with OHRQoL dimensions and overall measurement scores in a representative sample of Australian adults while accounting for a range of confounders, and statistically estimating whether TMD experience is meaningfully associated with OHRQoL. Method: Australia’s National Survey of Adult Oral Health 2004–2006 data were used. The outcome variables were the Oral Health Impact Profle (OHIP-14) domains and overall scores while the main exposure was self-reported Diagnostic Criteria Question for TMD. The analysis accounted for confounders including oral health status obtained from the oral examination, demographics, socioeconomics, health behaviours and health including perceived stress subscales of the PSS-14. We conducted complex samples analysis while using Cohen’s f 2 efect size to estimate whether the association is meaningful. Results: TMD prevalence was 9.9% (95% CI: 8.4–11.6%) among 4133 Australian adults. TMD experience was associated with impairments to the seven OHIP-14 OHRQoL domains (P<.05) with higher impairments observed in physical pain (B=0.82, 95% CI: .45–1.20, P<.001), psychological discomfort (B=0.68, 95% CI: .29–1.06, P=.001) and psychological disability (B=0.52, 95% CI: .20–.84, P=.001) in adjusted multivariate analyses. The diference in the mean OHIP-14 scores for those reporting TMD (Mean=13.1, 95% CI: 12.0–14.0) and those who did not (Mean=6.6, 95% CI: 6.0–6.8) was signifcant (t=7.51, P<.001). In an adjusted multivariable model for OHIP-14 scores, TMD experience was associated with higher OHIP-14 scores (B=3.34, 95% CI: 1.94–4.75, P<.001) where the Cohen’s f 2 was .022. Further, perceived stress subscales: perceived distress and perceived control were associated with TMD experience and OHIP14 scores (P<.05). Conclusion: Lower OHRQoL was observed in Australian adults who reported TMD experience but with small clinical importance which might support considering TMD in regular dental care. The higher impairments observed in physical pain, psychological discomfort and psychological disability domains of OHRQL can help clinicians and researchers focus their attention on these domains. The confounding efect exhibited by the perceived stress subscale might support their inclusion in future TMD and OHRQoL research.Kamal Hanna, Rahul Nair, Najith Amarasena, Jason M. Armfeld, and David S. Brenna

Australian children’s oral health behaviours

JM Armfield, S Chrisopoulos, KG Peres, KF Roberts-Thomson and AJ Spence

School absenteeism associated with child protection system involvement, maltreatment type, and time in out-of-home care

Greater school absenteeism is associated with numerous negative educational outcomes. We used a retrospective cohort design with linked administrative data on 296,422 children to examine the relationship between school absenteeism and child protection system (CPS) involvement. Children with substantiated maltreatment had 4.1 times more unexplained and problem absences than children with no CPS involvement. In multivariate analyses, children with substantiated maltreatment had significantly greater "chronic" truancy (OR = 3.41) and less "acceptable" levels of absences (OR = 0.74) compared to children with no CPS involvement. Greater absenteeism was seen for children with substantiated neglect and who had their first CPS notification earlier in life. Being in out-of-home care for 3+ years was a protective factor for children who had a CPS notification before age 5. Additional adversities had a strong additive effect with CPS involvement on absenteeism and chronic truancy. This study demonstrates the potential scope for reducing problem absenteeism and helps inform the public debate regarding how the type and timing of CPS involvement might ameliorate or exacerbate harm for children.Jason M. Armfield, Emmanuel Gnanamanickam, Ha T. Nguyen, James C. Doidge, Derek S. Brown, David B. Preen, and Leonie Sega

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 selfharm, 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.Emmanuel S. Gnanamanickam, Ha Nguyen, Jason M. Armfield, James C. Doidge, Derek S. Brown, David B. Preen, Leonie Sega

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

BACKGROUND: Despite considerable health consequences of child abuse and neglect, there is limited evidence on hospitalizations in this population. OBJECTIVES: To describe frequency and reasons for hospitalization by lifetime child protection system (CPS) involvement. PARTICIPANTS: 608,540 children born from January 1, 1986 to June 30, 2017 in South Australia, Australia METHODS: Using linked administrative data on CPS involvement and hospitalizations, we descriptively examined cumulative incidence, cumulative count and reasons for hospitalization from infancy to early adulthood by CPS involvement. RESULTS: By 16.5 years of age, cumulative incidence of ever-being hospitalized was 58% (95% CI 58-58) for children with no CPS involvement and significantly higher (72% (95% CI 71-73) to 88% (95% CI 86-90), P < 0.001) among those with different levels of CPS involvement. Cumulative mean counts of hospitalizations were highest at every age for those placed in out-of-home-care (reaching 7.7 by 16.5 years), almost four times higher than for children with no CPS involvement (2.0 by 16.5 years). Most frequent reasons for hospitalizations were similar across CPS involvement in the early years. From adolescence through early adulthood, mental health, and 'injury, poisoning or toxic effects of drugs' were frequent reasons for hospitalization among individuals with CPS involvement. CONCLUSIONS: This study highlights the vulnerability of children who have been maltreated, or are at risk of maltreatment, and the urgency of implementing effective preventive strategies early in life including consideration of adequate responses of child protection services. Frequent hospitalizations for mental health and injury confirms the potentially preventable nature of these hospitalizations.Emmanuel Sumithran Gnanamanickam, Ha Nguyen, Jason M.Armfield, James C.Doidge, Derek S.Brown, David B.Preen, Leonie Sega