National Guide

Chapter 4 | Child and family safety

Child maltreatment – supporting families to optimise child safety and wellbeing







National Guide to preventive healthcare for Aboriginal and <br/>Torres Strait Islander people
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      1. Child maltreatment – supporting families to optimise child safety and wellbeing

Child and family safety | Child maltreatment – supporting families to optimise child  safety and wellbeing

Dr Kim Jones, Dr Mary Belfrage 

Key messages

  • Historical and current experiences of trauma underpin intergenerational cycles that can impact on the capacity of parents to nurture and care for their children.1
  • Recognition and understanding of trauma and its impact on relationships, parenting and child development are needed to ensure care and services are safe and appropriate.2
  • Supporting parents who have experienced trauma to understand the effects and to care for their children provides an opportunity to help parents transform cycles of intergenerational trauma to cycles of nurturing and recovery.3
  • Most parenting programs have not been adequately trialled in Aboriginal and Torres Strait Islander communities to understand whether acceptability and effectiveness is generalisable to this population.
  • The key role for general practitioners (GPs) and primary care teams at all levels of prevention is to use a trauma-informed and culturally safe approach to provide comprehensive primary healthcare, build trusting relationships through continuity of care, understand and address complex needs, make appropriate referrals and help families access support.4,5
  • Before making child protection notifications based on identification of ‘risk factors’, primary care providers should ensure families are linked to targeted, culturally safe supports and services, and actively assisted to access these (eg through financial or transportation assistance).4
  • Primary care providers should engage in ongoing cultural safety training to ensure service delivery is strengths based and does not retraumatise.4–6
Type of preventive activity - Screening
Who/ Target population What When Strength of recommendation Key Source(s) & Reference(s) Rationale/key considerations informing recommendation
All pregnant women Assess the need for support to address factors such as alcohol and other drug use, personal history of family abuse and violence (refer to Chapter 4: Child and family safety, Family abuse and violence), housing adequacy, engagement with and accessibility of antenatal care and supportive factors, including social and family supports (Box 1)
Actively assist women to access these supports		 At first and subsequent antenatal visits Good practice point International guideline7
Aboriginal and Torres Strait Islander-specific guideline8		 Providing family support services early can help women who are experiencing vulnerabilities or facing personal or social barriers address these issues and provide a safe environment for their children to thrive

Family support services are more likely to be effective when programs incorporate cultural knowledge and are strengths based9
All children Conduct routine monitoring of developmental milestones (refer to Chapter 6: Child health, Childhood growth and development) Opportunistically and as part of a routine health assessments Good practice point International guideline7 Early detection of developmental delays or other health issues allows supports to be implemented to optimise opportunities for children to thrive

Use a culturally safe trauma-informed approach to build trust and optimise service engagement (refer to Box 3)
All children Do not routinely screen for maltreatment (eg a standard instrument, set of criteria or questions asked of all children in healthcare encounters) N/A Strong International guidelines10,11 There is no evidence or existing guideline that supports universal screening; the evidence suggests high false positive rates that are potentially harmful
All children Stay alert for signs and indicators of maltreatment, such as particular types of physical injury (non-accidental injury), emotional distress or behavioural problems Opportunistically Good practice point International guideline11  
Families with complex needs (Box 1) Using a trauma-informed approach, conduct a culturally safe comprehensive psychosocial assessment, including mental health, trauma, alcohol and other drug use and family violence, and assess for the availability of social supports with an emphasis on building trust and engagement with healthcare Opportunistically Good practice point Aboriginal and Torres Strait Islander resource8
International guideline12		 The impacts of intergenerational and other traumas are drivers of service need

Programs are more likely to be effective where they have been culturally adapted with local Aboriginal community involvement and are strengths based

Building trust helps improve engagement with service supports

Refer to Box 1 for complex needs requiring support

Refer to Chapter 7: The health of young people

Refer to Chapter 20: Mental health
Type of preventive activity - Behavioural
Who/ Target population What When Strength of recommendation Key Source(s) & Reference(s) Rationale/key considerations informing recommendation
All families Offer referral to a culturally informed parenting program where services are available as a universal precaution in the prevention of child maltreatment Opportunistically Good practice point Aboriginal and Torres Strait Islander-specific resource9
Single study6		 Refer to Resources for programs

Note that there is no consistent rigorous evidence to support the effectiveness of parenting programs, and these have not been adequately trialled with Aboriginal and Torres Strait Islander families

Programs are more likely to be effective where they have been culturally adapted with local Aboriginal community involvement and are strengths based
Families with complex needs (Box 1) Identify and provide an integrated service response that provides for the full range of a child’s and family’s needs. This can include resources such as housing, financial, transportation, mental health, drug and alcohol supports and childcare services

Actively assist the family to access these supports		 Opportunistically and as clinically indicated Good practice point Aboriginal and Torres Strait Islander-specific guideline4 An integrated service response ensures that families have the opportunity to access the resources and supports needed to provide for a child’s health and wellbeing4

Family support services are more likely to be effective when programs incorporate cultural knowledge and are strengths based9

