Transcript Slide 1

Opportunities to change the
outcomes of traumatized children
(Draft Narrative)
Frank Putnam, MD and William Harris, PhD
OhioCanDo4Kids.Org
February, 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
Disease and Disability
•Major Depression, Suicide, PTSD
•Drug and Alcohol Abuse
•Heart Disease
•Cancer
•Chronic Lung Disease
•Sexually Transmitted Diseases
•Intergenerational transmission of abuse
Data: www.AceStudy.org, www.nasmhpd.org
Social Problems
•Homelessness
•Prostitution
•Criminal Behavior
•Unemployment
•Parenting problems
•High utilization of health and social services
OhioCanDo4Kids.Org
Developmental Cascade of
Transgenerational Child Maltreatment Risk
Child
Abuse
Aggression
Conduct
Problems
Revictimization
Parenting
Problems
Depression
PTSD
Anxiety
Depression
PTSD
Anxiety
Domestic
Violence
Maternal
Depression
PTSD
Child
Abuse
School
Problems
School
Dropout
Child
Substance
Abuse
Poverty
Adolescent
Substance
Abuse
Adult
OhioCanDo4Kids.Org
Incidence and Types of Child Maltreatment
NCANDS, 2004
National Estimated Child Maltreatment Reports
3.5
3
Million
2.5
2
1.5
1
0.5
0
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Year
Victimization Rates by Age Group, 2000
age 16-17
5.8
age 12-15
10.4
age 8-11
11.8
age 4-7
13.3
age 0-3
15.7
0
5
10
15
Rate per 1,000 children of same age group
20
Most Maltreatment is Never Reported!
• Random-digit dialing computerized telephone survey
in North & South Carolina found that maternalreported physical abuse was 40 times greater and
sexual abuse was 15 times greater than official
statistics for same period
(Theodore et al., (2005) Pediatrics 115:e331-337)
• 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
CDC, 2008
OhioCanDo4Kids.Org
“Dose-Effect” Responses for Number of Traumas
in Children
N=1420
Copeland et al., Archives of Gen Psychiatry 2007, 64:577-584
www.Acestudy.org
Mean Number of DSM Dx
Mean Number of DSM diagnoses
by Cumulative Risk Score
8
NCS- R
All Respondents N=5692
7
CR score
mean
se
n
6
0
1
2
3
4+
1.42
2.06
3.82
5.26
7.47
0.04
0.10
0.14
0.31
0.62
3269
1549
559
230
85
5
4
3
2
1
0
0
1
2
3
4+
Putnam, Perry, Putnam, Harris unpublished data, 2008
OhioCanDo4Kids.Org
Males – Childhood Sexual Abuse
ADD
Agoraphobia
Conduct Disorder
Drug Abuse
Dysthymia
Major Depressive Episode
Mania
Nicotine Dependence
Panic Disorder
PTSD
0
1
2
3
4
5
6
7
8
9
10
11
DSM 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
12
Odds Ratio
Putnam, Perry, Putnam, Harris unpublished data, 2008
OhioCanDo4Kids.Org
Females – Childhood Sexual Abuse
ADD
Alcohol Dependence
Bipolar I
Drug Abuse
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
Intermittent Explosive Disorder
Major Depressive Episode
Mania
Nicotine Dependence
Oppositional Defiant Disorder
PTSD
0
1
2
3
4
5
6
7
8
9
10 11 12 13 14
Odds Ratio
Putnam, Perry, Putnam, Harris unpublished data, 2008
OhioCanDo4Kids.Org
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.org
www.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, 2007
2 – 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.
• 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
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Child care
Education
Medical
Well-child
Home visitation
Military families
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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
Developmental Cascade of Transgenerational Child Maltreatment Risk?
Child
Abuse
Aggression
Conduct
Problems
Revictimization
Parenting
Problems
Depression
PTSD
Anxiety
Depression
PTSD
Anxiety
Domestic
Violence
Maternal
Depression
PTSD
Child
Abuse
School
Problems
School
Dropout
Child
Substance
Abuse
Poverty
Adolescent
Substance
Abuse
Adult
OhioCanDo4Kids.Org
Every system and piece of legislation
that serves children and families
should consider a “Trauma Impact
Statement”
OhioCanDo4Kids.Org