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BACKGROUND: Reducing the over-representation of Aboriginal children in the child protection system is a key target for the Australian government. OBJECTIVE: We aimed to provide more recent evidence on the population-level cumulative incidence of contacts for Aboriginal children with child protective services (CPS) in Western Australia (WA). PARTICIPANTS AND SETTING: Linked administrative data was provided for WA CPS between 2000 and 2015 for 33,709 Aboriginal children born in WA between 2000 and 2013. METHODS: Descriptive summaries and cumulative incidence estimates were used to examine changes in CPS contact trends over time and within sibling groups. RESULTS: There was an increase in early-childhood contacts for children born more recently, with 7.6 % and 2.3 % of children born in 2000-2001 having a notification and placement in out-of-home care by age one, respectively, compared to 15.1 % and 4.3 % of children born in 2012-2013. Among sibling groups where at least one sibling had a CPS contact, approximately half of children had their first contacts on the same date as another sibling. For children born after one of their siblings had been placed in out-of-home care, 31.9 % had themselves been placed in out-of-home care by age one. CONCLUSIONS: Multiple children tend to be placed into out-of-home care when at least one sibling is, which is likely to have a significant impact on families affected. The additional risk of placement also carries over to children born after the first removal in a sibling group, highlighting the need for further support to prevent future removals.

Background: Functional Family Therapy – Child Welfare (FFT-CW®) aims to reduce the risk of child maltreatment and out-of-home care entry for vulnerable children. Objective: To identify enablers and barriers to implementing FFT-CW® into the routine delivery of child protection services from policy and service provider perspectives. Participants/setting: Eighteen program and policy experts, and 54 service providers, involved in the delivery of FFT-CW® across 6 districts in New South Wales, Australia. Methods: Semi-structured interviews with policy and program experts, and four discussion groups with service providers using nominal group technique (NGT). Interview data were thematically analyzed to identify enablers and barriers. An adapted Consolidated Framework for Implementation Research (CFIR) scoring system was used to quantify themes, with scores of −2 assigned for barriers, 0 for neutral, and 2 for enablers. NGT was used to generate and rank enablers and barriers of program implementation with service providers. Results: The semi-structured interviews generated 16 themes, from which three enablers and four barriers were identified using CFIR scoring. The NGT discussions generated nine enablers and eight barriers. Key enablers common to both interviews and NGTs were FFT-CW's therapeutic and empowering approach, model purveyor training and support, and the supervision and feedback provided to service providers. Key barriers included referral difficulties, staff burnout, turnover and training logistical challenges, and problems with data collection and the safety impacts of outcome measures on participants. Conclusions: Sustained uptake of FFT-CW® is likely feasible and evaluating its effectiveness within the routine delivery of NSW child protection services is warranted.

Background: Multisystemic Therapy for Child Abuse and Neglect (MST-CAN) aims to reduce the likelihood of child maltreatment and out-of-home care (OOHC) entry for high-risk children aged between six and 17 years. Objective: To identify the key enablers and barriers to implementing MST-CAN into the routine delivery of child protection services. Participants/setting: Twenty MST-CAN and policy experts, and 25 service providers, involved in the delivery of MST-CAN in New South Wales (NSW), Australia. Methods: Semi-structured interviews with MST-CAN and policy experts were thematically analyzed to identify enablers and barriers to the uptake of MST-CAN. These themes were quantified using a modified Consolidated Framework for Implementation Research (CFIR) scoring approach: −2 for barriers, 0 for neutral, and 2 for enablers. The nominal group technique (NGT) identified and ranked the enablers and barriers to MST-CAN delivery perceived by service providers in two discussion groups. Results: The semi-structured interviews generated 15 themes, of which two enablers and four barriers were identified using CFIR scoring. The two NGTs identified six enablers and six barriers. Key enablers common to both interviews and NGTs were the training and supervision of therapists delivering MST-CAN in NSW, and MST-CAN's analytic approach. Key barriers included referral and adaptation challenges for the NSW context and population (including Aboriginal families), staff recruitment difficulties, and problems with the absence and interpretation of outcome data. Conclusions: Barriers to sustained implementation of MST-CAN may be overcome by revising staff qualification thresholds and data collection procedures, and improved adaptation of MST-CAN in partnership with Aboriginal organizations.

Family-based therapy is a common front-line strategy to prevent child maltreatment in high-risk families. This review aimed to systematically assess the evidence of the effect of family-based therapy programs on child maltreatment outcomes. CINAHL, Scopus and PsycINFO were systematically searched to March 25, 2023. Outcome data were extracted for child protection reports and out-of-home care (OOHC) placements from administrative data, and parent- or child-reported maltreatment risk. 12 RCTs and two observational studies of 8,410 screened were included. All 14 studies had high risk of bias. Sample sizes ranged from 43 in an RCT to 3875 families in an observational study. In seven studies with child protection report risk estimates, five studies (3 RCTs, 2 observational) showed results in favor of the intervention (risk differences (RD) of 2.0–41.1 percentage points) and two RCTs in favor of the comparison (RD, 2.0–8.6 percentage points). In the four studies with OOHC risk estimates, three studies (2 RCTs, 1 observational) showed results in favor of the intervention (RD, 0.9–17.4 percentage points) and one observational study showed results in favor of the comparison (RD, 1.5 percentage points). Most studies had ≤ 100 participants, did not estimate main causal effects, and had high risk of bias. Thus, although family-based therapy programs may reduce child maltreatment, the high risk of bias, typically small sample sizes (> 62% of studies had sample sizes < 100), and inconsistent results across studies means it is currently unclear whether family-based therapy interventions achieve better child maltreatment outcomes, compared with usual care services.

