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Keywords:

  • Child;
  • abuse;
  • prevention;
  • protection;
  • public;
  • health

Abstract

  1. Top of page
  2. Abstract
  3. Current Australian child protection systems
  4. A public health approach
  5. The knowledge challenge
  6. Primary prevention — universal services for all families
  7. Secondary prevention — targeted Services
  8. Tertiary prevention — management
  9. Conclusions
  10. Acknowledgements
  11. References

Australia is seeing an unprecedented increase in the rate of child protection notifications and children being taken into care. The burden of such high levels of notifications and removals impact not only the children and families but also the system which is trying to resource them. The concern is that these increases are unsustainable and overloaded child protection systems can be dangerous for the vulnerable families and children they are trying to protect and support.

This paper hopes to raise some alternative thinking as to the overall approaches to child abuse and neglect with a greater focus on prevention. Is it time to consider a public health approach, using population-based measures of child abuse and neglect to accurately describe the epidemiology of population risk and protective factors? Should we investigate the potential of universal health, welfare and education services as platforms for prevention? And should we investigate whether the provision of secondary prevention for vulnerable families which address major contributing factors, such as parental substance dependence and mental health issues are effective in reducing abuse of children in these families?

Attempts to deal with child abuse and neglect are not new. It is now 40 years since the paper “The Maltreatment Syndrome in Children” by the Victorian police surgeon Dr John Birrell and his paediatrician brother Dr Robert Birrell was published in the Medical Journal of Australia.1 It documented non-accidental injuries inflicted on children. The same issue included Dr Dora Bialestock's study of 289 neglected infants consecutively admitted to the care of Victorian child welfare authorities, many with significant developmental delays.2

‘The battered baby syndrome’, the evocative term coined by Professor Henry Kempe in the 1960s, caught the attention of professionals, press and public alike.3 Most Australian States and Territories followed the United States in introducing mandatory reporting laws for suspected child abuse in relation to certain professions, including medical practitioners.4 In contrast, the United Kingdom adopted policies based on a voluntary professional duty of care, reinforced by strong inter-agency protocols across health, education and social services. What now is the current state of affairs in Australia and why do we think that a different approach is required?

Current Australian child protection systems

  1. Top of page
  2. Abstract
  3. Current Australian child protection systems
  4. A public health approach
  5. The knowledge challenge
  6. Primary prevention — universal services for all families
  7. Secondary prevention — targeted Services
  8. Tertiary prevention — management
  9. Conclusions
  10. Acknowledgements
  11. References

Current Australian child protection systems are primarily focused at the residual end of the pathway of child abuse and neglect in which families are investigated, a child identified as harmed or potentially harmed, and often coercive actions taken. In this system prevention of abuse and neglect is largely lacking. There are no sound prevalence data on child abuse and neglect in Australia but there are increasingly good data on child protection notifications and substantiations compiled by the Australian Institute of Health and Welfare.5 There has been a large increase in the number of notifications of suspected child abuse and neglect, for example, in 2005/06 there were 266,745 notifications of suspected abuse and neglect in Australia, more than double the number of notifications in 2000/01.6 Of those investigated, 55,921 notifications or approximately 1 in 4.77 notifications were “substantiated”.6Figure 1 demonstrates the changing numbers of notifications and substantiations across Australia from 1999-2000 to 2005-06.

image

Figure 1. Numbers of Notifications and Substantiations in Australia from 1999-2000 to 2005-06 as reported by the AIHW, 2007.6

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International comparisons of child protection data indicate that Australia had 52.4 notifications per 1000 children in 2004/05,5 almost nine times that of England which had 6.2 notifications per 1000 children,7 while the United States had 43.9 notifications per 1000 children in 2004.8 Despite the differences in notifications, Australia and England had a very similar proportion of children in State care, 5.3 children per 1000 in Australia6 and 5.0 per 1000 children in England.7 The burden of such high levels of notifications and investigations of families in comparison to those who meet the threshold for statutory intervention is therefore called into question. As will be discussed further, the burden of these investigations is not only on the families themselves but also on the system which has to increase resources for the increasing notifications.