Adequate support and services for families are key parts of primary prevention of child maltreatment
Children with identified developmental delay, behavioural disturbance, harmful child–parent interactions Refer to community paediatrician for comprehensive health, behaviour and development assessment

Actively assist the family to access appropriate supports.		 As clinically indicated Good practice point International guideline7 Timely and supported access to specialised services ensures opportunities for support are optimised
Children with identified developmental delay, behavioural disturbance, harmful child–parent interactions Consider referral to other services depending on the specific developmental issue, such as mental health, speech Opportunistically Good practice point International guideline7 Refer to Chapter 6: Child health, Childhood growth and development
Families with complex needs (Box 1) Offer referral to Aboriginal and Torres Strait Islander-specific support services, including a home visiting program where available

Actively assist the family to access these supports		 Opportunistically Good practice point Aboriginal and Torres Strait Islander-specific narrative review13 Early intervention can help families address safety concerns that risk bringing them to the attention of a statutory agency and reduce the need for more intrusive interventions4

Family support services are more likely to be effective when programs incorporate cultural knowledge and are strengths based9
Children when there are serious concerns or evidence of maltreatment, including neglect, and active efforts to keep a child safe at home have been exhausted Notify child protection services as per jurisdictional requirements (refer to Useful resources)

Ensure families, communities and Aboriginal Community Controlled Organisations (ACCOs) are involved in all significant decisions about children wherever possible

Use the Aboriginal and Torres Strait Islander child placement principle: A guide to support implementation (see Useful resources) to ensure concerns are justified (refer to Box 2)		 As clinically indicated Good practice point National standard and guideline14,15
Single study6
Aboriginal and Torres Strait Islander-specific guideline4		 The influence of service provider bias on decisions can be reduced through full and proper assessment of the holistic strengths, needs and risk for the family, including cultural factors
Children when there are serious concerns or evidence of maltreatment, including neglect Involve extended family members and/or culturally specific support services whenever possible As clinically indicated Good practice point Aboriginal and Torres Strait Islander-specific guideline4 Working respectfully with the whole family can help draw on the broader networks of family and community support that many Aboriginal and Torres Strait Islander families have.

Refer to Useful resources
Type of preventive activity - Environmental
Who/ Target population What When Strength of recommendation Key Source(s) & Reference(s) Rationale/key considerations informing recommendation
Health professionals Become familiar with health and support services for Aboriginal and Torres Strait Islander peoples in your area, particularly family support services Opportunistic Good practice point National standard and guideline16
Aboriginal and Torres Strait Islander-specific guideline4		 Develop effective working relationships with local ACCOs because these services can improve the access of families to culturally safe and acceptable services that are appropriate to complex needs4

Refer to Useful resources
Health professionals Health professionals should attend cultural competency training programs and become familiar with principles of trauma-informed practice Opportunistic Good practice point Single study6
Aboriginal and Torres Strait Islander-specific guideline4		 Providers engaging safely and meaningfully with Aboriginal and Torres Strait Islander families reduces the risk of retraumatising, builds respect and trust in relationships, improves service engagement, reduces bias and promotes greater understanding of cultural differences and strengths and the ongoing impacts of intergenerational trauma

Refer to Box 3 and Useful resources
 

Box 1. Complex needs requiring targeted supports
  • Alcohol and other drug misuse
  • Parental history maltreatment
  • Family violence
  • Housing instability
  • Significant mental health issues, including intergenerational trauma
  • Significant financial stress
  • Parental incarceration
  • Child experiencing disability
  • Parent with intellectual disability

Box 2. Principles for effective engagement with Aboriginal and Torres Strait Islander families

  • Understanding differences in child-rearing practices to avoid parental strengths being misinterpreted as risks
  • Understanding the issues facing Aboriginal and Torres Strait Islander families, such as intergenerational trauma, poverty and marginalisation, to ensure that supports are tailored to the need
  • Practitioner insight into factors influencing their own decision-making thresholds
  • Recognition of the strengths of Aboriginal and Torres Strait Islander cultures
  • Primary care providers should attend cultural safety training. Evidence suggests the most effective training:
    • is interactive and draws on variety of techniques
    • is delivered face-to-face in a safe learning environment
    • is designed and delivered with or by Aboriginal or Torres Strait Islander people and skilled trainers
    • is mandatory and monitored
    • includes reflective practice and exploration of pre-existing knowledge
    • identifies and acknowledges the diversity among Aboriginal and Torres Strait Islander people
    • clearly names racism and its effect on health outcomes
    • provides practical tools and resources
    • includes case studies and lived experience presentations17 (refer to Useful resources).
  • Primary care providers should become familiar with the principles of trauma-informed care, including the use of a strengths-based approach, and apply these principles when engaging with Aboriginal and Torres Strait Islander clients (refer to Box 3).
  • Primary care providers should prioritise building respectful trusting relationships through continuity of care and adopting the principles in Box 2).
  •  Primary care providers should actively assist parents to access any supports they are referred to.
  • Any mainstream program-based supports should be adapted with Aboriginal and Torres Strait Islander communities.
  • Primary care providers should be aware that parents may be reluctant to disclose complex needs due to fear of child protection involvement and that this is related to intergenerational and historical trauma.
  • Complete a GP management plan and team care arrangements and/or a GP mental health treatment plan as appropriate to facilitate access to Medicare Benefit Schedule-funded allied health services.

