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

On Global Aspects Of Gauged Wess-Zumino-Witten Model

This is a thesis for Rigaku-Hakushi($\simeq$ Ph. D.). It clarifies the geometric meaning and field theoretical consequences of the spectral flows acting on the space of states of the `$G/H$ coset model'. As suggested by Moore and Seiberg, the spectral flow is realized as the response of states to certain change of background gauge field together with the gauge transformation on a circle. Applied to the boundary circle of a disc with field insertion, such a realization leads to a certain relation among correlators of the gauged WZW model for various principal $H$-bundles. In the course of derivation, we find an expression of a (dressed) gauge invariant field as an integral over the flag manifold of $H$ and an expression of a correlator as an integral over a certain moduli space of holomorphic $H_{\bf C}$-bundles with quasi-flag structure at the insertion point. We also find that the gauge transformation on the circle corresponding to the spectral flow determines a bijection of the set of isomorphism classes of holomorphic $H_{\bf C}$-bundles with quasi-flag structure of one topological type to that of another. As an application, it is pointed out that problems arising from the field identification fixed points may be resolved by taking into account of all principal $H$-bundles.Comment: (Thesis) 125 pages, UT-Komaba/94-3 (Latex errors are corrected

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

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

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