Opportunities to change the outcomes of traumatized children
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Transcript of Opportunities to change the outcomes of traumatized children
Opportunities to change the
outcomes of traumatized children
Child Welfare Reform
Urban Caucus and Rural Working Group
June 19, 2008
Frank W. Putnam, MD
Cincinnati Children’s Hospital Medical Center
Adverse Childhood Experiences •Abuse and Neglect (e.g., psychological, physical, sexual)
•Household Dysfunction (e.g., domestic violence, substance abuse, mental illness)
Impact on Child Development •Neurobiologic Effects (e.g., brain abnormalities, stress hormone dysregulation)
•Psychosocial Effects (e.g., poor attachment, poor socialization, poor self-efficacy)
•Health Risk Behaviors (e.g., smoking, obesity, substance abuse, promiscuity)
Long-Term Consequences
Data: www.AceStudy.org, www.nasmhpd.org
Disease and Disability •Major Depression, Suicide, PTSD
•Drug and Alcohol Abuse
•Heart Disease
•Cancer
•Chronic Lung Disease
•Sexually Transmitted Diseases
•Intergenerational transmission of abuse
Social Problems •Homelessness
•Prostitution
•Criminal Behavior
•Unemployment
•Parenting problems
•Family violence
•High utilization of health and social services
1
Lifetime Consequences of Childhood
Trauma
• Impaired brain development – Smaller brain size for body size
– Decreased IQ (4-12 IQ points)
– Doubled rate of learning disabilities
– Impaired control of emotions and impulses
• Impaired stress responses – Dysregulation of cortisol stress response
– Increased arousal in the sympathetic nervous system
– Immune and inflammatory system abnormalities
• Alterations in physical growth – – Doubled risk for obesity
• Gene by Environment interactions for depression and aggression
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Developmental Cascade of
Transgenerational Child Maltreatment Risk
Child
Adolescent
Adult
Child
Abuse
Child
Abuse
Aggression
Conduct
Problems
Depression
PTSD
Anxiety
School
Problems
Revictim-
ization
School
Dropout
Substance
Abuse
Depression
PTSD
Anxiety
Parenting
Problems
Domestic
Violence
Maternal
Depression
PTSD
PovertySubstance
Abuse
OhioCanDo4Kids.Org 3
Incidence and Types of Child Maltreatment
Victimization Rates by Age Group, 2000
15.7
13.3
11.8
10.4
5.8
0 5 10 15 20
age 0-3
age 4-7
age 8-11
age 12-15
age 16-17
Rate per 1,000 children of same age group
NCANDS, 2005 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Year
0
0.5
1
1.5
2
2.5
3
3.5
Mil
lio
n
National Estimated Child Maltreatment Reports
4
Child Maltreatment is Common
• The Centers for Disease Control estimates
that 1 of 7 children between ages 2 and 17 is
a victim of maltreatment CDC, 2008
• In 2006 1 of 43 infants less than 1 year of age
suffered abuse or neglect
• Population surveys find much higher rates of
child abuse and neglect than are officially
reported
CDC, 2008
OhioCanDo4Kids.Org
(Theodore et al., (2005) Pediatrics 115:e331-337)
5
Childhood Trauma is Cumulative
www.Acestudy.org Copeland et al., Archives of Gen Psychiatry 2007, 64:577-584
N=1420
Great Smokey Mountains Study of
Child Mental Health Adverse Childhood Experiences (ACE) Study
N>17,000
6
Childhood Trauma is Cumulative
0
1
2
3
4
5
6
7
8
Mean
Nu
mb
er
of
DS
M D
x
0 1 2 3 4+
NCS- R All Respondents N=5692
Putnam, Perry, Putnam, Harris
unpublished data, 2008
National Comorbidity Study – Replication Sample
MoodAnxiety
Substance Abuse
Any Disorder
Type of Disorder
0
2
4
6
8
10
Od
ds R
ati
o
No. of Adverse
Childhood Events
1
2
3
Adjusted Odds Ratios for Psychiatric Disorders about Women in the US General Population: National Comorbidity
Survey Replication, 2001-2003
Afifi, et al (2008). Population attributable fractions of psychiatric disorders and
suicide ideation and attempts associated with adverse childhood experiences.
Research and Practice, 98(5), 946-952. 7
Cumulative Trauma Lowers Intelligence
Koenen et al. Development and Psychology, 2003, 15:297-311
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www.acestudy.org www.Acestudy.org 9
Family Violence and Public Health
• Single most preventable cause of mental illness
• Single most preventable cause of drug and alcohol abuse in women
• Single most preventable cause of HIV high-risk behavior (IV drugs, promiscuity)
• Significant contributor to leading causes of death (heart disease, cancer, stroke, diabetes, suicide)
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Trauma is to Mental Health
as
Smoking is to Cancer! Steven Sharfstein, MD
Past President of the American Psychiatric Association
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Cost Estimates of Child Maltreatment
• Alabama1 – in 2005 dollars – Direct costs - $392 Million
– Indirect costs - $129 Million
– Total annual costs - $521 Million
• Ohio2 – in 2007 dollars – Direct costs - $290 Million
– Indirect costs - $2.1 Billion
– Total annual costs – $3 Billion
• US3 – in 2007 dollars – Direct costs - $33 Billion
– Indirect costs - $71 Billion
– Total annual costs - $104 Billion
1 – Center for Business & Economic Research, Univ of Alabama, 2007
2 – Preventing Family Violence, Anthem Foundation of Ohio, 2007
3 – Wang & Holton – Economic Impact Study, Prevent Child Abuse America, 2007
OhioCanDo4Kids.Org 12
What can we do now?
• Examples of effective, evidence-based
prevention and treatment models
• Multiple systems and networks within
which to embed screening, prevention and
treatment
• Replication strategies to scale existing
interventions
• Scientific and technological tools to
maintain and improve quality in the field 13
There are several congressional committees
with jurisdiction over programs and policies
affecting traumatized children and their
families.
Reexamining programs and policies through
a trauma-informed lens could be beneficial to
the constituents whom they serve.
14
Prevention, identification, and treatment can
be embedded in systems that serve children
• Child care
• Education
• Medical
• Well-child
• Home visitation
• Military families
• Child welfare
• Mental health
• Drug and alcohol
• Criminal justice
• Immigration
• Faith based
OhioCanDo4Kids.Org 15
Every system and piece of legislation
that serves children and families
should consider a “Trauma Impact
Statement”
OhioCanDo4Kids.Org
16