Are long-term trends in child maltreatment decreasing in England and Wales? A time-series analysis of official record data, 1858–2016

Background

Child maltreatment can result in serious immediate and long-term consequences for the child, family, and society. With mounting pressure from media scrutiny and public debate, establishing whether rates of child maltreatment are increasing or decreasing in England and Wales is a public health priority.

Physical abuse and neglect of children

Child maltreatment includes physical abuse and neglect, and happens in all countries and cultures. Child maltreatment usually results from interactions between several risk factors (such as parental depression, stress, and social isolation). Physicians can incorporate methods to screen for risk factors into their usual appointments with the family. Detection of physical abuse is dependent on the doctor's ability to recognise suspicious injuries, such as bruising, bite marks, burns, bone fractures, or trauma to the head or abdomen. Neglect is the most common form of child maltreatment in the USA. It can be caused by insufficient parental knowledge; intentional negligence is rare. Suspected cases of child abuse should be well documented and reported to the appropriate public agency which should assess the situation and help to protect the child.     

Geographic variation in the incidence of and mortality from inflammatory bowel disease

The geographic and temporal variations in mortality from Crohn's disease and ulcerative colitis were investigated. The validity of mortality data as indicators of morbidity was tested by comparing the death rates and incidences among different countries. Death rates from Crohn's disease and ulcerative colitis were high in England, Germany, and the Scandinavian countries, and low in the Mediterranean countries. There was a significant correlation between the incidence and mortality of both diseases among different countries. In addition, the incidence and mortality of Crohn's disease were correlated with those of ulcerative colitis. In countries with a low mortality rate from Crohn's disease, the death rates in men tended to be higher than those in women. In contrast, countries with high death rates from Crohn's disease showed female predominance. No such relationship existed for ulcerative colitis. The overall change in mortality rates during the last 20 to 30 years was characterized by a rise of Crohn's disease and a marked fall of ulcerative colitis. In countries with a high mortality rate from Crohn's disease, the death rates started to fall in recent times. The significant correlations between incidence and mortality show that the death rates from both diseases represent reliable indicators of the morbidity and that the severity of the two diseases is similar in different countries. The marked temporal and geographic variations in both incidence and mortality suggest that environmental factors play an important role in the etiology of both diseases. Supported by grant number So 172/1-1 from the Deutsche Forschungsgemeinschaft.     

Risk factors for injuries in young children in four developing countries: the Young Lives Study

OBJECTIVE: To assess the occurrence of child injury in four developing country settings and to explore potential risk factors for injury. METHODS: Injury occurrence was studied in cohorts of 2000 children of age 6-17 months at enrolment, in each of Ethiopia, Peru, Vietnam and India (Andhra Pradesh). Generalized estimating equation models were used to explore potential risk factors for child injury. RESULTS: Occurrence of child injury was high in all countries. Caregiver depression emerged as a consistent risk factor for all types of injury measured (burns, serious falls, broken bones and near-fatal injury) across all countries. Other risk factors also showed consistent associations, including long-term child health problems, region of residence and the regular care of the child by a non-household member. CONCLUSIONS: This report provides further evidence of the importance of childhood injury in developing countries and emphasizes the importance of including infants in injury research and prevention strategies. It provides strong evidence of an association between caregiver mental health and child injury risk and contributes to the limited knowledge base on risk factors for child injury in developing countries.     

Recent International Reductions and Increases in Liver Cirrhosis Deaths

This paper examines changes in liver cirrhosis death rates in 29 countries between 1974 and 1983 or the latest year available. Seven countries show a decline in death rates, six an increase, and the remaining 17 show no clear significant trends. Changes were more common among countries with high rates of alcohol consumption and high rates of liver cirrhosis deaths. Limited evidence for a widespread amelioration in liver cirrhosis seems to exist.     

