Economic Issues in the Community Response to Child Maltreatment
Type of maltreatment
Odds ratio for suicide attempt
Physical abuse by an adult living in the household
Sexual abuse by a family member
Drug or alcohol abuse by family
Witnessing physical violence (family member on another family member)
The role for government to intervene in relation to child abuse and neglect is thus absolutely clear and rests on three core arguments:
The ethical argument
There is a clear ethical imperative to protect highly vulnerable members of our society from the damaging actions of others. Children are absolutely defenceless, unable to understand or articulate their distress and can be somewhat invisible. Concerns about equity are also pertinent. Child maltreatment is considerably more common in lower socio-economic sectors of society and is also likely to perpetuate social and economic disadvantage. Low educational attainment, teen pregnancy, unemployment, welfare dependency, involvement in crime, drug and alcohol abuse and mental illness are all consequences of child maltreatment. For any society that has a ‘closing the gap’ agenda related to income, educational or health disparities, addressing child maltreatment to ensure harms are minimised is a logical strategy component.
Violation of the assumption of the rational consumer/agent or skills/knowledge gap
The inability of the parent to act in the best interests of their child, even though this is what every parent would want, can be considered irrational behaviour warranting government intervention. This argument does not require maltreatment to be extreme but simply that parental behaviour is other than that consistent with creating a safe and nurturing environment for the child as the parent would wish. The appropriate response would depend on the level of harm and the reason for the inappropriate parenting behaviour. This might start with parenting classes for expectant or new parents, an infant welfare centre/infant visiting programme to improve knowledge and skills or social supports for very isolated parents advancing to a more therapeutic approach or a more intrusive regulatory approach for more chaotic and disturbed families where the situation for the child is of serious concern. In the more serious cases of abuse or neglect, poor parenting is unlikely to reflect a simple knowledge or skills gap, but rather the effects of unresolved childhood trauma on the capacity for intimate relationships such as that between a mother and her child (Amos et al. 2011, 2014a, b). Amos and colleagues argue convincingly that the child acts as a potent trauma trigger for the mother. The mother’s behaviour in neglecting or abusing her child is a logical response given the distorted perspective created by her own trauma history, but irrational from the perspective of an undamaged individual or the wider societal good. (While the model explicitly refers to mothers, it almost certainly applies also to fathers.) Some of the known consequences of child maltreatment, such as drug and alcohol abuse, mental illness and inability to develop healthy relationships, directly impact on the capacity of parents with a history of maltreatment to adopt behaviours that are protective of others in their care.
It is also the case that the private market will inherently exploit, for profit the more vulnerable in society who experience poor impulse control. This can exacerbate the unfavourable conditions for these parents by fuelling their abuse of alcohol, tobacco, illicit drugs, gambling and the like, which further compromise their capacity to parent in a safe manner.
Externalities (costs on others) – considerable costs incurred by society of failing to intervene
The dominant costs of child maltreatment are borne not by the perpetrator but by others; in the first place the child and secondly society. These costs are considerable. For the child, there is the immediate and acute distress, which can result in an ever-present fear, anxiety and hypervigilance, morbidity and, in cases of fatality, a life cut short. There are in addition ongoing or downstream consequences of developmental delay, drug and alcohol abuse or other addictive behaviours, risk taking/adoption of harmful lifestyle behaviours (such as tobacco smoking and poor nutrition), poor mental health/serious mental illness (e.g. up to 12 times the rate for schizophrenia13), compromised physical health, placement in care, involvement in crime as victim and / or perpetrator, low educational attainment, welfare dependency, unemployment, difficulty with intimate relationships, teenage pregnancy, likelihood of maltreating their own children and premature death. These consequences are reported to have from 1.5 to 12 times the relative risk for persons with a child maltreatment history relative to those without. See, for example, Table 10.1 above. The odds ratios for child maltreatment for poor mental health vary by study, but large excess risk is uniformly reported (Chapman et al. 2007; Duke et al. 2010; Norman et al. 2012). Studies also report a more than doubling the risk for physical conditions (e.g. stroke 1.7–3.00 times (Norman et al. 2012); obesity 1.3–9.8 times (Gilbert et al. 2009)).
