Early Developmental Effects

The cumulative effect on a child, particularly when less than 5 years of age, of the anticipatory stress and fear of those events reoccurring can be at least distracting and, at the most, debilitating. Osborn and Delfabbro's (Reference Osborn and Delfabbro2006) exploration of the characteristics of children and young people with ‘high support’ needs in out-of-home care found that 91.7% of the Victorian sample required psychological assistance in the past six months due to early childhood traumatic experiences of reoccurring, multiple forms of abuse (Miller, Reference Miller2007).

In the pre-verbal child, cumulatively harmful experiences and traumatic experiences, such as experiencing or witnessing domestic violence or neglect and inconsistent attachments, are stored in a child's pre-verbal memory (Victorian Government, Department of Human Services, 2007). These memories are intense, perceptual experiences and often intrude on awareness later in life, in the form of hyper-vigilance, nightmares and hyper-arousal. Behaviour and feeling is directed by the physiological processes; thus, in hyper-vigilant children, these impacts may manifest themselves in behaviour such as oversensitivity or misinterpreting non-verbal cues, perceiving eye contact as a threat, and interpret any touch as an antecedent to abuse or seduction (Perry, Reference Perry and Wedd2006).

Disruptions to normal brain development in early life may alter later development of other areas of the brain. According to Shonkoff and Phillips (Reference Shonkoff and Phillips2001), researchers investigating brain development have used the term ‘toxic stress’ to describe prolonged activation of stress management systems in the absence of support. If prolonged, such as when a child experiences multiple adverse circumstances or events, stress can disrupt the brain's architecture and stress management systems, leading to hypersensitivity and over activity (Shonkoff & Phillips, Reference Shonkoff and Phillips2001).

Cumulative harm negatively affects the attachment process between parent and child. Trauma is particular devastating when experienced at the hands of an attachment figure as being particularly as it forms a ‘dual liability’ by creating extreme distress and undermining the development of the biological, emotional and behavioural capacities which regulate that distress (Allen, Reference Allen2002). The most devastating impacts exist in worryingly frequent cases, whereby a child experiences both neglect and abuse (Nader, Reference Nader2008). In such cases, the interpersonal trauma, inflicted by someone with attachment to the child, may indeed override any genetic, constitutional, social or psychological resilience (De Bellis et al., Reference De Bellis, Keshaven, Clark, Caseey, Giedd, Boring and Ryan1999).

Long-Term Developmental Outcomes: Adolescence

Ethien et al. (Reference Ethien, Lemelin and Lacharite2004) and Frederico, Jackson and Black (Reference Frederico, Jackson and Black2008) have found that the earlier the abuse and neglect, the more probable behavioural problems will develop in adolescence. Behavioural manifestations include internalising such as withdrawal, sadness, isolation and depression (Ethien et al., Reference Ethien, Lemelin and Lacharite2004) and externalising by way of aggression and hyperactivity (Frederico et al., Reference Frederico, Jackson and Black2008). Mental health problems including depressive and anxiety disorders have constantly been linked with abuse and neglect, particularly in adolescence and major depression is shown to be approximately four times higher in adolescence than in younger children (Lamont, Reference Lamont2010). A longitudinal study by Brown, Cohen, Johnson and Smailes (Reference Brown, Cohen, Johnson and Smailes1999) shows that maltreated adolescents are three times more likely to exhibit depressive disorders than non-maltreated children. There is evidence indicating that neglect may be even more damaging than abuse, highlighting the link between neglect in early childhood and antisocial personality disorders in adolescence and adulthood (Nader, Reference Nader2008). Current research also suggests that abuse and neglect doubles the threat of suicide for young people (Lamont, Reference Lamont2010). Another profound consequence of cumulative harm is the development of Post-Traumatic Stress Disorder.

