![12/05/2012
8
To date, there has been little relevant research
in most of Asia
• There has been some qualitative research with
high risk groups (mainly done by NGOs)
high risk groups (mainly done by NGOs)
• Several surveys of adolescents/young adults
early experiences of physical, emotional and
sexual abuse and neglect (mainly in Hong
Kong & mainland China)
N t ti l it di l t di
• No retrospective or longitudinal studies
involving adults in this region
• Our work has included studies in China,
Malaysia and Vietnam
Child maltreatment and mental health of
adolescents in Viet Nam
Nguyen, Dunne, Le (2010) Bulletin of the WHO, 88, 22‐3
[Collaboration between QUT and Hanoi School of Public Health]
• Self‐report anonymous survey of 2,591 students in
secondary and high schools in Hai Duong (rural) and
Ha Noi (urban)
• Assessed emotional abuse (7), neglect (7), physical
abuse (6) and sexual abuse (8) items
• Adolescents were classified as positive for
maltreatment if their sub‐type score was at or
above the mean
Vietnamese adolescents’ reports of
multiple type maltreatment, by gender Multiple adversity and Depression
15
20
25
30
n
s
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ore
Females
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5
10
no abuse 1 form 2 forms 3 forms 4 forms
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PUN106 Mental Health and early life adversity Dunne.pdf
- 1. 12/05/2012 1 Mental Health and Mental Health and early life adversity Prof Michael Dunne PUN106 Population Health May 14th, 2012 Key readings • Anda, R.F., Butchart, A., Felitti, V.J., Brown, D.W. (2010) Building a Framework for Global Surveillance of the Public Health Implications of Adverse Childhood Experiences. American Journal of Preventive Medicine, 39(1), 93–98 • US CDC ACE study website: http://www.cdc.gov/ace/ • WHO ACE‐International Questionnaire website: • http://www.who.int/violence_injury_prevention/violence/activities/adverse_childhood_expe riences/en/index.html • Shonkoff, Boyce & McEwan (2009) Neuroscience, molecular biology and the childhood roots of health disparities. Journal of the American Medical Association, 301, 2252‐2259 • Afifi et l (2008) Population attributable fractions of psychiatric disorders and suicide ideation and attempts associated with adverse childhood experiences. American Journal of Public Health, 98, 946‐952 The global burden of non‐communicable diseases Impacts on Disability Adjusted Life Years Prince M et al (2007): No health without mental health, Lancet, 370:859 ‐77 Time Trends in Global Mortality from Chronic Diseases The well-known epidemiological transition Yach, D. et al. JAMA 2004;291:2616-2622 Source derived from data in the World Health Report 20031 and Murray and Lopez.3 *The 2020 projections were estimated by Murray and Lopez.3.
- 2. 12/05/2012 2 Which types of mental health problems contribute most to morbidity? • 10 leading causes of disability among people aged 15‐44 years, global estimates • HIV/AIDS 13.0% • Unipolar depression 8.6 • Road traffic accidents 4.9 • Tuberculosis 3.9 • Alcohol use disorders 3.0 • Self‐inflicted injuries 2.7 I d fi i i i 2 6 • Iron deficiciency anemia 2.6 • Schizophrenia 2.6 • Bipolar disorder 2.5 • Violence 2.3 – Data from Patel et al, 2006 The total burden of mental disorders is difficult to measure M t l di d INTERACT ith bid • Mental disorders INTERACT with many co‐morbid health conditions • Consider diabetes and/or morbid obesity • HIV/AIDS and other chronic viral infections • Injuries • The CAUSES of mental disorder are difficult to understand, and to control Focus of my research in recent years • What are the important proximal and distal influences on the health of young people? – Particular focus on the effects of childhood adversity such as violence, emotional maltreatment, educational stress, social and family connectedness, poverty etc • How can research findings be directed toward mental health promotion? A Lifecourse Approach to Health In-utero Home Genetic & Social Inheritance Educational Success Parental SEP Chains of Social Causation Home School Neighborhood Day Care Lipid Metabolism Glucose Regulation Immune Function Background Infection Diet - Physical Activity - Smoking Role Models - Peer Groups Beliefs - Dispositions Adult Disease Work Hypertension Atherosclerosis Obesity Chains of Biological Causation Stress Lynch, 2000; Kaplan, 2007
