Leonie Segal, Jason M. Armfield, Emmanuel S. Gnanamanickam, David B. Preen, Derek S. Brown, James Doidge and Ha Nguyen
Pediatrics January 2021, 147 (1) e2020023416;
BACKGROUND: Child maltreatment (CM) is a global public health issue, with reported impacts on health and social outcomes. Evidence on mortality is lacking. In this study, we aimed to estimate the impact of CM on death rates in persons 16 to 33 years.
METHODS: A retrospective cohort study of all persons born in South Australia 1986 to 2003 using linked administrative data. CM exposure was based on child protection service (CPS) contact: unexposed, no CPS contact before 16 years, and 7 exposed groups. Deaths were observed until May 31, 2019 and plotted from 16 years. Adjusted hazard ratios (aHRs) by CPS category were estimated using Cox proportional hazards models, adjusting for child and maternal characteristics. Incident rate ratios (IRRs) were derived for major causes of death, with and without CPS contact.
RESULTS: The cohort included 331 254 persons, 20% with CPS contact. Persons with a child protection matter notification and nonsubstantiated or substantiated investigation had more than twice the death rate compared with persons with no CPS contact: aHR = 2.09 (95% confidence interval [CI] = 1.62–2.70) to aHR = 2.61 (95% CI = 1.99–3.43). Relative to no CPS contact, persons ever placed in out-of-home care had the highest mortality if first placed in care aged ≥3 years (aHR = 4.67 [95% CI = 3.52–6.20]); aHR was 1.75(95% CI = 0.98–3.14) if first placed in care aged <3 years. The largest differential cause-specific mortality (any contact versus no CPS contact) was death from poisonings, alcohol, and/or other substances (IRR = 4.82 [95% CI = 3.31–7.01]) and from suicide (IRR = 2.82 [95% CI = 2.15–3.68]).
CONCLUSIONS: CM is a major underlying cause of potentially avoidable deaths in early adulthood. Clinical and family-based support for children and families in which CM is occurring must be a priority to protect children from imminent risk of harm and early death as young adults.Abbreviations:ACE — adverse childhood experienceaHR — adjusted hazard ratioCI — confidence intervalCM — child maltreatmentCPM — child protection matterCPS — child protection serviceDCP — Department for Child ProtectionHR — hazard ratioICD-10 — International Classification of Diseases, 10th RevisionIRR — incident rate ratioIRSD — Index of Relative Socioeconomic DisadvantageNOC — notifier only concernOOHC — out-of-home careRR — rate ratioSA — South Australia
What’s Known on This Subject:
Child maltreatment (CM) impacts a wide range of health conditions across the life course, including mental illness and substance use disorders. Impacts on mortality in late adolescence and early adulthood have not been reported.
What This Study Adds:
Persons exposed to CM have considerable excess risk of death during late adolescence and young adulthood. Adjusted hazard ratios were 1.75 to 4.67 times that of persons without CM exposure. Death from substances and suicide contributed most to excess mortality.
Child maltreatment (CM) is a major public health and social welfare issue in Australia1 and globally.2,3 Large numbers of children are exposed, estimated at 25% of young people in the United States,4 20% of Australians,5,6 and a higher proportion (up to 50%) of the global population.3 The consequences of CM are extensive.2,7 CM has profound effects on mental and physical health during childhood and across the life course.7,8 It also impacts economic and social outcomes, such as school participation9 and achievement, welfare dependency, addiction, risky sexual behaviors, and involvement in violence.10 The described physiological effects of child abuse and neglect on brain development, stress, and inflammatory responses support the observations as causal.11,12
Despite a vast amount of literature on the impacts of child abuse and neglect, the effect on mortality has received limited attention, especially in adolescence and young adulthood. The seminal Adverse Childhood Experiences (ACEs) Study13 found adults self-reporting >6 ACEs (CM and household dysfunction) died, on average, 20 years earlier than those reporting no ACEs.14 But only 15% of study participants were younger than 40 years on enrollment. In a UK study of persons born in 1958, researchers reported higher adjusted hazard ratios (aHRs) for death before age 50 in persons with >2 ACEs compared with those with none,15 and in a Swedish study of persons born in 1953, researchers reported a higher risk of death before age 65 in persons with child protection service (CPS) involvement relative to none.16 In neither study did researchers report the specific mortality impact in early adulthood.
Late adolescence and early adulthood is a crucial developmental stage, in which the effects of mental illness, suicidality, and substance use drive a sharp increase in death rates.17,18 Yet we know little about whether CM contributes to these premature deaths. With the current study, our aim was to address this evidence gap, examining all-cause and cause-specific mortality by CM exposure in individuals aged 16 to 33 years, as indicated by CPS involvement.
Studies ascertain CM exposure through either (1) surveys of survivors (years or decades after events), parents, educators, or other service providers or (2) administrative records of child protection agencies or death registries. All methods suffer potential sources of error. Survey-based methods are subject to recall failure (especially of early-in-life events), the distorting effect of community norms, social acceptability bias, survivor bias, and variable thresholds for CM. CPS involvement as an indicator of CM avoids these pitfalls but also can involve imperfect case ascertainment. However, in jurisdictions with wide-spread mandatory reporting of suspected CM, serious maltreatment is unlikely to go unreported. CPS administrative categories, designed to ensure a proportionate response by child protection authorities, can be used as indicators of the levels of CM exposure. CPS administrative data are really the only option for CM ascertainment to explore the association between CM and death in early adulthood at the population level, given the rareness of the outcome.