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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 self-harm, 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.

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. Refereed/Peer-reviewed

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. Refereed/Peer-reviewed

Background: Child protection services exist to reduce potential harms from child maltreatment. Many jurisdictions produce annual data on child protection system (CPS) involvement, leaving a gap in knowledge of lifetime involvement. Objective: To describe lifetime involvement in CPS, by type of contact. Participants: All 608,547 children born in South Australia (SA), Australia between 1986 and 2017. Methods: A retrospective cohort design using linked administrative data to report cumulative incidence of CPS involvement from birth to age

Adverse childhood experiences have wide-ranging impacts on population health but are inherently difficult to study. Retrospective self-report is commonly used to identify exposure but adult population samples may be biased by non-response and loss to follow-up. We explored the implications of missing data for research on child abuse and neglect, domestic violence, parental mental illness and parental substance use. Using 15 waves of data collected over 28 years in a population-based birth cohort, the Australian Temperament Project, we examined the relationship between retrospective self-reports of adverse childhood experiences and parent- and cohort-responsiveness at other time points. We then compared prevalence estimates under complete case analysis, inverse probability-weighting using baseline auxiliary variables, multiple imputation using baseline auxiliary variables, multiple imputation using auxiliary variables from all waves, and multiple imputation using additional measures of participant responsiveness. Retrospective self-reports of adverse childhood experiences were strongly associated with non-response by both parents and cohort members at all observable time points. Biases in complete case estimates appeared large and inverse probability-weighting did not reduce them. Multiple imputation increased the estimated prevalence of any adverse childhood experiences from 30.0% to 36.9% with only baseline auxiliary variables, 39.7% with a larger set of auxiliary variables and 44.0% when measures of responsiveness were added. Close attention must be paid to missing data and non-response in research on adverse childhood experiences as data are unlikely to be missing at random. Common approaches may greatly underestimate their prevalence and compromise analysis of their causes and consequences. Sophisticated techniques using a wide r ange of auxiliary variables are critical in this field of research, including, where possible, measures of participant responsiveness. Refereed/Peer-reviewed

A correlation between socioeconomic disadvantage and child maltreatment has long been observed, but the drivers of this association are poorly understood. We sought to estimate the effects of economic factors on risk of child maltreatment after adjusting for other known influences using the Australian Temperament Project, a population-based birth cohort of 2443 individuals and their parents. We used logistic regression to estimate associations of childhood economic factors (parental education, occupation, and unemployment; type of housing; and retrospective perception of poverty) with retrospective reports of perceived child maltreatment (physical abuse, sexual abuse, emotional abuse, neglect, and witnessing of domestic violence), controlling for demographic factors, parental mental health and substance use, and child health. We then used these estimates to approximate the proportions of child maltreatment-population attributable fractions-that are theoretically preventable by addressing childhood economic disadvantage. Economic factors were associated with all types of child maltreatment. For the most part, these associations diminished only partially when controlling for noneconomic confounders, supporting hypotheses of causal relationships. Jointly, economic factors were significant predictors of physical abuse, sexual abuse, and witnessing of domestic violence but not of emotional abuse or neglect. Retrospective perceptions of childhood poverty were, in particular, strongly associated with most forms of child maltreatment but not with sexual abuse after accounting for other economic factors. We estimated that 27% of all child maltreatment was jointly attributable to economic factors. These findings suggest that strategies that reduce economic disadvantage are likely to hold significant potential to reduce the prevalence of child maltreatment. Refereed/Peer-reviewed

Child maltreatment and other adverse childhood experiences adversely influence population health and socioeconomic outcomes. Knowledge of the risk factors for child maltreatment can be used to identify children at risk and may represent opportunities for prevention. We examined a range of possible child, parent and family risk factors for child maltreatment in a prospective 27-year population-based birth cohort of 2443 Australians. Physical abuse, sexual abuse, emotional abuse, neglect and witnessing of domestic violence were recorded retrospectively in early adulthood. Potential risk factors were collected prospectively during childhood or reported retrospectively. Associations were estimated using bivariate and multivariate logistic regressions and combined into cumulative risk scores. Higher levels of economic disadvantage, poor parental mental health and substance use, and social instability were strongly associated with increased risk of child maltreatment. Indicators of child health displayed mixed associations and infant temperament was uncorrelated to maltreatment. Some differences were observed across types of maltreatment but risk profiles were generally similar. In multivariate analyses, nine independent risk factors were identified, including some that are potentially modifiable: economic disadvantage and parental substance use problems. Risk of maltreatment increased exponentially with the number of risk factors experienced, with prevalence of maltreatment in the highest risk groups exceeding 80%. A cumulative risk score based on the independent risk factors allowed identification of individuals at very high risk of maltreatment, while a score that incorporated all significant risk and protective factors provided better identification of low-risk individuals. Refereed/Peer-reviewed