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It is well established that parental mental health problems can be associated with parenting difficulties and adverse effects on children's development. A review1 linked parental mental health problems with less responsive parenting, reduced safety behaviours, impaired attachments, and worse child development outcomes. Previous research has found parental mental health problems are a risk factor for substantiated maltreatment.2 However, there is limited information about the extent of increased risk overall and for specific mental health diagnoses, which is important as mental health issues and their impacts on parenting are not homogeneous.3
More than 1 in 10 children born in Western Australia (WA) have a mother who, prior to childbirth, was diagnosed with a mental health disorder, and this rate has increased over time (76/1000 births in 1990 to 131/1000 births in 2005).2 Within this context, it is important to understand the relationship between mental health problems and child protection contact, including the age at which children of parents with mental health problems are vulnerable to involvement by child protection services.
Despite recognition that parental mental illness is an important risk factor for maltreatment,4 few studies have quantified the relationship between parental mental health and child protection involvement.3 Among substantiated maltreatment cases, Jeffreys et al,5 found 51% of family assessments indicated the primary caregiver had a mental/emotional health problem. However, not all families had an assessment, and these were not conducted by mental health professionals. By contrast, a Canadian study found only 19.7% of child protection cases noted maternal mental health issues, which were associated with doubled risk of substantiations.6 Park et al,7 using linked administrative data, found increased rates of service provision and out-of-home care among Medicaid-eligible mothers with psychiatric diagnoses.
Perinatal mental health problems (those occurring during pregnancy or after childbirth) have received particular attention as women are at increased risk for mental health problems during this time.8 Increased contact with health services during the perinatal period provides opportunities for early intervention. Within Australia, there has been funding from 2008 to 2013 to increase screening and treatment for depression via the National Perinatal Depression Initiative.9 Given this focus, it is pertinent to examine the relationship between perinatal and overall mental health and child protection contact.
The aim of this study is to investigate at a population level whether children of mothers diagnosed with mental health issues are at higher risk for maltreatment allegations. This research will determine the age at which children are at most risk of child protection involvement and the types of mental health diagnoses associated with increased risk to identify where prevention activities and support could be directed.
Study population and data sources
The retrospective cohort included all parents of children born in WA from 1990 to 2005. The study used deidentified linked data from health and child protection data collections. Hospital morbidity data records all hospital admissions for parents from 1970 to 2005, including International Classification of Diseases (ICD) codes. The Mental Health Information System contains information on public and private mental health in-patient admissions and public out-patient contacts, and this study used data from 1980 to 2005. Department for Child Protection and Family Support data sets from 1990 to 2005 provided child maltreatment information. The Midwives Notification System and Birth Registrations provided information on all births in WA, including parental age and marital status. The Cerebral Palsy Register, Birth Defects Register and Intellectual Disability Exploring Answers Database were used to identify child disabilities.10–12
WA Data Linkage Branch linked the data using common identifiers such as name, address and birthdate.13 The identifiers were separated from health and child protection information to maximise privacy during the linkage process, with only deidentified information provided to researchers.
Ethics approval for the study was granted by the University of WA Human Research Ethics Committee, the Department of Health Human Research Ethics Committee, and the WA Aboriginal Human Information and Ethics Committee.
Maternal mental health, child maltreatment and demographic variables
Maternal mental health information was drawn from the Mental Health Information System and the Hospital Morbidity Data System. Mental health contacts by mothers included any reported mental health diagnosis prior to the child's first maltreatment allegation. Mothers were classified as having had a mental health contact if any of the following mental health-related diagnostic codes were recorded: ICD-9:‘290–319’, or external cause of self-harm ICD-9:'E950-E959’. ICD-8 and ICD-10 codes were mapped to ICD-9 codes.
Only mental health contacts prior to the first maltreatment allegation were counted, to avoid issues of reverse causality. Contacts could occur before or after the child's birth. Perinatal mental health contacts were mental health contacts made during the birth year or subsequent year, as full date of birth was not available due to the anonymised data.