OBJECTIVE: Evaluate ear health and hearing among urban Aboriginal children and quantify relationships with child, family and social factors. METHODS: Baseline questionnaire and ear health examinations from 1430 children with diagnoses (0.5-18 years) attending Aboriginal Health Services enrolled in SEARCH. Ear health outcomes were Otitis Media (OM), and hearing loss (three-frequency average hearing loss >20dB) diagnosed using pneumatic otoscopy, tympanometry, and audiometry. RESULTS: Half the children 0.5-3 years had OM (51.5%, 136/264). One third 0.5-18 years (30.4%; 435/1430) had OM, including 1.8% (26/1430) with perforation (0.8% chronic suppurative OM, 0.6% dry perforation and 0.4% acute OM with perforation). One quarter 0.5-18 years (25.7%; 279/1087) had hearing loss; 12.4% unilateral, 13.2% bilateral (70.6% with bilateral loss had concurrent OM). OM was associated with: younger age (0.5-<3 years versus 6-18 years) age-sex-site; adjusted prevalence ratio (aPR)=2.64, 95%, 2.18-3.19); attending childcare/preschool (aPR=1.24, 95%CI, 1.04-1.49); foster care (aPR=1.40, 95%CI, 1.10-1.79); previous ear infection/s (aPR=1.68, 95%CI, 1.42-1.98); and ≥2 people/bedroom (aPR=1.66, 95%CI, 1.24-2.21). Hearing impairment was associated with younger age (0.5-<6 years vs. ≥6 years aPR=1.89, 95%CI, 1.40-2.55) and previous ear infection (aPR=1.87, 95%CI, 1.31-2.68). CONCLUSIONS: Half the urban Aboriginal children in this cohort had OM and two-thirds with hearing impairment had OM. IMPLICATIONS FOR PUBLIC HEALTH: Findings highlight importance of early detection and support for ear health, particularly in pre-school-aged children with risk factors.

INTRODUCTION: Perinatal outcomes for singleton pregnancies are poorer, on average, for Aboriginal people than non-Aboriginal people, but little is known about Aboriginal multifetal pregnancies. Yet multifetal pregnancies and births are often more complicated and have poorer outcomes than singleton pregnancies. We describe the pregnancies, births and perinatal outcomes for Aboriginal twins born in Western Australia (WA) and New South Wales (NSW) with comparisons to Aboriginal singletons in both states and to non-Aboriginal births in NSW. MATERIALS AND METHODS: Whole-population birth records and birth and death registrations were linked for all births during 2000-2013 (WA) and 2002-2008 (NSW). Hospital records and the WA Register of Developmental Anomalies - Cerebral Palsy were linked for all WA births and hospital records for a subset of NSW births. Descriptive statistics are reported for maternal and child demographics, maternal health, pregnancy complications, births and perinatal outcomes. RESULTS: Thirty-four thousand one hundred twenty-seven WA Aboriginal, 32,352 NSW Aboriginal and 601,233 NSW non-Aboriginal births were included. Pregnancy complications were more common among mothers of Aboriginal twins than Aboriginal singletons (e.g. 17% of mothers of WA twins had hypertension/pre-eclampsia/eclampsia vs 8% of mothers of singletons) but similar to mothers of NSW non-Aboriginal twins. Most Aboriginal twins were born in a principal referral, women's or large public hospital. The hospitals were often far from the mother's home (e.g. 31% of mothers of WA Aboriginal twins gave birth at hospitals located more than 3 h by road from their home). Outcomes were worse for Aboriginal liveborn twins than Aboriginal singletons and non-Aboriginal twins (e.g. 58% of NSW Aboriginal twins were preterm compared to 9% of Aboriginal singletons and 49% non-Aboriginal twins). CONCLUSIONS: Mothers of Aboriginal twins faced significant challenges during the pregnancy, birth and the pos

BACKGROUND: Policies to increase Australian Indigenous children's participation in preschool aim to reduce developmental inequities between Indigenous and non-Indigenous children. This study aims to understand the benefits of preschool participation by quantifying the association between preschool participation in the year before school and developmental outcomes at age five in Indigenous and non-Indigenous children. METHODS: We used data from perinatal, hospital, birth registration and school enrolment records, and the Australian Early Development Census (AEDC), for 7384 Indigenous and 95 104 non-Indigenous children who started school in New South Wales, Australia in 2009/2012. Preschool in the year before school was recorded in the AEDC. The outcome was developmental vulnerability on ≥1 of five AEDC domains, including physical health, emotional maturity, social competence, language/cognitive skills and communication skills/general knowledge. RESULTS: 5051 (71%) Indigenous and 68 998 (74%) non-Indigenous children attended preschool. Among Indigenous children, 33% of preschool attenders and 44% of the home-based care group were vulnerable on ≥1 domains, compared with 17% of preschool attenders and 33% in the home-based care group among non-Indigenous children. In the whole population model, the adjusted risk difference for developmental vulnerability among preschool attenders was -7.9 percentage points (95% CI, -9.8 to -6.1) in non-Indigenous children and -2.8 percentage points (95% CI -4.8 to -0.7) in Indigenous children, compared with Indigenous children in home-based care. CONCLUSIONS: Our findings suggest a likely beneficial effect of preschool participation on developmental outcomes, although the magnitude of the benefit was less among Indigenous compared with non-Indigenous children.

Aim: To describe socio-demographic patterns of asthma prevalence in urban Aboriginal children and quantify associations between asthma prevalence and pre-natal maternal and current carer smoking. Methods: Analyses used carer-reported survey data for 1290 urban Aboriginal children aged 2–17 years from the Study of Environment on Aboriginal Resilience and Child Health. Multilevel log-binomial regression was used to estimate asthma prevalence ratios (PRs) for child- and family-level socio-demographic factors, pre-natal maternal smoking and current carer smoking. Smoking-related PRs were compared with general-population estimates derived from meta-analyses of published cross-sectional data. Results: Overall, 33.9% of children had ever had asthma, and 12.9% had received treatment for asthma in the past month. Prevalence estimates declined with increasing household income and increasing household size (posterior probabilities of decreasing trend '0.98), while children exposed to pre-natal maternal smoking had a higher risk of asthma ever than unexposed children (PR 1.18 (95% credible interval 1.00–1.40)). Recently treated asthma prevalence was not significantly associated with pre-natal maternal (0.98 (0.71–1.41)) or current carer smoking (0.97 (0.68–1.37)); however, there was substantial uncertainty in our PR estimates, and 95% credible intervals contained general-population estimates derived from the meta-analyses (1.37 (1.17–1.65) for pre-natal smoking, 1.28 (1.15–1.44) for current parental or household smoking). Conclusion: Among urban Aboriginal children in the Study of Environment on Aboriginal Resilience and Child Health cohort, asthma prevalence declines as household income and household size increase, while children exposed to pre-natal maternal smoking are at increased risk of ever having asthma. Our results emphasise the importance of reducing smoking in Aboriginal communities, particularly among pregnant women.

