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Childhood Maltreatment and Mental Health

The CDC Adverse Childhood Experiences Study: Childhood Mental Health and Lifetime Health Early Childhood Mental Health Institute May 11-13, 2009 Anchorage, Alaska Mark Erickson, MD Southcentral Foundation Childhood Maltreatment and Mental Health

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Childhood Maltreatment and Mental Health

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  1. The CDC Adverse Childhood Experiences Study:Childhood Mental Health and Lifetime HealthEarly Childhood Mental Health InstituteMay 11-13, 2009Anchorage, AlaskaMark Erickson, MDSouthcentral Foundation

  2. Childhood Maltreatment and Mental Health • Over the last 25 years many studies have explored whether childhood maltreatment influences later mental health. • It does but… • Earlier studies were too small and narrowly focused to answer a crucial question. • Q. To what extent does severe stress, in the childhood home, influence later mental and physical health?

  3. Childhood Maltreatment and Health • Needed: • Study with a large number of participants. • Participants of age to have significant medical histories. • Medical records available for all participants. • Expanded conceptualization of child maltreatment: • Include sexual and physical abuse, neglect • But also other child stressors, e.g., parental alcoholism, marriage discord, etc.

  4. Childhood Maltreatment and Health • CDC Adverse Childhood Experiences (ACE) Study: • Over 17,000 men and women surveyed. • Average age = 57 years • Members of San Diego HMO • Participants surveyed on 10 types of adverse childhood experiences . • Now over 25 peer reviewed publications from CDC study (1998-present).

  5. ACE Study Expanded definition of child maltreatment: • 10 types of adverse experiences surveyed. • 1. Sexual abuse 2. Emotional abuse 3. Emotional neglect. 4. Physical abuse 5. Physical neglect 6. Substance abuse in home. 7.Mental illness in home. 8. Incarceration of family member. 9. Parental separation or divorce. 10. Witness violence against mother.

  6. ACE Study Key finding 1: Expanding definition of childhood “maltreatment” had real life significance: Each of the 10 types of adverse childhood experiences influence adult health. Key Finding 2: Adverse childhood experiences can have an astonishingly broad based, harmful influence on adult health. Key finding 3: The health effects of adverse childhood experiences may not manifest for decades.

  7. ACE Study Key Finding 4: The more kinds of adverse childhood experiences a participant reported the greater the risk for a given health problem (trauma-dose relationship). Key Finding 5: The more kinds of adverse childhood experiences a participant reported the greater the risk for more health problems (co-morbidity).

  8. Heart disease Teen pregnancy Cancer COPD STDs Liver dis. Smoking Alcohol abuse Promiscuity Obesity Drug dependence IV drug use Somatization Depression Anxiety disorders Hallucinations Sleep disturbances Memory disturbances Anger problems Domestic violence risk Early intercourse Job problems Relationship problems Skeletal fractures Anda et al. (2008) BMC Public Health 8, doi:10.1186/1471-2458/8/198 Health Elements Influenced by ACEs(broad based & life long)

  9. Cardiovascular Disease and ACE’s Risk factors for heart disease • History of smoking 1.2x • Domestic violence in home 1.4x • Childhood physical abuse 1.5 x • Hypertension 1.9x • Complex childhood abuse 3.6x (trauma dose) M Dong et al. (2004) Circulation v110:1761-66

  10. Lifetime Risk for Attempted Suicide and ACE’s CDC Adverse Childhood Experiences Study (2001) Key Findings on suicide risk: (trauma dose relationship) 0 adverse childhood experiences – baseline 1.0x 1 adverse childhood experience increased lifetime risk of suicide attempt 1.9x 2 adverse childhood experiences increased lifetime suicide attempt risk 3.3x 3 adverse childhood experiences increased lifetime suicide attempt risk 4.3x 4 “ “ 6.2x 5 “ “ 10.6x 6 “ “ 16.5x 7 or more adverse childhood experiences increased lifetime risk 31x S.H. Dube et al. (2001) JAMA v 286:3089-96

  11. ACE Study: Trauma-dose relationship I. Common diseases influenced by trauma-dose: • Heart disease • Cancer • COPD • Skeletal fractures • Sexually transmitted diseases • Liver disease

  12. ACE Study: Trauma-dose relationship III. Mental health problems influenced by trauma-dose: - Depressive disorders - Anxiety disorders - Panic attacks - Hallucinations - Sleep disturbances - Autobiographical memory disturbances - Poor anger control - Suicide attempts - Risk of perpetrating or being a victim of domestic violence.

