Cumulative Incidence of Child Protection Services Involvement Before Age 5 Years in 153 670 Australian Children

Child maltreatment has immediate and lifelong consequences for health and well-being and is costly for governments.¹ Historically, reporting of child protection services (CPS) contacts has offered a system view of child protection based on point incidence. Because CPS data have become increasingly available for research, the scale of the child maltreatment problem across the life span has begun to emerge. In the US, maltreatment is investigated in 37% of children,² confirmed in 13% of children,³ and results in the placement of 6% of children in out-of-home care (OOHC) at least once by the time the child is 18 years of age. In New Zealand, 24% of children born in 1998 had 1 or more CPS notifications, 10% had experienced substantiated maltreatment, and 3% had 1 or more OOHC placements by 17 years of age.⁴ More than one-third of New Zealand children reported to CPS by adulthood were first reported by age 5 years.⁴ This study used cross-sectoral data linkage to quantify the cumulative incidence of CPS involvement before 5 years of age among children in their first year of school in New South Wales, Australia.

We used linked birth registrations, perinatal records, and CPS data for 153 670 Australian children who started school in New South Wales in 2009 or 2012 and had a birth record in New South Wales. Ethical approval was obtained from the New South Wales Population Health Services and Research Ethics Committee, the New South Wales Aboriginal Health and Medical Research Council Ethics Committee, and the Australian National University Human Research Ethics Committee, which included a waiver of consent to obtain the deidentified, population-level data for this record linkage cohort study. Data on CPS outcomes included notifications that were screened in after meeting the statutory threshold for risk of significant harm, investigations, incidents of substantiated maltreatment, and OOHC placements.

We estimated children’s ages at the first of each CPS outcome using date of birth and the outcome. The numerator for age-specific cumulative incidence was the cumulative number of children with 1 or more CPS outcomes at each age. Because the cohort was defined as children who started school in 2009 or 2012, the denominator was 153 670 children for all incidence estimates from 0 to 5 years. We report the cumulative incidence of primary substantiated neglect and physical, emotional, and sexual abuse. These do not sum to the cumulative incidence of 1 or more records of substantiated maltreatment because children may have experienced multiple notifications for different maltreatment types. The analysis of the data for this study was undertaken between November 2018 and March 2019 using Stata version 12 (StataCorp).

A total of 153 670 children were included. Of these, 79 085 (51.5%) were male, 9625 (6.3%) were Aboriginal and Torres Strait Islanders, 40 480 (26.3%) had a mother who was born overseas, 5638 (3.7%) were born to mothers younger than 20 years; 95 544 (62.2%) lived in major cities, 56 723 (36.9%) lived in regional areas of New South Wales, and 1401 (0.9%) lived in remote areas of New South Wales. The cumulative incidence of screened-in notifications increased from 5.4% (n = 8309) at 1 year of age to 13.8% (n = 21 179) at 5 years of age (Figure 1). Of the children reported to CPS by age 5 years, 8309 (39.2%) were first reported by 1 year of age. By age 5 years, 12 185 of the 21 179 children (57.5%) with 1 or more screened-in notifications were investigated by CPS. The cumulative incidence of substantiated maltreatment was 3.2% (n = 4927 children) by age 5 years. Emotional abuse was the primary substantiated maltreatment type in 2584 children (1.7%) by 5 years of age, neglect in 1936 children (1.3%), physical abuse in 1155 children (0.8%), and sexual abuse in 471 children (0.3%) (Figure 2). The cumulative incidence of 1 or more OOHC placements was 0.5% of children (n = 751) by age 1 year and 1.4% (n = 2177) by age 5 years.

We found that 1 in 7 children in New South Wales had 1 or more screened-in notifications to CPS by age 5 years, which is comparable in scale with common childhood illnesses, such as asthma. By age 5 years, maltreatment was substantiated in 1 in 30 children and 1 in 70 children were placed at least once in an OOHC placement. Despite differences in the processing of notifications and data recording practices, we found that early-childhood CPS involvement is common in children in New South Wales, similar to other Australian jurisdictions^5,6 and internationally.^2-4 Although variation in CPS involvement between jurisdictions may reflect differences in the prevalence of child maltreatment, it also reflects differences in system responses to vulnerable children.