A significant impact cumulative harm can have on the developing adolescent self, is the transition into adulthood, such as early pregnancy, marriage, educational disengagement or abandoning a peer cohort for an older set of friends, which can lead to risk taking or unsafe behaviours (Lamont, Reference Lamont2010). Clearly, this early transition into adult behaviours and roles can dramatically impact on adolescents as they embark on the next stages of their development, in some cases perpetuating a cycle of abuse and neglect.

Long-Term Developmental Outcomes: Adulthood

The impacts of chronic maltreatment that extend into adulthood are varied and are dependent on several factors, including age, severity, frequency, relationship to perpetrator, type/s of abuse, intervention and preventative actions taken and the protective factors which may have mitigated the effects of maltreatment (Bromfield & Miller, Reference Bromfield and Miller2012). For some adults, the effects of child abuse and neglect are chronic and debilitating, whilst others have more positive outcomes as adults, despite their abuse and neglect histories (Miller-Perrin & Perrin, Reference Miller-Perrin and Perrin2007). McQueen, Itzin, Kennedy, Sinason and Maxted (Reference McQueen, Itzin, Kennedy, Sinason and Maxted2009) assert that the effects of child abuse and neglect can remain largely hidden, only to emerge at key times in later life. Adults with a history of child abuse and neglect are more likely to have physical health problems and chronic pain symptoms (Lamont, Reference Lamont2010). Research indicates that adult survivors of childhood maltreatment have more health problems than the general population, and the more cumulative the adversity, the higher the risk of poor health, including diabetes, gastrointestinal problems, arthritis, headaches, gynaecological problems, stroke, hepatitis and heart disease (Felitti et al., Reference Felitti, Anda, Nordenberg, Williamson, Spitz, Edwards and Koss1998). In a review of recent research, Sachs-Ericsson, Cromer, Hernandez and Kendall-Tackett (Reference Sachs-Ericsson, Cromer, Hernandez and Kendall-Tackett2009) found that a majority of studies showed that adult survivors of prolonged childhood abuse had more medical problems than their non-abused counterparts. Some researchers suggest that poor health outcomes in adult survivors of chronic child abuse and neglect could be due to the impact early life stress has on the immune system or to the greater propensity for adult survivors to engage in high-risk behaviours, including smoking, alcohol abuse and risky sexual behaviour (Sachs-Ericsson et al., Reference Sachs-Ericsson, Cromer, Hernandez and Kendall-Tackett2009). In a longitudinal study in the United States, Widom, DuMont and Czaja (Reference Widom, DuMont and Czaja2007) found that children who were physically abused or experienced multiple types of abuse were at increased risk of lifetime major depressive disorder in early adulthood. Higher rates of suicidal behaviour in adult survivors of child abuse and neglect, has also been attributed to the greater likelihood of adult survivors suffering from mental health problems (Lamont, Reference Lamont2010).

Findings gleaned from a comprehensive study conducted in North America, identifies the overall significance of chronicity of maltreatment and its impact as compared with maltreatment type. The Adverse Childhood Experiences (ACE) study, conducted by Felitti et al. (Reference Felitti, Anda, Nordenberg, Williamson, Spitz, Edwards and Koss1998) analyses the lifetime health records of 17,000 participants with a view to identifying if they had experienced certain nominated adverse experiences as children. The range of adverse experiences included drug and alcohol use by parents, physical, sexual, emotional abuse, parental mental health issues, exposure to domestic violence and parental incarceration. These experiences were allocated a score depending on the severity and frequency of their occurrence during childhood for each participant. The findings concluded that there were significant correlations between ACE and medical, psychological and behavioural issues later in life (Felitti et al., Reference Felitti, Anda, Nordenberg, Williamson, Spitz, Edwards and Koss1998). The findings indicated one in six participants had experienced multiple (more than four) ACEs.

