A population level study into health vulnerabilities of mothers and fathers involved in public law care proceedings in Wales, UK between 2011 and 2019

Main Article Content

Rhodri David Johnson
https://orcid.org/0000-0001-9636-0753
Dr Laura North
https://orcid.org/0000-0001-9058-5871
Dr Bachar Alrouh
https://orcid.org/0000-0002-3977-5685
Professor Ann John
Professor Kerina A Jones
https://orcid.org/0000-0001-8164-3718
Ashley Akbari
https://orcid.org/0000-0003-0814-0801
Jon Smart
Simon Thompson
Dr Claire Hargreaves
https://orcid.org/0000-0002-4769-4017
Dr Stefanie Doebler
https://orcid.org/0000-0002-8611-4601
Dr Linda Cusworth
https://orcid.org/0000-0002-4694-992X
Professor Karen Broadhurst
https://orcid.org/0000-0003-1424-3022
Professor David V Ford
Dr Lucy J Griffiths
https://orcid.org/0000-0001-9230-624X

Abstract

Introduction
Under section 31 of the Children Act 1989, public law care proceedings can be issued if there is concern a child is subject to, or at risk of significant harm, which can lead to removal of a child from parents. Appropriate and effective health and social support are required to potentially prevent some of the need for these proceedings. More comprehensive evidence of the health needs and vulnerabilities of parents will enable enhanced response from family courts and integrated other services.


Objective
To examine health vulnerabilities of parents involved in care proceedings in the two-year period prior to involvement.


Methods
Family court data provided by Cafcass Cymru were linked to population-based health records held within the Secure Anonymised Information Linkage Databank. Linked data were available for 8,821 parents of children involved in care proceedings between 2011 and 2019. Findings were benchmarked with reference to a comparison group of parents matched on sex, age, and deprivation (n = 32,006), not subject to care proceedings. Demographic characteristics, overall health service use, and health profiles of parents were examined. Descriptive and statistical tests of independence were used.


Results
Nearly half of cohort parents (47.6%) resided in the most deprived quintile. They had higher levels of healthcare use compared to the comparison group across multiple healthcare settings, with the most pronounced differences for emergency department attendances (59.3% vs 37.0%). Health conditions with the largest variation between groups were related to mental health (43.6% vs 16.0%), substance use (19.4% vs 1.6%) and injuries (41.5% vs 23.6%).


Conclusion
This study highlights the heightened socioeconomic and health vulnerabilities of parents who experience care proceedings concerning a child. Better understanding of the needs and vulnerabilities of this population may provide opportunities to improve a range of support and preventative interventions that respond to crises in the community.

Introduction

Under section 31 (s.31) of the Children Act 1989, (public law) care proceedings can be issued if there is concern a child is subject to, or at risk of significant harm, which can lead to removal of a child from their parents. Previous analysis of infants and newborn babies subject to care proceedings in Wales revealed the scale and rising number of families involved and recommended the need for preventative action [1]. Characteristics of mothers of infants involved in such proceedings have also been examined, including mental health needs [24]. We aim to extend this work by examining a broader range of parental vulnerabilities for both mothers and fathers of children of any age involved in care proceedings.

Appropriate and effective health and social support are required to potentially prevent some of the need for care proceedings [5, 6]. However, a joined-up health and children’s social care response to parents requires far greater knowledge about parents’ healthcare needs and their interaction with health, and social care services. This study aims to advance the evidence base regarding interaction with health services by focusing on parents in care proceedings and providing completely new evidence, which will enable services to be more effectively tailored.

Combinations of domestic violence, parental mental health issues and/or learning disability, and parental alcohol and/or drug misuse have received considerable attention in relation to risk of child abuse and neglect [7, 8]. Skinner and colleagues [9] have recently called for a better understanding of wider factors impacting on families involved with child protection services. More comprehensive evidence of health needs and vulnerabilities, including more in-depth exploration of specific health conditions of parents entering care proceedings and their use of different types of healthcare provision (routine; emergency), will also enable enhanced response from the family courts and other services.

This study sought to address such evidence gaps with a view to aiding assessment of current policy and its future development. Population-level data collected routinely by Cafcass Cymru (a Welsh Government organisation that represents children’s best interests in family justice proceedings in Wales) for mothers and fathers was linked to electronic health records, to examine demographic characteristics of parents, overall health service use, and health profiles.

Methods

Study design and data sources

A population-level cohort study with a matched comparison group, with the group of interest being parents involved in public law care proceedings.

Data sources and linkage

Data were accessed via the SAIL (Secure Anonymised Information Linkage) Databank [1012], a trusted research environment (TRE) that hosts extensive individual-level anonymised health and administrative data for the population of Wales. During the anonymisation process of data sources within the SAIL Databank, individuals are assigned unique identifier fields – Anonymous Linking Field (ALF) and Residential Anonymous Linking Field (RALF) [13, 14] – to link data at individual and residential levels respectively.

The primary source of family justice data was electronic case management data routinely produced and maintained by Cafcass Cymru. All instances of s.31 care proceedings initiated between January 2011 and December 2019 were included. Further detail on Cafcass data are available elsewhere [15, 16].