- 3. 12/05/2012 3 The science base supporting the impact of early life adversity on p y y physical and mental health CONCEPTUAL MODEL See also Gilbert R, Widom CS, Browne K, et al (2009) The Lancet, Shonkoff et al (2009) JAMA and Anda et al (2010) Am J Preventive Medicine. CAUSAL PATHWAY HOW ADVERSITY IS BUILT INTO THE BODY “Weathering” of the body under persistent stress • Persistent stressful experiences overuse and d l t l th ll d dysregulate neural pathways normally used for adaptation to threat. • This is believed to accelerate the normal ageing process. • There is a growing body of patho‐ There is a growing body of patho‐ physiological research to support this idea. • See Shonkoff et al, JAMA (2009) Toxic Stress Damages Brain Architecture • Excessive and repeated stress causes the release of chemicals that impair cell growth and interfere with the formation of healthy neural circuits in the brain • Toxic stress can damage the brain's Healthy brain stress response system and contribute to premature ageing of the body Abused brain
- 4. 12/05/2012 4 Latent effects of adversity during sensitive periods • Adult disease and risk factors for poor health can be embedded during periods of child development g p p where the brain is sensitive to a variety of environmental stimuli, both positive and negative (Shonkoff et al, 2009). • Biological pathways: Inadequate nutrition, low birthweight and recurrent infections are linked to diabetes and respiratory and cardiovascular disease diabetes and respiratory and cardiovascular disease • Bio‐Behavioural pathways: Maternal drug use during pregnancy leads to child’s high tolerance for stimulants or depressants and drug‐seeking behaviour in adolescence This model is interesting.... but is it clinically meaningful? Evidence regarding links between ACEs and adult chronic diseases, and common risk factors in the biological pathways to disease onset .....but is it clinically meaningful? Straightforward method: Count the amount of serious adverse experiences reported by people who develop a disease or who have health-risk behaviours • The largest study of its kind – more than 17000 adult members of a health maintenance organisation in the USA The ADVERSE CHILDHOOD EXPERIENCES (ACE) study members of a health maintenance organisation in the USA • All were interviewed about many aspects of their health and early life adverse experiences • These people were followed up over more than 10 years, through health checks and search of death registers • Excellent resource: • US CDC ACE study website: http://www.cdc.gov/ace/ ACE model – the main types of CHILDHOOD ADVERSITY CHILD ABUSE/NEGLECT HOUSEHOLD dysfunction Psychological (by parents) Substance abuse in close relatives Physical (by parents) Living with a mentally ill person Sexual (anyone) Parental Separation / Divorce Emotional neglect Mother treated violently g y Physical neglect Imprisoned family member CDC Also - Exposure to trauma in the community (war and interpersonal violence) that induces sustained periods of fear, distress and confusion