Not only are we seeing increases in the number of notifications in the system but we are also seeing increases in the number of children in out of home care. There were 25,454 children in “out of home care” in Australia on June 30, 2006, an 82% increase in a decade.6 Multiple placements are common, in Victoria on June 30, 2001, 65% of children in State care had experienced four or more placements9 which pose serious risks to the mental health and emotional well-being of these children. The rate of Indigenous children in out-of-home care is over seven times the rate of other children, with 30.1 per 1000 Indigenous children aged 0-17 years in out of home care compared to the total rate of 5.3 per 1000 children.6 There are almost 203,000 Indigenous children in Australia and a growing recognition of a child abuse and neglect crisis in many Indigenous communities.

Due to the high number of children and families being notified and investigated, and increasing numbers of children entering state care, there is growing concern about the ability of State and Territory child protection systems to cope with the increasing proportion of high risk and vulnerable families notified to the system. The challenge faced by the current Child Protection systems is that in reality they are services primarily targeting children at high risk and who meet the threshold for statutory intervention. However, the majority of cases that are being notified are children in vulnerable families in which there is a risk from chronic adverse family circumstances and not from a specific episode of harm.10 Contrary to most media coverage which focuses on physical and sexual abuse, it is neglect and emotional abuse that comprise the vast majority of substantiated cases.6

Overloaded child protection systems make it harder to identify and respond to those children in serious jeopardy due to unallocated cases, hasty assessments and premature case closure. A high level of intervention by statutory services in the lives of vulnerable families, where protective concerns do not reach a threshold for statutory intervention, can also unnecessarily traumatise parents and make it more difficult to engage them in services which may reduce the risk of child abuse and neglect. UK research has reported that many parents view statutory intervention as intrusive and providing little supportive assistance,11 while the US child protection system has been criticised for the lack of support for families who voluntarily request assistance compared with the large amount of resources focused on reporting and investigating families.12 Concerns are also being raised about the potential harm of intervention, with research emerging that children in foster care could be more damaged by being removed from their parents and being subject to multiple placements than had they remained with their families.13,14

The current child protection system also faces financial challenges, for example within the period of 2005-06, $1.4 billion was reported to have been spent on child protection and out-of-home care services across Australia.15 This does not include the money required to deal with the short-term effects of abuse including treatment of injuries, chronic health problems, mental health care and legal interventions, nor the long-term indirect effects of child abuse which include special education, mental and physical health care, juvenile delinquency and adult criminality. For Australia, these short and long term consequences of abuse and neglect were estimated to be $4,929 million in 2000-01.16 This is not an unrealistic estimate as in 1996 the United Kingdom estimated the cost of child abuse to statutory and voluntary agencies to be £1 billion per year.17 and in America, the New York State alone estimated that in 2003 their costs to exceed $2.4 billion annually.18

The present child protection systems in Australia are costly and cannot be sustained in terms of workforce capacity. They are also not effective in reducing family and community vulnerability to child abuse and neglect. We will always need to spend money to address the result of maltreatment. Our argument in this paper is that unless we start to put adequate resources into the prevention of child abuse and neglect, we will have to spend increasing amounts of money on increasing numbers of notifications, children being placed in out of home care and direct and indirect effects of abuse and neglect outlined above. There is also clearly a moral obligation to ensure that government intervention does no further harm to children and an even greater obligation to prevent the harm of abuse and neglect occurring in the first place.

