Child Development, September/October 2018, Volume 89, Number 5, Pages 1599–1612

Childhood Maltreatment and Early Developmental Vulnerabilities

at Age 5 Years
Melissa J. Green, and Stacy Tzoumakis Brooke McIntyre
University of New South Wales and Neuroscience Research University of New South Wales and University of New
Australia England

Maina Kariuki, and Kristin R. Laurens

University of New South Wales and Neuroscience Research Australia

Kimberlie Dean Marilyn Chilvers

University of New South Wales and Neuroscience Research NSW Department of Family and Community Services
Australia and Justice Health & Forensic Mental Health
Network

Felicity Harris Merran Butler

University of New South Wales and Neuroscience Research NSW Department of Family and Community Services
Australia

Sally A. Brinkman Vaughan J. Carr

University of Western Australia and University of Adelaide University of New South Wales and Neuroscience Research
Australia and Monash University

This study examined associations between maltreatment and early developmental vulnerabilities in a popula-
tion sample of 68,459 children (Mage = 5.62 years, SD = .37) drawn from the Australian state of New South
Wales, using linked administrative data for the children and their parents (collected 2001–2009). Associations
were estimated between (a) any maltreatment, (b) the number of maltreatment types, and (c) the timing of
first reported maltreatment and vulnerability and risk status on multiple developmental domains (i.e., physi-
cal, social, emotional, cognitive, and communication). Pervasive associations were revealed between maltreat-
ment and all developmental domains; children exposed to two or more maltreatment types, and with first
maltreatment reported after 3 years of age, showed greater likelihood of vulnerability on multiple domains,
relative to nonmaltreated children.

This research was conducted by the University of New South Wales with financial support from the Australian Research Council
(Linkage Project LP110100150, with the NSW Ministry of Health, NSW Department of Education and Communities, and the NSW
Department of Family and Community Services representing the Linkage Project Partners), the National Health and Medical Research
Council (NHMRC Project Grant APP1058652), the Australian Rotary Health (Mental Health Research Grant RG104090 and RG162302),
and the Australian Institute of Criminology (Research Grant CRG 19/14-15). Maina Kariuki, Kristin R. Laurens, Felicity Harris, and
Vaughan J. Carr were supported by funding from the Schizophrenia Research Institute (Australia) using infrastructure funding from
the NSW Ministry of Health, and Melissa J. Green was supported by a NHMRC R.D. Wright Biomedical Career Development Fellow-
ship (APP1061875). The research was conducted using population data owned by the Commonwealth Department of Education, the
NSW Department of Family and Community Services, the NSW Ministry of Health, and the NSW Registry of Births, Deaths and Mar-
riages. The information and views contained in this study do not necessarily, or at all, reflect the views or information held by these
departments.
Correspondence concerning this article should be addressed to Melissa Green, UNSW Research Unit for Schizophrenia Epidemiology,
The O’Brien Centre, St Vincent’s Hospital, Level 4, 394-404 Victoria Street, Darlinghurst, NSW 2010, Australia. Electronic mail may be
sent to melissa.green@unsw.edu.au.