IntroductionMultifetal pregnancies and births tend to be more complicated and have poorer outcomes than singleton pregnancies. Singleton pregnancies and perinatal outcomes are worse, on average, for Indigenous people than non-Indigenous people, but little is known about Indigenous multifetal pregnancies. Objectives and ApproachWe comprehensively describe and compare Indigenous twin and singleton pregnancies and births in Western Australia (WA) and New South Wales (NSW) and compare to NSW non-Indigenous pregnancies and births. Birth records and infant and maternal hospital records were linked for births during 2000-2013 (WA) and 2002-2008 (NSW). Time travelled for the birth was based on the distance from the hospital to the centroid of the mother’s geographical residential area. ResultsIn the Indigenous populations, mothers of twins had poorer health than mothers of singletons (e.g. in WA, 19% of mothers of twins had hypertension/pre-eclampsia/eclampsia vs 9% of mothers of singletons). They were more likely to have antenatal care during the first trimester (e.g. 69% vs 64% in NSW), though less likely than non-Indigenous mothers of both twins (80%) and singletons (75%).The majority of Indigenous twins were born in a hospital with a neonatal intensive care unit (NICU) (e.g. 66% vs 26% in WA) and many mothers of twins travelled further for the birth (e.g. 8% of mothers of Indigenous twins in NSW travelled 3 hours or more vs 4% of mothers of singletons). In both jurisdictions, outcomes were worse for twins than singletons (e.g. 67% of twins in WA were preterm vs 13% of singletons and 30% of twins were admitted to a NICU vs 6% of singletons). Conclusion / ImplicationsMothers of Indigenous twins faced significant challenges during the pregnancy, birth and the postnatal period in hospital and, in addition to accessible specialist medical care, these mothers may need practical and psychosocial support throughout their journey.

BACKGROUND: Indigenous Australian children are twice as likely to score poorly on developmental outcomes at age 5 years than their non-Indigenous peers. Indigenous children are also more likely to be born to younger mothers. We aimed to quantify the relationship between maternal age at childbirth and early childhood development outcomes in Indigenous and non-Indigenous children. METHODS: In this population-based, retrospective cohort study, we used data from the Australian Early Development Census (AEDC) that were probabilistically linked by the New South Wales (NSW) Centre for Health Record Linkage to several NSW administrative datasets, including the Perinatal Data Collection, the Register of Births, Deaths and Marriages (for birth registrations), the Admitted Patient Data Collection, and public school enrolment records, as part of the Seeding Success study. The resulting data resource comprises a cohort of 166 278 children born in NSW whose first year of school was reported in a 2009 or 2012 AEDC record (which were the years of AEDC data available at the time of data linkage). The primary outcome was the aggregate outcome of developmental vulnerability (scores in the bottom decile, according to the 2009 benchmark, on one or more of the five AEDC domains, which include physical, social, emotional, language and cognitive, and communication development). This outcome was measured in singleton children without special needs recorded on the AEDC, in those with available developmental data. As a secondary outcome analysis, we also repeated the main analyses on the outcome of developmental vulnerability on the individual domains. We estimated the absolute risk of developmental vulnerability by maternal age in Indigenous and non-Indigenous populations, and we also estimated the risk difference and relative risk between Indigenous and non-Indigenous children by use of modified Poisson regression. FINDINGS: Of 166 278 children in the cohort, 107 666 (64·8%) children were e

Background: Early childhood social and emotional development underpins later social, emotional, academic and other outcomes. The first aim of this study was to explore the association between child, family and area-level characteristics associated with developmental vulnerability, amongst Aboriginal and non-Aboriginal children in their first year of school. The second aim was to quantify the magnitude of the social and emotional developmental inequalities between Aboriginal and non-Aboriginal children and the extent to which differences in socioeconomic disadvantage and perinatal characteristics explained this inequality. Methods: This retrospective cohort study used cross-sectoral data linkage to identify and follow participants from birth to school age. In this way, social and emotional development was examined in 7,384 Aboriginal and 95,104 non-Aboriginal children who were included in the Australian Early Development Census in their first year of full-time school in New South Wales (NSW) in 2009 or 2012 and had a birth registration and/or perinatal record in NSW. The primary outcome measures were teacher-reported social competence and emotional maturity as measured using the Australian version of the Early Development Instrument. Results: The mean age at the start of the school year for children in the study sample was 5.2 years (SD = 0.36 years). While 84% of Aboriginal children scored favourably - above the vulnerability threshold - for social competence and 88% for emotional maturity, Aboriginal children were twice as likely as non-Aboriginal children to be vulnerable on measures of social development (RR = 2.00; 95%CI, 1.89-2.12) and had 89% more risk of emotional vulnerability (RR = 1.89; 95%CI, 1.77-2.02). The inequality between Aboriginal and non-Aboriginal children was largely explained by differences in the socioeconomic and perinatal health characteristics of children and families. Thus, after adjusting for differences in measures of socioeconomic advan

Objective: Despite being disproportionately affected by injury, little is known about factors associated with injury in Aboriginal children. We investigated factors associated with injury among urban Aboriginal children attending four Aboriginal Community Controlled Health Services in New South Wales, Australia. Methods: We examined characteristics of caregiver-reported child injury, and calculated prevalence ratios of ‘ever-injury’ by child, family, and environmental factors. Results: Among children in the cohort, 29% (n=373/1,303) had ever broken a bone, been knocked out, required stitches or been hospitalised for a burn or poisoning; 40–78% of first injuries occurred at home and 60–91% were treated in hospital. Reported ever-injury was significantly lower (prevalence ratio ≤0.80) among children who were female, younger, whose caregiver had low psychological distress and had not been imprisoned, whose family experienced few major life events, and who hadn't experienced alcohol misuse in the household or theft in the community, compared to other cohort members. Conclusions: In this urban Aboriginal child cohort, injury was common and associated with measures of family and community vulnerability. Implications for public health: Prevention efforts targeting upstream injury determinants and Aboriginal children living in vulnerable families may reduce child injury. Existing broad-based intervention programs for vulnerable families may present opportunities to deliver targeted injury prevention.