In short, child maltreatment imposes large negative health, social and economic consequences, both contemporaneous with the maltreatment and ongoing (Shonkoff and Garner 2012). These consequences result in huge budgetary impacts in the form of additional expenditure on services and lost production. Expenditure is incurred to address the consequences of child maltreatment particularly on hospital in-patient services and Emergency Department presentations, drug and alcohol programmes, suicide prevention and response, rehabilitation, on the criminal justice system, housing support, income support/welfare payments, remedial education and on the child protection system. These consequences are expensive. A child placement in 24 h out-of-home care can cost more than $300,000/year (for residential care) (ROGS 2014a); involvement in crime is also costly (prison > $80,000 per prisoner year and more for juveniles) (ROGS 2014b). A life of welfare dependency, drug and alcohol addiction or serious mental illness involves ongoing government expenditures as well as impacts on social cohesion. Child maltreatment is also responsible for a considerable reduction in the productive potential of society and thus lower gross domestic product as a consequence of premature death, low workforce participation and educational failure limiting skills and knowledge formation.
The total societal burden of child maltreatment is undoubtedly very large with several published estimates, for example an estimated total cost of child maltreatment in the USA of US$124 billion, or a cost per nonfatal case of US$210,000 (Fang et al. 2012). But the full costs are difficult to quantify, given the wide scope of impacts. None of the published studies provide a fully comprehensive estimate. For example, studies fail to incorporate the effect of child maltreatment on harmful behaviours such as smoking or morbid obesity (themselves being large source of disease burden). They also ignore the intergenerational nature of abuse, which in effect attaches an infinite stream of costs to child maltreatment.
It is increasingly understood that the observed relationships between child maltreatment and the health, social and economic consequences can be taken as causal, not merely correlational. There are well-defined causal mechanisms that predict the serious consequences of child abuse and neglect that are observed. These mechanisms are found in the attachment and trauma literature (Bowlby 1982; Amos et al. 2011), evolutionary theory (Amos et al. 2014a, b), developmental psychology and neural biology (Shonkoff et al. 2009).
The results of randomised controlled trials confirm that it is possible to intervene with families to reduce rates of maltreatment and that this has the expected impact on health, social and economic outcomes (Reynolds et al. 2002; Olds et al. 1997; Mikton and Butchart 2009; Berry et al. 2007).
This means that there are effective interventions to reduce rates of child maltreatment and reduce the consequent harms, both in families at risk (no contact with the child protection system) and in families where abuse or neglect is already present.
Not surprisingly, given the ethical and efficiency arguments for a government role in addressing child maltreatment and the existence of effective strategies, governments across countries and jurisdictions have policies to protect children. The question is not whether a formal child protection system should exist, but what should it look like? How should maltreatment be defined? At what point is intervention warranted? Is there to be a different system response for different maltreatment thresholds? What are the strategy components? What is the balance between investigation, child removal and family support? And in relation to family support, what is the balance between case management and practical support and a therapeutic approach incorporating treatment for past and current trauma?
If we had full information about (1) the consequences of child maltreatment, including budgetary impacts, and (2) the effectiveness and cost of all possible intervention strategies, it would be possible to develop an evidence-driven child protection strategy. In the interim, the challenge is to draw on the best available evidence to inform the policy response and determine the evidence that we should be gathering to better inform future policy.
Determining the Optimal Policy Response to Child Maltreatment and the Role of Mandatory Reporting
This section considers how governments might respond to families where there is a level of concern about the welfare of the child such that cases should be brought to the attention of the child protection system for specific action to protect children from harm. It is assumed in this discussion that a regulatory child protection system is part of a broader system of family support, incorporating a suite of options of varying intensities to offer families the necessary supports for creating a nurturing environment for their children.
In understanding the performance of the child protection system, it is necessary to think through how to define child maltreatment. Definitions of child abuse and neglect (CAN) vary considerably, partly reflecting varying contexts and the purpose of the definition. The cut point, in terms of what constitutes a case of maltreatment of sufficient severity to warrant action – which may be a family support rather than a formal child protection investigation – is ideally determined by (1) evidence of harms, (2) source of harms and (3) capacity of the system to improve outcomes for children and families. Evidence around all three aspects is pertinent where the definition is designed to trigger a government response. In contrast, if a definition is for use in epidemiological research into the risks for and/or consequences of child maltreatment, the capacity for and impact of a response is irrelevant.
A common premise underpinning the statutory system is that the highest risk cases offer the greatest potential for benefit through government intervention (e.g. immediate life-saving), with progressively lower potential for benefit as extent and likelihood of harm falls. This is consistent with a recent review of intervention studies of family support/preschool/infant visiting that identify greatest benefit in programmes that target the most vulnerable families (Segal et al. 2013).