Demographic information for parents was obtained using the Welsh Demographic Service Dataset (WDSD), which provides demographic characteristics of people registered with a general practice (GP).

Health records from the Patient Episode Database for Wales (PEDW), Emergency Department Data Set (EDDS), Outpatient Data Set Wales (OPDW) and Welsh Longitudinal General Practice (WLGP) were analysed for two years pre care proceedings. These records contain attendance and diagnosis data on inpatient activity, emergency admissions, outpatient appointments, and GP appointments respectively.

Study population

Parents of children involved in s.31 care proceedings in Wales between January 2011 and December 2019 were included in the study (n = 11,349). Of these, 9,269 were successfully matched and assigned an ALF. Only parents with valid demographic information of sex, age and deprivation were included. The final cohort consisted of 8,821 parents (Figure 1).

Figure 1: Flow diagram of study participants.

An existing method was used [17] to create a list of all parents with children in Wales at a fixed date of 1st July 2015 (study period mid-point) and who were not involved in care proceedings. A comparison group of parents was selected from this list using frequency matching (matched on area-level income domain deprivation quintiles, sex, and parent age band (<=25, 26-35, and >=36) at index date). The final matched comparison group consisted of 32,006 parents.

Index dates for the cohort were set at the earliest court date, and study mid-point for the comparisons. The baseline period for health data coverage was set as two years proceeding an individual’s index date.

Measures

Demographic characteristics

Demographic characteristics of sex, parental age and youngest child age were derived from Cafcass Cymru and WDSD at index date. The income domain from the 2014 version of the Welsh Index of Multiple Deprivation (WIMD) was used as area level deprivation, taken at or within two years of index date and grouped into quintiles.

Overall healthcare use

Healthcare interactions within the baseline period were analysed for any hospital admission, new emergency department attendances (excluding follow-up), new outpatient appointment attendance and any GP record. Hospital admissions were categorised into emergency, elective or maternity; and emergency department attendances were classified as urgent and non-urgent based on triage classifications (urgent included ‘1-immediate’, ‘2-very urgent’, or ‘3-urgent’).

General health conditions

We provide a broad categorisation of health conditions grouped according to the chapter level of the International Statistical Classification of Diseases (ICD-10) [18]. For emergency hospital admissions, all diagnostic codes in primary or secondary diagnostic code positions were included. As a high proportion of mothers would have had routine pregnancy and birth related admissions we excluded ICD-10 chapter 15 (pregnancy related). Any primary care diagnoses codes within the GP Read classification system were included with codes mapped to approximations of ICD-10 chapters (excluding pregnancy related chapters) (Supplementary Table 1).

Mental health and substance use conditions

Parents’ primary care (GP) and hospital records were examined for the presence of clinical codes indicating mental health contacts or admissions. If an individual had one or more mental health-related contact or admission code recorded during the baseline period, they were categorised as having a mental health outcome. Code lists developed and provided by the Adolescent Mental Health Data Platform [19] were used and included common mental disorders e.g. depression and anxiety; severe mental illness; eating disorders; neurodevelopmental disorders e.g. attention deficit hyperactivity disorder, autistic spectrum disorder; and conduct disorders [20].

Health records were also analysed for clinical codes indicating substance use indicative of problem, harmful or hazardous use of alcohol and/or illicit drugs [20]. If an individual had any such code recorded during the baseline period, they were classified as having a substance use contact or admission.

Injuries

Emergency department attendances were analysed for the presence of injury-related clinical codes during the baseline period, using the attendance group variable for accidents, assault, and self-harm [21].

Data analysis

Descriptive analyses were conducted to characterise the cohort and comparison groups. Proportions of parents with the measures of interest were calculated during the two-year period prior to the index date; outcomes were not required to be mutually exclusive. One-way analysis of variance tests were computed to compare means between cohort and comparison groups for continuous variables. Chi-squared analyses was used to investigate differences between groups for categorical variables. Data processing and analyses were carried out using SQL and R [22].

Results

Demographic characteristics

Mothers accounted for 57.4% of the cohort. Nearly three quarters (73.0%) of cohort parents lived within the two most deprived quintiles (Table 1). The mean age of cohort mothers (29.2 years) was around three years younger than fathers (32.3 years). There was a notable difference in the proportions of younger parents (<20 years) between the groups, with 8.4% of cohort parents aged 15-19 years compared to 1.3% of the comparison group. The mean age of the youngest child was 1.5 years younger in the cohort, compared to the comparison group.