- 5. 12/05/2012 5 ADVERSE CHILDHOOD EVENTS & ISCHEMIC HEART DISEASE (Dong et al, 2004) Dong et al found a dose‐response relation of ACEs to IHD and a relation between almost all individual ACEs and IHD. Nine of 10 categories of ACE significantly increased the risk of IHD by 1.3‐ to 1.7‐fold compared to persons with no ACEs ADVERSE CHILDHOOD EVENTS & COPD (Anda et al, 2008) 2 2.5 Association between ACE score and IHD (Adjusted OR) The age of first hospitalisation for COPD was strongly 0 0.5 1 1.5 2 0 1 2 3 4 5+ OR ACE SCORE g y related to ACEs The ACE Score had a graded relationship to the occurrence of COPD. ). ACEs AND LUNG CANCER (Anda et al, 2010) 3 3.5 0.5 1 1.5 2 2.5 RR for lung cancer 0 0 1 2 3 4,5 6,7,8 • Compared to persons without ACEs, the risk of lung cancer for those with >or= 6 ACEs was increased approximately 3‐fold. Persons with 6 or more ACEs were hospitalized 13 years earlier on average than those without ACEs ACEs & LIVER DISEASE (Dong et al, 2004) Each of 10 ACEs increased the risk of liver disease 1.2 to 1.6 times (P<.001). ACE SCORE
- 6. 12/05/2012 6 USA adults Childhood adversity and adult SMOKING % smoker , Felitti et al, 1998 ACE SCORE Childhood adversity and adult ALCOHOL abuse 4 USA adults with alcohol disorder 2 3 0 Adverse Childhood Experiences and attempted suicide, USA 4 20 25 2 1 3 2 3 4 % attempting suicide 5 10 15 20 Felitti et al, 1998 0 0 0 1 0 ACE score 0 0 0 4+ 1 2 3 Number of Adverse Childhood Experiences and Teen Sexual Behaviors, USA 35 40 45 m (%) 0 1 2 3 4 or more Number of adverse factors: 10 15 20 25 30 ent With Health Problem 0 5 10 Perce Intercourse by age 15 Teen pregnancy Teen paternity For more information, see the CDC (2012) ACE study reports
- 7. 12/05/2012 7 Other disorders linked to ACEs • Clinical depression • Anxiety disorders • Diabetes • Morbid obesity • Chronic, medically unexplained pain disorders • (www.cdc.gov/ace/index.htm) Adversity is also inked with unresponsiveness to pharmacotherapy for mental disorder (clinical trial by Klein et al, 2009) A longer duration of illness; earlier onset; greater number of episodes, symptom severity, self‐rated functional impairment, suicidality, and symptom severity, self rated functional impairment, suicidality, and comorbid anxiety disorder; and higher levels of dysfunctional attitudes and self‐criticism were each associated with multiple forms of childhood adversity A history of maternal overcontrol, paternal abuse, paternal indifference, sexual abuse, and an index of clinically significant abuse each predicted a lower probability of remission. Among patients completing a 12‐week trial, 32% with a history of clinically significant abuse, compared to 44% without such a history, achieved remission of symptoms. These findings indicate that a history of childhood adversity is associated with an especially chronic form of Depression that is less responsive to medication The end result? Potential years of life lost due to ACEs (Brown et al, 2009) Brown et al (2009) carried out a remarkable longitudinal analysis as part of the ACE study. People were followed up 9 to 10 years ft i t i th h h f d th d Of th i iti l after interview through search of death records. Of the initial sample, 1,539 had died. People with six or more ACEs died nearly 20 years earlier on average than those with no ACEs (60.6 years compared to 79.1 years). The magnitude of that effect is truly extraordinary and demands closer analysis in much further research. Brown et al (2009) found that some of the effect, but certainly not all, was mediated by an effect of ACEs on health-risk behaviours and low socio-economic position QUT’s East Asian research QUT s East Asian research into the health consequences of childhood adversity
- 8. 12/05/2012 8 To date, there has been little relevant research in most of Asia • There has been some qualitative research with high risk groups (mainly done by NGOs) high risk groups (mainly done by NGOs) • Several surveys of adolescents/young adults early experiences of physical, emotional and sexual abuse and neglect (mainly in Hong Kong & mainland China) N t ti l it di l t di • No retrospective or longitudinal studies involving adults in this region • Our work has included studies in China, Malaysia and Vietnam Child maltreatment and mental health of adolescents in Viet Nam Nguyen, Dunne, Le (2010) Bulletin of the WHO, 88, 22‐3 [Collaboration between QUT and Hanoi School of Public Health] • Self‐report anonymous survey of 2,591 students in secondary and high schools in Hai Duong (rural) and Ha Noi (urban) • Assessed emotional abuse (7), neglect (7), physical abuse (6) and sexual abuse (8) items • Adolescents were classified as positive for maltreatment if their sub‐type score was at or above the mean Vietnamese adolescents’ reports of multiple type maltreatment, by gender Multiple adversity and Depression 15 20 25 30 n s c ore Females 0 5 10 no abuse 1 form 2 forms 3 forms 4 forms M e a n Males
