Elsevier

Child Abuse & Neglect

Volume 48, October 2015, Pages 208-220
Child Abuse & Neglect

Research article
Burden attributable to child maltreatment in Australia

https://doi.org/10.1016/j.chiabu.2015.05.006Get rights and content

Abstract

Child maltreatment is a complex phenomenon, with four main types (childhood sexual abuse, physical abuse, emotional abuse, and neglect) highly interrelated. All types of maltreatment have been linked to adverse health consequences and exposure to multiple forms of maltreatment increases risk. In Australia to date, only burden attributable to childhood sexual abuse has been estimated. This study synthesized the national evidence and quantified the burden attributable to the four main types of child maltreatment. Meta-analyses, based on quality-effects models, generated pooled prevalence estimates for each maltreatment type. Exposure to child maltreatment was examined as a risk factor for depressive disorders, anxiety disorders and intentional self-harm using counterfactual estimation and comparative risk assessment methods. Adjustments were made for co-occurrence of multiple forms of child maltreatment. Overall, an estimated 23.5% of self-harm, 20.9% of anxiety disorders and 15.7% of depressive disorders burden in males; and 33.0% of self-harm, 30.6% of anxiety disorders and 22.8% of depressive disorders burden in females was attributable to child maltreatment. Child maltreatment was estimated to cause 1.4% (95% uncertainty interval 0.4–2.3%) of all disability-adjusted life years (DALYs) in males, and 2.4% (0.7–4.1%) of all DALYs in females in Australia in 2010. Child maltreatment contributes to a substantial proportion of burden from depressive and anxiety disorders and intentional self-harm in Australia. This study demonstrates the importance of including all forms of child maltreatment as risk factors in future burden of disease studies.

Introduction

Child maltreatment is a serious public health problem in Australia and worldwide, adversely affecting short- and long-term physical and mental health (Chen et al., 2010, Norman et al., 2012), social development and functioning (Alink et al., 2012, Kim and Cicchetti, 2003). Maltreatment of children is commonly divided into four main types: childhood sexual abuse (CSA), childhood physical abuse (CPA), childhood emotional abuse (CEA), and childhood neglect (CN) (Butchart, Phinney Harvey, Kahane, Mian, & Furniss, 2006).

The definition of child maltreatment varies within Australian studies and globally, along with the definition of what constitutes a child (under 15, 16 or 18 years of age). These sources of variation, as well as other methodological factors such as the mode of data collection and type of sample assessed, lead to differences in the reported prevalence (Andrews, Corry, Slade, Issakidis, & Swanston, 2004). For instance, meta-analyses of CSA prevalence around the world have made use of estimates ranging from 8% to 31% in females and 3% to 17% in males; with pooled self-reported prevalence estimated higher in females (approximately 18% for females and 8% for males) (Barth et al., 2013, Pereda et al., 2009, Stoltenborgh et al., 2011). The prevalence of other forms of child maltreatment has not been as extensively investigated; however, available literature suggests that every year 4–16% of children are physically abused and 10% emotionally abused or neglected in high income countries (Gilbert et al., 2009). In recent meta-analyses of worldwide prevalence, the overall estimate was 23% for studies using self-report measures of CPA, with no apparent gender differences, (Stoltenborgh, Bakermans-Kranenburg, van IJzendoorn, & Alink, 2013) and 36% for studies using self-report measures of CEA (Stoltenborgh, Bakermans-Kranenburg, Alink, & van IJzendoorn, 2012). Regarding CN, estimated global prevalence based on a modest number of studies was 16% for physical neglect and 18% for emotional neglect with no apparent gender differences (Stoltenborgh, Bakermans-Kranenburg, & van IJzendoorn, 2013). Currently there are no Australia-wide studies of the prevalence of child maltreatment. National Child Protection data exist, but these likely under-represent the true number of children experiencing maltreatment as they only capture cases where maltreatment has been reported to authorities, it can be substantiated, and the risk of harm to the child is deemed to be sufficiently high to justify intervention (Australian Institute of Health and Welfare, 2014).