Background: Preterm birth and developmental vulnerability are more common in Australian Aboriginal compared with non-Aboriginal children. We quantified how gestational age relates to developmental vulnerability in both populations. Methods: Perinatal datasets were linked to the Australian Early Development Census (AEDC), which collects data on five domains, including physical, social, emotional, language/cognitive, and general knowledge/communication development. We quantified the risk of developmental vulnerability on ≥1 domains at age 5, according to gestational age and Aboriginality, for 97 989 children born in New South Wales, Australia, who started school in 2009 or 2012. Results: Seven thousand and seventy-nine children (7%) were Aboriginal. Compared with non-Aboriginal children, Aboriginal children were more likely to be preterm (5% vs. 9%), and developmentally vulnerable on ≥1 domains (20% vs. 36%). Overall, the proportion of developmentally vulnerable children decreased with increasing gestational age, from 44% at ≤27 weeks to 20% at 40 weeks. Aboriginal children had higher risks than non-Aboriginal children across the gestational age range, peaking among early term children (risk difference [RD] 19.0, 95% confidence interval [CI] 16.3, 21.7; relative risk [RR] 1.91, 95% CI 1.77, 2.06). The relation of gestational age to developmental outcomes was the same in Aboriginal and non-Aboriginal children, and adjustment for socio-economic disadvantage attenuated the risk differences and risk ratios across the gestational age range. Conclusions: Although the relation of gestational age to developmental vulnerability was similar in Aboriginal and non-Aboriginal children, Aboriginal children had a higher risk of developmental vulnerability at all gestational ages, which was largely accounted for by socio-economic disadvantage.

BACKGROUND: In recent decades, there has been a shift to later childbearing in high-income countries. There is limited large-scale evidence of the relationship between maternal age and child outcomes beyond the perinatal period. The objective of this study is to quantify a child's risk of developmental vulnerability at age five, according to their mother's age at childbirth. METHODS AND FINDINGS: Linkage of population-level perinatal, hospital, and birth registration datasets to data from the Australian Early Development Census (AEDC) and school enrolments in Australia's most populous state, New South Wales (NSW), enabled us to follow a cohort of 99,530 children from birth to their first year of school in 2009 or 2012. The study outcome was teacher-reported child development on five domains measured by the AEDC, including physical health and well-being, emotional maturity, social competence, language and cognitive skills, and communication skills and general knowledge. Developmental vulnerability was defined as domain scores below the 2009 AEDC 10th percentile cut point. The mean maternal age at childbirth was 29.6 years (standard deviation [SD], 5.7), with 4,382 children (4.4%) born to mothers aged <20 years and 20,026 children (20.1%) born to mothers aged ≥35 years. The proportion vulnerable on ≥1 domains was 21% overall and followed a reverse J-shaped distribution according to maternal age: it was highest in children born to mothers aged ≤15 years, at 40% (95% CI, 32-49), and was lowest in children born to mothers aged between 30 years and ≤35 years, at 17%-18%. For maternal ages 36 years to ≥45 years, the proportion vulnerable on ≥1 domains increased to 17%-24%. Adjustment for sociodemographic characteristics significantly attenuated vulnerability risk in children born to younger mothers, while adjustment for potentially modifiable factors, such as antenatal visits, had little additional impact across all ages. Although the multi-agency linkage yielded a broad r

OBJECTIVES: The aim of the current study is to quantify mental health-related emergency department (ED) presentations and hospitalisations, and associated child and family characteristics, in children recruited through four Aboriginal Community Controlled Health Organisations. SETTING: Four Aboriginal Community Controlled Health Services that deliver primary care. All services were located in urban or large regional centres in New South Wales, Australia. PARTICIPANTS: 1476 Aboriginal children aged 0-17 years at recruitment to the Study of Environment on Aboriginal Resilience and Child Health. PRIMARY OUTCOME MEASURES: ED presentations and hospital admissions with a primary mental health diagnosis obtained via linkage to population health datasets. RESULTS: Over a median of 6-year follow-up, there were 96 ED presentations affecting 62 children (10.7/1000 person-years) and 49 hospitalisations affecting 34 children (5.5/1000 person-years) for mental health conditions. Presentations/admissions increased with age. ED presentation was increased with: living in foster versus parental care (adjusted rate ratio (RR)=3.97, 95% CrI 1.26 to 11.80); high versus low baseline child emotional/behavioural problems (adjusted RR=2.93, 95% CrI 1.50 to 6.10); and caregiver chronic health conditions versus none (adjusted RR=2.81, 95% CrI 1.31 to 6.63). Hospitalisations were significantly increased with caregiver unemployment versus home duties (adjusted RR=4.48, 95% CrI 1.26 to 17.94) and caregiver chronic health problems versus none (adjusted RR=3.83, 95% CrI 1.33 to 12.12). CONCLUSIONS: Tertiary care for mental health issues was relatively common among participating Aboriginal children, with risk elevated for those living in foster care, with prior mental health and behavioural problems and with carers with chronic illness and/or unemployment. While this study suggests high rates of serious mental health events among children from participating communities, the optimum means for reduci