- 9. 12/05/2012 9 Multiple adversity and anxiety 30 10 15 20 25 Mean score Females Males 0 5 no abuse 1 form 2 forms 3 forms 4 forms Adversity & suicidal thinking (past year) ADVERSE CHILDHOOD EXPERIENCES, MENTAL HEALTH and RISK BEHAVIOURS AMONG 2,300 ADOLESCENTS IN VIETNAM Researchers: Thai Thanh Truc1,2, Kim Xuan Loan1,2, Nguyen Do Nguyen1 and Michael Dunne2 1. Faculty of Public Health, HCMC UMP 2. School of Public Health, Queensland University of Technology 1 ACE International Questionnaire, World Health Organisation Technical advisory meeting WHO Geneva 4-5 April 2011 We integrated the ACE-IQ into a broad survey of health and well-being • In a collaboration between Ho Chi Minh • In a collaboration between Ho Chi Minh City UMP Faculty of Public Health and QUT, and recently the Hue UMP, we have completed qualitative work in Hue and surveys of 2,300 adolescents in HCMC and A Long An
- 10. 12/05/2012 10 Three risk behaviour indicators • Youth health risk behaviors (%) Youth health risk behaviors (%) M F Total – Smoking during the past 30 days 5.7 2.1 3.7 – Drinking during the past 30 days 30.6 31.4 31.1 U d d i i ( t bik ) 12 6 4 8 8 3 – Underage driving ever (motorbikes) 12.6 4.8 8.3 Sex Age Total N % ANY endorsement of an item on Male Female ≤15 > 15 Neglect Emotional neglect 350 (63.2) 412 (61.3)** 419 (63.2) 343 (60.9) 762 (62.2) Physical neglect 63 (11.4) 45 (6.7) 47 (7.1) 61 (10.8)* 108 (8.8) ACE SUMMARY (HCMC survey in 6 schools Physical neglect ( ) ( ) ( ) ( ) ( ) Household dysfunction Household substance abuse 60 (10.8) 59 (8.8) 54 (8.1) 65 (11.6)* 119 (9.7) Household mental illness 24 (4.3) 38 (5.7) 34 (5.1) 28 (5.0) 62 (5.1) Household member treated violently 107 (19.3) 131 (19.5) 119 (18.0) 119 (21.1) 238 (19.4) Incarcerated household member 16 (2.9) 18 (2.7) 16 (2.4) 18 (3.2) 34 (2.8) Parental separation or divorce 66 (11.9) 136 (20.2)*** 100 (15.1) 102 (18.1) 202 (16.5) Childhood abuse Emotional abuse 57 (10.3) 91 (13.5) 72 (10.9) 76 (13.5) 148 (12.1) Physical abuse 29 (5.2) 37 (5.5) 35 (5.3) 31 (5.5) 66 (5.4) Sexual abuse 47 (8.5) 57 (8.5) 41 (6.2) 63 (11.2)** 104 (8.5) Exposure to community violence 163 (29.4) 158 (23.5)* 169 (25.5) 152 (27.0) 321 (26.2) Multiple adversity (all events before age 18) By Gender and Age (N and %) Multiple occurrence of Sex Age ACE Total Male Female ≤15 > 15 0 92 (16.6) 109 (16.2) 120 (18.1) 81 (14.4) 201 (16.4) 1 195 (35.2) 262 (39.0) 257 (38.8) 200 (35.5) 457 (37.3) 2 133 (24.0) 133 (19.8) 130 (19.6) 136 (24.2) 266 (21.7) 3 73 (13.2) 86 (12.8) 87 (13.1) 72 (12.8) 159 (13.0) ≥ 4 61 (11.0) 82 (12.2) 69 (10.4) 74 (13.1) 143 (11.7) * 40 50 e Multiple adversity and Depression 10 20 30 CES-D score 0 0 1 2 3 4+ Multiple Adverse Childhood Experiences Male Female Overall
- 11. 12/05/2012 11 Multiple adversity and suicidal thoughts 40 50 0 20 30 Suicidal thought (%) 0 1 0 1 2 3 4+ Multiple Adverse Childhood Experiences Male Female Overall Multiple adversity and smoking 20 25 %) 5 10 15 Male Female Total Smoking (% 0 0 1 2 3 4+ Multiple ACE Multiple adversity and drinking %) 50 60 Drinking (% 10 20 30 40 Male Female Total Multiple ACE 0 0 1 2 3 4+ Multiple adversity and underage driving g (%) 30 35 40 Underage driving 5 10 15 20 25 30 Male Female Total Multiple ACE 0 5 0 1 2 3 4+