© 2017 The Authors

Child Development © 2017 Society for Research in Child Development, Inc.
All rights reserved. 0009-3920/2018/8905-0013
DOI: 10.1111/cdev.12928
1600 Green et al.
The long-term consequences of childhood maltreat-
ment are well established (Gilbert et al., 2009). Mal-
treated children are at increased risk of mental
health problems (Spinazzola et al., 2014; Vachon,
Krueger, Rogosch, & Cicchetti, 2015), criminality,
and violence (Maxfield & Widom, 1996). Consider-
able research from the neurosciences and develop-
mental psychology has shown the adverse effects of
child maltreatment on developmental competencies
in middle childhood and adolescence, but there has
been relatively less study of associations between
maltreatment and developmental functioning during
the early childhood period, which may induce long-
term adverse neurodevelopmental effects (Cicchetti,
2016). In this developmental period, neuroplasticity
is at a peak, providing an opportunity for remedia-
tion during critical stages of development (Cicchetti,
2015b). We thus adopt a developmental psy-
chopathology framework (Cicchetti & Toth, 1995)
for understanding the association between maltreat-
ment and developmental vulnerabilities in early
childhood, with emphasis on distinguishing the
effects of the timing of first maltreatment, and
exposure to multiple maltreatment types, on several
developmental indices at age 5 years in a large
population cohort (Carr et al., 2016).
Relatively few studies of child maltreatment
interrogate the impact on developmental stages
during the first 5 years of life. This period is one of
rapid brain development (Gogtay et al., 2004; Lyall
et al., 2015), making it highly sensitive to stress
(Panzer, 2008). Maltreatment exposure during this
period may critically impair developmental achieve-
ments (Hodel et al., 2015) and learning opportuni-
ties (Healy, 2004; Shonkoff, Garner, & Committee
on Psychosocial Aspects of Child and Family
Health; Committee on Early Childhood, Adoption,
and Dependent Care; Section on Developmental
and Behavioral Pediatrics, 2012), with potential
ramifications for cognitive and educational out-
comes (Cheatham, Larkina, Bauer, Toth, & Cic-
chetti, 2010; Eigsti & Cicchetti, 2004; Font & Berger,
2015) as well as social development (Curtis & Cic-
chetti, 2013; Pollak, Klorman, Thatcher, & Cicchetti,
2001; Shonk & Cicchetti, 2001).
There is considerable theoretical (Cicchetti,
2015a), and empirical support for the hypothesis
that early-life maltreatment is associated with worse
outcomes across an array of developmental compe-
tencies and psychological functions (Cicchetti,
2016), extending to psychopathology in childhood
(Berzenski & Yates, 2011; Pears, Kim, & Fisher,
2008) and mental health problems in adulthood
(Kaplow & Widom, 2007). Two population cohorts
of 11,835 (Fantuzzo, Perlman, & Dobbins, 2011) and
4,898 children (Font & Berger, 2015) show that mal-
treatment prior to kindergarten is associated with
worse psychological functioning in middle child-
hood, and a study of 814 children (of whom 492
were maltreated; Manly, Kim, Rogosch, & Cicchetti,
2001) showed that chronic maltreatment with onset
during infancy or preschool was associated with
greater psychopathology in middle childhood, rela-
tive to later onset maltreatment. Only one previous
study of 1,777 children drawn from the general
population (Jaffee & Maikovich-Fong, 2011) has
examined the timing of first maltreatment within
the early childhood period using short time win-
dows (i.e., 0–18 months, 19–36 months, and
≥ 37 months) corresponding with stages in Erik-
son’s theory of early psychosocial development
(Erikson, 1968, 1980). Erikson’s theory places stages
of personality development from early infancy to
adulthood in a social context (Erikson, 1980, 2006).
Failure to adequately achieve mastery of these
stages may compromise successful completion of
later stages and result in less healthy psychological
development. In the early stages to age 5, the indi-
vidual faces social challenges including the estab-
lishment of trust in others (i.e., 0–18 months),
acquiring a sense of autonomy (19–36 months), and
establishing initiative (3–5 years). There may be
specific effects of maltreatment within each devel-
opmental stage. Using this framework, Jaffee and
Maikovich-Fong (2011) showed that maltreatment
occurring after 3 years of age increased the associa-
tion between chronic maltreatment (i.e., maltreat-
ment occurring over multiple, later developmental
time periods) and prosocial behavior in middle
childhood (Jaffee & Maikovich-Fong, 2011).
Just as children exposed to chronic maltreatment
have especially poor outcomes (Cowell, Cicchetti,
Rogosch, & Toth, 2015; English, Graham, Litrownik,
Everson, & Bangdiwala, 2005), children exposed to
multiple types of maltreatment are at increased risk
for negative behavioral and clinical outcomes in
later childhood (Berzenski & Yates, 2011; Ecken-
rode, Laird, & Doris, 1993; Kaufman & Cicchetti,
1989; Lau et al., 2005; Pears et al., 2008; Spinazzola
et al., 2014; Trickett, Kim, & Prindle, 2011). The util-
ity of studying groups of children who have experi-
enced particular types of maltreatment together
(e.g., maltreatment typologies) has revealed specific
associations with internalizing and externalizing
psychopathologies in later stages of childhood
(Berzenski & Yates, 2011; Kaufman & Cicchetti,
1989; Lau et al., 2005), but the additional explana-
tory power of these typologies appears to be
 Maltreatment and Early Developmental Vulnerability
relatively small (Lau et al., 2005). A recent study of
developmental trajectories of cognitive and social-
emotional well-being from early to middle childhood
in the general population (N = 4,898) combined the
study of children exposed to physical and emo-
tional abuse owing to their substantial co-occur-
rence (Font & Berger, 2015). This study showed the
strongest associations with aggressive behavior in
middle childhood when multiple maltreatment
types (physical and emotional abuse) were experi-
enced prior to age 3 years. Here, we sought to
determine the relative associations between single
and multiple types of maltreatment experienced in
the early childhood period and a broad range of
developmental competencies at age 5 years.
We thus set out to estimate (a) associations
between any exposure to child maltreatment and
developmental vulnerability on five individual
domains of functioning assessed at age 5 years (in-
cluding social, emotional, physical, cognitive, and
communication competencies), as well as any single
or multiple vulnerabilities on these domains; (b) the
relative strength of association between develop-
mental vulnerabilities and exposure to multiple
types of maltreatment versus a single type of mal-
treatment; and (c) the relative strength of associa-
tions between differential timing of first reported
maltreatment (using short time windows) on any
single or multiple domains of developmental vul-
nerability at age 5 years.
Method
Study Setting and Record Linkage
Data were drawn from a population of 87,026
children in the Australian state of New South
Wales (NSW), representing 99.7% of NSW children
entering their 1st year of formal schooling in NSW
in 2009, who were assessed with the Australian
Early Development Census (AEDC; Brinkman,
Gregory, Goldfeld, Lynch, & Hardy, 2014). The
predominant first language spoken by the cohort
was English (84.1%), and approximately 23.3% fell
in the lowest (most disadvantaged) quintile of an
