Peter is a reader in child health at Warwick Medical School, and formerly a consultant paediatrician at South Warwickshire NHS Trust and designated doctor for safeguarding children and for child death review. He has over 20 years’ experience as a practitioner and academic specialising in child protection. Peter is co-editor of Child Abuse Review and is also a Trustee of the Lullaby Trust.
The prevalence of domestic violence, substance misuse and parental mental health issues as risk factors for child maltreatment has been recognised for a long time. It was identified by Marian Brandon and colleagues as a particular factor in serious and fatal cases of maltreatment in the 2003-5 biennial review of Serious Case Reviews (SCRs) (Brandon, Belderson et al. 2008). The subsequent 2005-7 biennial review pointed out that ‘nearly three quarters of the children had lived with current or past domestic violence and/or parental mental ill-health and/or substance misuse’ and went on to comment that the ‘combination of these three problems can produce a toxic caregiving environment for the child’ (Brandon, Bailey et al. 2009, p43). This concept of a ‘toxic trio’ (Brandon 2009) gained traction and is now common parlance among child protection professionals. The term continues to feature in many SCRs as well as in training, books and journal articles.
Increasingly, however, Marian Brandon and I have been concerned by the term and feel that it may, in itself, have become toxic. In spite of the caveats expressed in each of the national analyses, the concept is often misinterpreted or given undue prominence. In the most recent triennial reviews (2011-14 and 2014-17), we have avoided using the term and focused instead on concepts of cumulative harm (Sidebotham, Brandon et al. 2016, Brandon, Sidebotham et al. in press).
There is no doubt that these three parental risk factors do feature prominently in cases of child maltreatment. In the 2011-14 triennial review, each of them was found in around 50% of SCRs, 52% of SCRs featured at least two of them in combination, and 22% all three (Figure).
However, there is a danger in concluding that these parental risk factors are central to the phenomenon of child maltreatment, and that the presence of any one of these risks in a family implies that the children of that family are being or inevitably will be abused, or – conversely – that their absence means the children are safe. The reality is that there are many families where children are abused – sometimes seriously – without any of these factors being present (21% of cases in the 2011-14 triennial review). Equally, there will inevitably be families in which one or more of these factors is or has been present, where the children are nevertheless loved, cared for and nurtured, and free from any form of abuse or neglect.
Not only are these three factors neither necessary nor sufficient to explain child maltreatment, they are also not the only parental risk factors recognised. Parental adverse childhood experiences, a history of crime, especially violent crime, teenage pregnancy, social isolation, poor education and many other factors have all been shown to increase the risks of maltreatment. A narrow focus on domestic violence, parental substance misuse and parental mental ill-health can mask the very real risks posed by any of these and many other recognised risk factors.
A third danger lies in conflating these three risks, and indeed confusing risk factors with indicators of or forms of abuse. The reality is that these three characteristics are very different in nature – while domestic violence is always harmful to children, parental mental ill-health ‘does not, in and of itself, necessarily indicate any risk of harm to the children’ (Sidebotham, Brandon et al. 2016, p83).
There has been a growing awareness of the harm caused to children by domestic violence, even when that violence is not necessarily physical or directly witnessed by the children (Katz 2016, Sidebotham, Brandon et al. 2016, Turner, Hester et al. 2017). Thus, where a child is living in a family where either or both parents are violent or controlling in their behaviour, that domestic violence should be treated not just as a risk factor for child maltreatment, but as evidence that the child is experiencing abuse. How we respond to that is not straightforward, and we need to beware of assuming that separation of the child and non-violent partner (usually, but not exclusively the mother) from the violent partner necessarily solves the problems or removes the abuse that the child is experiencing. Equally we should be careful of assuming that once the domestic violence is identified there is no hope of change and reconciliation in the future.
Alcohol and substance misuse is much more clearly a risk factor for child maltreatment rather than evidence of maltreatment. Both pose serious risks to the child in terms of neglect, physical abuse and emotional abuse. There are significant risks that, where parents’ lives are dominated by addictions (of any kind), the children’s needs will not be prioritised. However, where substance misuse is recognised and managed, is not accompanied by violence, and is within a wider, supportive family context, it need not inevitably result in abuse or neglect of the child. What is needed in these situations is a carefully planned collaborative approach to management and support (Hanson, Duryea et al. 2019).