Suicide among older people in relation to their subjective and objective well-being in different European regions

The aim of this study was to establish how different types of welfare states shape the context of the everyday life of older people by influencing their subjective well-being, which in turn might manifest itself in suicide rates. Twenty-two European countries studied were divided into Continental, Nordic, Island, Southern, and post-socialist countries, which were subdivided into Baltic, Slavic, and Central-Eastern groups based on their socio-political and welfare organization. Suicide rates, subjective well-being data, and objective well-being data were used as parameters of different welfare states and obtained from the World Health Organization European Mortality Database, European Social Survey, and Eurostat Database. This study revealed that the suicide rates of older people were the highest in the Baltic countries, while in the Island group, the suicide rate was the lowest. The suicide rate ratios between the age groups 65+ and 0–64 were above 1 (from 1.2 to 2.5), except for the group of the Island countries with a suicide rate ratio of 0.8. Among subjective well-being indicators, relatively high levels of life satisfaction and happiness were revealed in Continental, Nordic, and Island countries. Objective well-being indicators like old age pension, expenditure on old age, and social protection benefits in GDP were the highest in the Continental countries. The expected inverse relationship between subjective well-being indicators and suicide rates among older people was found across the 22 countries. We conclude that welfare states shape the context and exert influence on subjective well-being, and thus may lead to variations in risk of suicide at the individual level.     

The Role of Alcohol in Accident and Violent Deaths in Finland

BACKGROUND: In Finland, the high rates of forensic autopsy and postmortem toxicology furnish a reliable base for nation-wide studies on alcohol-related violent deaths. MATERIAL AND METHODS: National mortality and population data within Finland, from 1987 to 1996, were used to analyze sex- and age-specific rates, proportions, and trends of violent deaths associated with alcohol. Deaths were defined as alcohol-related when alcohol was certified as a contributing factor to death. RESULTS: During the study period, 10,360 (23.3%) of the 45,544 violent deaths that occurred were alcohol-related. Among 15- to 64-year-olds, 28.6% of accidents, 30.5% of suicides, and 55.3% of homicides were associated with alcohol (alcohol-positive). Differences in epidemiologic patterns and trends for different types of violent death were observed between sexes and age groups. For instance, alcohol-positive accidents significantly decreased in males (-2.3%/year; CL95: -3.3, -1.2; p < 0.001), but not in females (+0.5%/year; CL95: -2.7, +3.7; p = 0.772), and alcohol-positive suicides increased slightly in females (+3.9%/year; CL95: +0.0, +7.9; p = 0.047), but not in males (-0.2%/year, CL95: -1.4, +1.0; p = 0.704). CONCLUSIONS: The victims of violent deaths have often consumed or abused alcohol before the fatal events. Especially in young adults, consumption of alcohol is likely one of the most serious risk factors in accidents and may decrease the threshold for suicide ideation and impulsive behaviors. Studies that explore the effects of sociodemographic and health factors on random populations with relevant control data will increase the understanding of the causal connection between alcohol and violent deaths.     

Relationship between Multiple Forms of Maltreatment by a Parent or Guardian and Adolescent Alcohol Use

This study examined the effect of the co‐occurrence of multiple categories of maltreatment on adolescent alcohol use. Data were from the National Longitudinal Study of Adolescent Health which used a nationally representative sample of adolescents (n = 14,078). Among those reporting any maltreatment, over one‐third had experienced more than one type of maltreatment. Logistic regression models found that all types or combinations of types of maltreatment except physical‐abuse‐only were strongly associated with adolescent alcohol use, controlling for age, gender, race, and parental alcoholism. These results add to accumulating evidence that child maltreatment has a deleterious impact on adolescent alcohol use.     

Injury prevention and control in children

Injury is the number one cause of death and life-years lost for children. In children, injury mortality is greater than childhood mortality from all other causes combined. Modern injury prevention and control seeks to prevent and limit or control injuries through the 4 Es of injury prevention: engineering, enforcement, education, and economics. Emergency physicians are often placed in a critical role in the lives of individuals, are respected authorities on the health and safety of children and adults, and have daily exposure to high-risk populations. This gives emergency physicians a unique perspective and an opportunity to take an active role in injury control and prevention. Specific methods or strategies for promulgating injury prevention and control in our emergency medicine practices are suggested, ranging from education (for our patients and health professionals); screening and intervention for domestic violence, child maltreatment, drug-alcohol dependency and abuse; data collection; reporting unsafe products; research; legislation; serving in regulatory and governmental agencies; emergency medical services-community involvement; and violence prevention. Emergency physicians can play a significant role in decreasing pediatric injury and its concomitant morbidity and mortality.     