Variable Cohort n (%) Comparison n (%) p-value
(Chi-squared)
Sex Female 5062 (57.4) 18369 (57.4) 1.000
Male 3759 (42.6) 13637 (42.6)
Deprivation at index date Quintile 1: Most deprived 4199 (47.6) 15241 (47.6) 1.000
Quintile 2 2240 (25.4) 8129 (25.4)
Quintile 3 1311 (14.9) 4756 (14.9)
Quintile 4 701 (7.9) 2541 (7.9)
Quintile 5: Least deprived 370 (4.2) 1339 (4.2)
Parental age at index date 15-19 744 (8.4) 413 (1.3) <0.001
20-24 1771 (20.1) 7116 (22.2)
25-29 1873 (21.2) 7019 (21.9)
30-34 1768 (20.0) 7211 (22.5)
35-39 1248 (14.1) 3730 (11.7)
40-44 763 (8.6) 2779 (8.7)
>45 654 (7.4) 3738 (11.7)
(One-way ANOVA)
Mother’s age at index date (mean (SD)) Age in years 29.2 (8.2) 30.6 (8.2) <0.001
Father’s age at index date (mean (SD)) Age in years 32.3 (9.1) 33.8 (9.4) <0.001
Age of youngest child at index date (mean (SD)) Age in years 3.2 (4.3) 4.7 (4.7) <0.001
Age of youngest child at index date (median (IQR)) Age in years 1 (5) 3 (6) <0.001
Table 1: Demographic characteristics for the cohort (n = 8,821) and comparison group (n = 32,006). *Given the matched comparison design there were no significant differences between cohort and comparison for sex and deprivation. For all other variables shown in this table p-values were >0.001.

Health measures

Overall healthcare use

Both cohort mothers and fathers experienced higher healthcare use across all measured healthcare settings apart from elective hospital admissions in the two years prior to care proceedings (Figure 2, Supplementary Table 2). Differences between the groups were generally more pronounced for mothers than fathers.

Figure 2: Proportion of individuals within study groups by type of healthcare use for two years prior to care proceedings. P-values: *p < 0.05; **p < 0.01; ***p < 0.001.

The largest differences between groups were ‘reactive’ type health services, such as emergency admissions and attendances. Within the cohort, a third of mothers (33.6%) and nearly a fifth (18.5%) of fathers had at least one emergency hospital admission compared to 15.3% and 7.8% in the comparison respectively. Cohort mothers (62.7%) and fathers (54.9%) had higher emergency attendances than comparisons (37.2% for mothers and 36.8% for fathers). Cohort parents were also more likely to have higher severity emergency attendances (27.7% compared to 12.3% for comparisons), based on attendances triaged as ‘immediate’, ‘very urgent’, or ‘urgent’.

Since a greater proportion of cohort mothers had infants at the index date compared to the comparisons, this may have influenced the maternity hospital admissions.

Health conditions

There were also higher levels of emergency admissions in the cohort than comparison group for both parents (Figure 2), with reasons for these admissions shown in Figure 3 and Supplementary Table 3. The most common conditions in the cohort also had the largest variation compared to the comparison group, which included mental and behavioural disorders (13.4% mothers and 8.5% fathers), external causes of morbidity and mortality (7.9% mothers and 5.9% fathers), and injury, poisoning and other consequences of external causes (6.9% mothers and 5.7% fathers).

Figure 3: Proportion of individuals within study groups by health condition (ICD-10 chapter grouping for emergency hospital admissions) for two years prior to care proceedings. P-values: *p < 0.05; **p < 0.01; ***p < 0.001.

Significant differences were found between groups for both mothers and fathers (p<0.001) except for neoplasms, eye diseases, ear diseases, congenital conditions, and genitourinary system diseases for fathers.

The conditions with large relative differences between the study groups in primary care diagnosis records were mental disorders, ‘injury and poisoning’, causes of injury and poisoning (for example, accidents, assault, and self-harm) and causes of morbidity and mortality (Figure 4, Supplementary Table 4). These were in common with emergency hospital admission conditions. The conditions with the largest relative differences in emergency hospital admissions and GP records are assessed in more detail in Supplementary Tables 3, 4.

Figure 4: Proportion of individuals within study groups by health condition (ICD-10 chapter grouping for GP diagnosis records) for two years prior to care proceedings. P-values: *p < 0.05; **p < 0.01; ***p < 0.001.

Mental health and substance use conditions

Mental disorders were by far the most common recorded health condition for individuals in the cohort (53.2% for mothers and 30.6% for fathers), over 2.5 and 3 times higher than for comparison mothers and fathers respectively (Table 2). The most common type of mental health condition was depression. The relative differences of severe mental illnesses (including schizophrenia and bipolar disorders) were 11 times higher for mothers in the cohort group and 7 times higher for fathers. Conditions such as developmental disorders, attention deficit hyperactivity disorders, eating disorders and autism were all also considerably more prevalent in the cohort group.