Mental health diagnostic groups were ascertained using the mental health diagnoses of the most recent contact prior to the maltreatment allegation. Perinatal mental health diagnostic groups were ascertained using the final perinatal contact prior to any maltreatment allegation. The mother could be grouped into one or more diagnostic groups for each analysis. Secondary analyses were conducted examining whether mothers had a mental health diagnosis only, substance-related diagnosis only, or comorbid diagnosis (both mental health and substance-related diagnoses that occurred together or in separate contacts). The ascertainment of comorbidity was not limited to the most recent diagnosis: any relevant contact prior to the child maltreatment allegation was identified. For the perinatal comorbidity subanalysis, this was further limited to contacts during the perinatal period. Substance-related contacts were included in mental health figures except where contact type was divided into substance-related only, comorbid, or mental health only. Assault-related admissions included any hospital admission for assault-related injuries inflicted on the mother (ICD-9:E960-E969, ICD-10:X85-Y09) any time before a maltreatment allegation. Housing issues included any hospital admission for mothers that contained a code for problems related to housing and economic circumstances such as homelessness (ICD-9:V60, ICD-10:Z59) any time prior to a maltreatment allegation.
Child maltreatment allegations and substantiations were identified from the Department for Child Protection and Family Support datasets. Children and parents were identified as Aboriginal and Torres Strait Islander (Aboriginal) from Midwives and Birth Registration data. Child gender and parents’ age at the time of the child's birth were ascertained from Midwives and Birth Registration data. Neighbourhood socioeconomic disadvantage was determined by the Index of Relative Social Disadvantage from the Australian Bureau of Statistics.14
Risk of maltreatment allegations associated with mental health contacts was assessed using multivariable Cox regression, controlling for demographics and family factors known to increase risk of maltreatment allegations. Follow-up time was calculated from birth to first allegation. Children without an allegation by 2005 were censored. As rates of allegations and mental health contacts differ between Aboriginal and non-Aboriginal mothers, separate analyses were undertaken to assess risk factors. SAS V.9.3 was utilised, and results presented using HRs and 95% CIs.
Of the 404 022 live births from 1990 to 2005, 74 888 children (18.6%) had mothers with a mental health contact. Across the entire birth cohort, 14 317 children had a maltreatment allegation. Almost half (48.1%) the children with an allegation had mothers with a mental health contact. Compared to the total population, children of mothers with mental health contacts were more likely to be Aboriginal (15.2%), born to single mothers (17.0%), teenage mothers (7.8%), and teenage fathers (2.1%), and live in the most socioeconomically disadvantaged areas (15.1%) (table 1). Among children with an allegation and maternal mental health contact, 32.2% were Aboriginal, 33.6% were born to single mothers, 15.7% to teenage mothers, 4.3% to teenage fathers, and 28.1% lived in the most disadvantaged areas. Two-thirds of maternal mental health records included only mental health issues, 16% included only substance-related issues, and 17% included both. Table 2 shows demographic information by Aboriginality and maternal mental health contact history.
There were 22 748 (5.6%) children whose mothers had a perinatal mental health contact (table 1). Of these, in 55% of cases, this was the mother's first mental health contact. These children were demographically similar to children of mothers with any mental health contacts. On average, children of mothers with perinatal mental health contacts were younger at first maltreatment allegation (M=2.8 years, SD=2.9), than children of mothers with any mental health contacts (M=4.0 years, SD=4.6). Neglect was the first most common allegation comprising 33% of all allegations, 38% among children of mothers with mental health contacts, and 44% among children of mothers with perinatal mental health contacts. First allegations were substantiated in 41% of all cases, 45% where mothers had any mental health contacts, and 48% where mothers had perinatal mental health contacts. Most diagnostic groups had neglect or physical abuse listed as the alleged type of maltreatment, and the majority had neglect substantiated as the main maltreatment type. A parent was believed to be responsible for maltreatment in 74% of substantiated cases, 79% of substantiations in cases with a maternal mental health contact, and 83% with a perinatal contact. Unfortunately, the data does not indicate which parent was responsible.
Any mental health contact prior to child maltreatment allegation
Overall, nearly 1 in 10 children of mothers with a mental health contact had a maltreatment allegation. Table 1 shows marked variation in the prevalence of such allegations associated with different types of mental health issues. Intellectual disability had the highest proportion of maltreatment allegations, followed by substance-related disorders and personality disorders. It should be noted that the number of parents with intellectual disabilities is low, and the more prevalent mental health issues are also more common among families with maltreatment allegations: substance-related disorders, depression not elsewhere classified (NEC) and neurotic disorders, and adjustment and stress-related disorders.
Perinatal mental health contact
Of the 22 748 children of mothers who had a perinatal mental health contact 2850 (12.5%) had a maltreatment allegation, which is higher than for a mental health contact at any time. The percentage of children with maltreatment allegations is shown for each maternal diagnostic group (table 1).