What has changed in this edition?

  • Greater recognition of structural racism, particularly the way risk is understood and identified, as a driver of notifications to child protection services
  • Increasing strengths-based understanding of the context in which child maltreatment may occur, characterised as ‘parents/families with complex needs’ rather than being ‘at risk of maltreatment’
  • A new strong recommendation against universal screening for maltreatment based on the Canadian Taskforce on Preventive Health Care guidelines and World Health Organization (WHO) recommendations
  • A new good practice point to remain alert for signs and indicators such as particular types of physical injury (non-accidental injury), emotional distress or behavioural problems or signs of family-level risk factors based on WHO guidelines recommendation
A new good practice point to provide an integrated service response for families with complex needs that provides for the full range of a child’s and family’s needs, and to actively help the family to access these services.
 

Box 3. Principles of culturally safe, trauma-informed care18–21
  • Trauma awareness: Be aware of and understand the impacts of traumatic experiences on individuals, families and communities
  • Safety: Create environments where people feel physically and emotionally safe, and avoid re-traumatisation
  • Cultural competency: Employ culturally competent staff and adopt practices that acknowledge and demonstrate respect for specific cultural backgrounds
  • Choice: Support people who have experienced trauma to regain a sense of control over their daily lives through maximising choice, and actively involve them in the healing journey
  • Collaboration: Share power and governance, including collaborating with community members in the design and evaluation of services
  • Trustworthiness: Maximise trustworthiness and engagement through safe, authentic relationship building and transparency to assist healing and recovery
  • Empowerment: Adopt a strengths-based approach to promote empowerment and skill building to enable people to take control of their own healing and recovery

General

Community directories

  • Explore a community directory for social support services in your jurisdiction: for example, for Townsville.

Parenting programs

Other resources

Background

The quality of a child's relationship with their caregivers has a profound influence on their development. When at least one attentive and responsive parent/carer provides a nurturing environment, children are more likely to thrive.22–25 Parents’ (and a family’s) ability to respond sensitively to their child’s physical and emotional needs protects children from harm, provides opportunities for learning and exploration and engages with them in emotionally and cognitively stimulating ways, all of which are important in preventing child maltreatment. Research consistently shows that child maltreatment exerts lifelong negative impacts on health and quality of life,26–28 regardless of whether maltreatment is reported to statutory child protection services or not. Therefore, early intervention and prevention are critical to positively influencing a child's life trajectory and long-term health and wellbeing.29–33 Health service providers play a crucial role in supporting parents to develop and maintain the capacity to provide the stable, nurturing care for their children that is essential to preventing child maltreatment.

What is child maltreatment?

Child maltreatment is defined as intentional and non-intentional behaviours by parents, caregivers or other adults considered to be in a position of responsibility, trust or power that result in a child being harmed physically or emotionally.34,35 Most definitions also include the witnessing of family violence as child maltreatment. Child maltreatment is commonly categorised as:

  • physical abuse
  • sexual abuse
  • emotional abuse
  • neglect
  •  witnessing of family violence.36,37

What are the causes of child maltreatment?

The causes of child maltreatment are complex and can be influenced by a range of individual, family, community and wider societal factors. Having a caregiver who was maltreated or in out-of-home care (OOHC) is one of the strongest predictors of maltreatment.38–40 However, it is important to highlight that most people who experienced maltreatment themselves do not maltreat their children.41 Trauma exposure, especially in early life, can increase the risk of parental mental health issues, alcohol and other drug use, family violence and general health issues, which can interact to impact profoundly and detrimentally on the capacity to parent effectively and to provide a safe and nurturing environment for children. It is in this context that child maltreatment, most commonly neglect and emotional abuse, may occur.

Are there specific considerations for Aboriginal and Torres Strait Islander populations?

Historical events and ongoing discrimination experienced by Aboriginal and Torres Strait Islander communities, including colonisation and dispossession, the fragmentation of families through forced removal of children and other assimilation policies, and the associated loss of cultural practices and knowledge systems have left a legacy of intergenerational trauma.1 

Since the 1997 Bringing them home report,42 Aboriginal and Torres Strait Islander children who were removed from their families as a result of government policies have been recognised as the Stolen Generations. According to the report, between one in three and one in 10 Aboriginal and Torres Strait Islander children were forcibly removed from their families and communities in the period from approximately 1910 until 1970.42 These removals were often justified as measures to ‘protect the welfare’ of the children and, as a result, the involvement of child protection services remains a highly sensitive issue for Aboriginal and Torres Strait Islander people and can represent a barrier to engagement with health services.42 In 2018–19, more than one-third of Aboriginal and Torres Strait Islander adults were descendants of the estimated 33,600 survivors of the Stolen Generations.43

