The Long-term Consequences of Child Maltreatment: Should we rethink Prevention ??

The Long-term Consequences of Child Maltreatment:

Should we rethink Prevention??

Jennie G. Noll, PhDProfessor, Human Development and Family StudiesDirector of Research & Education, Network on Child Protection & Well-beingThe Pennsylvania State University

Child Maltreatment

“ANY RECENT ACT OR FAILURE TO ACT ON THE PART OF A PARENT OR CARETAKER WHICH RESULTS IN DEATH, SERIOUS PHYSICAL OR EMOTIONAL HARM, SEXUAL ABUSE OR EXPLOITATION; OR AN ACT OR FAILURE TO ACT, WHICH PRESENTS AN IMMINENT RISK OF SERIOUS HARM.”

Physical & Medical NeglectPhysical abuseSexual abuse

Other (Emotional, Family violence, Parent’s drug/alcohol abuse)

U.S. Department of Health and Human Services, 2012

6.3 MILLION CHILDREN WERE SUBJECTS OF CHILD MALTREATMENT ALLEGATIONS

3.2 MILLION CHILDREN WERE INVESTIGATED

1.2 MILLION VICTIMS OF MALTREATMENT 17.1 victims per 1000 children (~1 in 58)

800,000 REACHED “ENDANGERED” STANDARDS

2,400 FATALITIES ATTRIBUTED TO CHILD ABUSEThe National Incidence Study of Child Abuse & Neglect , 2010

National Prevalence Rates

% of children involved in protective services at least once by age 17

Age

1987

2005

1989

1991

1993

1997

1995

1999

2003

2001

Year

6 10 381814 26 4222 30 34

Time 2; mean age=12.22






2007

2009

2011

2013

2015

2017Time 8; mean age=36.47


96% retained

89% located/agreed

Offspring 0-9; M=4.08



ChildhoodSexualAbuse

Psychosocialdistress

Physiologicalstress

Competencies: cognitive ability family/social support self-esteem

acute responses to trauma in childhood/

early adolescenceTimes 1-3 (mean ages 11, 12 & 13)

outcomes in late adolescenceTimes 4 & 5

(mean ages 18 &19)

Psychosexual: risky sex behaviors

Physica l Heal th: HPA dysreg/DHEA obesity accelerated puberty

ORIGINAL CONCEPTUAL MODEL

Psychopathology: depression/anxiety dissociation delinquency

Puberta lTiming

Revictimization: victimization hx

Psychopathology: depression/anxiety dissociation behavior problems


hormone disruption

outcomes in early adulthood

Time 6(mean age 24)

Psychosexual: risky sex behaviors teen pregnancy

Physical Heal th: HPA dysreg/DHEA obesity health hx

Psychopathology: depression/anxiety dissociation psychiatric symptoms substance use

Revictimization: victimization hx intimate partner viol.

Competencies: cognitive ability family/social support self-esteem education atta in.

Offspring wellbeing (mean age 4): competencies psychopathology developmenta l hx

adulthoodoutcomes

Parenting: parenting style* parenting stress home environment*

offspring wellbeing

Physica l Heal th: HPA dysreg/DHEA obesity health hx risk for cardiovascular disease, diabetes & cancer*

Psychosexual: risky sex behaviors HIV-risk* sexual dysfunction*

Physical Heal th: HPA dysreg/DHEA obesity developmenta l hx puberta l timing*

Times 7 & 8

Revictimization: victimization hx domestic violence*

Psychopathology: depression/anxiety dissociation psychiatric symptoms substance abuse*

Psychopathology: depression/anxiety dissociation behavior problems

Competencies: cognitive ability family/social support self-esteem occupational atta in.* dyadic adjustment*


(mean ages 33 & 35) (mean ages 9 & 11)

Childhood Maltreatment

SES is diverse; the majority being either working class or lower SES

Race is diverse; 49% Caucasian 46% African American 4% Hispanic 1% Asian

Comparison Families well matched on demographics plus family constellation and non-sexual trauma hx.