area-based socioeconomic index (Pink, 2013). Mul-
tiagency probabilistic record linkage was con-
ducted by the NSW Centre for Health Record
Linkage (http://www.cherel.org.au/), according to
nationally legislated privacy protocols (Carr et al.,
2016); AEDC records were combined with the chil-
dren’s routinely collected administrative records
from health, education, and child protection ser-
vices, as well as parental (mortality, health, crime)
1601
records for 72,245 children (83.0%) whose births
were registered in NSW (Carr et al., 2016). Cross-
agency records were linked on the basis of per-
sonal information (including name, date of birth,
residential address, and sex) using automated
algorithms and machine learning techniques for
assigning weights to personal information. Pairs of
records with probabilities above .75 were desig-
nated as “true matches,” and all those below .25
were designated as “false matches.” Clerical
reviews were performed on all pairs with proba-
bilities between these limits. False positive linkages
in the NSW Child Development Study (NSW-CDS)
were low, with a rate of 3/1,000 persons (0.3%)
associated with linkage of child data collections
and 5/1,000 persons (0.5%) for the linkage of par-
ents to their children.
For the present analyses, linked data were
derived from the following administrative record
sets, spanning the period prior to the child’s birth
up to approximately 5 years of age: Common-
wealth Department of Education’s AEDC (2009);
NSW Registry of Births, Deaths and Marriages
(RBDM; 2000–2009); NSW Ministry of Health’s
Admitted Patient Data Collection (APDC; 2005–
2009), Perinatal Data Collection (PDC; 2000–2006),
and Mental Health Ambulatory (MHA) data collec-
tion from 2001 to 2009; NSW Department of Fam-
ily and Community Services (FACS) Child
Protection Case Management System—Key infor-
mation Directory System (CMS-KiDS), and addi-
tional FACS data sets pertaining to allocation to a
family remedial program and Out of Home Care
from 2000 to 2009.
Participants
A total of 68,459 children (34,562 male) with a
mean age of 5.62 years (SD = .37) were selected
from the NSW-CDS cohort for analysis (Figure S1),
of which 2,135 had been exposed to substantiated
maltreatment (harm, or risk of harm) before age
5 years. Exclusion criteria included children for
whom births were not registered in NSW (i.e., for
whom parental data could not be linked;
n = 14,781), children identified on the AEDC as
having special needs (i.e., those with a chronic
medical, physical, or intellectually disabling condi-
tion; n = 3,129), those for whom domain scores on
the AEDC were unavailable (n = 176), and chil-
dren represented in the FACS CMS-KiDS as mem-
bers of family assistance programs but for whom
there was no record of substantiated maltreatment
(n = 481).
1602 Green et al.
Materials
Early Childhood Development Indicators
The AEDC is a population measure of the extent
to which children have gained the necessary compe-
tencies to engage effectively in school-based learning
on five domains (Brinkman et al., 2014) each with
acceptable reliability (Cronbach’s alpha; Janus,
Brinkman, & Duku, 2011): social competence (social;
a = .95), emotional maturity (emotional; a = .93),
physical health and well-being (physical; a = .80), lan-
guage and cognition (cognitive; a = .91), and commu-
nication and general knowledge (communication;
a = .90). The 104-item instrument was developed in
Canada (Janus & Offord, 2007) and cross-national
comparison has demonstrated similar psychometric
properties across Canada, Australia, the United
States, and Jamaica (Andrich & Styles, 2004; Janus
et al., 2011). The predictive validity of the AEDC has
been demonstrated in association with later national
literacy and numeracy scores obtained in third, fifth,
and seventh grades (Brinkman et al., 2013).
For each child in the cohort, the AEDC question-
naire was completed during the 1st year of formal
schooling by the child’s teacher on the basis of at
least 1 month’s (most commonly, 5 months) knowl-
edge of the child. Children scoring in the lowest 10%
of the national population on any domain are classi-
fied as developmentally vulnerable in that domain
(Brinkman et al., 2007). For the examination of the
effects of any maltreatment on individual AEDC
domains, we examined outcomes of (a) vulnerable (0–
10th percentiles), (b) at risk of vulnerability (11th–
25th percentiles), or (c) on track (26th–100th per-
centiles) for each individual AEDC domain. For the
examination of the effects of any maltreatment, multi-
ple maltreatment types, and maltreatment timing on
cumulative AEDC vulnerabilities, we used mutually
exclusive AEDC indices representing vulnerable (0–
10th percentiles) or at-risk status (11th–25th per-
centiles) on any (unspecified) single or multiple
AEDC domains. The reference group comprised chil-
dren classified as on track (26th–100th percentiles) on
all five AEDC domains and were compared to those
showing vulnerability on any one AEDC domain,
any two AEDC domains, or any three or more
domains. This outcome variable was constructed
hierarchically, such that any child displaying vulner-
ability on three or more AEDC domains was auto-
matically excluded from the groups with fewer
AEDC vulnerabilities, and children showing vulner-
ability on two AEDC domains were excluded from
the group showing vulnerability on any single
domain of the AEDC.
Childhood Maltreatment
Any Maltreatment
Children with substantiated records of childhood
maltreatment (representing instances of actual harm
or risk of significant harm, which had been verified
by child protection case workers) in the FACS
CMS-KiDS database (2000–2009) were regarded as
exposed to maltreatment.
Multiple Maltreatment Types (Single/Multiple)
Exposure to one or more types of childhood mal-
treatment (sexual, physical, emotional, or neglect)
was determined by case workers during safety and
risk assessments conducted according to Structured
Decision Makingâ Tools (Children’s Research Cen-
ter, 2008). Children were allocated to mutually
exclusive categories according to exposure to (a) a
single type of maltreatment or (b) exposed to two
or more types of maltreatment.
Age of First Maltreatment
We categorized maltreated children into three
mutually exclusive groups, according to the timing
of their first report of substantiated maltreatment
before 18 months of age, 19–36 months, and
≥ 37 months.
Covariates
The following covariates derived from linked
records were examined in view of their known
associations with maltreatment and/or develop-
mental vulnerability at this age (Curtin, Madden,
Staines, & Perry, 2013): child sex; having English as
a second language (ESL; coded dichotomously: no/
yes); socioeconomic index for areas, a measure of
the average income and employment status for each
postcode in Australia (Pink, 2013), from which the
quintiles based on national AEDC school-based
scores were dichotomized into disadvantaged
(Quintile 1) and not disadvantaged (Quintiles 2–5);
young maternal age at the child’s birth (< 25 years),
derived from the NSW RBDM; prenatal smoking
exposure (coded dichotomously: no/yes), maternal
pregnancy complications (coded dichotomously:
no/yes, including any history of maternal diabetes,
gestational diabetes, hypertension and preeclamp-
sia), and preterm birth (< 37 weeks; coded dichoto-
mously: no/yes), derived from the NSW Ministry
of Health PDC records. In addition, linked parental
health records from the NSW Ministry of Health’s
 Maltreatment and Early Developmental Vulnerability 1603