Objectives: Almost one-fifth of Australian Aboriginal mothers give birth before 20 years of age compared with 3% of non-Aboriginal mothers. We aim to quantify the effect of maternal age at birth on child development outcomes in Aboriginal compared with non-Aboriginal children. Approach: The ‘Seeding Success’ study cohort comprises an almost complete population of children who started school in Australia’s most populous state, New South Wales (NSW), in 2009 or 2012, and were born in NSW, identified by linking Australian Early Development Census (AEDC) data to perinatal and birth registration datasets. Of the 154,936 children in the cohort, 8001 (5%) were Aboriginal. We calculated the risk of developmental vulnerability on one or more AEDC domains by maternal age at birth and Aboriginality. Risk differences and risk ratios (RR) were estimated as measures of absolute and relative inequalities, respectively. Multilevel Poisson regression was used to test the effect of maternal age on child development by Aboriginality. Results: 1383 (17%) Aboriginal children were born to a mother <20 years compared with 4310 (3%) non-Aboriginal children. Among Aboriginal and non-Aboriginal children, the risk of developmental vulnerability decreased with increasing maternal age up to 35 years; the risk increased for children born to mothers >35 years. Among Aboriginal children, the risk decreased from 46% (95%CI, 39-52) to 31% (95%CI, 24-38) in children born to mothers’ aged ≤16 years to age 35 years, respectively. In non-Aboriginal children, the risk decreased from 38% (95%CI, 33-43) to 16% (95%CI, 15-17) in those born to mothers’ aged ≤16 years to 35 years, respectively. Risk differences and risk ratios for developmental vulnerability between Aboriginal and non-Aboriginal children increased with increasing maternal age. Compared to non-Aboriginal children born to mothers aged ≥20 years (ref group, RR, 1.0), the RR for developmental vulnerability was 1.7 (95% CI, 1.6-1.9) for non

Objective: In Australia’s most populous state, New South Wales (NSW), children must start school in the year they turn five, unless they are born between February-July, in which case they can delay starting until the year they turn six. Consequently, children start their first year of school aged 4.5-6 years. This may translate into a wide range of developmental ability in the classroom in the first year of school and may impact on the magnitude of inequalities in longer-term educational outcomes. To inform how this policy currently translates into the demographic composition of NSW classrooms, this study aims to identify child, family, and area-level characteristics associated with the practice of delaying school entry. Approach: The ‘Seeding Success’ study cohort (N=154,936) includes an almost complete population of children who started school in NSW in 2009 or 2012, and were born in NSW, identified by linking the Australian Early Development Census (AEDC) data to perinatal and birth registry data. Restricting this analysis to the 88,716 (57%) children born in February-July, we defined ‘delayed school entry’ as children who were eligible to start school the previous year (i.e. 2008 or 2011), but started in the AEDC data collection years (i.e. 2009 or 2012). Multilevel regression models were used to investigate child, family and area-level characteristics associated with delayed school entry. Results: The prevalence of delayed school entry was 46% in the 2009 AEDC cohort and 47% in the 2012 AEDC cohort. Boys and children born closer to July were more likely to be delayed, as were children of older mothers. Prevalence of delay was similar in Aboriginal and non-Aboriginal children, however, children of mothers born overseas were less likely to delay school entry compared to Australian-born mothers. Delaying was less common in major cities compared to remote and regional areas, and less common in socio-economically disadvantaged areas. Conclusion: Children born in Feb

Introduction: A shift to later childbearing has occurred over recent decades in high-income countries. There is limited large-scale evidence of the relationship between maternal age and child outcomes beyond the perinatal period.Methods: Perinatal, hospital and birth registration datasets were linked to data from the Australian Early Development Census (AEDC), which assessed five domains of development. We quantified a child’s risk of developmental vulnerability at age five, according to their mother’s age at childbirth, in a virtually complete population cohort of 82,049 children who were born in New South Wales, Australia, and started school in 2009 or 2012.Results: 19% of children were vulnerable on ≥1 of the five AEDC domains. The mean maternal age when study children were born was 29.8 years (SD, 5.6). The proportion vulnerable on ≥1 domains followed an inverse J-shaped distribution according to maternal age. The proportion vulnerable was highest in children born to mothers aged ≤15 years, at 45% (95% CI, 34-57%), followed by a monotonic decrease with increasing maternal age to 15-16% in children born to mothers aged 30-35 years, and a general increase in the proportion vulnerable for maternal ages 36-45 years. Adjustment for socio-demographic characteristics attenuated the increased risk of vulnerability in children born to younger mothers.Conclusions: Although children born to young mothers have the highest risk of developmental vulnerability at age five, there are few births to young mothers, particularly <20 years. Socioeconomic disadvantage underlies much of the increased risk of developmental vulnerability associated with younger motherhood.

Australian Aboriginal children are more likely than non-­Aboriginal children to have markers of developmental vulnerability at school entry, tracking through to poor school outcomes and disadvantage in later life. The Seeding Success study aims to identify key drivers of positive early childhood development in Aboriginal children, and supportive features of local communities and early childhood service provision. The study includes an almost complete population cohort of children (N=154,936) who started school in New South Wales (NSW) in 2009 or 2012, and were born in NSW, identified by linking Australian Early Development Census data to perinatal and birth registration datasets. Early childhood health and development trajectories are being constructed via linkage to administrative datasets relating to birth outcomes, congenital conditions, hospital admissions, emergency department presentations, use of mental health services, school enrolments and contact with child protection and out­of­home care services. Analyses now in progress, applying multilevel modelling techniques, are investigating the following in relation to early childhood development outcomes in Aboriginal compared with non­Aboriginal children: preterm birth; maternal age at birth; preschool attendance; and age at school entry. In partnership with policy agencies, we will use the linked data to assess the impact of two current NSW government programs that aim to address early childhood disadvantage. These analyses will use propensity matching methods and interrupted time series analysis to identify comparison areas and groups and to compare outcomes between areas and groups. The findings will be relevant to those working in the health, early childhood, community services and education sectors.