Variable Mothers, n (%) Fathers, n (%)
Cohort Comparison p-value Cohort Comparison p-value
Mental Health
Any mental health condition 2693 (53.2) 3752 (20.4) <0.001 1151 (30.6) 1359 (10.0) <0.001
Depression 2214 (43.7) 2804 (15.3) <0.001 887 (23.6) 956 (7.0) <0.001
Anxiety 1215 (24.0) 1764 (9.6) <0.001 573 (15.2) 667 (4.9) <0.001
Severe mental illness 216 (4.3) 79 (0.4) <0.001 78 (2.1) 40 (0.3) <0.001
Developmental disorder 119 (2.4) 16 (0.1) <0.001 12 (0.3) 6 (0.0) <0.001
Attention deficit hyperactivity disorder 61 (1.2) 15 (0.1) <0.001 39 (1.0) 18 (0.1) <0.001
Eating disorder 45 (0.9) 45 (0.2) <0.001 6 (0.2) <5 (0.0) 0.010
Autism spectrum disorder 18 (0.4) 7 (0.0) <0.001 9 (0.2) 7 (0.1) 0.002
Conduct disorder 8 (0.2) <5 (0.0) <0.001 6 (0.2) <5 (0.0) 0.001
Substance use
Any substance use 1042 (20.6) 214 (1.2) <0.001 665 (17.7) 313 (2.3) <0.001
Substance use: drugs 801 (15.8) 134 (0.7) <0.001 489 (13.0) 186 (1.4) <0.001
Substance use: alcohol 434 (8.6) 101 (0.5) <0.001 309 (8.2) 160 (1.2) <0.001
Table 2: Numbers and proportions of individuals with hospital admissions or GP records indicating mental health conditions or substance use disorders for two years prior to court proceedings. *p-values indicate differences between cohort and comparison groups by parent type.

Substance use was recorded for around one in five parents. Parents in the cohort were around 14 and 10 times more likely to have drug and alcohol related substance use conditions recorded respectively.

Injuries

The cohort group had increased levels of accident and emergency attendances for overall injury and all injury sub-categories (Table 3). Accident-related injuries were 1.5 times more likely in the cohort. Cohort mothers were nearly 10 times more likely to have an assault related attendance; cohort fathers were 5 times as likely. Cohort mothers and fathers were 14 and 10 times more likely respectively to have an attendance for self-harm than the comparison group.

Variable Mothers, n (%) Fathers, n (%)
Cohort Comparison p-value Cohort Comparison p-value
Any injury 2124 (42.0) 3969 (21.6) <0.001 1538 (40.9) 3585 (26.3) <0.001
Accident 1391 (27.5) 3206 (17.5) <0.001 1141 (30.4) 2987 (21.9) <0.001
Assault 439 (8.7) 163 (0.9) <0.001 254 (6.8) 176 (1.3) <0.001
Self-harm 313 (6.2) 83 (0.5) <0.001 191 (5.1) 66 (0.5) <0.001
Table 3: Numbers and proportions of individuals with injury-related emergency department attendances for two years prior to court proceedings. *p-values indicate differences between cohort and comparison groups by parent type.

Discussion

Summary of main findings

The most pronounced difference between the cohort parents and the comparison group was found in emergency type health services. Differences between the study groups were particularly pronounced with regards the use of services for mental health need, substance use and injuries/injury and poisoning. Although overall healthcare use across healthcare settings was higher for mothers in the study cohort than fathers, the differences between the cohort parents and the comparison groups were similar. Common mental health conditions were around three times more likely in cohort parents. Although overall only a small proportion of parents had severe mental illness diagnoses (under 5%), the levels were far greater for cohort parents, than comparison parents (9 times higher). It is evident that for a proportion of parents, vulnerabilities include both mental health need and problems of substance use. The elevated level of assault or self-harm for the cohort parents is also notable, with a stark difference between parents involved in care proceedings and our comparison group.

Study strengths and limitations

To our knowledge, this is the first study to examine parental vulnerabilities of both mothers and fathers involved in care proceedings in the UK, and as such allows comparisons between parent type within the cohort, but also against a comparison group of parents matched on age and deprivation. This paper builds on previous work by the same lead authors of the Family Justice Data Partnership [23] first published as a descriptive funder report [24]. For this publication we have added further academic rigour through addition of statistical testing for all health care use outcomes.

Better understanding of the needs and vulnerabilities of these parents may provide opportunities to improve a range of support and preventative intervention for these families. This work covers wide range of measures, providing a broad picture of health service use and underlying conditions, and by linking health and family justice data at population level for fathers, builds on the evidence base [25, 26] for this group as well - a group often excluded from such research and policy work [27, 28].

Studies based on administrative data are necessarily limited by the scope and quality of available data and are collected primarily for non-research purposes. Specific strengths and limitations of Cafcass Cymru data are reported elsewhere [15, 16]. Cohort parents had more children aged under 1 year at the index date compared to comparisons, which may have influenced levels of healthcare use for mothers – for example, for pre- and post-natal appointments. The earliest application date within the study period for each parent was also used, as a proxy measure to represent the first occurrence within care proceedings. We recommend future work aims to account for any bias resulting from recurrent care proceedings [29].

The SAIL Databank contains data from around 80% of general practitioner (GP) practices in Wales; as such, data for GP-based measures was available for the majority, but not all individuals; GP measures were not adjusted for the reduced coverage, which we recognise is a study limitation.

We compared cohort findings against a matched comparison group (using age, deprivation, sex, and parent-type); this study design choice was made to allow more meaningful comparisons to be drawn between study groups. Factors such as deprivation are known to adversely affect health outcomes [30, 31] and as we matched on deprivation readers should be aware that results are likely to underestimate effects in comparison to the general population. As our comparison group selection method used category matching using age bands this resulted in imbalances in ages between groups as noted in Table 1; this choice was made to increase the size of the comparison group, however, further studies should consider matching on more closely aligned ages.