APDC and MHA were used to identify any paren- Table 1

tal mental illness as diagnosed during contact with
these health services, and records indicating child
hospital admission for infection before age 4 years
(coded dichotomously: no/yes) were derived from
the APDC.
Prevalence of Any Substantiated Childhood Maltreatment, Multiple
Maltreatment Types, and Timing of Maltreatment (Exposure Vari-
ables), Early Childhood Developmental Vulnerability (Outcome Vari-
ables), and Sociodemographic Covariates in the Sample of 68,459
Children and Their Parents
N %

Statistical Analysis Exposure variables: Childhood maltreatment

All analyses were conducted with SPSS version Any (substantiated) childhood maltreatment 2,135 3.1
Multiple maltreatment types
24.0 (IBM Corporation, Armonk, NY, USA) and SAS
Single 1,664 2.4
version 9.4 (SAS Institute, Cary, NC, USA). The first
Multiple 471 0.7
series of bivariate (unadjusted) and multivariate (ad- Age of first reported maltreatment
justed for covariates) multinomial logistic regressions < 19 months 738 1.1
(MLRs) estimated the association between any mal- 19–36 months 543 0.8
treatment and vulnerable, and at-risk status for each ≥37 months 854 1.2
of the five independent AEDC domains (with on Outcome variables: Developmental vulnerabilitya
track as the reference group; 10 tests). A second ser- Vulnerable on AEDC domains:
ies of bivariate (unadjusted) and multivariate (ad- Social competence 5,658 8.3
justed for covariates) MLRs estimated associations Emotional maturity 4,821 7.1
between exposure to (a) any maltreatment, (b) multi- Language and cognitive skills 3,640 5.3
Communication skills and general knowledge 5,610 8.2
ple maltreatment types, and (c) the age of first mal-
Physical health and well-being 5,542 8.1
treatment, on vulnerable and at-risk status on any
At risk on AEDC domains:
one, two, or three or more AEDC domains (i.e., 18 Social competence 9,415 13.8
tests). We thus conducted a total of 28 focal tests; Emotional maturity 9,536 13.9
the Bonferroni corrected significance level was thus Language and cognitive skills 6,198 9.1
set at a threshold of p < .001 (.05/28 tests = .0017). Communication skills and general knowledge 10,446 15.3
Odds ratios (ORs) for all variables included in unad- Physical health and well-being 8,728 12.7
justed and adjusted models were converted to Number of vulnerable AEDC domains:
Cohen’s d estimates of effect size (Borenstein, Any one domain 7,143 10.4
Hedges, Higgins, & Rothstein, 2009). Any two domains 3,364 4.9
Any three or more domains 3,152 4.6
Number of at-risk AEDC domains:
Any one domain 8,831 12.9
Results
Any two domains 4,991 7.3
Sample Characteristics Any three or more domains 2,388 3.5
Covariates
The prevalence of maltreatment, developmental Child sex (male) 34,562 50.5
outcomes on the AEDC, and covariates for 68,459 Child speaks English as a second language 10,891 15.9
children included in the analyses are presented in Socioeconomic disadvantage (SEIFA lowest 15,948 23.3
Table 1; the distribution of outcomes on AEDC vari- quintile)
ables and covariates, for maltreated and nonmal- Young maternal age at child’s birth 11,819 17.4
treated groups, are presented in Table 2. Of the 2,135 (< 25 years)
(3.1%) children exposed to maltreatment, 60% had Prenatal smoking exposure 9,330 13.7
Preterm birth (< 37 weeks) 4,165 6.1
been first reported for maltreatment before age
Parental mental illness 10,664 15.6
3 years (0–18 months: 34.6%; 19–36 months: 25.4%),
Child hospitalization for infection 16,440 24.0
records for 77.9% (n = 1,664) indicated exposure to a (age < 4 years)
single maltreatment type, whereas 22.1% (n = 471)
were coded as exposed to more than one type of Note. AEDC = Australian Early Development Census;
maltreatment. For those exposed to a single maltreat- SEIFA = Socio-Economic Indexes for Areas. aMissing data on the
individual AEDC domain outcome variables ranged between 1
ment type, emotional abuse was the most frequently and 258.
reported (n = 775; 46.6%), followed by neglect
(n = 437; 26.3%), physical abuse (n = 268; 16.1%), of emotional abuse and neglect was most common
and sexual abuse (n = 184; 11.1%). Among those (n = 186; 39.5%), followed by physical and emotional
with multiple types of maltreatment, the combination abuse (n = 90; 19.1%), physical abuse and neglect
1604 Green et al.