Background: Almost one-fifth of Aboriginal mothers give birth before 20 years (y) of age compared with 3% of non-Aboriginal mothers.Aims: We aim to quantify the relationship between maternal age at childbirth and development outcomes in Aboriginal and non-Aboriginal children.Method: The ‘Seeding Success’ study comprises an almost complete population of children (N=154,936) who started school in New South Wales (NSW) in 2009 or 2012, and were born in NSW, identified by linking Australian Early Development Census (AEDC) data to perinatal and birth registration datasets. Of these, 8001 (5%) were Aboriginal. We calculated the risk of developmental vulnerability on one or more AEDC domains by maternal age at childbirth and Aboriginality.Results: 1383 (17%) Aboriginal children were born to a mother <20y compared with 4310 (3%) non-Aboriginal children. Among Aboriginal children, the risk of developmental vulnerability decreased from 46% (95%CI, 39-52) to 31% (95%CI, 24-38) in children born to mothers’ aged ≤16y years to 35y, respectively. In non-Aboriginal children, the risk decreased from 38% (95%CI, 33-43) to 16% (95%CI, 15-17) in those born to mothers’ aged ≤16y to 35y, respectively. For children born to mothers aged >35y, the risk of developmental vulnerability increased with increasing maternal age at childbirth, regardless of Aboriginality.Conclusions: Aboriginal children have a greater risk of developmental vulnerability across the maternal age range. Children born to mothers <18y have a high risk of vulnerability regardless of Aboriginality. Early intervention targeted at Aboriginal mothers and their children, regardless of the mother’s age, may reduce this inequality.

BACKGROUND: Australian Aboriginal children experience a disproportionate burden of social and health disadvantage. Avoidable hospitalizations present a potentially modifiable health gap that can be targeted and monitored using population data. This study quantifies inequalities in pediatric avoidable hospitalizations between Australian Aboriginal and non-Aboriginal children. METHODS: This statewide population-based cohort study included 1 121 440 children born in New South Wales, Australia, between 1 July 2000 and 31 December 2012, including 35 609 Aboriginal children. Using linked hospital data from 1 July 2000 to 31 December 2013, we identified pediatric avoidable, ambulatory care sensitive and non-avoidable hospitalization rates for Aboriginal and non-Aboriginal children. Absolute and relative inequalities between Aboriginal and non-Aboriginal children were measured as rate differences and rate ratios, respectively. Individual-level covariates included age, sex, low birth weight and/or prematurity, and private health insurance/patient status. Area-level covariates included remoteness of residence and area socioeconomic disadvantage. RESULTS: There were 365 386 potentially avoidable hospitalizations observed over the study period, most commonly for respiratory and infectious conditions; Aboriginal children were admitted more frequently for all conditions. Avoidable hospitalization rates were 90.1/1000 person-years (95 % CI, 88.9-91.4) in Aboriginal children and 44.9/1000 person-years (44.8-45.1) in non-Aboriginal children (age and sex adjusted rate ratio = 1.7 (1.7-1.7)). Rate differences and rate ratios declined with age from 94/1000 person-years and 1.9, respectively, for children aged <2 years to 5/1000 person-years and 1.8, respectively, for ages 12- < 14 years. Findings were similar for the subset of ambulatory care sensitive hospitalizations, but in contrast, non-avoidable hospitalization rates were almost identical in Aboriginal (10.1/1000 person-years, (9.

Introduction: Australian Aboriginal children are more likely than non-Aboriginal children to have developmental vulnerability at school entry that tracks through to poorer literacy and numeracy outcomes and multiple social and health disadvantages in later life. Empirical evidence identifying the key drivers of positive early childhood development in Aboriginal children, and supportive features of local communities and early childhood service provision, are lacking. Methods and analysis: The study population will be identified via linkage of Australian Early Development Census data to perinatal and birth registration data sets. It will include an almost complete population of children who started their first year of full-time school in New South Wales (NSW), Australia, in 2009 and 2012. Early childhood health and development trajectories for these children will be constructed via linkage to a range of administrative data sets relating to birth outcomes, congenital conditions, hospital admissions, emergency department presentations, receipt of ambulatory mental healthcare services, use of general practitioner services, contact with child protection and out-of-home care services, receipt of income assistance and fact of death. Using multilevel modelling techniques, we will quantify the contributions of individual-level and area-level factors to variation in early childhood development outcomes in Aboriginal and non-Aboriginal children. Additionally, we will evaluate the impact of two government programmes that aim to address early childhood disadvantage, the NSW Aboriginal Maternal and Infant Health Service and the Brighter Futures Program. These evaluations will use propensity score matching methods and multilevel modelling. Ethics and dissemination: Ethical approval has been obtained for this study. Dissemination mechanisms include engagement of stakeholders (including representatives from Aboriginal community controlled organisations, policy agencies, service provi

Australian Aboriginal children are more likely than non-Aboriginal children to have markers of developmental vulnerability at school entry, tracking through to poor school outcomes and disadvantage in later life. The Seeding Success study will identify key drivers of positive early childhood development in Aboriginal children, and supportive features of local communities and early childhood service provision. The study will include children who started, or were eligible to start, their first year of full-time school in New South Wales (NSW), Australia, in 2009 and 2012, identified by linking Australian Early Development Census data to perinatal and birth registration datasets. Early childhood health and development trajectories will be constructed via linkage to administrative datasets relating to birth outcomes, congenital conditions, hospital admissions, emergency department presentations, use of general practitioner and mental health services, contact with child protection and out-of-home care services, receipt of income assistance and fact of death. Multilevel modelling techniques will be used to quantify the contributions of individual- and area-level factors to variation in early childhood development outcomes in Aboriginal and non-Aboriginal children. We will use the linked data to assess the impact of two current NSW government programs that aim to address early childhood disadvantage. These analyses will use propensity matching methods and interrupted time series analysis to identify comparison areas and groups and to compare outcomes between areas and groups. The findings will be relevant to those working in the health, early childhood, community services and education sectors.

