Preventing child maltreatment: everyone's responsibility

The profound effects of child maltreatment on health and wellbeing have long been voiced by survivors, write Hannah Thomas, Divna Haslam, Holly Erskine.

Knowledge of how widespread child maltreatment is across the Australian population and how extensive the associated harm is across the lifespan has been vastly underestimated, until now.

Child maltreatment is not something that happens to a small number of disadvantaged children, nor does its impact cease when the maltreatment stops.

The new Australian Child Maltreatment Study, published in the supplement of the 3 April 2023 edition of The Medical Journal of Australia, finds that it is widespread and associated with dramatically increased odds of mental disorders and other health risks.

Experiences of child maltreatment are likely to be a core contributing factor in most people presenting to services with mental and physical health-related issues.

Without appropriate intervention, the trauma associated with child maltreatment appears to perpetuate poor health across a person’s life, placing additional burden on an already struggling health system.

Child maltreatment and the transmission of risk

Experiences of child maltreatment activate the biological stress response, trigger epigenetic change, heighten threat perception, alter emotion regulation processes, and, in turn, shape beliefs about self and others. Children are highly vulnerable to internalising abusive emotional messages or blame themselves for their experiences. This can have a detrimental impact on their developing sense of worth and identity, and place them at risk of using harmful coping strategies and ways of relating to others. In adolescence and adulthood, these problems have a cascading effect and result in further elevated risk for poor health.

Latest data on child maltreatment

We recently published data from the Australian Child Maltreatment Study using a sample of 8503 randomly selected Australians aged 16 years and older (see S5). Our study generated the first reliable estimates of the national prevalence of child maltreatment in Australia and its associated impacts.

Our findings are staggering (see S3). Three in five Australians (62%) experienced at least one of the five types of child maltreatment (see S13), with each type prevalent across the Australian population: exposure to domestic violence (39.6%), physical abuse (32%), emotional abuse (30.9%), sexual abuse (28.5%), and neglect (8.9%). Two in five (39.4%) Australians experienced more than one type of child maltreatment (see S19).

Every mental disorder and health risk behaviour assessed was substantially higher in Australians who experienced child maltreatment.

Mental disorders were much more common among those who experienced child maltreatment (48% v 21.6%). Australians who experienced child maltreatment were between 2.6 and 4.6 times more likely to have one of four mental disorders (see s26), which were assessed using a diagnostic instrument: post-traumatic stress disorder, major depressive disorder, generalised anxiety disorder, and severe alcohol use disorder. This pattern was seen across men and women, and three age groups (16–24 years, 25–44 years, 45 years and older).

Similar patterns were found for health risks (see s34). Australians who experienced child maltreatment were 6.2 times more likely to have cannabis dependence, 4.6 times more likely to have attempted suicide in the prior 12 months, and 3.9 times more likely to have self-harmed in the prior 12 months. They were also more likely to smoke, binge drink, and be obese. In adults aged 25 years and older, almost all the identified cases of cannabis dependence, self-harm and suicide attempts occurred in those who had experienced child maltreatment.

The types of child maltreatment people experience also play a role predicting outcomes. We found that emotional abuse, sexual abuse, and multitype maltreatment (exposure to more than one type) were most strongly associated with negative health outcomes. In addition to maintaining the current focus on preventing sexual abuse, these findings also emphasise the importance of preventing emotional abuse, which may be particularly damaging, alongside other forms of child maltreatment such as exposure to domestic violence. The damage of these types of abuse must not be overlooked as they account for a considerable proportion of cases of child maltreatment and are independently associated with increased risk of mental disorders and health risk behaviours.

A call to action

Mental ill-health places significant burden on the health care system, estimated by the productivity commission to be $200–$220 billion annually. If Australia wishes to reduce the health burden and adequately address the mental health crisis, reducing child maltreatment must form part of the plan.

The results of our study signal a two-part call to action.

First, the results highlight the need to enhance trauma-informed health care for survivors of child maltreatment. While this form of care is becoming more widely adopted in specialist mental health settings, it is also highly relevant in primary health care, where a large proportion of health service encounters involve an aspect of mental health. In addition to the important moral imperative, there is a strong economic argument for action, given a lack of treatment or delays to treatment results in increased costs to the health system in the long term. Better meeting the health needs of survivors of child maltreatment as early as possible may help in reducing future health problems and health service costs.

Second, significant investment in prevention and early intervention for all five types of child maltreatment is needed. The prevention of child maltreatment and its associated harms must be a founding principle of mental health policy. This requires attention to three major priorities:

• We need to better integrate prevention and early intervention efforts by having closer service partnerships between child protection and health systems. For example, we need to better support vulnerable parents, who themselves may be survivors of child maltreatment, to access and engage with treatment for mental and substance use disorders.
• Parenting skills must be strengthened at a population level through widespread implementation of evidence-based parenting interventions for all parents with caregiver responsibilities.
• In addition to universal prevention programs, we recommend targeted parenting interventions for vulnerable families to help break intergenerational cycles. This form of support may also be needed during key developmental risk periods such as the perinatal period and early childhood, as well as during times of transiton or high stress (eg, economic hardship, parent separation or divorce).

We argue that these strategies are key to a concerted effort to addressing all types of child maltreatment, but particularly emotional abuse, which despite its high prevalence, to date has received much less attention. To reduce emotional abuse, it is imperative we offer support to ensure parents’ own needs are met so they have the desire, capacity and self-regulation to provide predictable loving environments free of violence and abuse.

Without sustained, universal prevention and early intervention, it is unlikely there will be a significant shift in the prevalence of child maltreatment. We acknowledge that these combined efforts also need to be underpinned by other important social policies, such as a living minimum wage, welfare support, affordable housing, access to childcare, and development of positive social norms.

The Australian Child Maltreatment Study marks the first time that the extent and impact of child maltreatment has been quantified at a national level. The results show child maltreatment is a significant factor in the health of an individual over their life. We must do more and now is the time to do it.

Dr Hannah Thomas is a Research Fellow and Clinical Psychologist at the Queensland Centre for Mental Health Research.

Divna Haslam is a  clinical psychologist and family researcher in the Faculty of Law at Queensland University of Technology.

Associate Professor Holly Erskine leads the Child and Adolescent Psychiatric Epidemiology and Services (CAPES) research stream at the Queensland Centre for Mental Health Research. She is also an Adjunct Associate Professor with the School of Public Health at the University of Queensland.

Read last week’s InSight+ article by Daryl Higgins and Ben Mathews about the Australian Child Maltreatment Study and the shocking findings.

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. 

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