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Wekerle CIHR Team - Anne Niec - Understanding Child Maltreatment

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Understanding Child Maltreatment

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Wekerle CIHR Team - Anne Niec - Understanding Child Maltreatment

  1. 1. UNDERSTANDING CHILD MALTREATMENT ANNE NIEC MD FRCPC DIRECTOR, CHILD ADVOCACY AND ASSESSMENT PROGRAM MCMASTER CHILDREN’S HOSPITAL, HAMILTON ONTARIO
  2. 2. CHILD ABUSE AND NEGLECT (CAN) DEFINITION (1) Physical abuse (e.g., excessive discipline) (2) Sexual abuse (e.g., assault) (3) Emotional abuse (e.g., verbal abuse; confinement) (4) Neglect (e.g., failures to supervise; to provide life essentials) Any act of omission or commission which results in harm to a child’s emotional, physical or social health or development
  3. 3. CHILD WELFARE: THE CANADIAN LANDSCAPE
  4. 4. CHARACTERISTICS OF SUBSTANTIATED MALTREATMENT: CANADIAN DATA Canadian Incidence Study (CIS) gathers data from child welfare agencies across Canada every five years Most recent report (2008) found: • Approximately 85,000 substantiated child maltreatment investigations in Canada that year • Five major categories of maltreatment studied
  5. 5. PREVALENCE OF CHILD TRAUMA IN CHILD WELFARE: MALTREATMENT TYPES
  6. 6. MALTREATMENT AS TRAUMA: STATISTICS •In 2008, 18% of substantiated investigations involved multiple categories of abuse (15,590 cases) – 24% - Neglect and Exposure to Intimate Partner Violence – 15% - Emotional Maltreatment and Exposure to Intimate Partner Violence – 15% - Neglect and Emotional Maltreatment – 15% - Physical Abuse and Emotional Maltreatment •Neglect is the primary substantiated concern in 68% of cases with multiple concerns •Data suggested that 42% of substantiated cases involved single incidents; 58% involved multiple incidents (i.e., chronic trauma) CIS, 2008
  7. 7. ETIOLOGY OF MALTREATMENT Multiply determined More likely when stressors outweigh supports and risks are greater than protective factors Associated factors include • lack of social support • lack of parenting skills • parental history of maltreatment • single or young parenthood • substance abuse • parental psychopathology • community tolerance of violence 8
  8. 8. IMPACT Localized Effects • specific to the trauma Developmental Effects • deeper and generalized impact which interferes with developmental tasks or distorts the course of development
  9. 9. CHILD DEVELOPMENT Basic developmental needs of all children are • physical • cognitive • emotional • social
  10. 10. BASIC DEVELOPMENTAL NEEDS Physical • nutrition • safety • adequate supervision • health care Cognitive • stimulating environment • opportunities for play and exploration • language promotion
  11. 11. BASIC DEVELOPMENTAL NEEDS Social and Emotional • development of reciprocal relationships with parents, caregivers, peers • trust • social competence • affect regulation
  12. 12. CHILD DEVELOPMENT Key Tasks: • attachment • emotional and behavioural self-regulation • development of self • cognitive and academic functioning • peer relationships
  13. 13. DEVELOPMENT • each developmental stages has milestones to achieve • development is impacted by experiences • positive experiences enhances development • negative experiences and adversity interfere with achievement of milestones
  14. 14. DEVELOPMENT early childhood is where cognitive and emotional learning develops and when interfered with, problems in thinking and reacting occur
  15. 15. WHAT HAPPENS IN MALTREATMENT
  16. 16. BIOLOGY The healthy brain physiologically adapts to the abnormal world in which the developing child finds himself or herself (Stirling et al 2008)
  17. 17. CORTISOL – THE STRESS HORMONE released in response to stress • helps generate new energy stores (blood sugar) and diverts energy away from low- priority activities in the body (ie. Immune system) forms a negative feedback loop to “turn off” the HPA axis receptors at key areas of the brain, including hypothalamus, hippocampus and the amygdala
  18. 18. BRAIN REGIONS ASSOCIATED WITH STRESS Hippocampus: learning and memory. Amygdala: emotional processing & memory for emotional events Corpus Callosum: communication between left and right hemisphere Prefrontal Cortex control of behaviour, cognition, emotional regulation Corpus Callosum
  19. 19. PHYSICAL IMPAIRMENT • fine and gross motor delays • failure to thrive • increased health difficulties (Kendall-Tackett, 2002)
  20. 20. PHYSICAL IMPAIRMENT of all child maltreatment fatalities demonstrated, 1/3 resulted from neglect • abandonment • starvation • inadequate supervision • medical neglect (Berkowitz, ‘01)
  21. 21. EMOTIONAL IMPAIRMENT affect regulation poor attachment • increased relationship difficulties and parenting difficulties development of the self-system • more likely to view themselves and others negatively more psychopathology