Table 2 association between any maltreatment and AEDC

Distribution of AEDC Outcomes and Covariates for Children Exposed vulnerable and at-risk status for each of the individ-
and Not Exposed to Childhood Maltreatment ual domains (full model results, including covariate
Not effects, are presented in Tables S2 and S3). Perva-
Exposed to exposed to sive, medium-sized associations between maltreat-
maltreat- maltreat- ment and early childhood functioning were evident
ment ment across all developmental domains (unadjusted ORs
(n = 2,135) (n = 66,324) of 2.96–4.97 for vulnerable, and 2.01–2.47 for at-risk
status). After adjusting for covariates, children
% n % n
exposed to maltreatment were more than twice as
AEDC outcome categoriesa likely to show vulnerability on each developmental
On track on all domains 30.2 644 57.2 37,946 domain (adjusted ORs = 2.11–2.50; Figure 1). Nota-
Vulnerable: physical 21.4 456 7.7 5,086 bly, the association of male sex with developmental
Vulnerable: social 21.0 448 7.9 5,210 vulnerabilities was greater than that for maltreat-
Vulnerable: emotion 18.3 390 6.7 4,431 ment on social and emotional domains (ORs = 2.61
Vulnerable: cognitive 17.9 383 4.9 3,257 and 4.16, respectively), whereas exposure to mater-
Vulnerable: communication 17.8 380 7.9 5,230 nal smoking during pregnancy (OR = 2.29) and
At risk: physical 18.9 404 12.6 8,324
speaking ESL (OR = 2.30) had greater associations
At risk: social 23.1 494 13.5 8,921
with cognitive vulnerability than did maltreatment
At risk: emotion 22.1 472 13.7 9,064
At risk: cognitive 18.5 395 8.7 5,803
exposure.
At risk: communication 23.4 499 15 9,947 Unadjusted and adjusted ORs emerging from
Vulnerable on any 1 domain 16.9 361 10.2 6,782 MLR to estimate associations between any maltreat-
Vulnerable on any 2 domains 12.2 261 4.7 3,103 ment on any single or multiple domains of AEDC
Vulnerable on ≥ 3 domains 14.8 315 4.3 2,837 vulnerable and at-risk status are summarized in
At risk on any 1 domain 11.3 242 13.0 8,589 Table 4 (Table S4 presents full models, including
At risk on any 2 domains 7.7 165 7.3 4,826 covariates). Maltreated children were more than 3
At risk on ≥ 3 domains 6.9 147 3.4 2,241 times more likely to be vulnerable, and 2.5 times
Child sex (male) 48.6 1,038 50.5 33,524 more likely to be at risk on ≥ 3 AEDC domains, in
Child speaks English as a second 7.6 162 16.2 10,729
the context of other contributing factors (Figure 2).
language
In adjusted models, male sex was just as strongly
SEIFA disadvantage (lowest 40.9 873 22.7 15,075
quintile)
associated with vulnerability on multiple AEDC
Mother < 25 years at child’s birth 44.6 942 16.5 10,877 domains as maltreatment (with some ORs exceed-
Prenatal smoking exposureb 56.5 1,192 12.4 8,138 ing those for maltreatment; see Table S4) and both
Preterm birth (< 37 weeks)b 12.3 260 5.9 3,905 maternal smoking during pregnancy and speaking
Parental mental illness 68.9 1,471 13.9 9,193 ESL were also strongly associated with multiple
Child hospital admission for 31.5 673 23.8 15,767 AEDC vulnerability and risk.
infection

Note. AEDC = Australian Early Development Census; Number of Maltreatment Types

SEIFA = Socio-Economic Indexes for Areas. aMissing data on the
individual AEDC domain outcome variables ranged between 1
and 249. bMissing data on the perinatal data collection ranged
from 556 to 565.
(n = 53; 11.3%), emotional and sexual abuse (n = 43;
9.1%), physical and sexual abuse (n = 14; 3.0%), sex-
ual abuse and neglect (n = 11; 2.3%), or the combina-
tion of sexual, physical, and emotional abuse (n = 8;
1.7%); < 1% of these children (n = 4) experienced all
four types of maltreatment.
Any Maltreatment
Table 3 presents a summary of unadjusted and
adjusted logistic regression models estimating the
Unadjusted and adjusted ORs emerging from
MLR to estimate the association between the num-
ber of maltreatment types and vulnerable and at-
risk status on any single or multiple AEDC
domains are presented in Table 4 (vulnerable) and
Table 5 (at risk); see Table S5 for the full model
results, including covariates. After adjusting for
covariates, children exposed to multiple types of
maltreatment were 5.76 times more likely to be vul-
nerable and 2.71 times more likely to be at risk on
≥ 3 AEDC domains, relative to nonmaltreated peers
(Figure 2). Post hoc tests of beta equivalence
revealed that the association between exposure to
multiple maltreatment types was significantly
greater than that for exposure to single
 Maltreatment and Early Developmental Vulnerability 1605

Table 3
Unadjusted and Adjusted Associations (Odds Ratios and 95% CIs) Between Any Maltreatment and Developmental Vulnerable and At-Risk Status
on Five Individual Domains of the AEDC

Vulnerable (lowest 10 centiles)

Unadjusted Adjusted

AEDC domain B Wald v2 OR 95% CI Cohen’s d B Wald v2 OR 95% CI Cohen’s d

Social 1.33 534.77 3.76** [3.36, 4.21] 0.73 0.82 164.59 2.28** [2.01, 2.58] 0.45
Emotional 1.30 467.88 3.66** [3.26, 4.12] 0.72 0.82 143.19 2.26** [1.98, 2.58] 0.45
Physical 1.31 540.73 3.72** [3.33, 4.16] 0.72 0.75 140.48 2.11** [1.87, 2.39] 0.42
Cognitive 1.60 699.04 4.97** [4.41, 5.59] 0.88 0.92 177.17 2.50** [2.19, 2.86] 0.51
Communication 1.09 323.26 2.96** [2.63, 3.33] 0.60 0.76 123.89 2.13** [1.87, 2.44] 0.42

At risk (11th–25th centiles)

Unadjusted Adjusted

AEDC domain B Wald v2 OR 95% CI Cohen’s d B Wald v2 OR 95% CI Cohen’s d

Social 0.89 261.39 2.42** [2.18, 2.70] 0.48 0.53 77.66 1.68** [1.50, 1.90] 0.29
Emotional 0.73 196.60 2.17** [1.94, 2.41 0.43 0.48 63.36 1.62** [1.44, 1.82] 0.26
Physical 0.70 144.27 2.01** [1.80, 2.26] 0.39 0.41 42.58 1.51** [1.33, 1.71] 0.23
Cognitive 1.05 322.19 2.87** [2.56, 3.23] 0.58 0.58 82.08 1.79** [1.58, 2.03] 0.32
Communication 0.71 174.62 2.04* [1.84, 2.27] 0.39 0.43 55.03 1.54** [1.38, 1.73] 0.24