Empirical evidence has linked all forms of child maltreatment with adverse mental and physical health outcomes (Chen et al., 2010, Norman et al., 2012). Experiencing at least one form of child maltreatment may double the risk of developing mental health problems such as depressive and anxiety disorders, and increase the risk of self-harm and suicidal ideation and attempts (Afifi et al., 2008, Chen et al., 2010, Devries et al., 2014, Norman et al., 2012). The four types of child maltreatment are highly interrelated (Dong et al., 2004, Finkelhor, 2008, Finkelhor et al., 2007, Jirapramukpitak et al., 2005, Mullen et al., 1996, Teicher et al., 2006). In a cross-sectional study of the effect of multiple types of maltreatment in children and adolescents in Viet Nam, substantial proportions of participants reported exposure to multiple abuse (21% reported two types; 15% three types, and 6% four types of maltreatment) (Nguyen, Dunne, & Le, 2010). Similar levels of multi-type maltreatment have been found in Malaysia (Choo, Dunne, Marret, Fleming, & Wong, 2011). Exposure to multiple forms of maltreatment increases the child's risk of developing later mental health problems (Edwards et al., 2003, Holt et al., 2007, Rikhye et al., 2008, Schneider et al., 2007, Teicher et al., 2006, Turner et al., 2006, Zoroglu et al., 2003).

In Australia, as in most countries, there has not been a comprehensive assessment of the health consequences of child maltreatment at the national level. CSA was the only form of maltreatment included as a risk factor in the Australian Burden of Disease 2003 study (Begg et al., 2008) and in the Global Burden of Disease 2010 study (GBD 2010) (Lim et al., 2012). The omission of other types of child maltreatment limits our understanding of how these complex phenomena relate to each other, and how co-occurrence of multiple types may influence the overall burden. This is also an important gap in the international literature (Fang et al., 2015). In addition, to date, studies estimating the economic burden of child maltreatment (Fang et al., 2012, Fang et al., 2015) have not adjusted for co-occurrence of maltreatment types. The present analysis aims to derive estimates of the burden of depressive disorders, anxiety disorders and intentional self-harm attributable to CSA, CPA, CEA and CN in Australia adjusting for co-occurrence of multiple forms of child maltreatment. It is hoped that this will lead to quantification of the burden attributable to all forms of child maltreatment in future iterations of the Australian and global burden of disease studies and inform estimation of the economic impact of child maltreatment.

Section snippets

Methods

Exposure to child maltreatment was treated as a risk factor for disease and injury using counterfactual estimation and comparative risk assessment methods (Lim et al., 2012). This involved comparing the current local health status with the theoretical-minimum-risk exposure defined as a population not ever having been exposed to child maltreatment. Population attributable fractions (PAFs) were determined by the prevalence of ever having been exposed to these risk factors in the population and

Systematic Review of Child Maltreatment Prevalence in Australia

A total of 687 articles were identified by the search of electronic databases with two additional reports identified from official statistics websites (Australian Bureau of Statistics, 2005, Australian Institute of Health and Welfare, 2014) and one article identified from scanning the reference lists of other articles (Goldman & Goldman, 1988). After duplicates were removed, the remaining 557 records were screened for prevalence of at least one form of child maltreatment that occurred within

Discussion

Although comparative risk assessment methodology has previously been applied to CSA in Australia, this study is novel in measuring the impact of the four main types of child maltreatment on mental health. In the absence of nationally representative data for Australia, our systematic review identified 23 studies reporting on the prevalence of child maltreatment that could be included in the meta-analysis. The majority of these studies reported on the prevalence of CSA, highlighting the dearth of

Limitations

Our study had some limitations. There are inconsistencies in how each form of maltreatment is defined and measured, as well as inconsistencies in how childhood is defined across studies. Studies included in this meta-analysis of prevalence used various definitions of childhood ranging from <15 to <18 years and included studies where the definition of childhood was not stated which is in alignment with RR estimates for non-sexual maltreatment (Norman et al., 2012), CSA and depressive disorders

Conclusions

This is the first study to quantify the burden of mental disorders attributable to all forms of child maltreatment in Australia and one of few internationally attempting to deal with the complexity of exposure to multiple types of maltreatment. It is important for future burden of disease studies to include all forms of child maltreatment as risk factors for mental disorders and self-harm. This study provides a method by which disease burden from all forms of child maltreatment can be

Conflict of Interest

All authors declare no conflicts of interest.

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