A public health approach

  1. Top of page
  2. Abstract
  3. Current Australian child protection systems
  4. A public health approach
  5. The knowledge challenge
  6. Primary prevention — universal services for all families
  7. Secondary prevention — targeted Services
  8. Tertiary prevention — management
  9. Conclusions
  10. Acknowledgements
  11. References

What might a public health approach offer? The knowledge base for a public health approach to child abuse and neglect is still in its infancy. What potential social marketing and health promotion approaches may have to offer is unclear. How population-based strategies to reduce parental alcohol abuse might affect the prevalence of child abuse and neglect is yet undetermined. However, even as a conceptual tool, a public health approach may stimulate a different service system response. Figure 2 applies the notions of primary, secondary and tertiary prevention, commonly used for many public health problems such as obesity and heart disease, to child abuse and neglect.

image

Figure 2. Universal, Secondary and Tertiary Prevention and Intervention (adapted from Tony Morrison, 2006).45

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The knowledge challenge

  1. Top of page
  2. Abstract
  3. Current Australian child protection systems
  4. A public health approach
  5. The knowledge challenge
  6. Primary prevention — universal services for all families
  7. Secondary prevention — targeted Services
  8. Tertiary prevention — management
  9. Conclusions
  10. Acknowledgements
  11. References

The first challenge is to measure accurately and repeatedly what it is we are trying to prevent or minimise. As mentioned, the only reliable data we have on child abuse and neglect are the number of notifications and substantiations processed by the child protection agencies. Child protection agency data is not a good measure of the true prevalence of child abuse and neglect, as the definition of a case is dependent upon the legislation and reporting policies and practices which vary over time and between jurisdictions. They were designed primarily for administrative reporting, not public health monitoring. Thus each child protection agency has its own definition of maltreatment or substantiated maltreatment and levels cannot be compared between them nor trends in incidence compared accurately over time as these definitions change. It is therefore not known whether any observed variations in rates over time or between jurisdictions are due to these differences, or to real changes in occurrence due to preventative services or other influences.

The Australian Institute of Health and Welfare19 has reported that the ‘definition of abuse and neglect has broadened considerably’ and concerns have been raised that this has resulted in “draw(ing) more children and families into the net, exposing them to child protection investigations without necessarily increasing service provision to address their needs” (p4). This highlights the importance of having a valid population health measure of child abuse and neglect which will allow us to monitor trends in child abuse and neglect, describe the risk and protective factors, enable comparisons across and within jurisdictions over time and provide a rigorous foundation for evidence based policy. At the World Health Organization First Meeting on Strategies for Child Protection in 1998, Dr Facchin discussed the importance of using public health indicators of child abuse and neglect rather than just legal or judicial statistics.20 The work of developing a measure of public health indicators has commenced at the Telethon Institute for Child Health Research using linked population level databases to investigate direct indicators, for example, rates of hospital admissions for non-accidental injury, to enable accurate descriptions of trends in abuse and neglect to use in evaluating the impact of prevention and intervention programs.

A valid population based measure would improve our attempts at determining the causal pathways to child maltreatment. This could be done in two ways, the first by determining those most vulnerable to child maltreatment and not just those who are most likely to be reported to child protection agencies, and the second by determining the changing level of risk factors associated with changes in the incidence of child abuse and neglect.

We already know from the literature about many of the risk factors for child abuse and neglect in communities, families and children. US research has found communities that are more vulnerable have greater poverty and unemployment, higher residential mobility and a low adult to child ratio.21 A low adult to child ratio is true of many Aboriginal communities and is associated with an increased burden for caregivers.22 Family characteristics that increase risk include parents with mental health problems, substance abuse issues, domestic violence, poor family functioning, young mothers, single parents and mothers who have little social support or contact.23–26 Children at greater risk include those with disabilities or chronic health problems, and children with difficult temperaments and externalising behaviours.27–30

Research also indicates that there have been changes in society which appear to make it more difficult for families to adequately parent. In the past decade there has been a significant increase in the proportion of single-parent families, with many of them living on significantly lower incomes than two parent families.31,32 Despite Australia's increasing wealth there has been an increase in the proportion of children living in poverty and concerns raised about housing affordability, particularly for low income earners and first home buyers.33 We have had an increase in risky and high-risk alcohol consumption in every age group and an increase in psychological distress.34,35 Therefore, with many of these factors increasing it is likely that more families are vulnerable to child abuse and neglect, hence the urgency of a public health approach.