Through this fragmentation of communities, traditional and long-lasting systems of kinship and community knowledge that fostered resilience were compromised, increasing vulnerability to effects of further trauma exposure. The disparities between Aboriginal and Torres Strait Islander and non-Indigenous Australians’ experiences of traumatic events are evident; for example, Aboriginal and Torres Strait Islander people are 2.2- to 2.8-fold more likely to experience violence than non-Indigenous Australians.44 Aboriginal and Torres Strait Islander people commonly experience individual-, family- and community-level trauma. A study in Western Australia found that 97% of Aboriginal people reported a history of trauma exposure, and there was a lifetime prevalence of 55% for post-traumatic stress disorder (PTSD).45 This trauma exposure includes:

  • historical events with intergenerational and transgenerational impacts
  • repeated exposure to life stressors
  • specific, intense life experiences
  • adverse childhood experiences.46

Intergenerational trauma refers to the effects of traumatic events experienced by one generation impacting the next. Ongoing effects of the historical trauma caused by ongoing child removals, dispossession, racism and marginalisation are important contextual factors when considering higher rates of child maltreatment in Aboriginal and Torres Strait Islander communities.

Traumatic experiences can have flow-on effects to related negative outcomes, such as an increased risk for self-harm. A history of involvement with child protection services is commonly associated with trauma and with a three- to ninefold increased relative risk of self-harm in adolescence, which is clearly reflected in national data showing that Aboriginal and Torres Strait Islander youth experience twice the rate of hospital admissions for self-harm and three times the rate of death by suicide compared with non-Indigenous young Australians.47 

National data indicate that Stolen Generations survivors and their families experience even greater levels of adversity than other Aboriginal and Torres Strait Islander people in relation to almost all key health and wellbeing outcomes.43

How common is child maltreatment?

The true prevalence of child maltreatment is difficult to establish due to differences in attitudes to childrearing, which may be culturally informed; different thresholds as to what constitutes harm; differences in data management between states and jurisdictions; and the occurrence of private, hidden and/or unreported or undetected maltreatment that is not included in data.48 

Although the association between experiences of traumatic events and child maltreatment, and the value and effectiveness of trauma- and healing-informed services, is recognised and elements of a public health policy approach to child maltreatment and the Aboriginal and Torres Strait Islander child placement principle4 have been adopted, Aboriginal and Torres Strait Islander children continue to be separated from family and culture at high and increasing rates.49,50 

In Australia, between 2016–17 and 2020–21:

  • notifications of all children to child protection services increased by 40%51
  • for Aboriginal and Torres Strait Islander children:
    • the number of children in the child protection system increased from 49,159 to 58,034 (Figure 1)
    • substantiations of maltreatment increased by 6.2% (emotional abuse 48%, neglect 31%, physical abuse 14%, sexual abuse 7%; Figure 2)47
    • care and protection orders increased from 60 to around 71 per 1000 children (compared with an increase from 10 to 11 per 1000 non-Indigenous Australian children)
    • children in OOHC increased from 51 to 58 per 1000 children (compared with a fairly stable 8 per 1000 non-Indigenous Australian children). The total number of children in OOHC increased by 7.3%, from 43,100 to 46,200, of whom approximately 42% (19,500) are Aboriginal and/or Torres Strait Islander.52
    • in OOHC, as per Aboriginal and Torres Strait Islander child placement principle4 indicators:
      • 63% were living with relatives or kin or other Aboriginal and Torres Strait Islander carers
      • 69% had documented cultural plans
      • 15% of those in OOHC in 2019–20 were reunited with family.52

Figure 1. Number of children receiving child protection services, by Indigenous status, from 2016–17 to 2020–21.51

 

 

Figure 2. Children who were the subject of substantiations of notifications, by Indigenous status and primary type of abuse or neglect, 2020–21.51 

Why are more Aboriginal and Torres Strait Islander children represented in the child protection data?

Aboriginal and Torres Strait Islander children are 11.5-fold more likely to be in OOHC than non-Indigenous Australian children.51 This disparity can be linked to a complex interplay of historical, social and cultural factors. These factors include: intergenerational trauma; severe poverty and poor living conditions; social determinants of family functioning; systemic racism and discrimination; failure to understand Aboriginal and Torres Strait Islander parenting practices; and the interface between Aboriginal and Torres Strait Islander families and child protection systems. 

In an Australian study that compared Aboriginal and non-Aboriginal children,53 parental factors associated with increased risk of child maltreatment were:

  • low socioeconomic status
  • parental hospital admissions related to mental health
  • substance misuse
  • assault.

Aboriginal and Torres Strait Islander parents are more likely than non-Indigenous parents to experience all these factors. Poverty and low socioeconomic status create barriers to parents’ ability to access the resources and supports needed to provide for a child’s health and wellbeing. This, in turn, increases parental stress and leads to higher levels of substance misuse, violence and housing instability, all of which increase the likelihood of child protection involvement. A 2014–16 review of 980 Aboriginal and Torres Strait Islander children and young people in statutory care in Victoria found that 87% of children had been exposed to parental alcohol and/or other substance misuse, 88% had experienced significant family violence and almost 60% were affected by parental mental illness.54 Other major factors included housing instability and homelessness, parental experience of child protection in their own family of origin and incarceration.54 Where mothers had a history of substantiated maltreatment in their own childhood and had spent time in OOHC, children were 25.8-fold more likely to spend time in OOHC.38 In addition, the 2014–16 enquiry found that there were systemic failures in the continuity, coordination and quality of primary healthcare and responses to complex health needs.54

What is being done to prevent child maltreatment in Australia?