Interestingly, this model contrasts with the population health maxim that greatest benefits are to be found in ‘shifting the entire population’ (Rose 2001) cited in favour of population approaches and universalism and against the targeting of services to those at highest risk. While this maxim is very popular, it needs to be understood as an empirical question. Whether a targeted or population approach will be the most efficient depends on the particular health or social problem being addressed, the cost of case finding those at high risk, the profile of harms and the costs and effectiveness of interventions across the risk spectrum.
That is, an approach based on the evidence of what works is what is required, not one that privileges a particular stage in risk creation or level of vulnerabilities. But that said, it is invariably desirable to offer something to populations wherever they sit on the primary, secondary and tertiary prevention continuum, with an approach proportional to the level of risk and potential for benefit. Further, contrary to popular wisdom, the level of benefit is typically proportional to level of risk; the higher the risk and expectation of harms, the greater the capacity for benefit. It is also clear that for children trapped in situations of serious harm, however that is defined, a policy response by government to protect children is paramount and must incorporate, at a minimum: (1) an efficient mechanism for case finding and (2) an effective multifaceted approach for protecting at-risk children.
We are concerned here with understanding the optimal mechanism for encouraging an ‘ideal’ level of reporting of suspected cases of serious child maltreatment. The options for such a mechanism fall into three categories: (1) legislative, involving mandatory legislation requiring specific occupations to report suspected cases of child abuse or neglect to the appropriate bodies, with protections for reporters, and usually (but not always) with penalties for failure to comply, (2) professional obligation under designated codes of practice for nominated professions to report suspected cases of child abuse or neglect, and (3) citizen option to report suspected cases. Any of these mechanisms presume an associated administrative process for receiving and acting on reports.
When mandatory reporting was first introduced in the USA in the 1960s, there was no formal mechanism to identify and respond to children subject to even extreme levels of abuse or neglect. This left many children at extreme and imminent risk, as societal action was rarely invoked to protect even those children who had been repeatedly and clearly subject to grievous harm. This was presumably a reflection of the pervading culture internationally, of nonintrusion into the lives of families by government and a perceived limit on the role of clinicians and others working with children. This culture of nonintrusion into family life is complex and arguably still limits the societal response to issues such as domestic violence and child maltreatment (leaving many of the most vulnerable citizens without protection). The reporting requirements or professional obligations are focused on the child experiencing significant harm and therefore also apply to cases of non-parental child maltreatment occurring outside the family, typically cases of sexual abuse. Again, social convention, in dealing with respected organisations, compounded by a high level of defensiveness from these same organisations has in the past demonstrably failed children experiencing harm.
It seems certain that the introduction of mandatory reporting in the 1960s has been instrumental in driving culture change in the behaviour of core professional groups in contact with vulnerable families and children. Mandatory reporting in bringing suspected cases of maltreatment to the attention of the child protection authorities demands a response and ultimately greater resourcing of the child protection system. For example, in Australia, resources allocated to child protection have more than doubled in real terms (2012–2013 dollars) from AUD 1,511.1 million in 2003–2004 to AUD 3,521.7 million in 2012–2013 (ROGS 2014a). (The benefit achieved by this increase in funding is hard to measure, but it was certainly aimed at advancing child and family welfare.)
Determining the best approach to case finding is complex. Historically, it is almost certain that mandatory reporting has been central in driving culture change and encouraging greater social responsibility in reporting children suspected to be at grave risk. However, it may be asked whether, in societies which have had mandatory reporting for some decades, such a model is still required? Where this has driven a culture shift, it may be that mandatory reporting and professional obligation are not very different in terms of outcomes. For example, in some contexts, certain reporter groups who only have a policy-based obligation (which is not covered by legislation), such as police, do make substantial numbers of reports. However, in other contexts and subsets of abuse, it is also known that some professional groups having only a policy-based duty make significantly fewer reports and identify far fewer cases than their counterparts who do have a legislative duty to report (Mathews et al. 2010). This can reflect a fear of reporting, lacking the protections provided by legislation, while being subject to identification, complaints and civil and disciplinary proceedings (Mathews et al. 2009). It is difficult to generalise because of the considerable variation in operational detail, such that there may be as much variation within a system type as across system types, relating to the precise reporting obligations and the administrative system for receiving and responding to reports.