Evidently, the relationship between chronic childhood maltreatment and adverse outcomes in adulthood is vast and significant. Nader states that ‘a large percentage of adults who are troubled and dangerous, have histories of traumatic experiences from childhood’ (2008, p.x). Evidence clearly asserts that experiencing chronic and multiple forms of maltreatment can increase the risk of more severe and damaging adverse consequences in adulthood.

Australian Approaches: States and Territories

In order to critically evaluate existing approaches to cumulative harm in the child protection context, one must first examine the means by which national child protection services acknowledge this maltreatment type. Cumulative harm is a relatively new component of Child Protection practice and is currently being considered in risk assessments and decision-making to varying degrees and in different ways across the service, nationwide. Bromfield and Miller (Reference Bromfield and Miller2012) identify the current Child Protection context as oriented toward ‘aetiology’, with a focus on causation and risk. Bromfield and Higgins (Reference Bromfield and Higgins2005) also highlight the current focus for national child protection practice as centring on consequences and the impact of an isolated event. However, it is clear across all states that case history and repeated notifications and reports are considered in identifying patterns of behaviour and maltreatment in order to assess likelihood of future harm.

The term ‘cumulative harm’ was first introduced into the Queensland Child Protection Act (1999) as recently as 2011. However, it does not feature at all in the Queensland Child Protection Practice Manual, except so far as to advise that cumulative harm should be considered in assessments and decision-making. In 2012, the Queensland Child Protection Commission of Inquiry was formed in order establish new reforms for the child protection system in the future, in response to system failures which had been identified to date. A review of the 1999 Commission of Inquiry into abuse of Children in Queensland and the 2004 Crime and Misconduct Commission of Inquiry Protecting Children: An inquiry into the abuse of children in foster care were undertaken to inform recommendations. In findings handed down at the completion of the Inquiry, only two mentions are made in reference to cumulative harm.

Queensland Police Service put forward opinion that every incident of domestic and family violence needs to be ‘recorded and considered in the context of cumulative harm’ so as to achieve an ‘intelligence-driven child protection system’ (Queensland Child Protection Commission of Inquiry, 2013, p.88). Further, it was argued that child safety services were not utilising this ‘intelligence’ due to over-reporting by agencies (Queensland Child Protection Commission of Inquiry, 2013, p.88). This finding has led to the recommendation (4.2 and 4.3) that mandatory reporting policies by Queensland Police be adjusted to mandate, only the reporting of domestic violence incidents in which the child has been physically harmed, not merely present or within ‘hearing and viewing range’ as has been previously stipulated. This could easily be considered a regression by agencies in the acknowledgement and management of cumulative harm and is in direct contradiction of the research which emphasises the cumulative impact of mere exposure to domestic and family violence and the impact on development and life trajectory. It is important to acknowledge that external agencies, such as police, will adopt their own policies based on their internal processes and practices. Arguably, child protection practitioners require information of ongoing exposure to adverse experiences and maltreatment so as to build a holistic image of the child's circumstances in order to address the cumulative impact appropriately.

The second reference to cumulative harm in the Inquiry was submitted by Mission Australia who stated ‘While individually, these factors represent a significant risk to children, they rarely occur in isolation and the cumulative harm has a profound and exponential impact on children, and diminishes their sense of safety and wellbeing’ (Queensland Child Protection Commission of Inquiry, 2013, p.152). The recommendation in response to this submission centred on the development of a more integrated and collaborative interagency response to complex need of vulnerable families. Whilst cumulative harm was mentioned in the submissions by external stakeholders in the Inquiry, the response has been underwhelming. The Queensland Government Response to the Queensland Child Protection Commission of Inquiry Final Report (2013) makes no specific mention whatsoever as to the importance of cumulative harm, nor the related gaps in service delivery. Recommendations are made with ‘complex and vulnerable’ families in mind, emphasising the importance of a collaborative and integrated response to complex need, which may have a secondary influence of the assessment and management of cumulative harm.