Premature mortality in adult survivors of child abuse and neglect: a nationwide birth cohort study

BackgroundChild neglect and abuse are not uncommon. Both are associated with deleterious outcomes in adulthood, but there is sparse evidence on the association between such trauma and premature adult mortality. We aimed to establish whether different types of child maltreatments were associated with all-cause mortality in mid-adulthood and examined potential intermediaries of this association.MethodsUsing the 1958 British birth cohort (n=9310), we examined associations between child neglect (prospectively recorded at years 7 and 11 of age) and abuse (physical, psychological, witnessing and sexual; self-reported at years 44–45 of age) with all-cause mortality, using Cox proportional hazard models adjusted for early-life covariates and other maltreatment types. We tested interactions between each maltreatment type and sex; there was little evidence of effect modification (p_interaction>0·001), hence models also adjust for sex. Mortality follow-up was between 2002–03 and December 2016 (participants aged 44–45 to 58 years). Death was ascertained from the National Health Service Central Register (n=296) or from survey updates (n=16). Potential intermediaries included: adult social factors, health behaviours, adiposity, mental health, cardiometabolic markers, and growth (height) at years 7 to 45 of age. Missing data were imputed via multiple imputation.FindingsChild maltreatment prevalence varied from 1·6% (n=149; sexual abuse) to 11% (n=1000; physiological abuse); 77% (n=6536) reported no maltreatment. Neglect and abuse (physical and sexual) were associated with increased risk of premature death, independent of covariates and other maltreatment types; adjusted hazard ratios (HRs) were 1·47 (95% CI 1·05–2·05) for neglect, 1·73 (1·10–2 ·71) for physical abuse, and 2·60 (1·49–4·52) for sexual abuse. Associations for neglect and physical abuse disappeared after adjustment for adult health behaviours, and, for neglect only, social factors; other intermediaries had little effect on these associations. Sexual abuse associations were largely unexplained by examined intermediaries. Risk of all-cause mortality increased with the number of maltreatments (versus none): adjusted HRs were 1·44 (1·07–1·93) for one maltreatment and 2·04 (1·45–2·87) for at least two maltreatments.InterpretationChild neglect and physical and sexual abuse are associated with increased risk of premature mortality in mid-adulthood. Our findings highlight the importance of preventing specific child maltreatments and of supporting survivors to potentially mitigate differences in premature mortality. Child abuse was reported retrospectively and estimated associations for sexual abuse might be imprecise due to low prevalence. However, child neglect, potential confounders, and mediators were ascertained prospectively.FundingUS National Institute on Aging, the UK Economic and Social Research Council, the UK Biotechnology and Biological Sciences Research Council, and the UK National Institute for Health Research Biomedical Research Centre.     

Moving from vertical to integrated child health programmes: experiences from a multi‐country assessment of the Child Health Days approach in Africa

Objectives To assess the effect of child health days (CHDs) on coverage of child survival interventions, to document country experiences with CHDs and to identify ways in which CHDs have strengthened or depleted primary health care (PHC) services. Methods Programme evaluation in six countries in sub‐Saharan Africa using both quantitative (review of routine child health indicators) and qualitative (key informant interviews) methods. Results We found that CHDs have raised the profile of child survival at different levels from central government to the community in all six countries. The approach has increased the coverage of vitamin A supplementation and immunizations, especially in previously poorly performing countries. However, similar improvements have not occurred in non‐CHD interventions, most notably exclusive breastfeeding. There were examples of duplication, especially in the capturing and use of health information. There was widespread evidence that PHC staff were being diverted from their usual PHC functions, and managers reported being distracted by the time required for the planning and execution of CHDs. Finally, there were examples of where the routine PHC system is becoming distorted through, for example, the payment of health worker incentives during CHD activities only. Conclusion Interventions such as CHDs can rapidly increase coverage of key child survival interventions; however, they need to do so in a manner that strengthens rather than depletes existing PHC services. Our findings suggest that stand alone child health day interventions may gradually need to be integrated with routine PHC through more general health system strengthening.     

