Bernadette Madrid, University of the Philippines, Director of the Child Protection Unit, Philippines - Parenting support in the context of violence prevention, Expert Consultation on Family and Parenting Support, UNICEF Office of Research – Innocenti Florence 26-27 May 2014

1. Family & Parenting Support in the
Context of Violence Prevention
Bernadette J. Madrid, MD
University of the Philippines Manila
and
Child Protection Network Foundation

2. 5 year-old Jackson
admitted for
generalized
weakness and
possible child
neglect

3. Critical Periods & Brain Plasticity
• A critical period is a
time during an
organism’s life span
when it is more
sensitive to
environmental
influences or
stimulation than at
other times during
its life.

4. ACEs HAVE MANY IMPACTS THROUGHOUT THE LIFESPAN
Critical &
Sensitive
Dev’tal period
ADVERSE CHILDHOOD
EXPERIENCE
MORE CATEGORIES –
GREATER IMPACT
Physical Abuse, Sexual Abuse,
Neglect Witnessing Domestic
Violence, Depression/Mental
Illness in Home
Incarcerated Family Member
Substance Abuse in Home
Loss of a Parent
GENETICS
Including gender –
Remember that
experience triggers
gene expression
(Epigentics)
CHRONIC DISEASE PSYCHIATRIC
ADAPTATION
Hard-Wired
Into Biology
Brain
Development
Electrical,
Chemical, Cellular
Mass
DISORDER
IMPAIRED
COGNITION
WORK/
SCHOOL
Attendance
Behavior,
Performance
OBESITY
ALCOHOL,
TOBACCO,
DRUGS
RISKY SEX
Carson & Porter, 2011
POVERTY CRIME
INTERGENERATIONAL
TRANSMISSION,
DISPARITY

5. Adverse Childhood Experiences and
Health-Risk Behaviors Among
Adults in a Developing Country Setting
Laurie S. Ramiro, PhD, Bernadette J. Madrid, MD,
David R. Brown, PhD
Child Abuse & Neglect 2010; 34: 842-855

6. Categories of adverse
childhood
experiences, Number
Percentage
(n=1068)
0 26.8
1 24.7
2 18.8
3 13.8
4 or more 9.2
75% had at least one ACE
Ramiro L, Madrid B, Brown D
Child Abuse & Neglect 2010; 34: 842-855

7. Results of the Metro Manila
ACE Study
Those who were sexually abused are:
• 12 times more likely to engage in early sex;
• 9 times more likely to have early pregnancy;
• 5 times more likely to commit suicide.
Ramiro L, Madrid B, Brown D
Child Abuse & Neglect 2010; 34: 842-855

8. Results of the Metro Manila
ACE Study
Individuals who felt that they were not loved
during childhood are:
• Twice as likely to smoke, use illicit drugs,
have early sex and multiple sex partners
• 5 times more likely to commit suicide.
Ramiro L, Madrid B, Brown D
Child Abuse & Neglect 2010; 34: 842-855

9. Strong graded response between number of
ACEs & poor health
• Bronchitis/
emphysema
• Asthma
• Ischemic Heart Disease
• Hypertension
• Tuberculosis
• Skin problems
• UTI
• Liver problems
• GI problems- ulcers,
constipation, indigestion
• Depression
Ramiro L, Madrid B, Brown D.
Child Abuse & Neglect 2010; 34:842-855

10. Diseases Number of deaths Percentage
1. Diseases of the heart 100,908 21.0
2. Cerebro-vascular Many disease chronic diseases 56,670 in adults
11.8
3. Malignant neoplasm 47,732 9.9
4. Pneumonia are determined decades 42,642 earlier,
8.9
5. Tuberculosis by experiences in childhood
25,470 5.3
6. COPD 22,755 4.7
7. Diabetes 22,345 4.6
8. Nephritis, Nephrotic Syndrome 13,799 2.9
9. Assault 12,227 2.5
10. Certain conditions arising from perinatal
11,514 2.4
period
Philippine National Statistics Office, 2009

12. Maternal and Child Health are
Intertwined
• The status of the mother such as stress, anxiety
and depression has been shown to be associated
with an increased risk of developing a wide
variety of disorders in the offspring e.g. LBW,
learning & memory
• Maternal over-and under-nutrition has been
associated with the onset of metabolic syndrome
as well as autism and developmental delays.

13. Maternal and Child Health are
Intertwined
• Maternal iron and iodine deficiency affects the
child’s cognitive development and later
behavioral problems.
• Iron deficiency affects learning & memory, motor
development, language development, behavior
problems including anxiety & depression
• Best time to correct the iron and iodine
deficiencies is during adolescence before the
pregnancy.

14. Age/sex/
Physiologic State Number Prevalence (%)
Philippines 22412
6 mos - < 1 yr 205
1-5 y 2279
6-12 y, M 2039
F 1830
13-19 y, M 1778
F 1488
Pregnant 1516
Lactating 891
19.5
55.7
20.9
20.4
19.2
10.4
18.2
42.5
31.4
Anemia prevalence by age, sex, and physiologic state: FNRI, 2008

15. Perinatal risk factors for infant
maltreatment
• Mother smoked during pregnancy
• Families with 3 or more siblings
• Maternal age less than 20 years
• Births to unmarried mothers
• Medicaid benficiaries (poverty)
• Inadequate prenatal care
Zhou Y, Hallisey E, Freymann G (2006)
International Journal of Health Geographics 5:53

16. Adolescent Risk Factors for Child
Maltreatment
• Area characteristics
• Family
background/structure
• Parent stressors
• Exposure to family
violence
• Parent-child
relationship
• Education
• Peer relationships
• Adolescent stressors
• Antisocial
behaviours
• Precocious
transitions
Thornberry, TP et. al., Child Abuse & Neglect 2013

17. Cumulative Risk
• Long-term damage that occurs through the
compounding of environmental,
socioeconomic and behavioral exposures
across the life-course.