It should be noted that match rates in the cohort were 82% (Figure 1), whilst this is in line with previous work [16] we have no further information to understand if there are differences between the matched and non-matched parents. It could be hypothesised that the non-matched parents are more vulnerable and as such could result in under reporting of heath care use. It would be worthwhile for agencies such as Cafcass Cymru to aim to improve data quality to improve future match rates and research design.

Comparison of research findings with previous literature

Uniquely, this study examined both mothers and fathers interaction with healthcare services prior to court proceedings. However, there is an important body of related international research on the mental health needs and co-morbid substance use, for parents involved with child welfare services [3237], and children in care [3840]. Although the research we report is specific to parents who are involved in formal family court proceedings, our findings are consistent with the broader published research in reporting elevated rates of mental health need often co-occurring with substance use. Notable in the published literature, is the work of Wall-Wiehler and colleagues in Canada (2017) who reported elevated rates of mental health diagnoses, treatment use and social factors for mothers, both 2 years prior to and 2 years after children were taken into care. In adding to the extant knowledge, the findings we report draw fathers clearly into view, a group whose needs are often marginal to discussions about the family justice system [41].

By differentiating health service utilisation, we have also uncovered the higher use of accident and emergency health services among parents with problems of mental health and substance use in this particular population [42, 43]. A key finding in the international literature is that parents with problems of mental health and substance use are more likely to require emergency healthcare on account of accidents, injury, or self-harm, or because they have not sought help with health conditions at a timely point from primary care providers. However, this is the first-time emergency health care use has been evidenced for mothers and fathers in care proceedings. Looking ahead it will be important to understand causal factors implicated in elevated use of high-cost emergency health care. Drawing on the broader literature, a range of explanations have been proffered, which include that same-day GP appointments can be difficult to obtain [44], that there are significant waiting lists for mental health and drug and alcohol services, and that these gaps in provision result in parents’ turning to emergency healthcare [45]. The same can be said, where community-based crisis services are unavailable [46]. Further research to probe reasons behind high rates of emergency care use are important, given problems of access to health care have been exacerbated by the COVID-19 pandemic [47].

Recommendations for policy and practice

The findings presented highlight the elevated health needs of both mothers and fathers prior to involvement in care proceedings in Wales. Higher levels of mental health needs, substance use and injury related conditions, compared to a comparison group are particularly noteworthy. The study suggests considerable healthcare costs for parents involved in public law care proceedings, however, this would require further substantiation through separate analysis of health and social care utilisation over a longer period. High use of emergency healthcare services strongly suggests the potential failure in provision of—or access to—support services at an earlier point to prevent or manage crisis. Elevated rates of self-harm are very concerning, for example. Given pressures on emergency healthcare provision, the evidence is that emergency departments are unable to offer treatment over and above attending to immediate physical healthcare needs [48]. However, this work indicates that proactively connecting parents with relevant support services, such as for mental health, is an important factor for those providing emergency healthcare services, which may help reduce demand in the longer term. This point is not new, and there is substantial literature that calls for better management of patient journeys through healthcare services, and far greater integration of health and social care provision (both within child and adult social services). This conclusion, which calls for improved and more tailored mental health care provision [49] is particularly relevant for parents in care proceedings, where services need to be attuned to parents histories of adversity and trauma [50].

Further work

International literature suggests such vulnerable populations experience higher rates of repeat emergency hospital use; a hypothesis that warrants testing through further research, as a particular service response is required in relation to frequent users of emergency services [51, 52].

Further work is required to provide more detailed findings to understand how healthcare use varies depending on a multitude of factors including: protected characteristics (for example, race, age, sex) and heritage; household-based factors (for example, age and number of children, family structure, parental relationship and presence of domestic violence); and factors related to family court (for example, type of court order). In the context of established awareness of the relationship between inequality and health need [30] it is critical that parents in care proceedings are not simply treated as a simple homogenous group. For example, future research should consider the intersectionality of characteristics such as gender or race with healthcare needs [53, 54].

In this work we concentrated on the period preceding care proceedings. Significant life events, such as having a child removed, can lead to immediate psychosocial crisis prompting a deterioration in health conditions, especially mental health-related issues including suicidal ideation, along with worsened socioeconomic conditions [55]. It is therefore important to also consider further work to understand health conditions, and patterns of healthcare use over the lifetime of involvement in care proceedings and beyond. This may indicate periods of highest health service demand and highlight when services are most required to support parents and families.

Such work should also consider other significant life events, such as incarceration. Linkage of datasets from across the justice system via the Data First programme [56] will provide future ability to investigate levels of incarceration for this population using SAIL.

Finally, the potential multiple and long-term effects of such experiences for the children and young people involved in the family justice system should be examined. This may further enforce the need for increased advocacy services within health and social care to support vulnerable children and families as laid out in the Well-being of Future Generations (Wales) Act (2015), and the Welsh Government Programme for Government [57].