Further compounding the concerning lack of reference to or acknowledgment of cumulative harm in new reforms for practice and legislation, is the recent Findings of Inquest, delivered by the Office of the State Coroner in Brisbane, Queensland in October 2015. This inquest into the death of a 13-year old female makes condemning assessment of the lack of consideration for the impact of cumulative harm. The Systems and Practice Review Report identified that the analysis of the concerns received ‘did not sufficiently consider the impact of cumulative harm’ (Queensland Office of the State Coroner, Reference Ryan2015, p.14). The Child Death Case Review Committee concluded in this coronial report that systemic action and inaction were linked to the child's death, reporting that ‘The Committee suggests that the Department's inadequate assessment of cumulative harm and an unwavering commitment to the reunification of the child to her family was detrimental to the child's long term stability and her emotional well-being’ (Queensland Office of the State Coroner, Reference Ryan2015, p.22). The finding of such a recent coronial inquest, providing powerful evidence of the lack of necessary acknowledgement, assessment and intervention in relation to cumulative harm, provides a concerning overview of the deficiencies in current Queensland child protection service delivery.

In contrast, however, the recent amendments to policy in Victoria appear to be more progressive and encompassing in term of cumulative harm. The Victorian Children, Youth & Families Act (2005) Section 10 includes a description of the best interests of the child including ‘the effects of cumulative patterns of harm on a child's safety and development’. Further to this, Section 62(2) includes that, ‘harm may be constituted by a single act, omission or circumstance or accumulate through a series of continuing acts, omissions or circumstances’ (2005). Broadley argues, however, that whilst changes were introduced, they were ‘superficial; ultimately, the grounds for statutory intervention did not change’ (Reference Broadley2014, p.276). Broadley (Reference Broadley2014) further asserts that grounds for statutory intervention remain consistent between the 1989 Victorian Children, Youth & Families Act and the 2005 Victorian Children, Youth & Families Act. According to Broadley (Reference Broadley2014), both legislations indicate that ‘if a child requires protection due to chronic maltreatment through cumulative harm, the application for intervention presented in a court of law must still be proven under grounds of physical, sexual, emotional abuse or physical neglect’ (p.271). Broadley (Reference Broadley2014) summarises the deficits in Victorian child protection practice in this field as being directly related to the need for negative child outcomes to be directly linked to adult actions. This focus perpetuates the idea that maltreatment is episodic, rather than cumulative and denies the intense likelihood that the impact of exposure to chronic maltreatment may not be visible at the time of the exposure, rather it will present over time. Broadley (Reference Broadley2014) emphasises the impact this perspective has on the ability of practitioners to intervene in matters of cumulative harm.

The Wood Special Commission of Inquiry into Child Protection Services (Reference Wood2008) 6.2(c) proposed that New South Wales child protection legislation should be amended to include a provision acknowledging cumulative impact in its definition of ‘harm’, identical to that in the Victorian Children, Youth and Families Act (2005). Comparatively, in a Final Report delivered in the Parliament of Tasmania in 2010 (O'Halloran, Reference O'Halloran2011), the Select Committee of Child Protection identified a number of weaknesses in addressing cumulative harm as a dominant maltreatment type.

O'Halloran and colleagues (Reference O'Halloran2011) highlighted a comparison between Victorian practices and the current Tasmanian legislation, asserting that, unlike the Victorian Children, Youth and Families Act 2005, the Tasmanian Children, Young Persons and their Families Act 1997 does not expressly consider the effects of cumulative patterns of harm on a child's safety and development. In the final report by O'Halloran (Reference O'Halloran2011), Tucci, the CEO of the Australian Childhood Foundation called attention to the crisis-driven response to child protection. Tucci (cited in O'Halloran, Reference O'Halloran2011) highlighted the lack of legislative requirements that exist to evaluate quantity of re-reporting and re-notifications for a child or the cumulative impact of chronic and pervasive maltreatment. O'Halloran et al. (Reference O'Halloran2011) further emphasised the prominence of episodic intervention, stressing the contribution made by this approach to patterns of reporting and re-reporting that result in minimal positive outcomes and leads to short-term decision making. Subsequently, following the findings presented in the report, several recommendations were made arguing that Tasmania Child Protection should adopt a longer term view of repeated referral and repeated notifications of child abuse. The Committee further recommended that ‘Legislation be amended to change the focus on episodic interventions to cumulative harm and new provisions introduced to enable child protection services to intervene with children who, over the long-term, have experienced cumulative trauma and harm’ (O'Halloran, Reference O'Halloran2011, p.191). A policy addressing cumulative harm based on the aforementioned recommendation was implemented and continued discussion occurs in relation to service delivery and policy review (Bromfield & Holzer, Reference Bromfield and Holzer2008).

