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

Cost effectiveness of a 1-hour high-sensitivity troponin-T protocol: an analysis of the RAPID-TnT trial

Background: To understand the economic impact of an accelerated 0/1-hour high-sensitivity troponin-T (hs-cTnT) protocol. Objective: To conduct a patient-level economic analysis of the RAPID-TnT randomised trial in patients presenting with suspected acute coronary syndrome (ACS). Methods: An economic evaluation was conducted with 3265 patients randomised to either the 0/1-hour hs-cTnT protocol (n = 1634) or the conventional 0/3-hour standard-of-care protocol (n = 1631) with costs reported in Australian dollars. The primary clinical outcome was all-cause mortality or new/recurrent myocardial infarction. Results: Over 12-months, mean per patient costs were numerically higher in the 0/1-hour arm compared to the conventional 0/3-hour arm (by $472.49/patient, 95$-1,380.15 to $2,325.13, P = 0.617) with no statistically significant difference in primary outcome (0/1-hour: 62/1634 [3.8$891.22/patient, 95 %CI: $-96.07 to 1,878.50, P = 0.077). Restricting the analysis to patients with hs-cTnT concentrations ≤ 29 ng/L, mean per patient cost remained numerically higher in the 0/1-hour arm (by$152.44/patient, 95 %CI:$-1,793.11 to$2,097.99, P = 0.988), whilst the reduction in ED LOS was more pronounced (by 0.70 h/patient, 95 %CI: 0.45–0.95, P < 0.001). Conclusions: There were no differences in resource utilization between the 0/1-hour hs-cTnT protocol versus the conventional 0/3-hour protocol for the assessment of suspected ACS, despite improved initial ED efficiency. Further refinements in strategies to improve clinical outcomes and subsequent management efficiency are needed.Ming-yu Anthony Chuang Emmanuel S. Gnanamanickam, Jonathan Karnon, Kristina Lambrakis, Matthew Horsfall, Andrew Blyth ... et al

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

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

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

Background: The extent of intergenerational transmission of child maltreatment is unclear due to methodological limitations in previous studies. In this study, we aimed to examine factors associated with intergenerational transmission of child maltreatment and quantify its extent in a population sample over a 30-year period in South Australia. Methods: In this retrospective cohort study, we used linked administrative data from the South Australian Birth Registry to identify dyads of mothers and their children both born in South Australia between July 1, 1986, and June 30, 2017. Three child protection system (CPS) outcomes (any CPS involvement, substantiated maltreatment, and time spent in out-of-home care) were computed from data obtained from the South Australian Department for Child Protection. Multivariable Cox regression models were used to estimate hazard ratios (HRs) for child CPS outcomes according to their mother's CPS exposure. Findings: 38 556 unique mother–child dyads were included. 458 (2·0%) of 23 437 children whose mothers had no CPS involvement in childhood had a substantiated report of maltreatment and 127 (0·5%) spent time in out-of-home care. By comparison, 970 (22·1%) of 4382 children whose mothers experienced substantiated maltreatment in childhood had substantiated maltreatment and 469 (10·7%) spent time in out-of-home care. After adjusting for potential confounders, children of mothers with any CPS involvement in childhood had an increased risk of CPS contact compared with children whose mothers had no CPS involvement; this risk was greatest for children of mothers who had both substantiated maltreatment and spent time in out-of-home care (HR 6·25 [95% CI 5·59–6·98] for any CPS involvement, 13·69 [10·08–16·92] for substantiated maltreatment, and 25·78 [18·23–36·45] for any time in out-of-home care). Risks of child CPS outcomes were substantially increased for children of mothers who had a first CPS notification under the age of 1 year or who had any CPS notification at age 13–17 years. Interpretation: Children are at high risk of maltreatment if their mother experienced maltreatment as a child. Assisting survivors of childhood maltreatment, particularly female survivors, provides a crucial intervention opportunity to help prevent further child abuse and neglect. Funding: Australian National Health and Medical Research Council; Channel 7 Children's Research Foundation.Jason M Armfield, Emmanuel S Gnanamanickam, David W Johnston, David B Preen, Derek S Brown, Ha Nguyen, 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

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 traumainformed family support services.Leonie Segal, Sharon Dawe, Ha Nguyen, Susan Dennison, Emmanuel S. Gnanamanickam, Megan Bell, Matthew Spittal, Stuart Kinner, David B. Pree