Primary prevention — universal services for all families

  1. Top of page
  2. Abstract
  3. Current Australian child protection systems
  4. A public health approach
  5. The knowledge challenge
  6. Primary prevention — universal services for all families
  7. Secondary prevention — targeted Services
  8. Tertiary prevention — management
  9. Conclusions
  10. Acknowledgements
  11. References

A growing body of research now demonstrates the considerable influence of the early years on health and development and how a safe and positive start to life is integral to good long-term outcomes.36 The good news is that universal prevention activities not only have the potential for preventing abuse and neglect; they also enhance child health and wellbeing overall by improving behaviour problems and school readiness.37

In relation to the health sector, the adequate provision of universal maternal and child health services, backed up by developmental pediatricians and allied health services, are the first steps in protecting children from harm and providing support to families to enhance their children's health and wellbeing. General Practitioners also have a vital role to play. The welfare sector needs to ensure that all families have access to affordable housing, accessible and low-cost child care, supportive employment practices including parental and maternity leave, tax relief for families and ready access to quality parenting programs and other supports. In the education sector there are some promising initiatives of universal prevention including programs such as Pathways to Prevention which are locating family support professionals within schools, creating circles of care for children and providing supportive communities for families.38 Other initiatives include Healthy Start to Life and Early Child Development Centres.

The United Kingdom has challenged the way governments do business with the ‘Every Child Matters Green Paper’39 stating that ‘child protection cannot be separated from policies to improve children's lives as a whole’ (p5). The policy recommendations were that universal services need to be strengthened for all children with an increasing focus on support of families and those at-risk. Another focus is on ensuring that all children have the chance to fulfil their potential and are not socially or economically excluded. This resulted in the 2004 Children's Act and the development of multi-agency services, joint strategic planning and joint funding agreements and common assessment frameworks to be used across children's services. There is yet to be a comprehensive evaluation of the outcomes but it is a brave attempt by government to challenge the way it does business in an attempt to improve the outcomes for all children.

Secondary prevention — targeted Services

  1. Top of page
  2. Abstract
  3. Current Australian child protection systems
  4. A public health approach
  5. The knowledge challenge
  6. Primary prevention — universal services for all families
  7. Secondary prevention — targeted Services
  8. Tertiary prevention — management
  9. Conclusions
  10. Acknowledgements
  11. References

Universal prevention services also need to have the ability to identify vulnerable families early enough to change risky behaviours and avoid pathways to abuse. These families can be offered secondary prevention or targeted services such as the South Australian Nurse Family Home Visiting Program, based on the work of Olds,40 which is offered to vulnerable families with a new baby (for example, all mothers under 20, all families of Aboriginal infants). Countries such as Canada are attempting universal screening of new mothers in Manitoba's ‘Baby First’ program and families who are deemed ‘at risk’ given a more in-depth assessment and referred to a home visiting program. Initial results suggest that the Baby First program is associated with lower rates of maltreatment and assault in children three years of age and younger.41 By using the platform of a universal maternal and child health service, it reduces the stigma of a targeted service. The challenge for such services is to broaden the paediatric surveillance role of nurses to encompass parental emotional and social well-being.42

Specialist mental health, domestic violence and drug treatment services also have an important role in secondary prevention efforts. The challenge for service providers in these areas is the opposite — to broaden their adult-focused role to encompass the well-being of the child as well as to support the parents. The Commonwealth-funded COPMI (Children of Parents with a Mental Illness) initiative is an example of a framework that attempts to do this.43 There is an urgent need to incorporate broader frameworks in the areas of drug treatment and domestic violence services, given the rising rate of these and their known association with child abuse and neglect.

Tertiary prevention — management

  1. Top of page
  2. Abstract
  3. Current Australian child protection systems
  4. A public health approach
  5. The knowledge challenge
  6. Primary prevention — universal services for all families
  7. Secondary prevention — targeted Services
  8. Tertiary prevention — management
  9. Conclusions
  10. Acknowledgements
  11. References

Even with well-funded primary and secondary prevention, there will still be a need for tertiary prevention — the inner circles of Figure 2. These children need to be quickly assessed and provided with effective treatment for their abuse and trauma, and appropriate and secure placements provided to avoid further damage in situations where it is unsafe for children to remain at home. Public health and social epidemiological research have a role to ensure that the best evidence of effective care are provided, which may include intensive family-centered interventions as well as removal.