Time trends in hospital admissions for violent,self-inflicted,and drug-related or alcohol-related injury for adolescents in England and Scotland, 2005–11: observational population-based study

BackgroundIn England, a third of emergency admissions of adolescents for injury are adversity related (violent, self-inflicted, drug-related, or alcohol-related). A comparison of time trends of the incidence of admissions for violent injury between England and Scotland revealed steeper declines in 2005–11 in Scotland. We aimed to determine whether incidence of admissions for any adversity-related injury varied substantially between the two countries.MethodsWe conducted time-series analyses of emergency admissions between 2005 and 2011 for adversity-related injury (defined by the 10th revision of the International Classification of Diseases) to National Health Service hospitals in England (Hospital Episode Statistics) and in Scotland (Scottish Morbidity Records) in 10–18 year olds. Analyses were stratified in groups by sex and age (10–12 years, 13–15, 16–18) and were adjusted for background trends in admissions for any injury.FindingsIn 2005, rates of admissions per 100 000 for adversity-related injury ranged from 48·9 for girls aged 10–12 years in Scotland (95% CI 0–98·9) to 978·2 for boys aged 16–18 years in Scotland (764·0–1184·3). Rates for 10–12-year-old girls and boys, respectively, were similar between the two countries, but were higher in Scotland for 13–15 year olds and 16–18 year olds. From 2005 to 2011, rates decreased in both countries for all groups by −1·5% per year (95% CI −3·2 to 0·21) to −10·0% per year (–15·2 to −4·4), except for 16–18-year-old girls and boys in England, where rates increased by 0·25% per year (0·09–0·41) to 2·5% per year (1·2–3·7). Decreases in all groups were greater in Scotland than in England after adjustment for trends in admissions for any injury. By 2011, although incidences of admissions for adversity-related injury in adolescents aged 13–15 and 16–18 years remained higher in Scotland, differences between England and Scotland were smaller than in 2005.InterpretationOur finding that rates of admissions for adversity-related injury decreased more steeply in Scotland than in England raises questions about the factors driving these discrepancies. Several initiatives within each country might have been influential. For example, the English government attempted to tackle incidence of violence and gangs by targeting high crime areas with higher levels of policing. The Scottish government set up contracts with local gangs to exchange a so-called clean slate for psychosocial support. Further research into potentially successful practices in Scotland could be used to develop future initiatives to reduce harm in adolescents in both countries and further afield. More research is needed, especially into why the incidence of admissions for adversity-related injury increased for older adolescents in England.FundingAH was supported by the Policy Research Unit in the Health of Children, Young People and Families, which is funded by the Department of Health Policy Research Programme (grant reference number 109/0001). AH is also supported by the University College London Impact studentship. The study sponsors played no part in the design, data analysis, and interpretation of this study; the writing of the abstract; or the decision to submit the abstract for publication.     

Mortality from ischaemic heart disease by country,region, and age: Statistics from World Health Organisation and United Nations

Background

Ischaemic heart disease (IHD) is the leading cause of death worldwide. The World Health Organisation (WHO) collects mortality data coded using the International Statistical Classification of Diseases (ICD) code.

Methods

We analysed IHD deaths world-wide between 1995 and 2009 and used the UN population database to calculate age-specific and directly and indirectly age-standardised IHD mortality rates by country and region.

Results

IHD is the single largest cause of death worldwide, causing 7,249,000 deaths in 2008, 12.7% of total global mortality. There is more than 20-fold variation in IHD mortality rates between countries. Highest IHD mortality rates are in Eastern Europe and Central Asian countries; lowest rates in high income countries. For the working-age population, IHD mortality rates are markedly higher in low-and-middle income countries than in high income countries.Over the last 25 years, age-standardised IHD mortality has fallen by more than half in high income countries, but the trend is flat or increasing in some low-and-middle income countries. Low-and-middle income countries now account for more than 80% of global IHD deaths.

