Australia’s first national prevalence study of all forms of child abuse and neglect reveals that the typical experience of maltreatment is of multiple types, write Professors Daryl Higgins and Ben Mathews.
In the Australian Child Maltreatment Study (ACMS) published today as a supplement in The Medical Journal of Australia, we surveyed 8500 randomly selected Australians aged 16 and over, asking about experiences of each type of child maltreatment (see Section S5 of the supplement).
We found the following prevalence rates of individual types of child maltreatment:
- neglect – 8.9%;
- sexual abuse – 28.5%;
- emotional abuse – 30.9%;
- physical abuse – 32.0%; and
- exposure to domestic violence – 39.6% (see Section S19).
Some of these maltreatment types have been found to be strongly associated with mental disorders (see Section S26) and health risk behaviours (see Section S34).
Although it is sobering to learn these results, and that 62.2% of Australians aged 16 years and over have experienced one or more types of child maltreatment, there’s even more to the story.
Traditionally, our view of child maltreatment has focused on the experience of individual types, without considering the possibility of their overlap.
For Australians who experience any childhood maltreatment, experiencing more than one type is a common experience.
Australian children are more likely to experience multitype maltreatment (39.4%) than single-type maltreatment (22.8%) (see Section S19).
The six most prevalent combinations all included exposure to domestic violence – affecting one-third of the population.
Although it is the most prevalent form of child maltreatment overall (39.6%), exposure to domestic violence is much less frequently experienced alone (by 8.3% of Australians) than in combination with other forms of maltreatment (31.2%).
Health practitioners need to be alert to the greater risk of multitype maltreatment and associated harm both generally, and particularly for females and for those who question or identify with a diverse gender category. Women were more likely to report multitype maltreatment in childhood (43.2%) than men (34.9%). But gender-diverse participants reported the highest prevalence (66.1%).
We found that four types of family adversity created more than twice the risk of multitype maltreatment:
- parental separation or divorce;
- living with someone who was mentally ill, suicidal or severely depressed;
- living with someone who had a problem with alcohol or drugs; and
- family economic hardship.
How should we respond?
In addition to deploying public health strategies, which we discuss in S47 of the supplement, to prevent all forms of child maltreatment, additional strategies are needed to address and respond to the high prevalence of multitype maltreatment and its greater health burden.
Better support for children and parents in families at risk
When health professionals see children, whose families are encountering these challenges, they should heighten their efforts to be aware of their risk of harm from child maltreatment in multiple forms.
Equally, when professionals across a variety of sectors work with parents who are going through adversities, they need to ask child-centred questions about their care responsibilities, and what’s going on for the young people in their lives. Resources for child-centred questions can be found on the Australian Catholic University’s website.
Using trauma-informed culturally aware approaches to treat patients, professionals can supportively convey information about the increased risk of one of the most challenging and impactful forms of childhood adversity: multitype maltreatment.
When parents are separating or struggling with their own experiences of mental ill health, substance misuse, economic hardship, or family violence, health care providers need to find ways of incorporating a focus on their children.
Even if their personal challenges cloud their ability to keep focused on child safety, health care practitioners can assist by regularly asking about their children and having direct interactions with children.
Governments at both federal and jurisdictional levels should use public health strategies that have prevention measures targeting multiple child maltreatment types and employ broad strategies targeting multiple risk factors and points of vulnerability, including families experiencing violence, divorce, mental illness, substance misuse, or economic hardship.
Prevention, protection and treatment services in each jurisdiction must coordinate to create safety and recovery from all forms of child maltreatment, particularly when they occur in combination. A useful example of this approach has been developed by the National Children’s Advocacy Center in Huntsville, Alabama, in the United States. Prevention of children’s exposure to domestic violence must be connected to the prevention of other types of child maltreatment.
It is now time for Australia’s child maltreatment prevention strategies to link up with those that address the burden of mental illness in Australia.
However, the likelihood of experiencing mental illness, being the highest for people who experience more than one type of abuse or neglect, means there are opportunities for early intervention to address the consequences of maltreatment if practitioners pay closer attention to the earliest signs of risk.
Public health strategies should support families with access to evidence-based parenting supports, tailored to their life circumstances and challenges.
Better support for adult survivors
People who have experienced multiple types of child maltreatment are at much greater risk of experiencing mental disorders, compared with those who experienced a single type or no child maltreatment.
We found over half (54.8%) of participants who experienced multitype maltreatment reported a mental disorder in adulthood. The rate of mental disorders was lower for those experiencing any single type of maltreatment (36.2%), and lower again for those with no childhood maltreatment (21.6%) (see Section S26). For health practitioners, this has major implications for diagnosis, individual patient care, and support.
We also found that experiencing more than one type of child maltreatment was associated with higher rates of health risk behaviours such as smoking, obesity and binge drinking, but particularly cannabis dependence, self-harm, and suicide attempts (see Section S34).
When responding to clients’ health risk behaviours, we must create space for them to talk about their experience of child maltreatment, and of multiple types. If practitioners work in a substance misuse service, or provide suicide interventions, they should be mindful that their client group likely includes a majority of victim-survivors of multiple forms of child maltreatment. Interventions will be more effective if practitioners help to identify these early traumas.
Better support for children from a multitype lens
In our opinion, health practitioners, including those who hear disclosures of maltreatment from children and adolescents for the first time, need to be alert that their patient may have already experienced more than one type of maltreatment. It is important to consider all maltreatment types the patient may be experiencing and their potential impacts.
We believe child welfare professionals also need to intensify provision of trauma-informed counselling and healing services for children and adolescents if they experience a form of child maltreatment. This is essential to protect them from further harm from other forms of maltreatment.
Where to from here?
At the societal level, we call for improved public health prevention measures to address the intersections between different types of child maltreatment for all children, with additional special attention to girls and gender-diverse individuals.
For more on prevention measures, see S47 of the Supplement.
At the service level, doctors and other health practitioners, as well as child welfare and prevention services, must assess and respond to the high likelihood of children’s experience of not only one but multiple forms of maltreatment.
To enable this, pre-service and in-service training must equip all health practitioners with the knowledge and skills to:
- understand the nature of each type of child maltreatment and associated harms;
- identify child maltreatment in child and adolescent patients; and
- support and treat patients — children, adolescents or adults — who have experienced child maltreatment.
Such enhanced professional education will promote the routine consideration of child maltreatment — and multitype maltreatment — when treating mental health, and health risk behaviours across life.
Professor Daryl Higgins is Director of the Institute of Child Protection Studies at the Australian Catholic University, Melbourne, Australia.
Professor Ben Mathews is Principal Research Fellow in the School of Law at Queensland University of Technology (QUT) in Brisbane, Australia; a member of the Australian Centre for Health Law Research at QUT; and Adjunct Professor at Johns Hopkins University, Bloomberg School of Public Health, in Baltimore, USA.
Read InSight+ next week for examples of child maltreatment prevention and what actions can be taken, in an opinion piece by ACMS researchers Hannah Thomas, Divna Haslam, and Holly Erskine.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
Subscribe to the free InSight+ weekly newsletter here. It is available to all readers, not just registered medical practitioners.
If you would like to submit an article for consideration, send a Word version to firstname.lastname@example.org.