Conclusion

Both mothers and fathers in care proceedings in Wales experienced greater levels of health vulnerabilities during the two-year period prior to court proceedings compared to a comparison group of parents matched on deprivation, sex, and age. The higher use of emergency healthcare is particularly noteworthy and indicates considerable crisis health need among parents. Elevated mental health, substance use, and injury-related conditions are coupled with higher use of emergency services. Better understanding of the needs and vulnerabilities of this population, including the reasons why parents are making greater use of emergency healthcare may provide opportunities to improve a range of support and preventative interventions that respond to crises in the community.

Acknowledgements

Authors are part of the Family Justice Data Partnership (FJDP) - a collaboration between Swansea University and Lancaster University, and Professor Ann John leads the Adolescent Mental Health Data Platform.

The authors would like to acknowledge all the data providers who make data available for research; as well as the following for their support with this project: Lisa Harker, Director, Nuffield Family Justice Observatory; Matthew Pinnell, Deputy Chief Executive, Cafcass Cymru; Saif Ullah, Senior Research and Evaluation Manager, Cafcass; ADR Wales (Administrative Data Research Wales); and Welsh Government.

Statement on conflicts of interest

None to declare.

Funding

Nuffield Family Justice Observatory (Nuffield FJO) aims to support the best possible decisions for children by improving the use of data and research evidence in the family justice system in England and Wales. Covering both public and private law, Nuffield FJO provides accessible analysis and research for professionals working in the family courts.

Nuffield FJO was established by the Nuffield Foundation, an independent charitable trust with a mission to advance social well-being. The Foundation funds research that informs social policy, primarily in education, welfare, and justice. It also funds student programmes for young people to develop skills and confidence in quantitative and scientific methods. The Nuffield Foundation is the founder and co-funder of the Ada Lovelace Institute and the Nuffield Council on Bioethics.

Nuffield FJO has funded this project (FJO/43766), but the views expressed are those of the authors and not necessarily those of Nuffield FJO or the Foundation.

Authors’ contributions

RDJ and LJG contributed to the conception. RDJ designed and performed the analysis, with RDJ and LJG interpreting the results. RDJ, LJG, LN and KB drafted the first iteration of the manuscript. All authors critically reviewed the manuscript, provided important intellectual input, approved the final version and agreed to be accountable for their contributions. KB and DF acquired the study funding.

Ethics statement

The project proposal was reviewed by an independent Information Governance Review Panel (IGRP) at Swansea University. This panel ensures that work complies with information governance principles and represents an appropriate use of data in the public interest. The IGRP includes representatives of professional and regulatory bodies, data providers and the general public. Approval for the project was granted by the IGRP under SAIL project 0990. Cafcass Cymru (the data owner of the family courts data) also approved use of the data for this project. The agency considered the public interest value of the study, benefits to the agency itself, as well as general standards for safe use of administrative data.

Abbreviations

GP: General practice
ICD: International Classification of Diseases
SAIL: Secure Anonymised Information Linkage
TRE: Trusted Research Environment

References

  1. Alrouh B, Broadhurst K, Cusworth L, Griffiths L, Johnson RD, Akbari A, et al. Born into care: newborns and infants in care proceedings in Wales [Internet]. 2019. Available from: www.nuffieldfjo.org

  2. Griffiths LJ, Johnson RD, Broadhurst K, Bedston S, Cusworth L, Alrouh B, et al. Born into care: one thousand mothers in care proceedings in Wales [Internet]. 2020. Available from: https://www.nuffieldfjo.org.uk/app/nuffield/files-module/local/documents/1000_mothers_report_english.pdf

  3. Griffiths LJ, Johnson RD, Broadhurst K, Bedston S, Cusworth L, Alrouh B, et al. Maternal health, pregnancy and birth outcomes for women involved in care proceedings in Wales: a linked data study. BMC Pregnancy Childbirth. 2020;20(1).

  4. Griffiths LJ, Johnson RD, Broadhurst K, John A. Born into care: One thousand mothers in care proceedings in Wales, A focus on maternal mental health |Nuffield Family Justice Observatory. 2021.

  5. Cox P, McPherson S, Mason C, Ryan M, Baxter V. Reducing recurrent care proceedings: Building a local evidence base in England. Societies. 2020;10(4).

  6. McCracken K, Priest S, FitzSimons A, Bracewell K, Torchia K, Parry W, et al. Evaluation of Pause [Internet]. 2017. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/625374/Evaluation_of_Pause.pdf

  7. Brandon M. Child fatality or serious injury through maltreatment: Making sense of outcomes. Child Youth Serv Rev. 2009;31(10).

  8. Hood R, Goldacre A, Gorin S, Bywaters P, Webb C. Identifying and understanding the link between system conditions and welfare inequalities in children’s social care services [Internet]. 2020. Available from: www.nuffieldfoundation.org

  9. Skinner GCM, Bywaters PWB, Bilson A, Duschinsky R, Clements K, Hutchinson D. The ‘toxic trio’ (domestic violence, substance misuse and mental ill-health): How good is the evidence base? Child Youth Serv Rev. 2021;120.

  10. Lyons RA, Jones KH, John G, Brooks CJ, Verplancke JP, Ford D V., et al. The SAIL databank: Linking multiple health and social care datasets. BMC Med Inform Decis Mak. 2009;9(1).