The Stress of Childhood Sexual

Abuse

Stress Response; HPA axis

Hypothalamus

AnteriorPituitary

AdrenalGlands

CRH

ACTH

+

+

-

-

Chronic Stress/Abuse

Cortisol+

Orbital Prefrontal Cortex

Amygdala

Ventral Prefrontal Cortex Dorsolateral Cortex

Anterior Cingulate

Review in Science Vol 289, p 592

Your Brain….on Stress

Noll, et al. (2010) Pediatrics

6 8 10 12 14 16 18 20 22 24 26 28 30 32

Age

40

80

120

160

200

PPV T

scor

es

Comparison LinearAbused Linear

Comparison QuadraticAbused Quadratic

Lower peak and slower acquisition of vocabulary

Lower overall: -graduation rates -educational attainment -occupational viability

Group X intercept interaction p<.01Group X linear time interaction p<.01Income and education attainment dynamically controlled

Neurocognitive effects of chronic stress Chronic stress may result in more prefrontal dopamine than is

functionally necessary causing impaired functioning (inattention, hypervigilance, social / learning problems)

Prefrontal cortex; executive functioning, decision making, working memory, activated in novelty or danger

Chronic stress “turn off” frontal inhibition impairing these functions

Implications for adolescent risk-behaviors; substance use, risky sexual behaviors

Split-Second Decisions and Judgment Activate the Anterior Cingulate

WJ Gehring & AR Willoughby, Science 295, March 2002

Maltreatment

HPA axisdysregulation

Brainmaldevelopment

Neurocognitiveimpairment

High-risk Social/Emotionalfunctioning

Outcomes: Alcohol, tobacco substance use

Neurocognitive mechanisms for Alcohol and Substance Abuse

Psychological Mechanisms for Alcohol and Substance Use

Trauma

PTSD

Re-experiencing

symptoms

Avoidantsymptoms

Arousalsymptoms

Numbingsymptoms

Alcohol and Substance Abuse

Psychological Mechanisms for Alcohol and Substance Use

Substance abuse can develop from untreated trauma

PTSD avoidant and numbing symptoms

Trauma-focused therapies not as effective for SUD patients

SUD treatments not as effective for trauma victims

Alcohol and Substance Abuse Findings

Substance Abuse Disorder (P<.01)

Abused = 19%Comparison = 5%

Alcohol Use Disorder (P<.05)Abused = 13%Comparison = 3%

Noll et al. (2007) Journal of Interpersonal Violence

Main Effect Findings

Early Adulthood:↑persisting PTSD↑psychiatric diagnoses ↑clinical depression ↑alcohol & drug abuse↑suicide attempts↑inter-partner violence↑sexual violence / rapes↑obesity

Trickett, PK., Noll, JG, & Putnam, FW. The impact of sexual abuse on female development: lessons from a multigenerational, longitudinal research study. Development and Psychopathology 2011; 23:453-476.

Adolescence:↑earlier pubertal timing ↑depressive symptoms↑PTSD symptoms↓cognitive abilities↓age at first voluntary intercourse↑teen pregnancy rates↑self harm↑sleep problems↑revictimization↑substance use

Childhood:↑childhood depression↑PTSD symptoms↑externalizing behavior problems↑somatic complaints↓family cohesion↑depressed mothers↓school performance

• Born Preterm (gestational age <37 wks)?

Offspring Outcomes (T6)

Intergenerational Transmission??

• Born Preterm (gestational age <37 wks)–Abused group: 19.4%–Comparison group: 10.1%

p<.01

Both pre-pregnancy cortisol levels and prenatal alcohol use were predictors

Noll et al. (2007) Journal of Pediatric Psychology


Cognitive Ability Scores

–Abused group: 87.47*–Comparison group: 94.48



Bayley Infant Development

PPVT-scores

WJ-R scores

• Child Protective Service (CPS) Involved–Abused group: 17%–Comparison group: 1%

p<.01majority neglect4 physical abuse1 sexual abuse

40% permanent removal from mom

4 deaths (all born to abused mothers)



20

10

5

17%*

< 1%

offspring born to sexuallyabused mothers

* = abused vs. comparison difference at p<.01

offspring born tocomparison mothers

%CPS involved offspringborn to a teenage mom

CPS-involved Offspring

Noll, JG SRA, 2006Noll, JG (2003) Journal of Consulting and Clinical Psychology

TeenParenthood

High-risk SexualBehaviors

Contextual Factors Young age at Menarche

High-risk Parenting

OutcomeHigh-risk Behaviors/

Attitudes andPsychosocial Difficulties

TeenPregnancy

High-risk Attitudes: Sexual Distortion Pregnancy Desire

Pregnancy-vulnerable Cognitions

High-risk Behaviors (non-sexual): Behavior Problems/Delinquency

Substance Use

Psychosocial Difficulties: Poor Cognitive Functioning

Psychological Distress Low Perceived Support Psychological Dysregulation

Key:

ChildhoodMaltreatment

High risk pathways for all adolescentsChild maltreatment amplifies these risksUnique pathways for maltreated adolescentsOutcome moderators