  22. 22. TRAUMA the brain engages in a form of pattern recognition to cues in the environment or in relationships which result in a similar body response (hormonal, neuronal and then behavioural) to the original trauma experiences most vulnerable children (repeated or cumulative exposure to adversity) • show the largest negative reaction • experience an exaggerated response to a stressor • may be more vulnerable to negative inputs from the social world • experience the worst of both worlds because their inherent risk factors increase both the likelihood of poor health outcomes and their susceptibility to the adverse effect of stressful experiences on health (Odger & Jaffee 2013)
  23. 23. DEVELOPMENTAL IMPACT ASSOCIATED WITH COMPLEX TRAUMA EXPOSURE National Child Traumatic Stress Network (NCTSN) have put forth a phenomenologically based framework to understand children’s adaptation to complex trauma exposure and have identified 7 domains of impairment 1. Attachment 2. Biology 3. Affect regulation 4. Dissociation 5. Behavioural control 6. Cognition 7. Self concept
  24. 24. COGNITION abused and neglected children have reduced I.Q. and lower academic achievement (Perez & Widom, 1994) neglected children have worst delays in expressive and receptive language compared to physically abused and non-maltreated children (Gaudin in Dubowitz, 1999) neglected children have poorest school performance (grades K – 12) of all maltreated children (Eckenrode et al., 1993)
  25. 25. SOCIAL • increased risk of aggression and violence in future relationships • higher rates of risky behaviour (violent criminal behaviours, substance misuse/abuse) • poor peer relationships • poor intimate relationships
  26. 26. BEHAVIOUR Behaviours • can’t sit still • not listening • hurting others, hitting • poor attention, lack of concentration • poor social interactions, speech delays Labels (Diagnosis): “ADD, ODD, CD, ASD” *Pervasive Developmental Problems of Neglect
  27. 27. STRESS AND HPA FUNCTIONING • HPA axis controls our reaction to stress • Stress/trauma experienced in early years can lead to ongoing dysregulation of the HPA axis • Predisposition to psychiatric vulnerability later in life.
  28. 28. Chronically elevated cortisol can have damaging effects on physiological processes in the body and predispose to psychiatric vulnerability HEART DISEASE OSTEOPOROSIS OBESITY DEPRESSION ANXIETY
  29. 29. IMPACT OF ADVERSITY “Significant links in the literature that growing up in a risky family with high emotional reactivity, decreased social competencies, deficits in emotional understanding and the failure to develop effective coping strategies within stressful situations disrupts the processes that are central to the maintenance of health.” (Odger & Jaffee, 2013)
  30. 30. ENVIRONMENT Poverty remains one of the most powerful determinants of whether and how children experience adversity. (Odgers & Jaffee, 2013)
  31. 31. ENVIRONMENT POVERTY = community stress high crime, violence, noise, overcrowding, poor schools decreased local resources (Cicchetti & Lynch 1993)
  32. 32. ENVIRONMENT Chronic adversity ongoing stressors • hostility • lack of warmth among family members • food insecurity • financial insecurity • under-resourced schools • under-resourced neighbourhoods (Odgers & Jaffee, 2013)
  33. 33. ACE STUDY Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Authors: Felitti, Anda, Nordenberg, Williamson, Spitz, Edwards, Koss, Marks. Reference: American Journal of Preventive Medicine 1998 May;14(4):245-58.
  34. 34. ABUSE NEGLECT HOUSEHOLD DYSFUNCTION SOURCE: DISEASE CONTROL AND PREVENTION
  35. 35. BEHAVIOUR
  36. 36. ACE STUDY
  37. 37. ALLOSTATIC LOAD the price the body pays when confronted with repeated major stressors result of chronic exposure to high and sustained neural and neuroendocrine responsiveness
  38. 38. PUBLIC HEALTH APPROACH 40 Surveillance What’s the problem? Risk Factor Identification What’s the cause? Intervention Evaluation What works? Implementation How do you do it? Problem Response (Potter et al., 1998)
  39. 39. INTERVENTION POINTS 41 Long-term outcomes Prevention before occurrence Prevention of recurrence Prevention of impairment Universal Targeted Maltreatment
  40. 40. NURSE FAMILY PARTNERSHIP PROGRAM First-time disadvantaged mothers received home visits by nurses Began prenatally and extended until child’s 2nd birthday (weekly and then tapered) Nurses promoted 3 aspects of maternal functioning: • health-related behaviors • maternal life course development • parental care of children 4 2
  41. 41. IMPLICATIONS FOR PREVENTION OF PSYCHIATRIC DISORDER Programs shown effective in preventing child maltreatment may also prevent psychiatric disorder Adolescents born to home-visited women reported: • less running away • fewer arrests and convictions • fewer behavioral problems related to use of alcohol and drugs (Olds et al., 1998) 4 3
  42. 42. 44 www.fhs.mcmaster.ca/net
  43. 43. IMPAIRMENT 1. Attachment: problems with relationship boundaries, lack of trust, social isolation, difficulty perceiving and respond to other’s emotional states and lack of empathy 2. Biology: sensory-motor developmental dysfunction, sensory-integration difficulties, somatization, and increased medical problems 3. Affect regulation: poor affect regulation, difficulty identifying and expressing emotions and internal states. Difficulties communicating needs, wants and wishes