Many countries, including Australia, have historically allocated the majority of child protection resources towards a tertiary response; that is, intervention after child maltreatment has occurred. This approach to risk assessment in response to maltreatment focuses on consequences and relies heavily on legal frameworks that can frequently be adversarial, punitive and divisive for families. Other countries respond primarily in ways that support families, are child-focused and aim to prevent harm from occurring in the first instance.55 Prevention strategies aim to address underlying causes and risk factors, and strengthen protective factors.7 Achieving this requires commitment at all levels of government and across service sectors to strengthen health systems.57,58

The strong relationship between being maltreated as a child and maltreating one’s own child in adulthood underscores the critical need to intervene with strategies before maltreatment occurs to break cycles of intergenerational maltreatment, as recognised in the Aboriginal and Torres Strait Islander child placement principle.4 There is growing recognition of the value of taking a prevention-focused public health approach to reduce notifications to child protection authorities and statutory orders relating to the care of a child.7,33,59 

A preventive approach includes:

  • Primary services: Focused on preventing child abuse and neglect within the broader community
  • Secondary services: Focused on targeted programs that aim to prevent child abuse and neglect in matters where there is an identified increased risk of child abuse and neglect
  • Tertiary services: Focused on investigating and responding to notified cases of suspected child abuse and neglect.60

Although Australia made a commitment to shift to a preventive public health-based approach in the National framework for protecting Australia’s children 2009–2020,57 relying only on tertiary services as a ‘last resort’, a recent national study concluded that this has not occurred, observing the ‘Australian child welfare workforce is not adequately resourced to meet the current or future demands or support preventative efforts’.60

The vast majority (84%) of investment remains committed to tertiary services and, despite the national framework outlining an aspirational and comprehensive 12-year plan, the aim to deliver a substantial and sustained reduction in levels of child abuse and neglect has not been achieved. The next iteration of the framework, Safe and supported: The national framework for protecting Australia's children 2021–2031,61 promises to strengthen preventive measures and early interventions and focus on higher-risk priority groups.

 The 2022 Secretariat of National Aboriginal and Islander Child Care – National voice for our children (SNAICC) Family matters report50 proposed four building blocks in its roadmap to guide the policy and practice change needed to turn around the increasing over-representation of Aboriginal children in the child protection system:

Building Block 1.All families enjoy access to quality, culturally safe, universal and targeted services necessary for Aboriginal and Torres Strait Islander children to thrive.
Building Block 2.Aboriginal and Torres Strait Islander people and organisations participate in and have control over decisions that affect their children.
Building Block 3.Law, policy and practice in child and family welfare are culturally safe and responsive.
Building Block 4.Governments and services are accountable to Aboriginal and Torres Strait Islander people. 

The unacceptably high and increasing number of Aboriginal and Torres Strait Islander children in the child protection system, combined with the known lifelong impacts on health and quality of life, requires urgent attention. The disproportionate and increasing rate at which Aboriginal and Torres Strait Islander families are being separated add priority for this key Closing the Gap target. Although primary prevention is paramount, secondary prevention is of equal importance due to the strong association of maltreatment of one child with maltreatment of a subsequent sibling.62

Universal services

Access to comprehensive primary healthcare for all children and families supports better health and wellbeing outcomes.7,63–65 With respect to preventing child maltreatment, the WHO specifically identifies the importance of access to medical care, maternal and child health services, mental health services, pregnancy-related advice and care, identification of the risk of child maltreatment and other healthcare as needed.7 Access to quality, culturally safe, universal service provision is also in line with Building Block 1 of the SNAICC roadmap.50 

For Aboriginal and Torres Strait Islander peoples, prevention measures must be implemented within a context that accounts for widespread experiences of intergenerational and complex trauma. Prevention measures should be culturally safe and focus on drivers and antecedents of maltreatment and address health inequity broadly. In the primary care setting this involves accessible and appropriate universal healthcare, understanding community needs, commitment to prevention across primary healthcare teams, including ACCHOs, general practice and allied health, and authentic engagement with, and individualised support for, families. 

Monitoring general health indicators, such as growth and development and ear, teeth and eye health, can:

  • help identify signs of maltreatment, particularly neglect
  • provide an opportunity for parental education on positive parenting practices, child development and healthy lifestyle habits
  • prompt collaboration with other health practitioners to provide support.