Another way of considering this question of case finding is to assess whether the system for reporting currently in place in the particular jurisdiction performs ‘well enough’. Desirable performance in this context is concerned with identifying a ‘high’ proportion of cases of severe maltreatment or risk of maltreatment reported to a child protection agency and followed up appropriately and ‘low’ reporting of cases involving lower levels or no maltreatment. What constitutes ‘high’ and ‘low’ is a matter for debate and discussion and might reasonably vary by level and type of abuse, given some abuse types are less hidden (e.g. serious physical abuse) than others (e.g. sexual abuse).
The aim is for a good overlap of the populations of ‘severely’ maltreated children and a child abuse and neglect report, which is then actioned appropriately. A reporting system that has a high proportion of reported cases (which after assessment are determined to require a child protection and/or family support response), and a low proportion of reports that require neither, may indicate a well-performing system, but it is also consistent with a system which is failing to detect too many serious cases. Assessing performance in terms of a match between reports and substantiated cases is fraught and further complicated by the contested nature of how to define a case of child maltreatment warranting intervention. In short, the claim of ‘over-reporting’ under a system of mandatory reporting is difficult to test (Mathews 2012) and certainly cannot be established by reference to rates of unsubstantiated reports or rates of unsubstantiated investigations (Drake 1996; Drake and Jonson-Reid 2007; Kohl et al. 2009).
The primary role of reporting (notification) under mandatory reporting systems is to identify children who have been significantly harmed by abuse or neglect or who are at imminent risk of being so harmed; a secondary function or consequence of such reports is to identify families in need of support to facilitate the provision of assistance. Measuring system success or failure simply by the proportion of abuse or neglect reports that are substantiated, does not address the possibility of children at considerable risk within the community about whom no reports have been made or the value of identifying highly vulnerable families in need of assistance. Child protection systems increasingly have an alternate pathway to the statutory route through which vulnerable families are offered a range of family support services, which may include case management (e.g. to support access to income support, housing, employment, practical and social supports), therapeutic trauma-based counselling and parenting programmes designed to improve the parent/child relationship (such as ‘circle of security’ or incredible years). Having such a referral occur through a child protection system may well increase the uptake of such services for more vulnerable families, who might otherwise not engage, creating an ‘early intervention’ pathway. Even for families who are referred to and progressed through the statutory child protection system, a finding of ‘not substantiated’ would not necessarily mean that the child was (is) not at serious risk of harm.
As in any legal process, a finding reflects on the evidence able to be gathered. In Australia 8–18 % of children – depending on jurisdiction – who were the subject of an unsubstantiated investigation were within 12 months subject to a substantiated investigation (ROGS 2014a).
Further, a statutory system with constrained capacity is likely to focus on abuse or neglect associated with a serious risk of imminent harm deemed to require immediate action. Cases of potentially serious harms, but of longer-term onset such as major developmental delay, risk of drug and alcohol abuse and a life of mental illness or of crime may be less likely to be investigated or substantiated. In short, a decision not to investigate a child harm report, or a non-substantiation of a report after investigation, does not necessarily mean the report was not appropriate. And as a matter of logic, given the challenges of accurately identifying cases, any system that had a very low rate of non-cases could be assumed to be missing many serious cases. Knowledge of the prevalence of child maltreatment of seriousness that would justify a report would be useful in considering whether the reporting regime is resulting in an appropriate number of reports, whether too few or too many (Fig. 10.1).
Depiction of prevalence of child abuse and neglect (CAN), report, substantiation
Estimates of prevalence of child maltreatment are generated from two distinct sources: (1) child protection data and (2) survey data. Both are interesting and provide distinct perspectives on likely underlying rates:
Child protection data – reports, investigations, substantiation, family support services
Data on the Australian child protection system are reported in detail by the Productivity Commission in their annual Report on Government Services (ROGS) (2014a). Selected data from this extensive report is presented in Table 10.2. This shows that in 2012–2013, 184,284 children were the subject of a notification and that 40,685 or 22.1 % had a substantiated notification. But we also note that the majority of notifications (55 %) were dealt with by ‘other means’, often through an alternate family support pathway. A ‘not substantiated’ finding was recorded for just 21.8 % of notifications, or only 19 %, if we adjust for those for whom a substantiated finding would be delivered within 12 months.
Child protection services: notifications, investigations, substantiations, Australia, ATSI and non-ATSI, number and rate/1,000 children 2002–2003 and 2012–2013