From the (Legal to Wet) Bench to Bedside:
Devon M. Fagel, JD
Pediatrics Clerkship, YSM III
Yale Child Sexual Abuse Clinic
October 29, 2010
Neurodevelopmental Effects of Child Abuse & Neglect
• Background: Why child abuse & neglect?
• Definitions: What is child abuse & neglect?
• Clinical Research: Does abuse & neglect cause delay?
• Neurobiology: Developmental delays & reduced neurogenesis.
• Prevention: What can be done to reduce prenatal abuse?
• Treatment: What can be done to reduce the impact of neglect?
• Conclusion: Utilizing translation of research to effect change.
• Conclusion: Stem Cells - Hope for the future
• Risk Factors:
• Family - domestic violence, poverty, social isolation, many children under 5.
• Parent - hx of maltreatment, mental illness, substance abuse and under 19.
• Children - undesired pregnancies, multiple gestation and disabled children.
• Sexual Abuse:
• Comprehension - involvement in sexual activities the child does not
• Informed Consent - age restrictions on ability to consent to sexual activities.
• Social Taboos - acts which violate norms (exposing children to pornography).
• Physical & Emotional Abuse:
• Non-Accidental Injury - includes striking, kicking, burning, biting, etc.
• Threats of Harm - acts which invoke fear of serious bodily harm.
• Psychological Abuse - behavior which impairs a child’s emotional
• Failure to Provide Basic Needs - food, clothing, shelter, supervision.
• Medical and Educational Needs - includes failure to provide mental health
Child Abuse & Neglect
Asnes & Leventhal, Pediatri. Rev. 31: 47-55, 2010
Leventhal & Asnes, Am. Aca. Ped: 1106-1114, 2009
• Abuse: Gen. Stat. Section 46b-120
• Inflicted with physical injury or injuries by other than accidental means.
• Injury or injuries that are at variance with the history given of them.
• In a condition that is the result of maltreatment which includes malnutrition,
sexual molestation, deprivation of necessities and emotional maltreatment
• Neglect: Gen. Stat. Section 46b-120
• Had been abandoned.
• Is being denied proper care and attention physically, educationally and
• Is being permitted to live under conditions, circumstances or associations
injurious to the well-being of the child or youth.
Prenatal Substance Abuse
14 States and the District of Columbia consider prenatal use
of an illegal drug or substance to constitute abuse or neglect.
• Children prenatally exposed to tobacco exhibit increased
rates of behavior problems related to response inhibition
• Smoking-exposed infants exhibit increased need for
handling and decreased self-regulation relative to matched
• Boys (4-9) exposed to cocaine have lower IQ scores and
difficulty with abstract/visual reasoning and short term
• Infants exposed to cocaine have greater cortisol reactivity
to caregiver instability compared to non-exposed controls.
• Infants exposed to alcohol exhibit cognitive and functional
disabilities due to stunted growth and decreasedBennet et al., Nerotoxicol. Tertaol. 2009 (e-pub ahead of Stroud et al., J. Pediatr. 154: 10-16 (2009)Bennet et al., Dev. Psychology 44: 919-928 (2008)
Elden et al., Child Dev. 80: 528-543 (2009)
Jones & Smith, Lancet 302: 999-1001 (1973)
Environmental Enrichment Following Hypoxia:
Can Therapy Improve Neurological Outcomes?
• Transgene marked
(green) are markedly
enrichment in both
D&E) and hypoxia
• This study confirms
that hypoxic mice
can further boost
• Yet translating these
findings to humansFagel et al., manuscript in progress
Successes and Challenges of Promoting Positive Parenting
• Special Child Welfare Clinic: Established
in 1994 in Norway to provide treatment and support
to substance-abusing pregnant women and their
children. More than 95% of women that completed
their pregnancies reduced their substance abuse
considerably. Study found that women who
continued substance abuse more likely to experience
premature birth and give birth to low birth weight
• Nurturing Families Network: Universal
screening targets recruitment of first-time mothers
which exhibit risk factors for poor parenting and
provide home visits with education on development
and reliable, consistent emotional support toMinozzi et al., Chochrane Database of Systemic Reviews 2:CD006318, 2008
Hjerkinn et al., Substance Abuse Treatment, Prevention and Policy 29: 5-17, 2010
• Special Outpatient Services: Of 2315
infants younger than 28 weeks’ gestational age
weighing less than 1000g, 55% used more than 3
SOS by 22 months with almost 20% needing 6-7
SOS. This demonstrates that extremely preterm
survivors have substantial needs for community
support regardless of their impairment.
Early Intervention to Reduce the Risk of Developmental Delays
Hintz et al., Arch Pediatr. Adolesc. Med. 162: 748-755, 2008
Utilizing Basic Science to Improve Children’s Lives
Gunnar et al., Dev. Psychopath. 18: 651-677, 2006
• Basic science research demonstrates risks of
premature birth associated with substance
abuse during pregnancy and need for
preventative programs for mothers and
treatment programs for at risk children.
• Basic science research also demonstrates risks
of limited environmental stimulation
associated with child abuse & neglect and
need for proper parenting programs for
mothers and special services for at risk