Because 38 480 children (53%) in the cohort starting school in 2009 were born 1 to 22 (median, 4; interquartile range, 2-6) months before notifications were first recorded in the Key Information Directory System (November 1, 2003), the proportion of children with 1 or more notifications may be underestimated in the first year of life. However, a sensitivity analysis using data on children starting school in 2012 suggest that more than 80% of children described in notifications before November 1, 2003, would have been the subject of notifications again by age 5 years.

The scale of CPS involvement and substantiated child maltreatment confirms this is an important public health problem for young Australian children. Given that 2 in 5 children reported to CPS by age 5 years were first reported by age 1 year, an effective public health response may leverage routine health system contacts in the antenatal and postnatal periods to engage and support vulnerable families in a nonstigmatizing way to prevent maltreatment.

Accepted for Publication: February 4, 2020.

Corresponding Author: Kathleen Falster, PhD, School of Public Health and Community Medicine, University of New South Wales, Samuels Building, Kensington Campus, Kensington 2052, New South Wales, Australia (k.falster@unsw.edu.au).

Published Online: June 15, 2020. doi:10.1001/jamapediatrics.2020.1151

Author Contributions: Drs Falster and Hanly had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Falster, Hanly, Pilkington, Lynch.

Critical revision of the manuscript for important intellectual content: Hanly, Pilkington, Eades, Stewart, Jorm, Lynch.

Statistical analysis: Hanly, Pilkington, Lynch.

Obtained funding: Falster, Eades, Jorm.

Administrative, technical, or material support: Falster, Hanly, Stewart.

Supervision: Falster, Jorm, Lynch.

Other—participation in policy and community engagement: Eades.

Other—facilitated policy and practice engagement: Stewart.

Other—engagement with policy and community stakeholders: Falster.

Conflict of Interest Disclosures: Drs Falster, Hanly, Lynch, Pilkington, Eades, and Jorm reported grants from National Health and Medical Research Council of Australia during the conduct of the study. Dr Stewart is employed by the Department of Communities and Justice. No other disclosures were reported.

Funding/Support: This work was supported by the National Health and Medical Research Council of Australia (project grant 1061713 [Drs Falster, Jorm, Lynch, and Eades], Early Career Fellowship grant 1016475 [Dr Falster], Career Development Fellowship grant 1013418 [Dr Eades] and Centre for Research Excellence grants [1099422 (Drs Lynch and Pilkington) and 1135273 (Dr Hanly)]).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: This study was conducted as part of the Seeding Success Study. The Seeding Success Study investigator team includes Louisa Jorm, PhD, Kathleen Falster, PhD, Sandra Eades, PhD, John Lynch, PhD, Emily Banks, PhD, Marni Brownell, PhD, Rhonda Craven, PhD, Kristjana Einarsdóttir, PhD, Deborah Randall, PhD, Sharon Goldfeld, PhD, Alastair Leyland, PhD, Elizabeth Best, MSc(OHS), BAppSc(HealthEd), and Marilyn Chilvers, MAppStat, BEcon(Hons). These individuals were not compensated for their contributions to this study. We thank the Australian Government Department of Education; the New South Wales (NSW) Ministry of Health; the NSW Register of Births, Deaths and Marriages; the NSW Department of Education; and the NSW Department of Family and Community Services (now the Department of Communities and Justice [DCJ]) for allowing access to the data included in the study data resource. We thank the NSW Centre for Health Record Linkage for conducting the linkage of data sources detailed in this article. We thank staff at NSW Health and the Department of Communities and Justice for discussing the policy and practice implications of the findings. We also acknowledge the University of New South Wales Centre for Big Data Research in Health's Aboriginal and Torres Strait Islander Maternal and Child Reference Group for their contributions to discussions about the design, findings, and translation of this research from the project outset. This research has been undertaken with input from the DCJ. However, the information and views contained in this study do not necessarily reflect the views or information held by the NSW GOVERNMENT, the Minister for Families, Community and Disability, or the DCJ.