ObjectiveOur study aimed to quantify potentially preventable hospital (PPH) admission rates for acute, chronic and vaccine- preventable conditions, and the inequality in these rates, in large whole-of-population cohort of Aboriginal and non-Aboriginal children living in Australia's most populous state, New South Wales (NSW).ApproachWe conducted a retrospective cohort study using linked hospital and mortality records for NSW from July 1, 2000 to December 31, 2008. A cohort of 653,575 children (2.6% Aboriginal) born in a NSW hospital between July 1, 2000, and December 31, 2007, were included in the analysis. The study outcome was PPH admissions. Admission rates per 1000 person-years were calculated with 95% confidence intervals (CIs) for acute, chronic and vaccine-preventable conditions, and stratified by demographic and birth characteristics (i.e. age, sex, low birth weight, prematurity, private patient/health insurance status, geographical remoteness and socioeconomic status).ResultsThere were 103,569 PPH admissions among the cohort during the study period, of which 5% were in Aboriginal children. The PPH admission rate was 63.9 and 33.4 per 1000 person-years in Aboriginal and non-Aboriginal children, respectively. Acute conditions accounted for almost two thirds of PPH admissions, and rates were highest in younger children. The size of the inequality was largest among 0-1 year olds for acute, chronic and vaccine-preventable PPH admissions. PPH admission rates were higher among more socioeconomically disadvantaged children, and the inequality between Aboriginal and non- Aboriginal children was largest among the most disadvantaged. Although PPH admission rates were higher in more remote areas regardless of Aboriginality, there was a significant inequality between Aboriginal and non-Aboriginal children in major cities, regional and remote areas.ConclusionThere is potential to achieve substantial health gains for Aboriginal children, and to reduce hospital admissions

OBJECTIVES: Australian Aboriginal children experience earlier, more frequent and more severe otitis media, particularly in remote communities, than non-Aboriginal children. Insertion of ventilation tubes is the main surgical procedure for otitis media. Our aim was to quantify inequalities in ventilation tube insertion (VTI) procedures between Australian Aboriginal and non-Aboriginal children, and to explore the influence of birth characteristics, socioeconomic background and geographical remoteness on this inequality. DESIGN: Retrospective cohort study using linked hospital and mortality data from July 2000 to December 2008. SETTING AND PARTICIPANTS: A whole-of-population cohort of 653 550 children (16 831 Aboriginal and 636 719 non-Aboriginal) born in a New South Wales hospital between 1 July 2000 and 31 December 2007 was included in the analysis. OUTCOME MEASURE: First VTI procedure. RESULTS: VTI rates were lower in Aboriginal compared with non-Aboriginal children (incidence rate (IR), 4.3/1000 person-years; 95% CI 3.8 to 4.8 vs IR 5.8/1000 person-years; 95% CI 5.7 to 5.8). Overall, Aboriginal children were 28% less likely than non-Aboriginal children to have ventilation tubes inserted (age-adjusted and sex-adjusted rate ratios (RRs) 0.72; 95% CI 0.64 to 0.80). After adjusting additionally for geographical remoteness, Aboriginal children were 19% less likely to have ventilation tubes inserted (age-adjusted and sex-adjusted RR 0.81; 95% CI 0.73 to 0.91). After adjusting separately for private patient/health insurance status and area socioeconomic status, there was no significant difference (age-adjusted and sex-adjusted RR 0.96; 95% CI 0.86 to 1.08 and RR 0.93; 95% CI 0.83 to 1.04, respectively). In the fully adjusted model, there were no significant differences in VTI rates between Aboriginal and non-Aboriginal children (RR 1.06; 95% CI 0.94 to 1.19). CONCLUSIONS: Despite a much higher prevalence of otitis media, Aboriginal children were less likely to receive VTI

Introduction: Australian Aboriginal children have the highest rates of otitis media (OM) in the world. The majority of OM cases are managed in the primary health care setting, but children are admitted to hospital for surgical interventions. Using linked hospital data in NSW, we investigated whether the rates of first myringotomy and ventilation tube insertion (MVTI) procedures for OM differed between Aboriginal and non-Aboriginal children in NSW. Methods: All children born in a NSW hospital between July 2000 and December 2008 were included and followed up to December 31, 2008. Poisson regression methods were used to estimate relative risks for first MVTI procedures in Aboriginal versus non-Aboriginal children. Results: Unadjusted MVTI rates were higher among non-Aboriginal compared with Aboriginal children (5.7 versus 4.2 per 1000 person years). Unadjusted rates were also higher among those admitted as private patients, those who lived in areas of higher socio-economic status or in major cities. After adjusting for age, sex and year of birth, Aboriginal children remained 30% less likely to have a MVTI procedure than non-Aboriginal children (adjusted risk ratio of 0.71, 95% CI 0.63-0.79). Conclusions: Despite higher documented rates of OM in Aboriginal versus non-Aboriginal children in the community, MVTI rates were lower in Aboriginal children in NSW. Key Message: Although different rates of MVTI procedures may reflect different rates of OM in the study population, it most likely indicates inequalities in health service access between Aboriginal and non-Aboriginal children that needs to be addressed.

BackgroundSevere middle ear disease places children at high risk of speech, language and learning impairments as a result of impaired hearing; this may in turn affect later educational outcome. Although middle ear disease is largely managed in the primary health care setting, children may also be admitted to hospital for treatment or surgical intervention. AimsTo investigate whether the incidence of first myringotomy and ventilation tube insertion (MVTI) procedures is different in Aboriginal and non-Aboriginal children in NSW.MethodsA birth cohort was identified in the NSW Admitted Patient Data Collection (APDC) including all live births from July 2000 to December 2008. Person-years accrued from date of birth and terminated at first MVTI procedure or first of either date of death or December 31, 2008. Poisson regression methods were used to estimate relative risks for first MVTI procedures in Aboriginal compared with non-Aboriginal children. ResultsUnadjusted rates of MVTI were higher among non-Aboriginal children, those admitted as a private patient at their birth admission, those living in areas of higher socio-economic status, and those in major cities. After adjusting for age, sex and year of birth, Aboriginal children were 30% less likely to have a MVTI procedure than non-Aboriginal children, despite higher rates of OM.ConclusionsThe lower rates of MVTI among Aboriginal children in NSW may be an indication of inequitable access to health services. Similar research in WA has also shown lower rates of hospitalisation for middle ear surgery for Aboriginal children compared with non-Aboriginal children.

