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

2

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)

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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

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