Conclusions

The global burden of IHD deaths has shifted to low-and-middle income countries as lifestyles approach those of high income countries. In high income countries, population ageing maintains IHD as the leading cause of death. Nevertheless, the progressive decline in age-standardised IHD mortality in high income countries shows that increasing IHD mortality is not inevitable. The 20-fold mortality difference between countries, and the temporal trends, may hold vital clues for handling IHD epidemic which is migratory, and still burgeoning.     

Alcohol's involvement in recurrent child abuse and neglect cases

Aims This paper examined whether or not: (a) care‐giver ‘alcohol abuse’ is associated with recurrent child maltreatment; (b) other ‘risk factors’ affect this relationship; and (c) which of alcohol abuse or other drug abuse plays a stronger role. It also examined (d) how children and families where alcohol‐related child abuse was identified were managed by child protection services (CPS) in Victoria, Australia. Design, setting and participants Using anonymized data from Victorian CPS, repeat cases were examined involving 29 455 children identified between 2001 and 2005. Measurements Carer alcohol abuse, other drug abuse, mental ill‐health, carer experience of abuse as a child, child age and gender, family type, socio‐economic variables and level of child protection service intervention as recorded in the CPS electronic database were examined as risk factors for recurrence, using bivariate and multivariate techniques. Findings Almost one‐quarter of children in CPS experienced a recurrent incident of child maltreatment in a 5‐year period. Where carer alcohol abuse was identified children were significantly more likely to experience multiple incidents compared with children where this was not identified (P < 0.001), as were children where other family risk factors (including markers of socio‐economic disadvantage) were identified. The majority of children whose carers were identified with alcohol abuse experienced either repeat incidents or interventions (84%), although almost three‐quarters of these children were managed without resort to the most serious outcome, involving court orders. Conclusions Alcohol and drug abuse in carers are important risk‐factors for recurrent child maltreatment after accounting for other known risk factors; the increased risk appears to be similar between alcohol and drug abuse.     

Improvement of child survival in Mexico: the diagonal approach

Public health interventions aimed at children in Mexico have placed the country among the seven countries on track to achieve the goal of child mortality reduction by 2015. We analysed census data, mortality registries, the nominal registry of children, national nutrition surveys, and explored temporal association and biological plausibility to explain the reduction of child, infant, and neonatal mortality rates. During the past 25 years, child mortality rates declined from 64 to 23 per 1000 livebirths. A dramatic decline in diarrhoea mortality rates was recorded. Polio, diphtheria, and measles were eliminated. Nutritional status of children improved significantly for wasting, stunting, and underweight. A selection of highly cost-effective interventions bridging clinics and homes, what we called the diagonal approach, were central to this progress. Although a causal link to the reduction of child mortality was not possible to establish, we saw evidence of temporal association and biological plausibility to the high level of coverage of public health interventions, as well as significant association to the investments in women education, social protection, water, and sanitation. Leadership and continuity of public health policies, along with investments on institutions and human resources strengthening, were also among the reasons for these achievements.     

Improvement of child survival in Mexico: the diagonal approach

Public health interventions aimed at children in Mexico have placed the country among the seven countries on track to achieve the goal of child mortality reduction by 2015. We analysed census data, mortality registries, the nominal registry of children, national nutrition surveys, and explored temporal association and biological plausibility to explain the reduction of child, infant, and neonatal mortality rates. During the past 25 years, child mortality rates declined from 64 to 23 per 1000 livebirths. A dramatic decline in diarrhoea mortality rates was recorded. Polio, diphtheria, and measles were eliminated. Nutritional status of children improved significantly for wasting, stunting, and underweight. A selection of highly cost-effective interventions bridging clinics and homes, what we called the diagonal approach, were central to this progress. Although a causal link to the reduction of child mortality was not possible to establish, we saw evidence of temporal association and biological plausibility to the high level of coverage of public health interventions, as well as significant association to the investments in women education, social protection, water, and sanitation. Leadership and continuity of public health policies, along with investments on institutions and human resources strengthening, were also among the reasons for these achievements.     

4 million neonatal deaths: when? Where? Why?