Note. N = 68,459. Adjusted model accounts for child’s sex, English as a second language, Socio-Economic Indexes for Areas, mother’s
age at birth, preterm birth, prenatal smoking, parental mental health, and childhood infection hospital admission. Reference group is
developmentally “on track” (26th–100th percentiles). AEDC = Australian Early Development Census; OR = odds ratio; CI = confidence
intervals. *p < .01. **p < .001.

maltreatment types for vulnerable status on 1
(p = .002), 2 (p = .009), and ≥ 3 AEDC domains
(p < .001), but not for at-risk categories. In adjusted
models, the association between male sex and vul-
nerability status on three or more domains
(OR = 3.49) exceeded the strength of association for
single maltreatment exposure (OR = 2.90), and this
pattern was evident for vulnerability status on two
domains and any single domain. Exposure to
maternal smoking during pregnancy (ORs = 1.82–
2.51) and speaking ESL (ORs = 2.40–3.41) were also
strongly associated with vulnerability status in
these models.
Age of First Reported Maltreatment
Tables 4 and 5 also present the unadjusted and
adjusted ORs for MLR models estimating associa-
tions between the age at first maltreatment report on
any single or multiple domains of AEDC vulnerable
(Table 4) and at-risk status (Table 5); see Table S6
for full model results, including covariates. Adjusted
models showed that maltreatment in all develop-
mental periods was associated with vulnerability on
three or more domains of the AEDC, most strongly
for children who were maltreatment in either of the
19–36 months and ≥ 37 months periods who were
more than three and a half times more likely than
nonmaltreated peers to be vulnerable on ≥ 3 AEDC
domains. Children who were maltreated after
≥ 37 months were also more than three times more
likely than nonmaltreated peers to be vulnerable on
two AEDC domains (Figure 3) or at risk on three or
more AEDC domains. Equivalence tests conducted
for pairs of beta coefficients in adjusted models
showed no significant difference in the strength of
associations between vulnerability on three or more
AEDC domains and maltreatment at ≥ 37 months
compared to maltreatment at 0–18 months (p = .12)
or 19–36 months (p = .98); however, the beta coeffi-
cient for association between first maltreatment at
≥ 37 months was significantly greater than that for
0–18 months (p = .001) for vulnerability on two or
more AEDC domains, and greater than that for the
maltreatment at 19–36 months (p = .02) for at-risk
status on three or more AEDC domains. Again,
other factors such as male sex, exposure to prenatal
smoking, and speaking ESL were strong predictors
of vulnerability and risk on multiple AEDC domains
in these models (Table S6).
1606 Green et al.

4
Odds Ratios (95% CI)

0
Social Emotional Physical Cognitive Communication
AEDC Domains

Vulnerable (Unadjusted) Vulnerable (Adjusted) At Risk (Unadjusted) At Risk (Adjusted)

Figure 1. Unadjusted and adjusted associations between any substantiated childhood maltreatment and vulnerability on the five early
childhood developmental domains (bars illustrate odds ratios and error bars the associated 95% confidence intervals).

Table 4
Summary of Unadjusted and Adjusted Associations Between Childhood Maltreatment Indices and Cumulative Developmental Vulnerability on the
AEDC

Vulnerable on AEDC domains

3+ Domains 2 Domains 1 Domain

OR 95% CI Cohen’s d OR 95% CI Cohen’s d OR 95% CI Cohen’s d

Any maltreatment
U 6.54** [5.69, 7.53] 1.04 4.96** [4.27, 5.75] 0.88 3.14** [2.75, 3.58] 0.63
A 3.38** [2.89, 3.96] 0.67 2.78** [2.36, 3.28] 0.56 2.03** [1.76, 2.34] 0.39
Maltreatment types
Single
U 5.36** [4.55, 6.30] 0.93 4.36** [3.68, 5.15] 0.81 2.74** [2.36, 3.18] 0.56
A 2.90** [2.42, 3.46] 0.58 2.53** [2.10, 3.03] 0.51 1.83** [1.56, 2.14] 0.33
Multiple
U 12.85** [9.71, 17.0] 1.41 8.15** [5.99, 11.10] 1.16 5.27** [3.98, 6.97] 0.92
A 5.76** [4.26, 7.79] 0.97 4.07** [2.94, 5.63] 0.77 3.05** [2.27, 4.08] 0.62
Timing of maltreatment
0–18 months
U 6.12** [4.89, 7.67] 1.00 5.80** [4.64, 7.24] 0.97 3.08** [2.50, 3.80] 0.62
A 2.83** [2.20, 3.65] 0.57 2.08** [1.58, 2.74] 0.40 1.92** [1.53, 2.41] 0.36
19–36 months
U 7.45** [5.76, 9.63] 1.11 4.83** [3.63, 6.44] 0.87 3.02** [2.33, 3.90] 0.61
A 3.67** [2.79, 4.83] 0.72 2.53** [1.87, 3.43] 0.51 1.86** [1.42, 2.43] 0.34
≥ 37 months
U 6.34** [5.02, 7.99] 1.02 4.13** [3.18, 5.36] 0.78 3.29** [2.65, 4.08] 0.66
A 3.69** [2.90, 4.69] 0.72 3.68** [2.90, 4.65] 0.72 2.23** [1.79, 2.77] 0.44

Note. Reference group for the models is no maltreatment. AEDC = Australian Early Development Census; OR = odds ratio; CI = confi-
dence interval; U = unadjusted; A = adjusted for child sex, child age, child English as a second language, Socio-Economic Indexes for
Areas, mother’s age at birth, birth complications, birth weight, preterm birth, prenatal smoking, parental mental health, and childhood
infection hospital admission. **p < .001.
 Maltreatment and Early Developmental Vulnerability 1607

Any Single Maltreatment Type Multiple Maltreatment Types

7
Odds Ratios (95% CI)

0
Vulnerable: ≥3 Vulnerable: 2 Vulnerable: 1 At Risk: ≥3 At Risk: 2 Domains At Risk: 1 Domain
Domains Domains Domain Domains
AEDC Outcome Categories

Figure 2. Adjusted associations between any substantiated childhood maltreatment, any single maltreatment type, and multiple mal-
treatment types, and the number of early childhood developmental domains on which children present vulnerability and risk (bars
illustrate adjusted odds ratios and error bars the associated 95% confidence intervals).