In contrast, parental mental ill-health may be, but is not necessarily, a risk factor for child maltreatment. Mental ill-health is widespread in the population, takes many forms, and in the majority of cases will not pose any risks to the children in the family, any more than will physical ill-health in a parent. In our 2011-14 triennial review we identified 31 children per year who were killed or seriously harmed in the context of a parent with a mental health disorder. The UK Biobank study (Smith, Nicholl et al. 2013), which assessed 172,751 adults from 2009-10, found that 27% met criteria for a mood disorder (major depression or bipolar disorder); extrapolating this to the 13,887,000 parents with dependent children living in the UK (HM Government 2015), suggests that there will be at least 3.7 million parents with a current or previous mood disorder. If you extend that to include lower levels of anxiety, depression, and other mental health problems, the numbers are likely to be even higher. In view of this, simply identifying a mental health problem in a parent does not mean that a child is at risk of maltreatment. Smarter approaches to evaluating parental mental health issues are needed that take account of the nature and severity of the condition, how it manifests within the family context, its management, the presence or absence of any other risk factors, and the presence or absence of any wider support systems.
These considerations bring us to the potentially toxic impact of the term ‘toxic trio’: as a label it is deeply stigmatising and does not help in appraising the real nature of any family dynamics, and of any support or protection needed for the child or family. If I, as a parent, happen to suffer from depression or anxiety, or any of the myriad other forms of mental health disorder, I do not want to be labelled as toxic. Conversely, if I, as a child, am living in a household where one or other of my parents is violent or controlling towards the other, or where my parent’s substance misuse means that they might fail to prioritise my needs, or where a severe mental health disorder might make them unpredictable or potentially violent, I would want that to be recognised and appropriate steps taken to ensure that I am safe from harm. I would not want to be separated from my parents just because a professional has decided they are ‘toxic’ without fully understanding my needs and wishes.
And what about all those other ‘toxic’ terms that we (and I recognise my own guilt in this) use so liberally when referring to parents, families or children and young people? What is the impact of referring to families as ‘hard to reach’ or ‘hard to engage’? Or to ‘transient’ families, ‘troubled’ young people, ‘resistant’ or ‘non-compliant’ parents?
Without losing the very real learning that has been achieved in relation to domestic violence, parental substance misuse, and parental mental ill-health, I think the time has come to abandon the term ‘toxic trio’ and to be a lot more cautious in the language that we use to talk about parents, families, children and young people.
Brandon, M. (2009). "Child fatality or serious injury through maltreatment: Making sense of outcomes." Children and Youth Services Review 31(10): 1107-1112.
Brandon, M., S. Bailey, P. Belderson, R. Gardner, P. Sidebotham, J. Dodsworth, C. Warren and J. Black (2009). Understanding Serious Case Reviews and their Impact: A Biennial Analysis of Serious Case Reviews 2005-07. London, DCSF.
Brandon, M., P. Belderson, C. Warren, D. Howe, R. Gardner, J. Dodsworth and J. Black (2008). Analysing child deaths and serious injury through abuse and neglect: what we can learn? A biennial analysis of serious case reviews 2003-2005. London, Department for Children Schools and Families.
Brandon, M., P. Sidebotham, P. Belderson, H. Cleaver, J. Dickens, J. Garstang, J. Harris, P. Sorensen and R. Wate (in press). Complexity and challenge: a triennial analysis of serious case reviews 2014-2017, Department for Education.
Hanson, K., E. Duryea, M. Painter, J. Vanderploeg and D. Saul (2019). "Family-Based Recovery: An innovative collaboration between community mental health agencies and child protective services to treat families impacted by parental substance use." Child Abuse Review 28(1).
HM Government (2015). Families and Households: 2015. Trends in living arrangements including families (with and without dependent children), people living alone and people in shared accommodation, broken down by size and type of household. London, Office for National Statistics.
Katz, E. (2016). "Beyond the Physical Incident Model: How Children Living with Domestic Violence are Harmed By and Resist Regimes of Coercive Control." Child Abuse Review 25(1): 46-59.
Sidebotham, P., M. Brandon, S. Bailey, P. Belderson, J. Dodsworth, J. Garstang, E. Harrison, A. Retzer and P. Sorensen (2016). Pathways to harm, pathways to protection: a triennial analysis of serious case reviews 2011 to 2014. London, Department for Education.
Smith, D. J., B. I. Nicholl, B. Cullen, D. Martin, Z. Ul-Haq, J. Evans, J. M. Gill, B. Roberts, J. Gallacher, D. Mackay, M. Hotopf, I. Deary, N. Craddock and J. P. Pell (2013). "Prevalence and characteristics of probable major depression and bipolar disorder within UK biobank: cross-sectional study of 172,751 participants." PLoS One 8(11): e75362.
Turner, W., M. Hester, J. Broad, E. Szilassy, G. Feder, J. Drinkwater, A. Firth and N. Stanley (2017). "Interventions to Improve the Response of Professionals to Children Exposed to Domestic Violence and Abuse: A Systematic Review." Child Abuse Review 26(1): 19-39.