From the (Legal to Wet) Bench to Bedside:

Devon M. Fagel, JDPediatrics Clerkship, YSM III

Yale Child Sexual Abuse ClinicOctober 29, 2010

Neurodevelopmental Effects of Child Abuse & Neglect

Overview• Background: Why child abuse & neglect?

• Definitions: What is child abuse & neglect?

• Clinical Research: Does abuse & neglect cause delay?

• Neurobiology: Developmental delays & reduced neurogenesis.

• Prevention: What can be done to reduce prenatal abuse?

• Treatment: What can be done to reduce the impact of neglect?

• Conclusion: Utilizing translation of research to effect change.

• Conclusion: Stem Cells - Hope for the future

Child Advocacy in the Courts

Child Advocacy in the Courts

• Risk Factors: • Family - domestic violence, poverty, social isolation, many children under 5.• Parent - hx of maltreatment, mental illness, substance abuse and under 19.• Children - undesired pregnancies, multiple gestation and disabled children.

• Sexual Abuse: • Comprehension - involvement in sexual activities the child does not understand.• Informed Consent - age restrictions on ability to consent to sexual activities.• Social Taboos - acts which violate norms (exposing children to pornography).

• Physical & Emotional Abuse: • Non-Accidental Injury - includes striking, kicking, burning, biting, etc.• Threats of Harm - acts which invoke fear of serious bodily harm.• Psychological Abuse - behavior which impairs a child’s emotional development.

• Neglect: • Failure to Provide Basic Needs - food, clothing, shelter, supervision.• Medical and Educational Needs - includes failure to provide mental health care.

Definitions: Child Abuse & Neglect

Asnes & Leventhal, Pediatri. Rev. 31: 47-55, 2010Leventhal & Asnes, Am. Aca. Ped: 1106-1114, 2009

• Abuse: Gen. Stat. Section 46b-120 • Inflicted with physical injury or injuries by other than accidental means.• Injury or injuries that are at variance with the history given of them.• In a condition that is the result of maltreatment which includes malnutrition,

sexual molestation, deprivation of necessities and emotional maltreatment

• Neglect: Gen. Stat. Section 46b-120• Had been abandoned.• Is being denied proper care and attention physically, educationally and

emotionally.• Is being permitted to live under conditions, circumstances or associations

injurious to the well-being of the child or youth.

Definitions: Connecticut Statutes

www.childwelfare.gov/systemwide/laws_policies/statutes

Definitions: The Leventhal Triangle

Asnes & Leventhal, Pediatri. Rev. 31: 47-55, 2010

Definitions: Environmental Stimulation

www.brightfutures.org/mentalhealth/pdf/families/in/environments

Clinical Studies: Prenatal Substance Abuse

14 States and the District of Columbia consider prenatal use of an illegal drug or substance to constitute abuse or neglect.

• Tobacco• Children prenatally exposed to tobacco exhibit increased

rates of behavior problems related to response inhibition deficits.

• Smoking-exposed infants exhibit increased need for handling and decreased self-regulation relative to matched controls.

• Cocaine• Boys (4-9) exposed to cocaine have lower IQ scores and

difficulty with abstract/visual reasoning and short term memory.

• Infants exposed to cocaine have greater cortisol reactivity to caregiver instability compared to non-exposed controls.

• Alcohol• Infants exposed to alcohol exhibit cognitive and functional

disabilities due to stunted growth and decreased neurogenesis.

Bennet et al., Nerotoxicol. Tertaol. 2009 (e-pub ahead of print)Stroud et al., J. Pediatr. 154: 10-16 (2009)Bennet et al., Dev. Psychology 44: 919-928 (2008)Elden et al., Child Dev. 80: 528-543 (2009)

Jones & Smith, Lancet 302: 999-1001 (1973)

Environmental Enrichment Following Hypoxia:Can Therapy Improve Neurological Outcomes?

• Transgene marked astrocyte cells (green) are markedly increased following enrichment in both normoxia (compare D&E) and hypoxia (compare F&G)

• This study confirms that hypoxic mice can further boost recovery through environmental enrichment.

• Yet translating these findings to humans proves challenging.

Fagel et al., manuscript in progress

Prevention:Successes and Challenges of Promoting Positive Parenting

• Special Child Welfare Clinic: Established in 1994 in Norway to provide treatment and support to substance-abusing pregnant women and their children. More than 95% of women that completed their pregnancies reduced their substance abuse considerably. Study found that women who continued substance abuse more likely to experience premature birth and give birth to low birth weight infants.

• Nurturing Families Network: Universal screening targets recruitment of first-time mothers which exhibit risk factors for poor parenting and provide home visits with education on development and reliable, consistent emotional support to decrease likelihood of child maltreatment.

Minozzi et al., Chochrane Database of Systemic Reviews 2:CD006318, 2008Hjerkinn et al., Substance Abuse Treatment, Prevention and Policy 29: 5-17, 2010

• Special Outpatient Services: Of 2315 infants younger than 28 weeks’ gestational age weighing less than 1000g, 55% used more than 3 SOS by 22 months with almost 20% needing 6-7 SOS. This demonstrates that extremely preterm survivors have substantial needs for community support regardless of their impairment.

Treatment:Early Intervention to Reduce the Risk of Developmental Delays

Hintz et al., Arch Pediatr. Adolesc. Med. 162: 748-755, 2008

Conclusion:Utilizing Basic Science to Improve Children’s Lives

Gunnar et al., Dev. Psychopath. 18: 651-677, 2006

• Basic science research demonstrates risks of premature birth associated with substance abuse during pregnancy and need for preventative programs for mothers and treatment programs for at risk children.

• Basic science research also demonstrates risks of limited environmental stimulation associated with child abuse & neglect and need for proper parenting programs for mothers and special services for at risk children.