The proportion of child deaths that occurs in the neonatal period (38% in 2000) is increasing, and the Millennium Development Goal for child survival cannot be met without substantial reductions in neonatal mortality. Every year an estimated 4 million babies die in the first 4 weeks of life (the neonatal period). A similar number are stillborn, and 0.5 million mothers die from pregnancy-related causes. Three-quarters of neonatal deaths happen in the first week--the highest risk of death is on the first day of life. Almost all (99%) neonatal deaths arise in low-income and middle-income countries, yet most epidemiological and other research focuses on the 1% of deaths in rich countries. The highest numbers of neonatal deaths are in south-central Asian countries and the highest rates are generally in sub-Saharan Africa. The countries in these regions (with some exceptions) have made little progress in reducing such deaths in the past 10-15 years. Globally, the main direct causes of neonatal death are estimated to be preterm birth (28%), severe infections (26%), and asphyxia (23%). Neonatal tetanus accounts for a smaller proportion of deaths (7%), but is easily preventable. Low birthweight is an important indirect cause of death. Maternal complications in labour carry a high risk of neonatal death, and poverty is strongly associated with an increased risk. Preventing deaths in newborn babies has not been a focus of child survival or safe motherhood programmes. While we neglect these challenges, 450 newborn children die every hour, mainly from preventable causes, which is unconscionable in the 21st century.     

Child maltreatment in China: comparison of parent and child reports

Background

Reporting of the incidence of child maltreatment by parents and children might differ with implications for optimum research methodologies to determine the incidence of maltreatment. Our aim was to compare parent and child reports of child maltreatment in mainland China.

The health gap in Mexico,measured through child mortality

OBJECTIVE: To estimate the health gap in Mexico, as evidenced by the difference between the observed 1998 mortality rate and the estimated rate and the estimated rate for the same year according to social and economic indicators, with rates from other countries. MATERIAL AND METHODS: An econometric model was developed, using the 1998 child mortality rate (CMR) as the dependent variable, and macro-social and economic indicators as independent variables. The model included 70 countries for which complete data were available. RESULTS: The proposed model explained over 90% of the variability in CMR among countries. The expected CMR for Mexico was 22% lower that the observed rate, which represented nearly 20,000 excess deaths. CONCLUSIONS: After adjusting for differences in productivity, distribution of wealth, and investment in human capital, the excess child mortality rate suggested efficiency problems in the Mexican health system, at least in relation to services intended to reduce child mortality. The English version of this paper is available at: http://www.insp.mx/salud/index.html.     

Myocardial infarction occurrence in Jerusalem: a Mediterranean anomaly

BACKGROUND: The Jewish population of Israel consumes a diet rich in polyunsaturated fatty acids with a relatively low proportion of saturated fat, has a small alcohol intake and a lipid profile characterized by low HDL-cholesterol and high lipoprotein(a) (Lp(a)). It is therefore of interest to compare occurrence rates of coronary heart disease (CHD) with those elsewhere. METHODS: The community-based event rate of CHD [comprising acute myocardial infarction (AMI) and CHD death] and case-fatality was determined in 1995-1997 by active surveillance among Jewish residents of the Jerusalem District aged 25-64 according to standardized WHO-MONICA criteria. We compared our findings with rates among MONICA populations in 21 countries. Twelve hundred and six events occurred in Jerusalem during approximately 399,000 [correction] person-years (930 non-fatal AMI and 276 CHD deaths). RESULTS: The age-adjusted incidence of CHD ranked high compared with the 21 countries (men third highest, women eighth highest), far exceeding the Mediterranean countries. In contrast, the pre-hospital mortality rate was low, similar to countries in the Mediterranean basin, and the 28-day case fatality was remarkably low, far lower than for any MONICA population in men, and second lowest in women. Correspondingly, the incidence of non-fatal AMI ranked extraordinarily high (men first, women third). The low case-fatality ranking persisted upon adjustment for treatment differences between populations. CONCLUSIONS: We report an unusual combination of a high incidence of CHD among Jewish residents of Jerusalem accompanied by extraordinarily low case fatality, the latter suggesting reduced susceptibility to lethal arrhythmias. Determinants of this anomaly require clarification.