Objectives To describe hospitalization rates, risk factors and associated diagnoses in people with HIV in Australia between 1999 and 2007. Design Retrospective cohort study of people with HIV (n = 842) using data linkage between the Australian HIV Observational Database and administrative hospital morbidity data collections. Methods Incidence rate ratios with 95% confidence intervals were estimated using Poisson regression models to assess risk factors for hospitalization. Predictors of length of stay were assessed using generalized mixed models. The association between hospitalization and mortality was assessed using Cox regression. Results In 4519 person-years of observation, there were 2667 hospital admissions; incidence rate of 59 per 100 person-years. Hospitalization rates were 50–300% higher in this cohort than comparable age and sex strata in the general population. Older age (incidence rate ratio 1.46, 95% confidence interval 1.28–1.65 per 10-year increase) and prior AIDS (incidence rate ratio 1.71, 95% confidence interval 1.24–2.35) were significantly associated with hospitalization. Other predictors of hospitalization included lower CD4 cell counts, higher HIV RNA, longer duration of HIV infection and experience with more drug classes. Lower CD4 cell counts, older age and hepatitis C virus antibody positivity were independently associated with longer hospital stay. Non-AIDS diseases were the principle reason for admission in the majority of cases. Mortality was associated with more frequent hospitalization during the study period. Conclusion Hospitalization rates are higher in people with HIV than the general population in Australia and are associated with markers of advanced HIV disease despite the widespread use of combination antiretroviral therapy.

Objective: Although studies have shown reductions in mortality from AIDS after the introduction of combination antiretroviral treatment (cART), little is known about cause-specific mortality in low-income settings in the cART era. We explored predictors of AIDS and non-AIDS mortality and compared cause-specific mortality across high-income and low-income settings in the Asia-Pacific region. Methods: We followed patients in the Asia Pacific HIV Observational Database from the date they started cART (or cohort enrolment if cART initiation was identified retrospectively), until the date of death or last follow-up visit. Competing risks methods were used to estimate the cumulative incidence, and to investigate predictors, of AIDS and non-AIDS mortality. Results: Of 4252 patients, 215 died; 89 from AIDS, 97 from non-AIDS causes and 29 from unknown causes. Age more than 50 years [hazard ratio 4.29; 95% confidence interval (CI) 2.10-8.79] and CD4 cell counts less than or equal to 100 cells/μl (hazard ratio 8.59; 95% CI 5.66-13.03) were associated with an increased risk of non-AIDS mortality. Risk factors for AIDS mortality included CD4 cell counts less than or equal to 100 cells/μl (hazard ratio 34.97; 95% CI 18.01-67.90) and HIV RNA 10 001 or more (hazard ratio 4.21; 95% CI 2.07-8.55). There was some indication of a lower risk of non-AIDS mortality in Asian high-income, and possibly low-income, countries compared to Australia. Conclusion: Immune deficiency is associated with an increased risk of AIDS and non-AIDS mortality. Older age predicts non-AIDS mortality in the cART era. Less conclusive was the association between country-income level and cause-specific mortality because of the relatively high proportion of unknown causes of death in low-income settings.

Background: Random effects models were used to explore how the shape of CD4 cell count responses after commencing combination antiretroviral therapy (cART) develop over time and, in particular, the role of baseline and follow-up covariates. Methods: Patients in Asia Pacific HIV Observational Database who first commenced cART after January 1, 1997, and who had a baseline CD4 cell count and viral load measure and at least 1 follow-up measure between 6 and 24 months, were included. CD4 cell counts were determined at every 6-month period after the commencement of cART for up to 6 years. Results: A total of 1638 patients fulfilled the inclusion criteria with a median follow-up time of 58 months. Lower post-cART mean CD4 cell counts were found to be associated with increasing age (P < 0.001), pre-cART hepatitis C coinfection (P = 0.038), prior AIDS (P = 0.019), baseline viral load ≤100,000 copies per milliliter (P < 0.001), and the Asia Pacific region compared with Australia (P = 0.005). A highly significant 3-way interaction between the effects of time, baseline CD4 cell count, and post-cART viral burden (P < 0.0001) was demonstrated. Higher long-term mean CD4 cell counts were associated with lower baseline CD4 cell count and consistently undetectable viral loads. Among patients with consistently detectable viral load, CD4 cell counts seemed to converge for all baseline CD4 levels. Conclusions: Our analyses suggest that the long-term shape of post-cART CD4 cell count changes depends only on a 3-way interaction between baseline CD4 cell count, viral load response, and time.

Objectives: To determine the prevalence and predictors of an incomplete immune response in patients with sustained viral suppression after starting their first or second combination antiretroviral treatment (cART) regimen. Methods: All patients were recruited to the Australian HIV Observational Database (AHOD) by March 2006. Data were analyzed to assess the prevalence of an incomplete immune response (,350 cells/mL) in the 12–24 months after starting the first or second cART regimen. Factors associated with an incomplete immune response were assessed using logistic regression and time to AIDS/death was assessed using survival analysis. Results: Of the 2493 patients recruited to AHOD by March 2006, 590 were eligible for the analysis. Twenty-eight percent of patients with a baseline CD4 count, 350 cells per microliter had an incomplete immune response 12–24 months after starting their first or second cART regimen. Lower baseline CD4 count before starting the cART regimen was predictive of an incomplete immune response. There was a nonsignificant trend toward faster AIDS or death in incomplete immune responders. Conclusions: An incomplete immune response in patients with sustained viral suppression is associated with poorer immune function before starting cART. Type of cART or individual antiretroviral drug was not associated with an incomplete immune response.