- 12. 12/05/2012 12 Influence of child abuse on pattern of expenditures Worldwide, these and many other effects lead to increased health care expenditure Influence of child abuse on pattern of expenditures in women's adult health service utilization in Ontario, Canada Tang et al (2006) Tang B, et. al. (2006). The influence of child abuse on the pattern of expenditures in women's adult health services utilization in Ontario, Canada. Social Science and Medicine, 63, 1711‐1719. Tang et al methods Probability based sample of women aged 15‐ 64 64 Child Maltreatment History Self‐Report Questionnaire Self‐reported health service utilization X unit cost cost Tang B, et. al. (2006). The influence of child abuse on the pattern of expenditures in women's adult health services utilization in Ontario, Canada. Social Science and Medicine, 63, 1711‐1719. Overall how much of the poor Overall, how much of the poor health can be attributed directly to adversity? This is a very complex question
- 13. 12/05/2012 13 Fraction of mental disorders and suicidal behaviour attributable to child sexual abuse Female % Male % Depression 7-8% 4-5% Alcohol use/dependence 7-8% 4-5% Drug use/dependence 7-8% 4-5% Panic disorder 13% 7% PTSD 33% 21% Suicide 11% 6% Andrews et al., Child sexual abuse, WHO, 2004 ACEs and Population Attributable Fractions for Psychiatric disorders (Afifi et al, American Journal of Public Health, 2008) • A PAF is the estimated proportion of an outcome in • A PAF is the estimated proportion of an outcome in a population that would be prevented if the exposure was eliminated • Afifi et al (2008) analysed US National Comorbidity Survey of Mental Health (N=5,692 adults interviewed) • Risk of disorder was strongly associated with ACEs. PAFs ranged from small to substantial, for both men and women PAFs of ACEs in the USA • Afifi et al focused on common mental disorders ( ) ( ) • Women (%) Men (%) • Any mood disorder: 17.2 10.9 • Anxiety Disorder 16.4 9.2 • Substance use disorder 7.6 19.0 • Suicidal ideation 10.3 8.7 • Suicide attempts 4.7 2.6 PAFs (%) of ACEs in the USA (Any mood disorder) • Adversity Female Male • Physical abuse 3.8 4.7 • Sexual abuse 13.2 4.8 • Witness D. Violence 11.8 12.2
- 14. 12/05/2012 14 PAFs (%) of ACEs in the USA (Suicidal thinking and actions) • Adversity Female Male • Suicidal thinking (ever) g ( ) • Physical abuse 3.2 5.8 • Sexual abuse 8.9 n.s. • Witness D. Violence n.s. 8.5 • Suicide attempt (ever) • Physical abuse 7.8 11.2 • Sexual abuse 30 0 5 9 • Sexual abuse 30.0 5.9 • Witness D. Violence 10.0 n.s. • Source: Afifi et al (2008) AJPH, 98(5), 946‐952 Questions • What is the relevance of this type of research f bli h lth? for public health? • Remember to think about both sides of the PAF • In August 2012 – UNICEF/WHO Think Tank meeting on the economic costs of violence against children in the Asia‐Pacific region Why are some people severely affected by difficulties in childhood, and others not? • Some people who suffer extreme adversity in childhood have social problems later in life, but p , many others do not • A fascinating study in New Zealand by Caspi et al (2002) stimulated considerable interest in biological factors that might promote resilience. • Monoamine oxydase (Enzyme) activity was y ( y ) y measured in violent and non‐violent young adults who were victims of child abuse New Zealand Longitudinal study findings • Longitudinal study of relationship between child maltreatment of males, MAOA activity and later proclivity for violence (Dunedin NZ study)
- 15. 12/05/2012 15 Those with a genotype conferring high MAOA activity were less likely to develop psychosocial problems and to perpetrate violence themselves. Similar results reported by Widom & Brzustowicz, 2006, in the USA, but only among white males. Genes, gender, and culture interact in complex ways. • Keep a sense of perspective Mental and physical ill health and disorders are caused p y by numerous factors. Health promotion and preventive Interventions must not be focused too much on single causes. Lifecourse development research is very active internationally and is making progress in identifying those physical diseases