Given that there are no reliable risk assessment instruments in the field of child protection and that the removal of children from their parents can both prevent significant harm and potentially cause harm, it is imperative that we reduce the number of families who are vulnerable to child abuse and neglect and the number of children who are abused. Statutory intervention and the removal of children will always be a requirement of the child protection system, however, coercive and deterrent responses are not ideal for engaging families with support agencies. It is therefore imperative to engage with parents and encourage regulation at low levels of risk with increasing levels of coercive and deterrent responses by the child protection system if cooperation and compliance is not achieved (Figure 3).10 Recent legislative and policy changes in Victoria are aimed at achieving this.

image

Figure 3. Responsive Regulation Model of Prevention and Intervention in Child Abuse and Neglect (modified from the Allen Consulting Group, 2003 based on the model by Ayres and Braithwaite, 1992).46

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Conclusions

  1. Top of page
  2. Abstract
  3. Current Australian child protection systems
  4. A public health approach
  5. The knowledge challenge
  6. Primary prevention — universal services for all families
  7. Secondary prevention — targeted Services
  8. Tertiary prevention — management
  9. Conclusions
  10. Acknowledgements
  11. References

If there is a real commitment to protect all children, then supporting families and children before they reach the point of being abused and neglected should be a priority. Clearly there is a need to ensure that we have a joint Commonwealth and State and Territory prevention strategy which adequately resources and integrates effective approaches. It is important that we ensure ongoing evaluation and that initiatives which are making a difference are given ongoing support to ensure their sustainability.

Australia, as a signatory to the ‘United Nations Convention on the Rights of the Child’, has agreed to protect children's rights through “assisting parents in the performance of their child rearing responsibilities” as well as ensuring “the development of institutions, facilities and services for the care of children”.44 This requires a public health approach with a platform of universal preventative services, secondary prevention with targeted services for at-risk families, and interventions at various levels depending on the risk of harm to the child and the needs of the family (see Figure 3).

In 1966, Bialestock2 recognised that prevention was key to dealing with the increasing numbers of children being identified following abuse and neglect:

“The communal advantage of developing individuals able to contribute instead of needing support to stay alive, and the growth of happiness and human dignity which would follow, scarcely needs to be stated… This situation should be considered as a national emergency as lethal to the lives of potential Australians as is a war. Immediate allocations of revenue to prevent this situation should be made if the(se children) … are to be allowed to grow into adults able to live in dignity and to work to contribute to our economy. We must not sentence these children to a lifelong need for State support” (p 1133).

Forty years on — is it now time for a public health approach?

Acknowledgements

  1. Top of page
  2. Abstract
  3. Current Australian child protection systems
  4. A public health approach
  5. The knowledge challenge
  6. Primary prevention — universal services for all families
  7. Secondary prevention — targeted Services
  8. Tertiary prevention — management
  9. Conclusions
  10. Acknowledgements
  11. References

Melissa O'Donnell's PhD is supported by an Australian Postgraduate Award Industry Scholarship provided through an Australian Research Council Linkage Project Grant (LP0455417). The Australian Centre for Child Protection is funded by the Department of Innovation, Industry, Science and Research.

References

  1. Top of page
  2. Abstract
  3. Current Australian child protection systems
  4. A public health approach
  5. The knowledge challenge
  6. Primary prevention — universal services for all families
  7. Secondary prevention — targeted Services
  8. Tertiary prevention — management
  9. Conclusions
  10. Acknowledgements
  11. References
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    Modified from The Allen Consulting Group Diagram p83 which was based on the enforcement pyramid in Ayres and Braithwaite, Responsive Regulation: Transcending the Deregulation Debate, Oxford University Press, New York , 1992, p39.