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

1. Jennie G. Noll, PhD Professor, Human Development and Family Studies Director of Research & Education, Network on Child Protection & Well-being The Pennsylvania State University The Long-term Consequences of Child Maltreatment: Should we rethink Prevention??

2. 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 Neglect Physical abuse Sexual abuse Other (Emotional, Family violence, Parent’s drug/alcohol abuse) U.S. Department of Health and Human Services, 2012

3. National Prevalence Rates 6.3 millionchildren 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 abuse The National Incidence Study of Child Abuse & Neglect , 2010

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

6. 89% located/agreed Offspring 4-20; M=12.29 Offspring 2-18; M=10.29 Offspring 0-9; M=4.08 96% retained

8. 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.

9. The Stress of Childhood Sexual Abuse

10. Stress Response; HPA axis Chronic Stress/Abuse - Hypothalamus CRH + Anterior Pituitary - ACTH + + Adrenal Glands Cortisol

11. Your Brain….on Stress Ventral Prefrontal Cortex Dorsolateral Cortex Orbital Prefrontal Cortex Anterior Cingulate Amygdala Review in Science Vol 289, p 592

12. 200 160 s e r o c 120 s T V P P 80 40 0 2 6 8 0 2 4 6 8 0 2 4 6 8 3 3 1 1 1 1 1 2 2 2 2 2 A g e Lower peak and slower acquisition of vocabulary Lower overall: -graduation rates -educational attainment -occupational viability Group X intercept interaction p<.01 Group X linear time interaction p<.01 Income and education attainment dynamically controlled Noll, et al. (2010) Pediatrics

13. 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

14. Split-Second Decisions and Judgment Activate the Anterior Cingulate WJ Gehring & AR Willoughby, Science 295, March 2002

15. Neurocognitive mechanisms for Alcohol and Substance Abuse

16. Psychological Mechanisms for Alcohol and Substance Use

17. 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

18. 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

19. Main Effect Findings Childhood:↑childhood depression ↑PTSD symptoms ↑externalizing behavior problems ↑somatic complaints ↓family cohesion ↑depressed mothers ↓school performance 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 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.

20. Born Preterm (gestational age <37 wks)? Offspring Outcomes (T6) Intergenerational Transmission??

21. Offspring Outcomes (T6) • Born Preterm (gestational age <37 wks) • Abused group: 19.4% • Comparison group: 10.1% p<.01 Both pre-pregnancy cortisol levels and prenatal alcohol usewere predictors Noll et al. (2007) Journal of Pediatric Psychology

22. Offspring Outcomes (T6) Cognitive Ability Scores • Abused group: 87.47* • Comparison group: 94.48 Bayley Infant Development PPVT-scores WJ-R scores Noll et al. (2007) Journal of Interpersonal Violence

23. Offspring Outcomes (T6) • Child Protective Service (CPS) Involved • Abused group: 17% • Comparison group: 1% p<.01 majority neglect 4 physical abuse 1 sexual abuse 40% permanent removal from mom 4 deaths (all born to abused mothers) Noll et al. (2007) Journal of Interpersonal Violence

24. CPS-involved Offspring 20 17%* offspring born to sexually abused mothers offspring born to comparison mothers 10 CPS involved offspring born to a teenage mom % 5 * = abused vs. comparison < 1% difference at p<.01 Noll, JG (2003) Journal of Consulting and Clinical Psychology Noll, JG SRA, 2006

25. Childhood Maltreatment High-risk Pathways to Teen Pregnancy Outcome High-risk Behaviors/ Attitudes and Psychosocial Difficulties Teen High-risk Behaviors (non-sexual): Parenthood Behavior Problems/Delinquency PTSD → Substance Use Substance Use High-risk Partner Affiliation High-risk Attitudes: Contextual Factors Sexual Distortion Teen Young age at Menarche Pregnancy Desire Pregnancy High-risk Parenting Pregnancy-vulnerable Cognitions Psychosocial Difficulties: Poor Cognitive Functioning Psychological Distress Low Perceived Support High-risk Sexual Psychological Dysregulation Behaviors Key: High risk pathways for all adolescents Child maltreatment amplifies these risks Unique pathways for maltreated adolescents 514 abused and non-abused adolescent females assessed yearly from age 14 through age 19 Outcome moderators PI: Noll, JG: R01 HD052533

26. Results: Teen Motherhood Rates Noll, & Shenk., Pediatrics, 2013

27. 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

28. Costs ofother 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

29. Estimates based on: hospitalizations Systems: child welfare, foster care, criminal justice Short-term mental heath needs lost wages truncated earning potentials immediate intervention requirements longer-term therapeutic and pharmacologic treatments special education needs

30. Estimates do NOT include: neurobiological and brain maldevelopment teen pregnancy Obesity substance dependencies domestic violence premature delivery S S S S S S S S S S

31. 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

32. 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

33. PSU’s Network on Child Protection and Well-being Director Research & Education: Jennie Noll Director Policy & Administration: Margaret Gray Co-fund 12 New Faculty members in a 5 college cluster-hire Multidisciplinary research to address important gaps in the field; impact, detection, prevention, treatment, dissemination, translation

34. Hershey University Park Campus College of Medicine / Department of Pediatrics Children, Youth & Families Consortium Social Science Research Institute Network On Child Protection Center for the Protection of Children(CPC) Division of Child Abuse Pediatrics Faculty Co-fund Faculty Co-fund ResearchSupport Transforming Lives of Children (TLC) Clinic -Forensic Evaluation -Mental Health -Medical Home -Advocacy -Research Faculty Co-fund Clinical Support Faculty Co-fund Faculty Co-fund College of Liberal Arts College of Education College of Health & Human Dev’l

35. PSU’s Network on Child Protection and Well-being Four Broad Areas of Impact: Basic Science biologic substrates of early trauma and chronic stress abuse promote optimal heath for victims prevalence, epidemiology Prevention Primary prevention Secondary prevention programs Targetedprevention program (integrated data research)

36. PSU’s Network on Child Protection and Well-being Four Broad Areas of Impact: Treatment & Translation personalized, evidence-basedtreatment approaches disseminationandimplementationscience -breaking down barriers to service -increasing family engagement -enhancing access for rural families -reduce costs -education and awareness for community providers

37. PSU’s Network on Child Protection and Well-being 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