Is the ‘toxic trio’ a useful framework for assessing and safeguarding children?

Content warning: this article discusses cases of child abuse.

In 1995, the Department of Health [1] began work on identifying parental risk factors for child abuse and neglect. This work found that significant trends were present in most cases involving serious child abuse and neglect, these themes were later termed the toxic trio. As a consequence, over the last 20 years, the idea of the trio has become deeply embedded in child protection policy and practice.

Written by Edward Gould-Brown

In preparation for a CareKnowledge webinar on non-accidental injuries of children under one, hosted by Consultant Clinical Psychologist Elie Godsi, Mental Health Today is analysing the toxic trio, asking how these risk factors affect the psychological development of children, why this framework has become so dominant in children’s social care and whether this approach helps professionals safeguard children at risk of extreme and violent child abuse.

What is the toxic trio?

The toxic trio or triad is shorthand for the combined child protection risk factors of domestic abuse, mental ill-health, and substance misuse in a family unit. Each of those factors, by themselves, naturally have an intense impact on the dynamics of a household, and especially on the psychological development of children. Although, it is argued by some in child protection practice that it is the interactive union of the trio which has the capacity to make the situation even more destructive and volatile compared to when these issues are individually present.

In isolation, these factors have been shown to have the capability to severely effect the psycho-development of children. Studies [2] consistently evidence that parental mental illness affects almost every aspect of child development into adulthood. Understandably, this is commonly manifested in terms of negative attachment patterns [3] formed on the template of an unstable child-parent relationship and in behaviours associated with a turbulent social and emotional upbringing. Similarly, long-term, longitudinal studies also report that parental mental ill-health is a significant genetic and environmental element in the psychopathological development of acute psychiatric disorders, for instance, schizophrenia [4] and severe anxiety and depressive conditions.

Regarding domestic violence, it is ‘unequivocally acknowledged [5]’ by researchers that childhood exposure is a major trauma-based originator of maladaptive coping strategies. For example, in response to episodes of violence, a child may experience symptoms of hypervigilance and insecure attachments or exhibit behaviours linked to low emotional regulation and frustration thresholds.

Lastly, research on parental drug abuse and dependence, such as the UK Government’s 2010 drug strategy [6], reflect the impact of drug and alcohol misuse on families and communities. The 2010 report stated: ‘From the crime in local neighbourhoods, through families forced apart by dependency, to the corrupting effect of international organised crime, drugs have a profound and negative effect on communities, families and individuals.’ More precisely, in the family unit, and very similar to how parental mental illness and domestic violence influences a child’s psychological development, parental drug and alcohol abuse elevates the risk for adverse mental health and social outcomes [7], including increasing the likelihood of the child normalising the maladaptive coping strategy [8] and as a result, potentially leading to a replication of the dependence.

It is apparent from the above literature that the toxic trio are interlaced because, on one level, the individual elements are interactive comorbidities (substance misuse, domestic violence, and mental illness generate and feed into each other), and on another level, they evidently lead to overall comparative outcomes in the households in which they exist (mental health and behavioural conditions, and a likely reproduction of the instability experienced in childhood into adulthood). Therefore, the assertion that adverse psychological outcomes will be considerably more probable if two or all the three ‘toxic’ factors are present in the parent-child relationship is, on the face of it, undeniable. However, from a critical, utilitarian perspective, this still begs the questions: is this framework for which child protection policy has been formulated around for the last 20 years a useful one? And consequently, in answering that question, how prevalent is the intersectionality of the trio?

Questions on the intersectionality and utility of the triad

In 2013, the Department for Education released a report [9] detailing learning from serious case reviews between 2009-11. The analysis found that the overwhelming number (86%) of the child protection cases reviewed were a result of an environment where one or more of the toxic trio were present. Breaking that statistic down further, the report evidenced the interrelationship of the risk factors: ?

• In 22% of cases, all three factors intersected.
• ?29% of the cases reviewed had an experience of a single characteristic.
• 35% of the cases, any two of the trio were present.
• Almost two-thirds of cases featured domestic violence.
• Parental mental illness was identified in 60% of cases.
• Substance misuse was evident in 42% of reviews.

