Opportunities to change the outcomes of traumatized children

(Draft Narrative)

Frank Putnam, MD and William Harris, PhD

OhioCanDo4Kids.OrgFebruary, 28, 2008

Draft Narrative

• This is the draft of a narrative that we are seeking to collectively construct with others. The purpose of the narrative is to inform policy makers and the public about the costs and consequences of child maltreatment.

• The purpose is to tell them that there are interventions and opportunities to change these personally tragic and socially costly outcomes.

• Feel free to use all or part of this narrative (with appropriate attribution) if helpful to advocate for children and families

OhioCanDo4Kids.Org

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•High utilization of health and social services

OhioCanDo4Kids.Org

Developmental Cascade of Developmental Cascade of Transgenerational Child Maltreatment RiskTransgenerational Child Maltreatment Risk

Child

Adolescent

Adult

ChildAbuse

ChildAbuse

AggressionConductProblems

DepressionPTSD

Anxiety

SchoolProblems

Revictim-ization

SchoolDropout

SubstanceAbuse

DepressionPTSD

Anxiety

ParentingProblems

DomesticViolence

MaternalDepression

PTSDPoverty

SubstanceAbuse

OhioCanDo4Kids.Org

Incidence and Types of Child MaltreatmentIncidence 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, 2004

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

Most Maltreatment is Never Reported!Most Maltreatment is Never Reported!

• Random-digit dialing computerized telephone survey in North & South Carolina found that maternal-reported physical abuse was 40 times greater and sexual abuse was 15 times greater than official statistics for same period

• There are an estimated 8,755,000 juvenile victims of child maltreatment in the United States – that means that more than 1 of 7 children between ages of 2 and 17 have experienced maltreatment

(Theodore et al., (2005) Pediatrics 115:e331-337)

CDC, 2008

OhioCanDo4Kids.Org

“Dose-Effect” Responses for Number of Traumas in Children

Copeland et al., Archives of Gen Psychiatry 2007, 64:577-584

N=1420

www.Acestudy.org

CR score mean se n

0 1.42 0.04 32691 2.06 0.10 15492 3.82 0.14 5593 5.26 0.31 230

4+ 7.47 0.62 85

Mean Number of DSM diagnoses by Cumulative Risk Score

0

1

2

3

4

5

6

7

8

Mea

n N

um

ber

of

DS

M D

x

0 1 2 3 4+

NCS- R All Respondents N=5692

Putnam, Perry, Putnam, Harris unpublished data, 2008 OhioCanDo4Kids.Org

0 1 2 3 4 5 6 7 8 9 10 11 12

PTSD

Panic Disorder

Nicotine Dependence

Mania

Major Depressive Episode

Dysthymia

Drug Abuse

Conduct Disorder

Agoraphobia

ADD

Odds Ratio

Males – Childhood Sexual AbuseDSM Lifetime Diagnoses OR 95% CI

ADD 3.8 2.0-7.1

Agoraphobia 3.6 1.5-9.1

Conduct Disorder 2.7 1.4-5.0

Drug Abuse 3.3 1.8-6.0

Dysthymia 5.4 2.6-11.2

Major Depressive Episode 2.6 1.5-4.6

Mania 3.5 1.8-6.9

Nicotine Dependence 2.2 1.1-4.4

Panic Disorder 3.6 1.8-7.2

PTSD 4.3 2.0-9.5

OhioCanDo4Kids.OrgPutnam, Perry, Putnam, Harris unpublished data, 2008

Females – Childhood Sexual Abuse

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14

PTSD

Oppositional Defiant Disorder

Nicotine Dependence

Mania

Major Depressive Episode

Intermittent Explosive Disorder

Drug Abuse

Bipolar I

Alcohol Dependence

ADD

Odds Ratio

DSM Lifetime Diagnoses OR 95% CI

ADD 2.5 1.7-3.9

Alcohol Dependence 4.7 3-7.3

Bipolar I 6.6 3.4-13

Drug Abuse 5.2 3.8-7.1

Intermittent Explosive Disorder 3.1 2.3-4

Major Depressive Episode 2.4 1.9-3

Mania 3.6 2.3-5.5

Nicotine Dependence 2.6 1.6-4.3

Oppositional Defiant Disorder 4.1 2.3-7.1

PTSD 4.8 3.4-6.8

OhioCanDo4Kids.OrgPutnam, Perry, Putnam, Harris unpublished data, 2008

Childhood Trauma and Public Health

• Single greatest preventable cause of mental illness

• Single greatest preventable cause of drug and alcohol abuse in women

• Single greatest preventable cause of HIV high-risk behavior (IV drugs, promiscuity)

• Significant contributor to leading causes of death (heart disease, cancer, stroke, diabetes, suicide)

OhioCanDo4Kids.Org

Trauma is to Mental Health as

Smoking is to Cancer!Steven Sharfstein, MD

Neurodevelopmental Consequences of Childhood Trauma

• Impaired brain development– Decreased IQ– Doubled learning disabilities– Impaired emotional regulation and impulse control

• Dysregulated stress response systems– Dysregulation of HPA (cortisol) stress response– Increased sympathetic nervous system activation– Increased immune system abnormalities

• Alterations in physical growth– Doubled risk for obesity

OhioCanDo4Kids.Org

Increasing Trauma Lowers Intelligence

Koenen et al. Development and Psychology, 2003, 15:297-311

www.acestudy.orgwww.Acestudy.org

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, 20072 – Preventing Family Violence, Anthem Foundation of Ohio, 2007 3 – Wang & Holton – Economic Impact Study, Prevent Child Abuse America, 2007

OhioCanDo4Kids.Org

What do we have available now.What do we have available now.

• Existing networks within which to embed

screening and intervention• Evidence-based prevention and treatment

models

• Replication strategies

• Web networking and data collection tools

• Prevention and quality improvement science

OhioCanDo4Kids.Org

What can we do about it?

• Prevention– Meta-analysis of 21 studies found that Home Visitation programs

significantly reduce child maltreatment (median reduction = 40%, range 24%-74%) (CDC, 2003)

– Meta-analysis of 27 studies of school-based programs found an average effect size of (d= 1.07) (Davis & Gidycz, 2000)

• Screening and identification – Validated screening measures– Validated symptoms and behaviors assessments

• Treatment– Evidence-based treatments for different age groups, and types

of trauma– Gaps remain for cultural, trauma, and family issues

OhioCanDo4Kids.Org

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

What are the bottlenecks to moving ahead?

OhioCanDo4Kids.Org

Where are the Opportunities for Prevention and Intervention in the Where are the Opportunities for Prevention and Intervention in the Developmental Cascade of Transgenerational Child Maltreatment Risk?Developmental Cascade of Transgenerational Child Maltreatment Risk?

Child

Adolescent

Adult

ChildAbuse

ChildAbuse

AggressionConductProblems

DepressionPTSD

Anxiety

SchoolProblems

Revictim-ization

SchoolDropout

SubstanceAbuse

DepressionPTSD

Anxiety

ParentingProblems

DomesticViolence

MaternalDepression

PTSDPoverty

SubstanceAbuse

OhioCanDo4Kids.Org

Every system and piece of legislation Every system and piece of legislation that serves children and families that serves children and families

should consider a “Trauma Impact should consider a “Trauma Impact Statement”Statement”

OhioCanDo4Kids.Org