Table 5
Summary of Unadjusted and Adjusted Associations Between Childhood Maltreatment Indices and Cumulative Developmental Risk on the AEDC

At risk on AEDC domains

3+ Domains 2 Domains 1 Domain

OR 95% CI Cohen’s d OR 95% CI Cohen’s d OR 95% CI Cohen’s d

Any maltreatment
U 3.86** [3.22, 4.65] 0.75 2.02** [1.69, 2.40] 0.39 1.66** [1.43, 1.93] 0.28
A 2.54** [2.08, 3.11] 0.51 1.46** [1.22, 1.75] 0.21 1.33** [1.14, 1.56] 0.16
Maltreatment types
Single
U 3.75** [3.06, 4.59] 0.73 1.90** [1.57, 2.31] 0.35 1.56** [1.36, 1.88] 0.25
A 2.52** [2.03, 3.13] 0.51 1.41** [1.15, 1.72] 0.19 1.30* [1.10, 1.54] 0.15
Multiple
U 4.48** [2.93, 6.87] 0.83 2.62** [1.78, 3.86] 0.53 1.99** [1.41, 2.82] 0.38
A 2.71** [1.75, 4.21] 0.55 1.75* [1.18, 2.60] 0.31 1.52 [1.06, 2.17] 0.23
Timing of maltreatment
0–18 months
U 4.63** [3.52, 6.06] 0.85 2.12** [1.61, 2.78] 0.41 1.79** [1.42, 2.26] 0.32
A 2.26** [1.63, 3.13] 0.45 1.30 [0.96, 1.76] 0.15 1.29 [1.00, 1.67] 0.14
19–36 months
U 3.04** [2.05, 4.50] 0.61 2.03** [1.45, 2.83] 0.39 1.43 [1.05, 1.93] 0.19
A 1.88** [1.26, 2.83] 0.35 1.41 [1.00, 1.99] 0.19 1.09 [0.80, 1.50] 0.05
≥ 37 months
U 3.64** [2.67, 4.97] 0.71 1.90** [1.41, 2.55] 0.35 1.69** [1.42, 2.26] 0.29
A 3.28** [2.47, 4.36] 0.66 1.65** [1.25, 2.17] 0.27 1.53** [1.21, 1.94] 0.24

Reference group for the models is no maltreatment. AEDC = Australian Early Development Census; OR = odds ratio; CI = confidence
interval; U = unadjusted; A = adjusted for child sex, child age, child English as a second language, Socio-Economic Indexes for Areas,
mother’s age at birth, birth complications, birth weight, preterm birth, prenatal smoking, parental mental health, and childhood infec-
tion hospital admission. *p < .01. **p < .001.