To ensure broad coverage of universal primary healthcare, barriers to access should be addressed, including the physical availability of health services, transport, flexible service delivery, affordability, language and cultural acceptability and appropriateness of health services.66,67 Recent national data reported the main reasons for Aboriginal and Torres Strait Islander people not visiting a GP were being too busy, discrimination and lack of culturally safety.68

Targeted services

As well as recommending comprehensive primary healthcare for all children and families (universal services), the WHO identifies that interventions in the context of high risk and/or identified harm (targeted services) may be preventive of either further harm to a child and/or maltreatment of other children in a family, thus constituting important secondary and tertiary preventive functions.7

NAICC’s roadmap Building Block 1 also calls for targeted services that are culturally safe and accessible for Aboriginal families.50 

The 2017 UK National Institute for Heath and Care Excellence (NICE) Child abuse and neglect guidelines provide some general guidance where abuse or neglect is suspected.12 Primary care providers are advised to:

  • support families through discussions about ‘early help’, including practical and emotional supports
  • build relationships and gain consent
  • understand typical and atypical child development and tailor interventions to need, including where disability is experienced
  • understand vulnerability or risk factors for abuse and be aware of escalation possibilities
  • understand how to work with the whole family
  • for caregivers with substance misuse issues, address issues causing stress that trigger substance use.12

Primary care providers are uniquely placed to intervene and support families with complex needs (at-risk parents) to prevent child maltreatment occurring (see Box 1). They have the opportunity to build trusted relationships over time with clients, who ideally establish continuity of care with their preferred provider. Continuity of care facilitates the development of trust and feelings of safety for families. This relationship places a primary care provider in a privileged position to detect changes in family dynamics, detect stresses and identify changes in risk factors early. This early identification can optimise timing for the delivery of supports. Respectful trusted relationships and sensitivity to the needs of families and individuals can facilitate the discussion of sensitive topics and offers of referrals to services where support is needed. Pregnancy provides a particularly opportune window in this regard due to frequent contacts and represents a time in which any indicated strategies and supports can be introduced before maltreatment has occurred or to prevent harm to other children in the family. 

The RACGP Abuse and violence: working with our patients in general practice (White Book),37 states that, in relation to child maltreatment, GPs should:

  • recognise risk factors and intervene early to reduce risk of abuse and neglect and prevent harm (primary prevention)
  • recognise harm and respond appropriately to mitigate future harm (secondary prevention)
  • support the ongoing wellbeing of both the child and family to manage the long-term negative impacts of harm (tertiary prevention).

More specifically, a recommendation is made for referral to parent training and nurse home visitation programs where primary care providers identify families where violence is occurring. However, evidence of the benefit of these programs is mixed.69–72 

A further practice point highlights that harmful alcohol and drug use has a strong link with child abuse and neglect, and recommends that providers work to reduce alcohol consumption in adults with children in their care, using evidence-based methods such as alcohol screening and brief interventions. More generally, the guidelines suggest offering ongoing supportive and trauma-informed care and linking to services as required. 

Parents with complex needs face significant barriers to engaging with services. The barriers may be directly related to the nature of the needs (eg financial insecurity, or depression or fear of child protection involvement).73,74 People may not seek health services or may be reluctant to disclose complex needs, such as housing insecurity, for fear of this leading to a child protection notification.75 These fears are related to Aboriginal and Torres Strait Islander peoples’ complex and traumatic history of forced child removal and further reinforce the critical need for service providers to build respectful trusting relationships with families.76,77 Strategies to help develop trusting relationships include:

  • being patient and persistent in initial engagement; families may have seen many providers and made previous attempts to get help
  • being clear about what the purpose of the service is and what support you are offering
  • setting goals with families, working towards these goals and reviewing them together
  • working with a manageable caseload to allow intensive engagement
  • yarning, listening and not being judgemental
  • allowing families to review notes (documentation) to ensure mutual understanding
  • highlighting strengths, positive changes and successes.4

The SNAICC Aboriginal and Torres Strait Islander child placement principle: A guide to support implementation highlights a number of care provision factors relevant to primary care providers that are specific to Aboriginal and Torres strait Islander child maltreatment prevention.4 To ensure effective engagement with Aboriginal and Torres Strait Islander families, it recommends the actions presented in Box 2.

When working with Aboriginal and Torres Strait Islander families, it is important to enable and facilitate the participation of individuals in decisions that affect them; this is a key principle underpinning culturally safe, trauma-informed care and aligns with SNAICC Building Block 2.50 Aboriginal and Torres Strait Islander families value involvement of more than the nuclear family and, as such, any decision making about a child should actively involve family, Elders and other significant people in the child’s life.76

Knowledge of predictive factors for maltreatment may help identify appropriate target strategies to help support parents to address complex needs and prevent maltreatment. Complex needs that warrant targeted support referrals and assistance to access these include parental alcohol abuse, high child medical needs or disability, poor social support, parental mental illness, intellectual disability, substance use issues, parents’ own experience of child maltreatment, low socioeconomic status, dependent and aggressive personality and intimate partner violence.37,62,78,79 Providers should determine and identify strengths in the family, as well assessing and responding to complex needs.4 Support services that incorporate cultural knowledge and are strengths based are more likely to have an impact.9

It should be noted that screening for child maltreatment risk is not recommended. The 2000 update of the Canadian Taskforce on Preventive Health Care (CTFPHC) guidelines for the prevention of child maltreatment recommends excluding screening for potential maltreatment due to high false-positive rates and the greater potential for harm than benefit.10 Similarly, the WHO recommends against universal screening for child maltreatment, but does recommend that providers are alert to the features of child maltreatment.11 

The impact of trauma on treatment

There is emerging evidence and discourse related to the pervasive influence of childhood trauma exposure and subsequent adult trauma symptoms, and how this impacts the effectiveness of a range of health and wellbeing interventions. It has been argued that childhood maltreatment represents a highly unrecognised confounder in psychiatric diagnosis and treatment.80 The recognition of complex post-traumatic stress disorder (CPTSD) in the International classification of diseases 11th revision81 has generated research efforts aimed at determining the intervention responsiveness and treatment needs of people experiencing CPTSD, which is commonly associated with prior childhood maltreatment. Emerging evidence suggests that individuals with CPTSD symptoms experience greater treatment resistance and require longer treatment protocols to attain the same effects as those with less complex trauma histories.82 Because CPTSD symptoms have been proposed to mediate the intergenerational transmission of childhood trauma,83 this parent population may benefit from the delivery of child maltreatment prevention strategies within a context of trauma-informed care.