In the total population, mental health contact resulted in a fourfold increased risk of a maltreatment allegation (table 3). After controlling for demographics, child disability, maternal assault admissions, and hospital records of housing and economic issues, this risk was attenuated to a twofold to threefold increased risk (table 3). Non-Aboriginal children had a nearly threefold increased risk, and Aboriginal children a nearly twofold increased risk of allegations associated with maternal mental health contacts, after adjustment for other risk factors.
Overall, and for non-Aboriginal children, all maternal mental health diagnostic groups were associated with a significantly increased risk of maltreatment allegations after adjusting for other factors (table 3). Among non-Aboriginal children, maternal intellectual disability was associated with the highest risk (HR 15.40, CI 10.68 to 22.20), followed by organic disorders, disorders of childhood and psychological development, substance-related disorders and personality disorders. Schizophrenia, affective and non-affective psychoses, adjustment and stress-related disorders, depression (NEC) and neurotic disorders were associated with approximately twice the risk of allegations compared with mothers without contacts indicating these disorders.
For Aboriginal children, the highest risk for allegations was also associated with intellectual disability (HR 4.77, CI 1.96 to 11.58), followed by substance-related disorders (HR 2.08, CI 1.79 to 2.42). Personality disorders and depression (NEC) and neurotic disorders were also associated with significantly elevated risk. No significant increase in allegations among Aboriginal children was found for other maternal diagnoses, however, results should be interpreted cautiously because of small sample sizes.
Overall, Aboriginal mothers had higher rates of mental health contacts and children protection involvement than non-Aboriginal mothers. Substance use or comorbidity, rather than mental health contacts alone, were more common among Aboriginal than non-Aboriginal women (61% and 28%, respectively, table 2). After controlling for risk factors, in Aboriginal women, comorbidity (HR 2.09, CI 1.75 to 2.50), and substance use only (HR 2.06, CI 1.71 to 2.47), were each associated with a twofold increased risk of allegations. By comparison, in non-Aboriginal women, comorbidity was associated with a fivefold increase in risk, whereas contacts for substance abuse or mental health only were associated with an almost threefold increased risk of allegations.
As sample size was smaller for perinatal mental health contacts, Aboriginal and non-Aboriginal results were combined. Perinatal mental health contacts are associated with higher risk of allegations (HR 3.16, CI 2.97 to 3.36) than contact at any time (HR 2.64, CI 2.50 to 2.80) (table 4). The increased risk of allegations was present across perinatal mental health contacts (HR 2.71, CI 2.51 to 2.93), substance-related contacts (HR 3.44, CI 3.11 to 3.81), and comorbid contacts (HR 5.71, CI 4.86 to 6.72).
Intellectual disability was associated with the highest increase in risk of allegations even after adjustment for other risk factors. Several diagnostic groups were more strongly associated with allegations when contact occurred during the perinatal period, including organic disorders, disorders of childhood and psychological development, and schizophrenia, affective and non-affective psychoses.
Although a link between maternal mental health and child maltreatment has been indicated in previous research, this is the first study to quantify the relationship at a population level, and to do so utilising lengthy historic data on maternal mental health contacts. Our findings show a strong association between mental health contacts and maltreatment allegations: 48.1% of children with an allegation had a mother with a mental health contact. Maternal mental health contact was associated with a twofold to threefold increased risk among non-Aboriginal children, and a nearly doubled risk of allegations among Aboriginal children. The risk of allegations is greatest when children are young (average age 4 years, and 3 years for perinatal mental health contacts), adding further weight to the evidence for supports and services targeting children's early years.
Prevalence findings are consistent with previous Australian research suggesting primary caregivers had mental health problems in 51% of maltreatment substantiations,5 and higher than reported elsewhere.6 ,7 Lower prevalence but similar risk ratios were found in American research among Medicaid-eligible mothers: child welfare services were received by 14.6% of mothers with serious mental illnesses, 10.8% of mothers with ‘other psychiatric diagnoses’ and 4.2% of mothers without diagnoses.7 Doubled risk of substantiated maltreatment was reported in Canada.6 These studies align with our findings regarding a twofold to fourfold increased risk of child protection involvement associated with mental illness.