In comparable legislation in the Australian Capital Territory and South Australia, measures have been taken to promote better record keeping and analysis of family history, necessary for an assessment of cumulative harm and professional development has been encouraged in relation to this maltreatment type since 2009 (Bromfield & Holzer, Reference Bromfield and Holzer2008). In fact, South Australia is in the process of making valuable adjustments to their legislation to account more accurately for cumulative harm.

Much adjustment has been made in relation to cumulative harm, clearly stemming from the Victoria model of practice. A document produced by the Department of Human Services Victoria (2010) outlining cumulative harm in terms of definition and implication for practice appears to inform nationwide reviews of cumulative harm legislation and policy since 2010.

In the Western Australian Policy on Neglect (2012), cumulative harm is adequately identified and acknowledged similarly to both NSW and Victorian legislation (2012, Section 28 (2)). The Policy on Neglect, ‘states the ongoing effects of neglect are harmful and can cause cumulative and long-term harm to a child's development, particularly in circumstances of chronic neglect and where neglect exists with other forms of abuse’ (2010, p.1). Furthermore, comprehensive assessment is employed when families present to child protection services on two or more occasions, highlighting potential patterns of maltreatment, regardless of type, as a priority. In comparison to Western Australian practice, and also informed by Victorian models of child protection practice, the Northern Territory has deemed assessment is required should three child protection reports be received without investigation, within a 12-month period, demonstrating an acknowledgement of cumulative impact of patterned maltreatment (Bromfield & Higgins, Reference Bromfield and Higgins2005).

In the present state by state evaluation of national child protection responses to cumulative harm, an evolutionary process is evident. There have been clear advances taking place in both the acknowledgement of, and the proactive approaches to, cumulative harm with clear parallels being drawn between Victorian models of practice and other state responses. The Victorian Government's response to cumulative harm, based on rigorous research since 2005, reviews by the Victorian Child Death Committee (Frederico, Jackson, & Jones, Reference Frederico, Jackson and Jones2006) and continual revisions to legislation, illustrates its position as leaders in the national approach to cumulative harm policy and procedure. Its role in informing practices adopted by all other states and the prevalence of Victorian research utilised in national governmental documentation addressing cumulative harm, further demonstrates its leadership in this field. In contrast to the progressions evident in Victorian practice and the Victorian Governments engagement in continual research and development, other Australian states appear to be comparable in relation to their systematic approach. All Australian state governments appear to have employed amendments to their child protection policies, at least, acknowledging a cumulative impact in the definition of harm and at best, altering practices to adequately address patterns of maltreatment events, regardless of type. There is an apparent shift away from episodic assessment towards what Bromfield & Higgins (Reference Bromfield and Higgins2005) identifies as ‘child maltreatment typology’, addressing harm in greater detail and acknowledging the importance of frequency, type, severity, source of harm (perpetrator) and duration. The acknowledgement of the combination of acts of commission, omission and circumstances as cited in the various Acts informing child protection practice (Child Protection Act 1999 (QLD); Care and Protection of Children Act 2007 (NT); Children, Youth and Families Act 2005 (VIC)) draws attention to the pattern and history of the child's experience, which may have a significant and harmful impact on their development. Specifying acts of ‘omission’, which may have been considered as low risk if considered episodically, enables a more holistic assessment of the child's lived experience.

