Article Text

Download PDFPDF

Role of pre-existing adversity and child maltreatment on mental health outcomes for children involved in child protection: population-based data linkage study
  1. Miriam Jennifer Maclean1,
  2. Scott Anthony Sims1,
  3. Melissa O'Donnell1,2
  1. 1 Linked Analytics and Social Policy, Telethon Kids Institute, Nedlands, Western Australia, Australia
  2. 2 Centre for Child Health Research, Faculty of Health and Medical Sciences, University of Western Australia, Crawley, Western Australia, Australia
  1. Correspondence to Dr Miriam Jennifer Maclean; miriam.maclean{at}


Objectives To determine mental health outcomes for children with a history of child protection system involvement, accounting for pre-existing adversity, and to examine variation in risk across diagnostic groupings and child protection subgroups.

Design A longitudinal, population-based record-linkage study.

Participants All children in Western Australia (WA) with birth records between 1990 and 2009.

Outcome measures Mental health diagnoses, mental health contacts and any mental health event ascertained from International Classification of Diseases codes within WA’s Hospital Morbidity Data Collection and Mental Health Information System from birth until 2013.

Results Compared with children without child protection contact, children with substantiated maltreatment had higher prevalence of mental health events (37.4% vs 5.9%) and diagnoses (20% vs 3.6%). After adjusting for background risks, all maltreatment types were associated with an almost twofold to almost threefold increased hazard for mental health events. Multivariate analysis also showed mental health events were elevated across all child protection groups, ranging from HR: 3.54 (95% CI 3.28 to 3.82) for children who had entered care to HR: 2.31 (95% CI 2.18 to 2.46) for unsubstantiated allegations. Maternal mental health, aboriginality, young maternal age and living in socially disadvantaged neighbourhoods were all associated with an increased likelihood of mental health events. The increase varied across diagnostic categories, with particularly increased risk for personality disorder, and frequent comorbidity of mental health and substance abuse disorders.

Conclusions Young people who have been involved in the child protection system are at increased risk for mental health events and diagnoses. These findings emphasise the importance of services and supports to improve mental health outcomes in this vulnerable population. Adversities in childhood along with genetic or environmental vulnerabilities resulting from maternal mental health issues also contribute to young people’s mental health outcomes, suggesting a role for broader social supports and early intervention services in addition to targeted mental health programmes.

  • child protection
  • mental health
  • abuse and neglect
  • linked data
  • population

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Contributors MJM drafted the paper, interpreted findings and revised the paper. SAS cleaned and analysed the data, contributed to the draft and revised the paper. MO conceptualised the paper, developed the statistical plan, contributed to the draft and revised the paper. All authors approved the final manuscript as submitted. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding MOD was supported by a National Health and Medical Research Council Early Career Fellowship (1012439). This research was also supported by an Australian Research Council Linkage Project Grant (LP100200507) and an Australian Research Council Discovery Grant (DP110100967).

  • Disclaimer The views expressed are not necessarily those of the Government Departments that have provided data for this project and any omissions are the responsibility of the authors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Western Australian Department of Health Human Research Ethics Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available. Third party restrictions are in place for legal and ethical reasons. The data used in this paper are owned by our respective Government Departments and therefore would require permissions by these departments for others to access.