  44. 44. IMPAIRMENT 4. Dissociation: amnesia, depersonalization, discrete states of consciousness with discrete memories, affect, and functioning, and impaired memory for state-based events 5. Behavioural control: problems with impulse control, aggression, pathological self-soothing, and sleep problems
  45. 45. IMPAIRMENT 6. Cognition: difficulty regulating attention, problems with a variety of executive functions, planning, judgment, initiative, processing new information, focusing, task completion, cause and effect, speech delay 7. Self-concept: Fragmented and disconnected autobiographical narrative, disturbed body image, low self- esteem, excessive shame, and negative internal working models of self
  46. 46. PROTECTIVE FACTORS Responsive care giver who believes and can validate the child and their feelings and experiences Tolerate and manage the associated affect Manage their own affective responses Child with easy temperament External attribution for blame Effective coping Talents, skill and spirituality Positive beliefs about ones self
  47. 47. RISK FACTORS Care giver has own history of childhood complex trauma Caregivers with impaired attachment relationships Child can trigger the parents own maladaptive coping
  48. 48. NCTSN PROPOSED TREATMENT MODEL Safety: Self-regulation: Self-reflective information processing: Traumatic experiences integration: Relational engagement: Positive affect enhancement:
  49. 49. WELL-BEING IS WELL-DOING HEALTH AND SOCIAL SERVICES
  50. 50. A PROMISE AND PREMISE OF INNOVATION …a dysfunctional policy environment has marginalized prevention to the detriment of health outcomes. … To deal with this change, we need new modes of distributed healthcare delivery, a health economy based on prevention, and new technological literacies. (Ranck, 2012, p.8). There is a need to apply this to CAN prevention as a key driver of human development, health, and resilience.
  51. 51. Vulnerability Resilience Sensitivity Re-setting Response Hazard / Loss Resources / Potential Child Abuse and Neglect as Toxic Stress
  52. 52. UN CONVENTION ON THE RIGHTS OF THE CHILD AND CHILD ABUSE AND NEGLECT (CAN) Globally adopted, legally binding, action-oriented (1) The right to survival  CAN is deadly (2) The right to protection from harmful influences, abuse and exploitation CAN is common (3) The right to develop to the fullest CAN increases odds of physical, mental, and financial poor health (4) The right to participate fully in family, cultural and social life Need to focus on resilience within CAN populations
  53. 53. RESILIENCE • Competence in the face of adversity (Garmezy 1984) • Socially supportive relationships promote resilience • Children’s ability to maintain and recover from significant adversity depends on the overall balance of risk and protective factors in the children’s environment (Ciccheti 2006)
  54. 54. INTERVENTIONS Physical safety Psychological safety “One of the most important factors influencing children’s psychological adjustment is the degree of support they receive from their parents and other caregivers.” (Stirling et al 2008)
  55. 55. INTERVENTION - PRINCIPLES 1. Reshape the child’s perceptions and emotional responses 2. Help caregivers address their own behaviours 3. Inform and educate caregivers about the effects of adversity and reasons for behaviours in the child 4. Guide caregivers to less reactive and more positive parenting strategies (discourage aggressive responses, promotion of calm, consistent and predictable environments)
  56. 56. INTERVENTION Informed by a formulation and understanding of the child and his/her needs vs. Removal of risk factors, provide safety and treat behaviours alone
  57. 57. INTERVENTIONS Range of options: comprehensive evaluation – developmental, neuropsychological, cognitive, medical academic supports education about child abuse and reactions of children teaching safety skills stress management, emotional regulation skills trauma therapy, trauma narrative, TF-CBT assisting emotional and cognitive processing (correcting untrue or distorted ideas about how and why the trauma occurred) home visitation (Nurse-Family Partnership) art therapy medications respite out of home placement
  58. 58. TAKE HOME MESSAGES • Neglect has some of the worst outcomes for children • Child abuse that occurs in the context of family relationships results in complex trauma • Children who have a history of maltreatment must be understood in a developmental perspective • It is important to formulate an understanding with the lens of adversity and trauma
  59. 59. CONCLUSION “The most beautiful people I've known are those who have known trials, have known struggles, have known loss, and have found their way out of the depths.” ― Elisabeth Kübler-Ross
  60. 60. THIS WORK IS IN PART DUE TO SUPPORT FROM A CIHR TEAM GRANT "UNDERSTANDING HEALTH RISKS AND PROMOTING RESILIENCE IN MALE YOUTH WITH SEXUAL VIOLENCE EXPERIENCE” (PI: C. WEKERLE, GRANT # TE3-138302) ACKNOWLEDGEMENTS:

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