  11. Ford D V., Jones KH, Verplancke JP, Lyons RA, John G, Brown G, et al. The SAIL Databank: Building a national architecture for e-health research and evaluation. BMC Health Serv Res. 2009;9.

  12. Jones KH, Ford D V., Thompson S, Lyons RA. A profile of the SAIL databank on the UK secure research platform. Int J Popul Data Sci. 2019;4(2).

  13. Rodgers SE, Lyons RA, Dsilva R, Jones KH, Brooks CJ, Ford D V., et al. Residential Anonymous Linking Fields (RALFs): A novel information infrastructure to study the interaction between the environment and individuals’ health. J Public Health (Bangkok). 2009;31(4).

  14. Johnson RD, Griffiths LJ. What is the household composition of families in the family justice system? Linking data to fill the evidence gaps - Guidance Note. Guidance Note. 2021.

  15. International Journal of Population Data Science. 2020.
  16. Johnson RD, Ford D V., Broadhurst K, Cusworth L, Jones KH, Akbari A, et al. Data Resource: Population level family justice administrative data with opportunities for data linkage. Int J Popul Data Sci. 2020;5(1).

  17. Johnson RD, Griffiths LJ, Hollinghurst JP, Akbari A, Lee A, Thompson DA, et al. Deriving household composition using population-scale electronic health record data-A reproducible methodology. PLoS One. 2021 Mar 1;16(3 March).

  18. WHO. ICDC-10 International Statistical Classification of Diseases and Related Health Problems. World Heal Organ. 2004;2(2).

  19. The Platform - Adolescent Mental Health Data Platform [Internet]. Available from: https://adolescentmentalhealth.uk/Platform

  20. Rees S, Watkins A, Keauffling J, John A. Incidence, Mortality and Survival in Young People with Co-Occurring Mental Disorders and Substance Use: A Retrospective Linked Routine Data Study in Wales. Clin Epidemiol. 2022;Volume 14(January):21–38.

  21. NHS Wales Data Dictionary [Internet]. Available from: http://www.datadictionary.wales.nhs.uk/#!WordDocuments/attendancegroup.htm

  22. Vienna, Austria; 2021.
  23. Nuffield Family Justice Observatory. Improving intelligence for the family justice system Improving intelligence for the family justice system-A Nuffield Family Justice Observatory Data Partnership (NFJO DP) [Internet]. 2019. Available from: https://www.nuffieldfjo.org.uk/wp-content/uploads/2021/05/NFJO-DP-Summary-Document.pdf

  24. Johnson RD, Alrouh B, Broadhurst K, Ford D, John A, Jones K, et al. Health vulnerabilities of parents in care proceedings in Wales [Internet]. 2021. Available from: https://www.nuffieldfjo.org.uk/wp-content/uploads/2021/07/health-vulnerabilities-of-parents-in-care-proceedings-in-wales-report-0721.pdf

  25. Bedston S, Philip G, Youansamouth L, Clifton J, Broadhurst K, Brandon M, et al. Linked lives: Gender, family relations and recurrent care proceedings in England. Child Youth Serv Rev. 2019;105.

  26. Philip G, Youansamouth L, Bedston S, Broadhurst K, Hu Y, Clifton J, et al. “I Had No Hope, I Had No Help at All”: Insights from a First Study of Fathers and Recurrent Care Proceedings. Societies. 2020;10(4).

  27. Brown L, Callahan M, Strega S, Walmsley C, Dominelli L. Manufacturing ghost fathers: The paradox of father presence and absence in child welfare. Child Fam Soc Work. 2009;14(1).

  28. Critchley A. Giving up the ghost: Findings on fathers and social work from a study of pre-birth child protection. Qual Soc Work. 2021;

  29. Alrouh B, Broadhurst K, Cusworth L. Women in recurrent care proceedings in Wales: a first benchmarking report. 2020.

  30. Marmot M, Allen J, Boyce T, Goldblatt P, Morrison J. Health Equity in England: The Marmot Review 10 Years On.

  31. Davies JM, Sleeman KE, Leniz J, Wilson R, Higginson IJ, Verne J, et al. Socioeconomic position and use of healthcare in the last year of life: A systematic review and meta-analysis. PLoS Med. 2019;16(4).

  32. Erickson SJ, Tonigan JS. Trauma and intraveneous drug use among pregnant alcohol/other drug abusing women: Factors in predicting child abuse potential. Alcohol Treat Q. 2008;26(3).

  33. O’Donnell M, Maclean MJ, Sims S, Morgan VA, Leonard H, Stanley FJ. Maternal mental health and risk of child protection involvement: Mental health diagnoses associated with increased risk. J Epidemiol Community Health. 2015;69(12).

  34. Hammond I, Eastman AL, Leventhal JM, Putnam-Hornstein E. Maternal mental health disorders and reports to child protective services: A birth cohort study. Int J Environ Res Public Health. 2017;14(11).

  35. Green MJ, Kariuki M, Chilvers M, Butler M, Katz I, Burke S, et al. Inter-agency indicators of out-of-home-care placement by age 13–14 years: A population record linkage study. Child Abus Negl. 2019;93.