Since the original study in 2007 (Bromfield, Gillingham, & Higgins, Reference Bromfield, Gillingham and Higgins2007), there appears to have been no significant research studies published which further investigate the concept of cumulative harm. Some publications have examined the issues related to cumulative harm at a practice level in the human services and welfare sector. Howard Bath (Reference Bath2014), Children's Commissioner for the Norther Territory, highlighted that although discussion regarding cumulative harm in child protection literature has been present for some time, there has been a dearth of specific research relating to the impact of multi-type abuse or the prevalence of chronic maltreatment leading to cumulative harm. Bath (Reference Bath2014) drew on the Australian Early Development Index (AEDI) which provides a census of population-based wellbeing indicators, undertaken by educators in a child first year of school. He argued that ‘the problematic AEDI scores for Indigenous children across Australia, and especially in the Northern Territory, provide a clear illustration of the impact of adverse experiences in early childhood and, by proxy, the phenomenon of cumulative harm’ (2014, p.6). Bath (Reference Bath2014) emphasised that despite the lack of studies specifically exploring cumulative harm, there was no lack of evidence for the phenomenon, drawing on statutory legislation as an indicative example. He purported that, by definition, child protection legislation recognises cumulative harm in that it empathises the need for neglect to be persistent and a child's basic needs repeatedly unmet (Bath, Reference Bath2014). Further to this, Bath (Reference Bath2014) highlight the presence of cumulative harm as an operational definition of maltreatment, present in child protection Acts Australia Wide.

International Approaches: Comparisons with Australia

Cumulative harm is largely an Australian term, with international research using the more global terminology of complex trauma, to encapsulate the lifespan implications of the accumulation of childhood adversity. However, the terms cumulative harm, cumulative abuse, cumulative trauma or cumulative risk has been utilised in some trustworthy research in the United States (Follette, Polusney, Bechtle, & Naugle, Reference Follette, Polusny and Milbeck1994; Kaplan, Schene, DePanfilis, & Gilmore, Reference Kaplan, Schene, DePanfilis and Gilmore2009; McNutt, Carlson, Persaud, & Postmus, Reference Mcnutt, Carlson, Persaud and Postmus2002). Whilst research into the accumulation of maltreatment experiences exists, there appears to have been minimal research into the response of global child protection systems to cumulative harm.

There is limited research relating specifically to cumulative harm, rather the focus is on the approaches to maltreatment, which then influence the acknowledgement and management of cumulative harm and chronic maltreatment. Rapid increase in reports of child maltreatment from 1980 to the early 1990s, globally, prompted studies that compared social policies and professional practices in nine countries. In this investigation of nine countries, Gilbert, Parton and Skivenes (Reference Gilbert, Parton and Skivenes2011) examined differences as well as common problems and policy orientations. One of the key findings revealed important variations among the countries concerning the extent to which their child abuse reporting systems were historically characterised by a child protection or a family service orientation (Gilbert et al., Reference Gilbert, Parton and Skivenes2011). In this sense, child protection indicated a forensic and statutory leaning and Family service orientation referred to a more intervention and support-based approach.

According to Gilbert et al. (Reference Gilbert, Parton and Skivenes2011), the two orientations were then classified into further cultural differences. First, and perhaps most significant, was the way the issue of child abuse was framed. In child protection-oriented systems, abuse was conceived of as an act that demanded the protection of children from harm by ‘degenerative relatives’; whereas, in other systems, abuse was conceived as an issue of family conflict or dysfunction that arose from social and psychological difficulties but which responded positively to help and support (Gilbert et al., Reference Gilbert, Parton and Skivenes2011). The second major difference in approaches to child abuse on a global level was, in their responses to abuse, operating either as a mechanism for investigating deviance in a highly legalistic way or as a service-oriented, and often therapeutic, response to a family's needs, in which the initial focus involved the assessment of need rather than risk (Gilbert et al., Reference Gilbert, Parton and Skivenes2011).