Culturally informed and trauma-informed services

Building Block 3 of the SNAICC roadmap calls for culturally safe and responsive practice.50 The National Aboriginal and Torres Strait Islander health plan84 draws attention to the central role of culture in the health and wellbeing of Aboriginal and Torres Strait Islander people, and the importance of reducing systematic, institutionalised racism. This can begin to be realised through the adoption of culturally informed approaches to service delivery. Given that child maltreatment most commonly occurs in the context of parental experiences of trauma and trauma symptoms, there is also a growing recognition of the value of a trauma-informed approach to care.6,18

Although there is limited empirical evidence of its effectiveness, there is general consensus that the approach represents a much needed service-level system of care that is responsive to the needs of those with experiences of trauma and is more holistic than a traditional clinical response.85 A trauma-informed approach can help avoid re-traumatisation in people with trauma histories. Re-traumatisation can result in extreme distress, re-experiencing or avoidance in response to regular primary care provision, such as sensitive inquiry, trauma screening or disclosure, invasive procedures or examination.85

Trauma-informed approaches:

  • realise the widespread impact of trauma
  • recognise the signs and symptoms of trauma, and the varied responses to trauma in both individuals and cultures
  • respond by integrating knowledge of trauma into all policies and practices
  • actively seek to resist retraumatisation through organisational polices and environments.58

Box 3 outlines the underlying principles that can help guide healthcare providers to deliver culturally safe, trauma-informed care. 

Service models that are underpinned by these principles, that are culturally resonant and reflect an understanding of the impact of trauma are likely to be much more acceptable to and accessed by Aboriginal and Torres Strait Islander peoples.9,36,86 

Consistent with a strengths-based approach, it is important to acknowledge the endurance and resilience demonstrated by Aboriginal and Torres Strait Islander peoples over thousands of generations. Evidence suggests that at the time of colonisation the wellbeing of Aboriginal and Torres Strait Islander children was better than that of most of their European counterparts.87 This state of wellbeing was not achieved by accident; rather, the physical, social and emotional wellbeing of children was nurtured from before birth until after death, supported by policies such as Grandmothers Law and sophisticated understandings of the importance of connectedness to wellbeing.1 It is important to recognise that many individuals and families are thriving. 

Tertiary approaches

In Australia, in the absence of guidelines, national standards for OOHC were developed as a priority of the National framework for protecting Australia’s children 2009–20.88 These highlight the importance of the Aboriginal and Torres Strait Islander child placement principle and include standards around healthcare and the importance of ongoing primary healthcare for children who have experienced maltreatment.88 The standards specifically identify the need for:

  • a preliminary health check on entry to OOHC
  • a comprehensive health and developmental assessment provided by a specialist service
  • ongoing monitoring and assessment of health and development.89

The key role for GPs at all levels of prevention is to provide comprehensive primary healthcare that is affordable and culturally safe, to make appropriate referrals, to ensure continuity of care and to actively assist people to access the care they need.4,5 

GPs should ensure the primary care provided is part of a broader comprehensive, coordinated multidisciplinary primary care team. Specific attention should be paid to children at risk of and/or experiencing harm. These children are more likely to have complex health and development needs and are less likely to receive both standard and specialised health services.28,90 To facilitate this, primary care practitioners should be aware of the risk factors for maltreatment. However, care should be taken when assessing risk, because understandings of neglect and emotional abuse are subject to interpretations that may be based on societal and cultural values are incompatible with Aboriginal and Torres Strait Islander collective child-rearing practices and fail to consider the impacts of poverty (see Box 2).4,48 Although factors including poverty, housing instability, trauma exposure, mental health symptoms and alcohol and other drugs are often viewed as risk factors, they are more accurately positioned as drivers for child protection involvement48 that may not always be justified.

Before making child protection notifications based on these types of ‘risk factors’, primary care providers should ensure families are linked to targeted, culturally safe supports and services, and are actively assisted to access these through, for example, financial or transportation assistance.4

Further, primary care providers should work to address systemic discrimination experienced by Aboriginal and Torres Strait Islander families that creates barriers to health and wellbeing service accessibility. High-quality cultural competence training and familiarity with principles of trauma-informed practice can facilitate these prevention strategies.