Another study [10], published in 2019 and conducted in the US, examined the intersectionality of the toxic trio in relation to physical abuse. The research found that the most salient risk factor in more than 20,000 cases was domestic violence, which was reported in two-thirds of cases. While parental addiction and mental illness, either alone or in combination, were discovered to be much less powerful predictors of physical abuse. The documented co-occurrent link between domestic violence and child abuse was then presented by the researchers as a potential key indicator in a safeguarding model. They suggested screening asymptomatic children for abuse if domestic violence exists (without any of the other risk factors) or if two of the toxic trio are present. The researchers argued that currently key indicators of physical abuse typically centre on bodily injuries. However, studies show that in violent abuse cases, only a small percentage of those who experience trauma had injuries that required medical treatment. Therefore, as the established screening process is unreliable in identifying physical harm, which is not always visible, there needs to be an expanded, more nuanced screening framework able to detect those abused children.

The evidence base for the toxic trio serving as an indicator of abuse, therefore, seems to be solid. However, recently, disquiet has been expressed around the alienating label of ‘toxic’, which led the Association of Directors of Children’s Services to re-phrase it as ‘trigger trio [11]’, and the evidence base for the interaction of the risk factors has been challenged by several academics.

A 2020 systematic literature review [12] of more than 6,000 papers concluded that only 20 provided an evidence base for the toxic trio. The University of Kent researchers reported that the safeguarding framework lacks definitions of key measures, analysis of the intersectionality of the risk factors, or a theoretical basis to warrant its centrality in safeguarding policy and practice. One of the conclusions of the review was that evidence is ‘alarmingly weak’; there is no research giving definitive answers on how these factors work in combination or how many children are experiencing abuse or neglect because of the interaction of risks. Another key criticism of the framework was the ill-defined measurement of factors. For example, questions are left unanswered as to: do all mental health conditions in parents pose the same level of risk? And do other factors associated with mental illness, such as stigma, unemployment, support networks and self-esteem, have considerably more impact?

Consequently, the researchers concluded, despite the term’s currency, there is little evidence supporting the assertion that the trio are a significant cause of child maltreatment. The review indicated that the concept is alienating to families and generates self-fulling biases in social work assessments. An alternative to the model, the researchers suggested, which policy and practice could be better informed by would be one based on more expansive, general socioeconomic and demographic factors, such as job insecurity, homelessness, identity, and parental separation.

On the other hand, regardless of the shortcoming in assessing risk through the trio, which is evidently is an overly simplistic framework, recent research has highlighted the influence, interaction, and prominence of the toxic trio in the cases of non-accidental injury of children under the age of one by male carers.

Findings of the national review of non-accidental injury in under ones and its relation to the toxic trio

In September 2021,The Child Safeguarding Practice Review Panel published the findings [13] of their national review into the non-accidental injury of infants. The review examined how well does the safeguarding system currently understand the role of male carers and the potential threat they can pose to the physical safety of children.

The accompanying psychological report [14], written by Clinical Psychologist Elie Godsi, focussed on interviewing nine men who had been convicted of either inflicting life-changing injuries onto a child or had inadvertently killed an infant in their care. The men’s testimony, while profoundly disturbing, established the toxic trio as important factors in their cases and causally related to the instigation of the at times serious and most often fatal injuries. This is shown in the common features of significant relationship problems, aggressive behaviours, domestic abuse both as perpetrator and victim, low self-esteem, and mental illness combined with escalating, spiralling cycles of drug abuse, lowering already low frustration thresholds and encouraging poor emotional regulation.

The findings of the psychological report and the broader national review have been supported by more extensive research profiling male perpetrators of violence towards children. In her PhD research [15] paper, Tara Dickens found that compared to adult harmers, child harmers report higher levels of psychological distress and are usually highly frustrated at the time of the incident, often misinterpreting normal child behaviour, such as crying and vomiting, as a form of rejection – which Ms Dickens noted is highly suggestive of historic attachment issues. The study also reported that these incidents were also characterised by drug use and by men who have normalised aggressive behaviours or low emotional regulation, which is indicated by their history of other violence-related offenses.