From this initial categorisation, global responses to harm are divided. A child protection approach in the context of the aforementioned research indicates an episodic, evidence-based approach more aligned with legalistic measures of assessment, a ‘black and white approach’. Comparatively, a family service orientation denotes a more holistic and person-centred approach open to a broader definition of harm, encompassing perhaps the more insidious and subtle complexities of chronic maltreatment. Gilbert's findings suggested that the ‘countries under investigation could be clustered into two groups with Anglo-American countries oriented toward child protection, while the Continental European and Nordic countries approached the problem of maltreatment from a family service orientation’ (Gilbert et al., Reference Gilbert, Parton and Skivenes2011, p.4).

This variation in approaches is accurately reflected in the current attitudes adopted across Australian child protection services. Arguably, there has been a shift towards a family support focused framework across several states, including Victoria most thoroughly. Similarly, Queensland has demonstrated an emerging commitment to a less forensic model in their ‘Stronger Families’ reforms, which adopts an ‘Appreciative Inquiry’ framework, suggesting a more therapeutic model of service delivery. According to the National Framework for Projecting Australia's Children 2009–2020 (2009), there is a growing acknowledgement that applying a ‘public health model’ to child protection, which expands the support and service continuum, may help to reduce the burden on child protection departments and foster better outcomes for children and families (Council of Australian Governments, 2009). The ‘public health model’, as applied to child abuse and neglect, is an encouraging approach to chronic maltreatment and cumulative harm as the central focus is on the prevention of child abuse and neglect, as opposed to focusing on the abuse and neglect which has already occurred (O'Donnell, Scott, & Stanley, Reference O'Donnell, Scott and Stanley2008; Scott, Reference Scott2006). However, as has been discussed in the aforementioned section of this paper, many states across Australia, Queensland in particular, continue to approach child maltreatment from a forensically dominant, risk-averse perspective, which is in conflict with the attitudes adopted by other states, namely Victoria, and the global shift towards a more family oriented model.

Although child abuse and neglect continue to be the main organising categories for child welfare work in the United States and Canada, which is also consistent with Australian child protection practices, this is not the case elsewhere. In Finland, the terms ‘child abuse’ and ‘child neglect’ barely exist in the child welfare vocabulary, indicating an alternative approach to child welfare thinking. According to Poso (Reference Poso, Gilbert, Parton and Skivenes2011), Belgium and the Netherlands are related in their approach to formal reporting and professional responsibility to intervene and take care of a child in need or at risk (Munro, Reference Munro2002). The ‘need versus risk’ distinction can be compared to the ‘parent action versus child outcome’ dilemma identified in current Australian legislation (Broadley, Reference Broadley2014). This alternative view of harm and maltreatment in terms of categorisation and labelling demonstrates the variation in cultural understanding of harm, thus impacting on global responses to chronic maltreatment and cumulative harm.

One key area which seems to dominate in relation to risk assessment and addressing maltreatment, particularly in the cumulative sense, is the importance of early intervention. In essence, this approach seeks to address the low-level, low severity indicators of abuse in order to prevent escalation and minimise the likelihood of reoccurring maltreatment. This intervention focus has motivated a blending of orientations by which former child protection approaches adopt characteristics previously associated with family service orientations. Munro (Reference Munro2002) has identified a number of states in the United States which have developed ‘differential response’ systems, so that not every report is perceived in the context of a potentially serious case of child abuse. Through this process meaningful attempts are made to respond to cases in qualitatively different ways depending on the level and nature of risk to the child. This indicates adequate priority being afforded to all harm, including low to medium severity. In comparison, a number of Australian states have also begun to integrate ‘differential responses’ into their child protection assessment, adopting this alternate pathway for low-risk families and those with repeated low-risk reports. This alternative to intrusive child protection investigations for families who are identified as ‘at risk’ seeks to interrupt and prevent the cumulative impact of repeated harmful experiences prior to, and hopefully mitigating, the need for intrusive child protection intervention. Similarly, in England, there is clear evidence of official policy aimed at refocusing practice in such a way that, wherever possible, family support is maximised, so as to minimise likelihood of re-report or reoccurrence of low-level harm or maltreatment (Parton & Berridge, Reference Parton, Berridge, Gilbert, Parton and Skivenes2011, p. 6).