Discussion treatment and multiple developmental vulnerabilities

in early childhood (i.e., age 5 years), spanning the
This study provides evidence of the pervasive, mostly
domains of physical health and well-being, social
medium-sized, associations between childhood mal-
1608 Green et al.
6
5
Odds Ratio (95% CI)
0
Vulnerable: ≥3
Domains
Figure 3. Adjusted associations between the timing of first reported maltreatment and the number of early childhood developmental
domains on which children present vulnerability and risk (bars illustrate adjusted odds ratios and error bars the associated 95% confi-
dence intervals).
competence, emotional maturity, language and cogni-
tive development, and communication. The largest
associations between childhood maltreatment indices
and AEDC functioning were revealed for children
scoring in the lowest 10th percentiles (regarded as
“vulnerable”) on multiple developmental domains,
with somewhat smaller associations seen in groups of
children scoring in the 11th–25th percentiles (referred
to as “at risk” on those domains). Exposure to multiple
types of maltreatment was associated with a greater
likelihood of vulnerability on multiple developmental
domains; these associations were larger than those for
any single maltreatment exposure. Finally, the
strength of association between maltreatment and
developmental vulnerability at age 5 years was only
somewhat greater for children whose first maltreat-
ment report had occurred after 3 years of age, consis-
tent with one recent study of children of comparable
age (Jaffee & Maikovich-Fong, 2011).
The strongest associations revealed in this study
were between multiple types of maltreatment expo-
sures and cumulative developmental vulnerabilities,
consistent with a number of previous studies with
outcomes in middle childhood (Berzenski & Yates,
2011; Eckenrode et al., 1993; Kaufman & Cicchetti,
1989; Lau et al., 2005; Pears et al., 2008; Spinazzola
et al., 2014; Trickett et al., 2011). These findings not
only support cumulative theories of risk of poor out-
comes (Trickett, 1998) but may also reflect the effects
of chronicity of maltreatment associated with multi-
ple reports of abuse over time (English, Graham,
et al., 2005). Moreover, there may be merit in
0-18 Months 19-36 Months ≥37 Months
Vulnerable: 2 Vulnerable: 1 At Risk: ≥3 At Risk: 2 Domains At Risk: 1 Domain
Domains Domain Domains
AEDC Outcome Category
examining particular combinations of maltreatment
that often occur (Kaufman & Cicchetti, 1989). Person-
centered typologies of maltreatment may be deter-
mined via hierarchical classification of maltreatment
types that prioritizes active abuse over passive
neglect (Lau et al., 2005), or statistical approaches
(e.g., latent class or cluster analyses), which have
revealed subtypes of children with propensities for
distinct types of psychopathology (Berzenski &
Yates, 2011; Pears et al., 2008; Trickett et al., 2011).
Although hierarchical methods may best approxi-
mate the procedures of child protection services, they
appear to provide only incremental increases in the
capacity to account for variation in socioemotional
and cognitive outcome measures among maltreated
children (Lau et al., 2005). Person-centered methods
of categorizing multiple maltreatments may prove
useful in future longitudinal study of this cohort in
relation to onset of overt psychopathology but
should not negate the importance of determining the
severity and chronicity of maltreatment over time.
Investigation of variation in early developmental
vulnerability and risk according to the age of first
maltreatment in this study reveals only weak evi-
dence for greater effect sizes when maltreatment
occurs after 3 years of age (≥ 37 months), consistent
with the one previous study showing that maltreat-
ment beginning after 3 years of age increased the
association between maltreatment chronicity and
poor prosocial behavior in middle childhood (Jaffee
& Maikovich-Fong, 2011). Although the majority of
previous studies have reported greater impact of
 Maltreatment and Early Developmental Vulnerability
earlier maltreatment on cognitive (Cowell et al.,
2015), socioemotional (Font & Berger, 2015), living
skills (English, Graham, et al., 2005), and other aca-
demic and behavioral outcomes in later childhood
and adolescence (Fantuzzo et al., 2011; Manly et al.,
2001), the timing of exposures and/or outcomes in
these studies typically extend over a longer time
period than that in the present study. The onset of
maltreatment when children begin school, and nor-
mally take initiative in developing peer relation-
ships in the course of social development (Erikson,
1968, 1980), may have specific effects on socioemo-
tional competencies in early and middle childhood,
but this has not been investigated here owing to
the use of cumulative, nonspecific AEDC outcome
categories. This is a limitation of this study that will
be addressed in future studies of this cohort as they
develop.
Other limitations of this study include the use of
administrative data obtained from government
agencies that was not originally collected for these
specific research purposes. Second, the maltreat-
ment exposure was restricted to substantiated child
protection reports, which may have influenced the
estimate of maltreatment timing and also leaves
open the possibility of some children in the refer-
ence group having been subjected to unsubstanti-
ated maltreatment. However, this would tend to
reduce rather than inflate focal associations, and it
is notable that comparably high levels of problem
behaviors have been reported in children with and
without substantiated reports of maltreatment
(Hussey et al., 2005; Jaffee & Gallop, 2007). Third,
we did not ascertain the unique effects of any indi-
vidual maltreatment types, or the specific effects of
maltreatment chronicity, despite theoretical interest
(English, Bangdiwala, & Runyan, 2005; Fantuzzo
et al., 2011). Fourth, our composite outcome indices
did not consider particular combinations of vulner-
abilities or the possibility that vulnerability ratings
across domains may not represent equal severity.
Fifth, it is possible that low cognitive function is
overrepresented in the parents of maltreated chil-
dren, but we were unable to test for genetic (in-
herited) risk specifically. Finally, although only a
small proportion of the population were exposed to
maltreatment, replication of the results using the
generalized estimating equation to produce robust
standard errors confirmed that models were not
subject to bias or instability.
In summary, these findings suggest that expo-
sure to multiple types of maltreatment has a greater
impact on early childhood vulnerability than expo-
sure to a single type only, in the context of other
1609
important risk factors for early childhood develop-
mental vulnerabilities that have been implicated in
previous studies. These other factors include male
sex, which was commonly the strongest predictor
of vulnerability in adjusted models (Andrich &
Styles, 2004; Curtin et al., 2013; Quirk, Nylund-Gib-
son, & Furlong, 2013), followed by prenatal expo-
sure to maternal smoking (Anthopolos, Edwards, &
Miranda, 2013) and speaking ESL (Puchala, Vu, &
Muhajarine, 2010). Our findings also raise questions
about the timing of maltreatment during critical
periods in early life that could be targeted in early
intervention programs at school entry (Zigler, Finn-
Stevenson, & Hall, 2002). Future studies of mal-
treatment in the early childhood developmental
period should aim to determine more specific asso-
ciations between particular developmental vulnera-
bilities and multiple maltreatment typologies.
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Supporting Information
Additional supporting information may be found in
the online version of this article at the publisher’s
website:
Figure S1. Sample Selection Process
Table S1. Description of Domains Measured by
the Australian Early Development Census (AEDC)
Table S2. Summary of Adjusted Models Estimat-
ing Associations Between Any Childhood Maltreat-
ment and Vulnerable Status on Individual
1612 Green et al.
Australian Early Development Census (AEDC)
Domains (Including Covariate Effects)
Table S3. Summary of Adjusted Models Estimat-
ing Associations Between Any Childhood Maltreat-
ment and At-Risk Status on Individual Australian
Early Development Census (AEDC) Domains
(Including Covariate Effects)
Table S4. Summary of Adjusted Models Estimat-
ing Associations Between Any Childhood Maltreat-
ment and the Number of Domains on Which the
Child Is Vulnerable or At Risk (Including Covariate
Effects)
Table S5. Summary of Adjusted Models Estimat-
ing Associations Between the Number of Maltreat-
ment Types and the Number of Domains on Which
the Child Is Vulnerable or At Risk (Including
Covariate Effects)
Table S6. Summary of Adjusted Models Estimat-
ing Associations Between the Age of First Maltreat-
ment and the Number of Domains on Which the
Child Is Vulnerable or At Risk (Including Covariate
Effects)
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