Opportunities to change the outcomes of traumatized children
- 1. 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
- 2. 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
- 3. 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
- 4. 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 Poverty Substance Abuse OhioCanDo4Kids.Org 3
- 5. 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 Million National Estimated Child Maltreatment Reports 4
- 6. 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) 5
- 7. 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
- 8. Childhood Trauma is Cumulative 0 1 2 3 4 5 6 7 8 Mean Number of DSM Dx 0 1 2 3 4+ NCS- R All Respondents N=5692 Putnam, Perry, Putnam, Harris unpublished data, 2008 National Comorbidity Study – Replication Sample Mood Anxiety Substance Abuse Any Disorder Type of Disorder 0 2 4 6 8 10 Odds Ratio 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
- 9. Cumulative Trauma Lowers Intelligence Koenen et al. Development and Psychology, 2003, 15:297-311 8
- 11. 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) 10
- 12. Trauma is to Mental Health as Smoking is to Cancer! Steven Sharfstein, MD Past President of the American Psychiatric Association 11
- 13. 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
- 14. 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
- 15. 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
- 16. 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
- 17. Every system and piece of legislation that serves children and families should consider a “Trauma Impact Statement” OhioCanDo4Kids.Org 16