and mental disorders which are NOT linked to childhood adversity Let’s agree that not all adversity has bad effects • Positive stress: – Short lived (eg. New school, favourite toy is stolen, pet is lost) – Minor physiological changes, such as elevated stress hormones – Children learn to cope and this aids their personal development Children learn to cope and this aids their personal development • Tolerable Stress – Much more intense, but usually short‐term duration (death of loved one, surviving a natural disaster, witnessing an accident) – With good support from parents and others, the child can overcome the stress and may become stronger and more resilient – With no support the child may have long term difficulty in coping • Toxic Stress – Intense adverse experiences over long periods of time (severe child abuse and Intense adverse experiences over long periods of time (severe child abuse and neglect; exposure to war or long‐term social unrest and community violence etc) – The child’s physiological stress response system is highly active for prolonged periods. Leads to permanent changes in development of the brain. This in turn increases risk of drug dependence, self‐harm, relationship problems, poor educational achievement etc) – Positive support can help, but sometimes the damage is too severe (Middlebrooks & Audage, 2010 - See summary in Dunne & Askari, 2012) Society‐level preventive public health interventions
- 16. 12/05/2012 16 Early investment in preventive programs for disadvantaged youth See Doyle et al (2009) The early childhood investment can The early childhood investment can start prior to and be sustained during pregnancy S D l l (2009) I i i l h See Doyle et al (2009) Investing in early human development: Timing and economic efficiency Economics and Human Biology, 7, 106. (Doyle et al, 2009) Academic, economic and social outcomes of pre‐ school based interventions (two decade follow‐up) Perry Preschool Abecedarian program Source: Knudsen et al (2006) PNAS, 201, 10155‐62
- 17. 12/05/2012 17 Final comments Of course, not all adverse experience can be prevented and in many circumstances, very few people know the experiences occurred, and t ifi ll d so cannot specifically respond. However, much can be done and there are many success stories. One of the most impressive is the decline in bullying and associated violence in schools over the past 20 years. Another is the substantial reduction in murder, rape and assault of adolescents in the past 15 years (especially in the USA). Much needs to be done and prevention of childhood adversity is becoming quite a strong focus of WHO Violence Prevention Division, the US CDC Injury Prevention Division, UNICEF and other global public health agencies. Further references • Ben‐Shlomo Y & Kuh D (2002) A life course approach to chronic disease epidemiology: conceptual models, empirical challenges and interdisciplinary perspectives International Journal of Epidemiology 2002;31:285‐293 • Braveman P and Barclay C (2009) Health Disparities Beginning in Childhood: A Life‐Course Perspective Pediatrics 124;S163 S175 Perspective. Pediatrics, 124;S163‐S175 • Dunne MP & Askari S (2012) Adverse childhood experiences and chronic diseases among adults. Hue University Journal of Medicine and Pharmacy, 2(1),22‐27. • Dunne MP, Chen JQ & Choo WY (2008) The evolving evidence base for child protection in Chinese societies. Asia Pacific Journal of Public Health, 20, 267‐76. • Doyle O et al (2009) Investing in early development: Timing and economic efficiency. Economics and Human Biology 7 1 6 Economics and Human Biology, 7, 1‐6. • Nguyen HT, Dunne MP, Le VA. (2010). Multiple types of child maltreatment and adolescent mental health in Vietnam. Bulletin of the World Health Organisation, 88, 22‐30 • Tang B, et. al. (2006). The influence of child abuse on the pattern of expenditures in women's adult health services utilization in Ontario, Canada. Social Science and Medicine, 63, 1711‐1719.