This study builds on previous research by examining types of mental health problems. All mental health groups were associated with increased maltreatment risk, but there were marked variations in risk levels across diagnostic groups. The increased risk associated with parental intellectual disability was also found in a court sample of child protection proceedings15 with a disproportionate number of children from these parents being made wards of the state. The authors state possible reasons as pessimism about the capacity of parents with intellectual disability to overcome parenting difficulties and/or concerns about availability of support services. The relative risk of maltreatment allegations associated with different types of mental health disorders has not previously been examined. Park et al,7 reported higher risk for child welfare services associated with serious mental illnesses (schizophrenia and major affective disorders combined) than other psychiatric disorders. However, in examining child protection involvement following a substantiated maltreatment report among mothers with mental illnesses, Kohl et al,3 reported significantly higher rates of subsequent maltreatment associated only with mood and anxiety disorders. The differences to our findings may be partially explained by Kohl et al,3 using a very high-risk and restricted sample with no general population comparison group, which may limit variation within the data.
Although we have addressed them where possible, the study had limitations. First, the available data is presumed to result in underascertainment of mental health problems, as only in-patient admissions and public out-patient contacts are available. Registry data would also capture more severe cases of mental illness and intellectual disability, therefore the association between maltreatment allegations and maternal diagnoses may be weaker among mothers with less severe mental health issues. Also the father's mental health status has not been accounted for when adjusting for maternal risk associated with maltreatment allegations.
Allegations are not a perfect measure of maltreatment as much abuse and neglect goes unreported.16 We cannot rule out the possibility that increased service contact and resulting monitoring may contribute to the higher allegation rates among mothers with mental health contacts. Nonetheless, substantiation rates of allegations were not lower than in the general population. We also addressed bidirectionality issues by ensuring mental health contacts occurred before maltreatment allegations.
Despite these limitations, this study overcomes many issues that affect studies using data from surveys or single organisations. Parents may be unwilling to disclose mental health problems and child maltreatment. Child protection data sets generally do not collect consistent parental mental health data. This is the first study to report prevalence and risk levels of maternal mental health in conjunction with maltreatment allegations for a state population birth cohort. Understanding the extent of increased allegation risk associated with mental health highlights the need for parenting support and is valuable to inform planning and policymaking. Knowledge of the risk levels associated with different diagnostic groups allows for more targeted service provision.
We found higher levels of risk among mothers with perinatal mental health contacts. Over the last decade, Australia has increased the focus on perinatal mental health, through the Beyondblue National Depression Initiative and National Perinatal Depression Initiative. Our results confirm the importance of initiatives that support mothers through early identification and treatment of depression. However, the risk associated with other mental health disorders indicates the need for support covering a range of perinatal mental health problems.
Another practical implication of the increased risk among mothers with mental health problems is the importance of mental health services awareness of safety considerations, to assess risk and possible referrals for families’ support and safety needs. Services often have a narrow focus and clientele, and families with parental mental health issues have members with a range of needs17 creating a need for service collaboration and integration.18 ,19 The prevalence of mental health issues within child protection families highlights the importance of collaborative case management of child safety concerns.
Service providers should be sensitive to the fears of mothers with mental health problems about having their children removed, which may be a barrier to seeking help.20 ,21 Having a mental health problem does not mean that a parent will maltreat their child or provide substandard parenting. It would be a disservice to children if increased stigma around mental illness and parenting led to parents being less willing to seek help. Rather, it is important to be aware of mental health as one of a number of risk factors for maltreatment, and to build services that are responsive to the needs of these families. Within Australia, organisations such as Children of Parents with a Mental Illness (COPMI) offer resources for safety planning, respite services, and parenting programmes. Although not assessing child protection outcomes, a recent meta-analysis found psychological interventions for families with parental mental illness had beneficial effects on children's mental health.22 Further research is needed to assess the effects of interventions on child protection outcomes for families with mental illness.
What is already known on this subject
Previous research indicates that children of mothers with mental health problems are at greater risk of child maltreatment than other children, and mental health problems are relatively common among families with involvement with the child protection system. Existing research on maternal mental health in child welfare samples typically relies on self-reported or case-worker-reported mental illness. Other related studies used community samples and relied on parent-reported maltreatment. Such designs may introduce bias, and issues of small sample size or lack of detailed data have prevented assessment of the risk associated with different diagnoses.
What this study adds
This study confirms findings from smaller studies that show diagnosed mental health disorders are related to child protection contact (maltreatment allegations) and quantifies the relationship at a population level. Our study also provides new information regarding the level of increased risk across different mental health diagnostic groups, which varies markedly.
The authors acknowledge the partnership of the Western Australian Government Departments who provided data for this project, including the WA Data Linkage Branch who linked the data. This paper does not necessarily reflect the views of the government departments involved in this research.
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