In addition to the various attempts made across a range of countries to achieve a balance between the child protection and family service orientations, Gilbert et al. (Reference Gilbert, Parton and Skivenes2011) identify the emergence of an alternative approach, which is referred to as a child-focused orientation. This approach is not limited to restricted concerns about harm and abuse; rather, the object of concern is the child's general development and wellbeing. These programmes seek to go beyond protecting children from risk to promoting children's welfare and the rights of the child to safety and protection. This reflects the current global attention paid to human rights, specifically those related to the child. Nadan, Spilsbury and Korbin (Reference Nadan, Spilsbury and Korbin2015) argue that whilst not always reflected in reality, ‘international conventions, notably the United Nations Convention on the Rights of the Child (UNCRC), have sought to establish universal criteria for child wellbeing and protection to which all nations and cultures are expected to adhere’ (p.41). This is evident, according to Gilbert et al. (Reference Gilbert, Parton and Skivenes2011), ‘in Finland and Norway, where policies are directed toward creating a “child friendly” society and in the comprehensive child-focused programmes in the United States, England, and Germany’ (p. 18).

Australia, in contrast, remains relatively focused on a ‘risk’ model of protection, rather than a ‘need’ focused approach which would reflect the UNCRC more accurately. This is evident in the dominant ‘parent action and resulting child outcome’ approach to statutory child protection, rather than a research based ‘parent action and potential child outcome’ approach, which prioritises need over risk and prevention over intervention (Broadley, Reference Broadley2014). Nadan et al. (Reference Nadan, Spilsbury and Korbin2015), assert that, in fact, the UNCRC demands that a global standards apply, in order to ‘promote wellbeing and freedom from maltreatment, applicable to all children’ (p.41), further emphasising the importance of prioritising need over risk.

Gilbert et al. (Reference Gilbert, Parton and Skivenes2011) also identify policies in a number of countries that are concerned with the quality of children's childhood, stating, as policies in Finland and Norway do, that it is a social justice issue to ensure children are regarded with respect and are provided with a loving upbringing. These countries promote the importance of a happy and caring childhood, securing children the same rights granted adults and aiming to give children in the child welfare system the same opportunities as other children in society (Gilbert et al., Reference Gilbert, Parton and Skivenes2011). A child-centred approach highlights the influence maltreatment has on children's development and wellbeing and illustrates the growing body of research which identifies the detrimental nature of chronic abuse and the cumulative harm.

In Australia in recent years, legislative reforms have been proposed and implemented in order to adopt a more wellbeing oriented system, including the National Framework for Protecting Australia's Children 2009–2020 and state specific frameworks including the Queensland Government ‘Stronger Families Reform’ and the New South Wales action plan ‘Keeping them safe’. However, there is limited specificity across all legislation in relation to cumulative harm and the impact of these reforms and initiative will likely be secondary. The impact will be resultant purely from the trickle-down effect of a more therapeutic, family-orientated system of child protection and family intervention. This shift toward a more wellbeing focused statutory system is constructive and the secondary benefits to this harm type are valuable. However, the research, retrospective analysis and evidence in practice clearly indicates a need for consistent and accurate legislative acknowledgement of the cumulative impact of maltreatment, to inform targeted prevention and intervention services and improve outcomes in adulthood.