In the above cases, the toxic trio is a major contextual factor in the perpetration of violence toward children. Therefore, evidently, the toxic trio is a useful framework in estimating risk of violent abuse toward children. Although, as the national review highlighted, the men who are characterised by the trio need to be identifiable by social services. It was found in the review that insufficient attention and engagement had been made by social services to male carers and the risk that they may pose to children. The accompanying ‘Myth of Invisible Men' [16] report suggested that, in particular, men with a history of domestic abuse need to be flagged to protection services, and information on other risk factors, such as drug abuse and aggressive behaviours, should be sharable and accessible across different agencies, i.e. children and adult protection services, the police, midwives, and GPs.

In reflecting on the findings of the national review into non-accidental injury, it is apparent that the safeguarding of children from abuse and maltreatment is multidisciplinary, requiring a diverse network of professions to first identify any risk and then to support and treat those men who pose a danger. In addition, it seems evident that the recurring themes of the toxic trio in cases of extreme child abuse is not an abnormality; the toxic trio are a symptom of how negative psychological phenomenon and maladaptive coping strategies are repetitive, passing down through generations as an occasionally tragic and catastrophic form of inheritance. Consequently, part of the answer to how do we respond to and prevent these cases of extreme neglect and violence plainly appears to be quality mental health services, able to promote the wellbeing of the male perpetrators and, as a result, prevent further intergenerational harm to children.

What more can we learn about safeguarding abused children and from the National Review of Non-Accidental Injury in Under 1s? Join CareKnowledge and Elie Godsi for a free webinar on April 27th exploring the nature of risk. This online event will develop your understanding of common 'red flags' and misconceptions, as well as giving you the practical information necessary to be able to assess and evidence your concerns.

If you work with children and young people or manage people that do, this session is for you. Register for free here.

References

[1] https://www.amazon.co.uk/Child-Protection-Abuse-Messages-Research/dp/0113217811

[2] https://www.sciencedirect.com/science/article/abs/pii/S1476179308002188

[3] https://pubmed.ncbi.nlm.nih.gov/1577898/

[4] https://pubmed.ncbi.nlm.nih.gov/14990519/

[5] https://link.springer.com/article/10.1023/A:1024910416164

[6] https://www.gov.uk/government/publications/drug-strategy-2010

[7] https://onlinelibrary.wiley.com/doi/abs/10.1002/chi.727

[8] https://pubmed.ncbi.nlm.nih.gov/12472638/

[9] https://www.gov.uk/government/publications/new-learning-from-serious-case-reviews-a-2-year-report-for-2009-to-2011

[10]https://pubmed.ncbi.nlm.nih.gov/31184531/#:~:text=Childhood%20Physical%20Abuse-,The%20Toxic%20Triad%3A%20Childhood%20Exposure%20to%20Parental%20Domestic%20Violence%2C%20Parental,Associated%20With%20Childhood%20Physical%20Abuse

[11]https://adcs.org.uk/assets/documentation/ADCS_SAFEGUARDING_PRESSURES_PHASE_6_EXECUTIVE_SUMMARY_FINAL.pdf

[12] https://www.sciencedirect.com/science/article/abs/pii/S0190740920321010?via%3Dihub

[13] https://www.gov.uk/government/publications/safeguarding-children-under-1-year-old-from-non-accidental-injury

[14] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1017237/Psychologist_report_National_Review_of_Non-Accidental_Injury_in_under_1s.pdf

[15] https://www.semanticscholar.org/paper/An-Exploration-of-the-Psychological-Characteristics-Dickens/6f7dcb2b9631511c2817d7e5194a0a3ace5a4a6a

[16] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1017944/The_myth_of_invisible_men_safeguarding_children_under_1_from_non-accidental_injury_caused_by_male_carers.pdf