18. Critical Periods
• Note that the peak of
plasticity for each sensitive
period is staggered
throughout development.
• More-complex or
multifaceted brain
functions, especially those
in humans, tend to reflect
cumulative sensitive
periods rather than one
critical period -

19. Connected by 25: Improving the life
chances of the country’s most
vulnerable 14-24 year olds
Disconnected youth: They have not acquired the
skills needed to connect with the labor force and
they have not established social support systems:
1. Those who do not complete high school.
2. Youth deeply involved in the juvenile justice
system.
3. Young, unmarried mothers
4. Adolescents in foster homes
Michael Wald & Tia Martinez 2003
Stanford University

20. Disconnected youth
• Unless something is done they become either
victims of trafficking, commercial sexual
exploitation or incarcerated.
• “These youth need major, major ongoing
support in overcoming the sense of
inadequacy, in acquiring job skills and
education and in staying connected once
change has started to occur.”
Michael Wald & Tia Martinez 2003
Stanford University

21. Child Maltreatment Prevention Readiness in
Low- and Middle-Income Countries
Mikton, Mehra, Butchart, et al (2011)
• Evidence-based interventions alone are not
sufficient to prevent child maltreatment, other
conditions must be met to bridge the
“science-practice” gap.

22. 10 Dimensions of the Readiness Assessment for
Child Maltreatment Prevention
Mikton, Mehra, Butchart, et al (2011)
1. Attitudes toward child maltreatment & its
prevention
2. Knowledge about child maltreatment & its
prevention
3. Existence of scientific data on child
maltreatment & its prevention in the country
4. Existing child maltreatment prevention
programs; CMP components could be
integrated; outcome evaluations

23. 10 Dimensions of the Readiness Assessment for
Child Maltreatment Prevention
Mikton, Mehra, Butchart, et al (2011)
5. Legislation, official mandates of government or
NGOs, and policies relevant to CMP.
6. Will to address the problem
7. Institutional links & resources of institutions
involved in CMP.
8. Material resources –funding, infrastructure,
equipment

24. 10 Dimensions of the Readiness Assessment for
Child Maltreatment Prevention
Mikton, Mehra, Butchart, et al (2011)
9. Human and technical resources
-mental health, social work
10. Informal social resources

25. 9. High Level of
Community Ownership
8. Confirmation /
Expansion
7. Stabilization
6. Initiation
STAGES OF COMMUNITY
5. Preparation
READINESS
4. Preplanning
3. Vague Awareness
2. Denial / Resistance
1. No Awareness

26. Way to Go
• Formation of a coalition of government agencies
and NGO’s that will steer the country’s direction
towards prevention of child maltreatment
• National Prevalence Study on Child Maltreatment
• Invest on a primary prevention program that is
population-based; has been shown to work and
can generate political support: Parenting
Program

27. Kenrich, et al 2010

28. Economies of Scale
• Universal Health Care
• Conditional Cash Transfers

29. Breakdown of sexual abuse cases by age
260
476
375
501
1147
675
83
'0-3 4-6 7-9 10-12 13-15 16-17 >18
Sexual abuse
Child Sexual Abuse Cases
(2012)

30. 70
60
50
40
30
20
10
0
Minor Perpetrator referred to Psychiatry
2 4
30
2003-2011
47
65
10
1 4
'0-3 4-6 7-9 10-12 13-15 16-17 >18 UV
Age

32. Material situation
M Lau and J Bradshaw 2010
Child Indicators Research
Vol. 3 No. 3, 367-383

33. Health
M Lau and J Bradshaw 2010
Child Indicators Research
Vol. 3 No. 3, 367-383

34. Education
M Lau and J Bradshaw 2010
Child Indicators Research
Vol. 3 No. 3, 367-383

35. Living environment
M Lau and J Bradshaw 2010
Child Indicators Research
Vol. 3 No. 3, 367-383

36. Risk and safety
M Lau and J Bradshaw 2010
Child Indicators Research
Vol. 3 No. 3, 367-383

37. Subjective well-being
M Lau and J Bradshaw 2010
Child Indicators Research
Vol. 3 No. 3, 367-383

38. Can Money buy happiness?

39. High income improves evaluation of
life but not emotional well-being
By Daniel Kahneman and Angus Deaton
Center for Health & Well-Being
Princeton University 2010
• When plotted against log income, life evaluation rises
steadily.
• Emotional well-being also rises with log income, but
there is no further progress beyond an annual income of
$75,000.
• Low income exacerbates the emotional pain associated
with misfortunes as divorce, ill health & being alone.

40. Can Money buy happiness?
High income improves evaluation of life but not emotional well-being
Daniel Kahneman and Angus Deaton
Center for Health & Well-Being
Princeton University 2010
• Conclusion: High income buys life satisfaction but
not happiness, and low income is associated with
both low life evaluation and low emotional well-being.