  36. Ammerman RT, Scheiber FA, Peugh JL, Messer EP, Van Ginkel JB, Putnam FW. Interpersonal trauma and suicide attempts in low-income depressed mothers in home visiting. Child Abus Negl. 2019;97.

  37. Suomi A, Bolton A, Pasalich D. The Prevalence of Post-Traumatic Stress Disorder in Birth Parents in Child Protection Services: Systematic Review and Meta-analysis. Trauma, Violence, and Abuse. 2021.

  38. Canfield M, Radcliffe P, Marlow S, Boreham M, Gilchrist G. Maternal substance use and child protection: a rapid evidence assessment of factors associated with loss of child care. Vol. 70, Child Abuse and Neglect. 2017.

  39. Wall-Wieler E, Roos LL, Brownell M, Nickel NC, Chateau D. Predictors of having a first child taken into care at birth: A population-based retrospective cohort study. Child Abus Negl. 2018;76.

  40. Wall-Wieler E, Roos LL, Bolton J, Brownell M, Nickel N, Chateau D. Maternal Mental Health after Custody Loss and Death of a Child: A Retrospective Cohort Study Using Linkable Administrative Data. Can J Psychiatry. 2018;63(5).

  41. Philip G, Bedston S, Hu Y, Youansamouth L, Clifton J, Broadhurst K, et al. Building a Picture of Fathers in Family Justice in England. Nuff Found. 2018;(November).

  42. Byrne M, Murphy AW, Plunkett PK, McGee HM, Murray A, Bury G. Frequent attenders to an emergency department: A study of primary health care use, medical profile, and psychosocial characteristics. Ann Emerg Med. 2003;41(3).

  43. Kim JJ, Kwok ESH, Cook OG, Calder LA. Characterizing highly frequent users of a large Canadian urban emergency department. West J Emerg Med. 2018;19(6).

  44. Welsh Government. GP Access in Wales, 2019 [Internet]. 2020. Available from: https://gov.wales/sites/default/files/statistics-and-research/2020-03/gp-access-2019.pdf

  45. Royal College of Psychiatrists. Two-fifths of patients waiting for mental health treatment forced to resort to emergency or crisis services [Internet]. 2020. Available from: https://www.rcpsych.ac.uk/news-and-features/latest-news/detail/2020/10/06/two-fifths-of-patients-waiting-for-mental-health-treatment-forced-to-resort-to-emergency-or-crisis-services

  46. Care Quality Commission. Assessment of mental health services in acute trusts programme: How are people’s mental health needs met in acute hospitals, and how can this be improved? 2020.

  47. Molodynski A, McLellan A, Craig T, Bhugra D. What does COVID mean for UK mental health care? International Journal of Social Psychiatry. 2020.

  48. ECIST, UEC Review Team. Transforming urgent and emergency care services in England. 2015;1–57. Available from: https://www.england.nhs.uk/wp-content/uploads/2015/06/trans-uec.pdf

  49. NHS England. Crisis and acute mental health services [Internet]. 2020. Available from: https://www.england.nhs.uk/mental-health/adults/crisis-and-acute-care/

  50. Mason C, Taggart D, Broadhurst K. Parental Non-Engagement within Child Protection Services—How Can Understandings of Complex Trauma and Epistemic Trust Help? Societies. 2020;10(4).

  51. Soril LJJ, Leggett LE, Lorenzetti DL, Noseworthy TW, Clement FM. Reducing frequent visits to the emergency department:A systematic review of interventions. Vol. 10, PLoS ONE. 2015.

  52. Laferté C, Dépelteau A, Hudon C. Injuries and frequent use of emergency department services: A systematic review. Vol. 10, BMJ Open. 2020.

  53. Lens V. Judging the Other: The Intersection of Race, Gender, and Class in Family Court. Fam Court Rev. 2019;57(1).

  54. Rice C, Harrison E, Friedman M. Doing Justice to Intersectionality in Research. Cult Stud - Crit Methodol. 2019;19(6):409–20.

  55. Broadhurst K, Mason C. Child removal as the gateway to further adversity: Birth mother accounts of the immediate and enduring collateral consequences of child removal. Qual Soc Work. 2020;19(1).

  56. Ministry of Justice. Guidance. Ministry of Justice: Data First [online], GOV.UK [Internet]. 2020. Available from: https://www.gov.uk/guidance/ministry-of-justice-data-first

  57. Welsh Government. Programme for government [Internet]. 2021. Available from: https://gov.wales/sites/default/files/publications/2021-06/programme-for-government-2021-to-2026.pdf

Article Details

How to Cite
Johnson, R. D., North, L., Alrouh, B., John, A., Jones, K., Akbari, A. ., Smart, J., Thompson, S., Hargreaves, C., Doebler, S. ., Cusworth, L., Broadhurst, K., Ford, D. and Griffiths, L. J. (2022) “A population level study into health vulnerabilities of mothers and fathers involved in public law care proceedings in Wales, UK between 2011 and 2019”, International Journal of Population Data Science, 7(1). doi: 10.23889/ijpds.v7i1.1723.

Most read articles by the same author(s)

<< < 10 11 12 13 14 15 16 17 18 > >>