High-risk Partner AffiliationPTSD → Substance

Use

High-risk Pathways to Teen Pregnancy

514 abused and non-abused adolescent females assessed yearly from age 14 through age 19

PI: Noll, JG: R01 HD052533

0%

10%

20%

NationalAverage(2007)

4.20%

ComparisonFemales

9.43%

MaltreatedFemales

20.30%

sexually abused

physically abused

neglected

NationalAverage(2010)

3.43%

Noll, & Shenk., Pediatrics, 2013

Results: Teen Motherhood Rates

The Estimated Costs of Child Maltreatment

Miller, Cohen, & Wierseman (1996) calculated $90.6 billion* Fromm (2001) calculated $152.1 billion* Wang & Holton (2007) calculated $167.9 billion* Fang, Brown, Florence, & Mercy (2012) calculated $134.6 billion*

*Converted to 2013 dollars using Inflation Calculator from DaveManuel.com

Costs of other Childhood Maladies

Child Maltreatment: $134.6 billion

Lead Exposure: $43.4 billion (Landrigan et al., 2002) Autism: $35 billion (Ganz, M.L., 2007) Childhood Obesity: $14.1 billion (Trasande, 2009) Cancer: $6.6 billion (Landrigan et al., 2002) Asthma: $1.2 billion (NIH, 2007)

$100.3 billion

HOSPITALIZATIONS SYSTEMS: CHILD WELFARE, FOSTER CARE, CRIMINAL JUSTICE SHORT-TERM MENTAL HEATH NEEDS LOST WAGESTRUNCATED EARNING POTENTIALS IMMEDIATE INTERVENTION REQUIREMENTS LONGER-TERM THERAPEUTIC AND PHARMACOLOGIC TREATMENTSSPECIAL EDUCATION NEEDS

Estimates based on:

NEUROBIOLOGICAL AND BRAIN MALDEVELOPMENT TEEN PREGNANCY OBESITYSUBSTANCE DEPENDENCIESDOMESTIC VIOLENCEPREMATURE DELIVERY

SS

SSSS

SSSS

Estimates do NOT include:

What is child maltreatment prevention?

Primary – prevent maltreatment BEFORE it happens

Secondary – prevent another problem that stems from child maltreatment (Intervention)

Targeted – prevent child maltreatment from occurring in an at-risk group

Embedded – prevent other public health problems by embedding primary prevention programs within child welfare

Thinking about “Embedded Prevention” within the child welfare system?

Abused children are at high risk for a host of conditions of grave public health concern:

-teen pregnancy (Noll & Shenk, 2013-obesity (Noll, et al, 2007)-substance use (Fergusson, 2010)

Children already in the child welfare system are prime targets for primary prevention of other public health problems

Director Research & Education:Jennie Noll

Director Policy & Administration:Margaret Gray

Co-fund 12 New Faculty members in a 5 college cluster-hireMultidisciplinary research to address important gaps in

the field; impact, detection, prevention, treatment, dissemination, translation

PSU’s Network on Child Protection and Well-being

NetworkOn Child Protection

Center for the Protection of Children(CPC)

Transforming Lives of Children (TLC) Clinic

-Forensic Evaluation-Mental Health-Medical Home-Advocacy-Research

Division of Child Abuse Pediatrics

University Park CampusChildren, Youth & Families Consortium

Social Science Research Institute College of Medicine / Department of Pediatrics

College of

Liberal Arts College of

Health & Human Dev’l

College of Education

Hershey

Clinical

Support Resea

rchSu

pportFaculty Co-fund

Faculty Co-fund

Faculty Co-fund

Faculty Co-fund

Faculty Co-fund

Four Broad Areas of Impact:Basic Science

biologic substrates of early trauma and chronic stress abuse

promote optimal heath for victimsprevalence, epidemiology

PreventionPrimary prevention Secondary prevention programsTargeted prevention program (integrated data research)


Four Broad Areas of Impact:Treatment & Translation

personalized, evidence-based treatment approaches

dissemination and implementation science-breaking down barriers to service-increasing family engagement-enhancing access for rural families-reduce costs -education and awareness for community

providers


Four Broad Areas of Impact:Engagement

Collaboration with stakeholders, including families, community groups, and state, federal and international organizations

Serve as PSU’s clearinghouse for information and resources

Provide interdisciplinary educational opportunities to promote awareness and understanding

-annual conference series -undergraduate minor


The Long-term Consequences of Child Maltreatment: Should we rethink Prevention ??

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