Child maltreatment prevention parenting interventions

There is a general lack of rigorous evidence on the effectiveness of preventive interventions to address child maltreatment, and even less on their effectiveness in Aboriginal and Torres Strait Islander populations. As a result, there is a paucity of guidelines to guide best practice. The US Preventive Services Task Force guidelines (2018), based on a systematic review of 22 studies assessing the effectiveness of interventions provided in or referable from primary care, concluded that ‘the current evidence is insufficient to assess the balance of benefits and harms of primary care interventions to prevent child maltreatment’.91 The evidence suggested that the interventions had no effect on direct measures of maltreatment or on proxy measures of abuse or neglect, including child development, school performance, injuries, failure to thrive, failure to immunise and school attendance. In addition, no trials reported on harms of primary care-led interventions.91

The 2017 NICE Child abuse and neglect guidelines also found no evidence relevant to the effective prevention interventions in the UK; however, recommendations are made for secondary or targeted strategies where abuse or neglect is suspected.12 For these parents, NICE recommend considering universal home visiting services and at least six months of weekly home visiting, set up before or close after birth.

Where parents are referred to parenting programs, the UK NICE guideline12 recommends those that:

  • run for 12 weeks or more
  • can be tailored
  • include skills in behaviour management, negative parenting beliefs and emotion management; the Triple P (Positive Parenting Program) program is indicated if anger is an issue.

For mothers in methadone maintenance programs, the UK NICE guideline specifically recommends considering engagement in the Parents Under Pressure program (see Useful resources).

The CTFPHC guidelines for the prevention of child maltreatment recommend home visitation programs, particularly the Nurse–Family Partnership (NFP) program, for disadvantaged families,10 as do the US Centers for Disease Control and Prevention (CDC), which also recommend parenting skill and family relationship approaches.92 The WHO recommends evidence-based parenting interventions informed by social learning theory (positive parenting approaches and alternatives to harsh punishment) globally.11

The effectiveness of child maltreatment prevention parenting programs is uncertain due to mixed results from a number of recent systematic reviews and meta-analyses.72,93,94 The largest of these synthesised the results from thousands of studies and found a modest effect of parenting interventions on the recurrence of physical abuse in families with substantiated or suspected physical abuse history. Interventions based on social learning theory were suggested to offer a useful secondary prevention measure.95 Program effectiveness is highly dependent on delivery setting, intensity, protocols and population characteristics. Reviews found that potentially more effective programs were delivered by professionals, were of short or moderate length and focused on improving parental expectations and self-confidence, or targeted parental responsiveness or sensitivity, whereas those that provided only support or focused on improving problem solving, personal skills or stimulating children’s prosocial behaviour were not effective.71,93,96,97

Parent participation/engagement is a major challenge for parenting programs. This may be due to poor rates of referral or low acceptability.98 The likelihood of referrals being followed up by parents may be increased by addressing factors highlighted by Aboriginal people surveyed in the Human Rights Commission report Keeping kids safe and well – your voices,99 which reported that people feeling like they are not listened to, concerns about the involvement of child protection services and experiences of racism and discrimination prevented engagement with preventive interventions, whereas increased access to information, greater cultural safety in delivery and increased investment in successful local programs were identified as promoting service engagement.99

Intervention types with some evidence of effective reduction in the number of reports of child maltreatment include cognitive behavioural therapy, home visitation, parent training, family-based/multisystemic, substance abuse and combined interventions.96
Specific programs that have been shown in more than one controlled study to be effective include intensive family therapy, such as Multisystemic Therapy for Child Abuse and Neglect (MST-CAN) and Multisystemic Therapy – Building Stronger Families (BSF), Triple P (parent training), ACT-Parent’s Raising Safe Kids program (short-term parent training) and Healthy Start (home visitation).96 The use of mainstream programs for Aboriginal and Torres Strait Islander families may not be appropriate due to cultural differences in family structure and child-rearing practices. If mainstream programs are adapted for Aboriginal and Torres Strait Islander communities, community consultation, support and involvement should be sought. Programs or services that do not engage the Aboriginal and Torres Strait Islander community are unlikely to be effective.9

Most programs have not been adequately trialled in Aboriginal and Torres Strait Islander communities to understand whether acceptability and effectiveness is generalisable to this population.

However, there are a small number of published studies and evaluations describing parenting programs for maltreatment prevention that have been adapted or designed for Aboriginal and Torres Strait Islander populations. One of most widely studied strategies, NFP,100 was developed in the US and targets first-time mothers who are teenagers, single or of low socioeconomic status.
 
It is an intensive nurse-delivered home visitation program from pregnancy to the child at age two years, providing education on preventive health behaviours, parenting skills and economic self-sufficiency. Reviews assessing the impact of NFP on child maltreatment from a range of countries have reported mixed results. An adapted NFP protocol targeting Aboriginal and Torres Strait Islander communities that included Aboriginal community workers showed positive results, including reduced child maltreatment, in a large trial in Central Australia.101 However, reporting since implementation in multiple sites has not assessed maltreatment impacts, and the maternal and infant wellbeing outcomes that have been reported show no difference from usual care.102
 
Thus, there is very little rigorous evidence to support the effectiveness of any prevention strategies. The New South Wales Government’s audit of the Their futures matter report103 drew attention to this evidence gap, highlighting that, often, funded interventions are not evidence based and are not tailored to meet the multiple and diverse needs of families and communities.104

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