  13. Trauma Dose: Why Any Success at Prevention of Child Maltreatment is Important Example: A prevention effort that reduces ACE’s in family from 3 to 1. • Suicide risk cut 84% • Alcohol dependence risk cut in half • …and so on for 33 measures of health

  14. Why Do Adverse Childhood Experiences, Alone, Increase the Risk for Diseases,Such as Cancer, Decades Later? Child maltreatment can cause: • Chronic inflammation - elevated C-reactive protein. A.Danese et al., (2008) Arch Gen Psych, v65: 409-416. • Chronic dysregulation of stress hormones ACTH and cortisol G Gerra et al.(2007) Addiction Biology v13:95-104. • Chronic inhibition of protein synthesis in the hippocampus – an area of the brain linked to emotion and memory P McGowan et al.,(2008).PLoS,v3.5 e2085.

  15. Southcentral Foundation Family Wellness Objectives FMW1: Reduce the rate child abuse and neglect ------------------------------------------------------------------------ FMW1’: Reduce the rate of domestic violenceFMW2: Reduce the rate of preventable cancersFMW3: Reduce the incidence of suicideFMW4: Reduce the rate of obesityFMW5: Reduce the rate of substance abuseFMW6: Reduce the rate of diabetesFMW7: Improve oral healthFMW8: Reduce the rate of cardiovascular disease

  16. CDC Study concluding comment • “Current practices of medicine…are fragmented by… a symptom based system of medical care. Prevention …of our nation’s leading health problems is likely to benefit from understanding that many of these problems tend to be co-morbid and may have common origins in the enduring ...consequences of abuse and…experiences during childhood.”

  17. The CDC Adverse Childhood Experiences Study:Childhood Mental Health and Lifetime HealthEarly Childhood Mental Health InstituteMay 11-13, 2009Anchorage, AlaskaMark Erickson, MDSouthcentral Foundation

  18. Preventing Child Maltreatment • Leveraging Nature: The Biology of Parental Bonding. - Dena A Coy • Teaching Parenting Skills and Providing Support. - Nutaqsiivik • The Power of Story: Generational Healing. - FWWI: Beauty for Ashes, Arrigah House **No prevention study has ever used more than one of the above types of preventative intervention.

  19. Leveraging Nature: France 1800’s La Maternité: Charity hospital in Paris. In 1830 - 64% of infants born at La Maternité were abandoned. Rachel Fuchs (1987). Journal of Interdisciplinary History, v18:55-80

  20. Leveraging Nature: France 1800’s In 1837 hospital policies were changed at La Maternite: • Mothers were asked to stay and nurse. • Abandonment decreased ~40% • Policies changed over the decades • Key finding: the longer mothers stayed and nursed the less likely they were to abandon infant. • Rachel Fuchs (1987). Journal of Interdisciplinary History, v18:55-80.

  21. Leveraging Nature: Global Data Costa Rica - Policy change increased mother-infant post-partum contact and reduced abandonment ~ 70% (n~78,000)L. Mata et al. (1988) In Programs to Promote Breastfeeding, ed B. Jelliffe, Oxford Univ. Press Thailand - Hospital adopts UNICEF proposal increasing mother-infant contact resulting in decreased abandonment, n~4000 births B Baranasin (1991) Asia-Pacific J Public Health v5:217-220. Russia - Large maternity hospital increased mother-infant contact in at-risk women resulting in ~46% reduction in infant abandonment, n~20,000. N. Lvoff et al. (2000) Arch Pediatr Adolesc Med v154:474-77.

  22. Teaching Parenting Skills • Nurse-family partnerships: • Nurses visit home, teach and support parents. • This approach can prevent child abuse. • Key Finding: At risk families visited by a nurse during the first two years of life were 48% less likely to have abused or neglected offspring. David Olds et al. (1997) J. Community Psych. v25:9-25

  23. The Power of Story and Generational Healing • Numerous studies have shown that generational patterns of parenting exist. • About 70% of parents who abuse were abused in their childhood • Good parenting tends to beget good parenting • Abusive parenting tends to beget abusive parenting.

  24. The Power of Story and Generational Healing • The CDC Adverse Childhood Experiences study shows that adults, traumatized as children, have difficulty remembering their childhood. • Attachment research, similarly, shows that many adults, traumatized as children, have difficulty describing their childhood - or telling their story.

  25. The Power of Story and Generational Healing • Attachment research also shows that adults who remember and “tell their story” in a full and honest way are unlikely to repeat generational abuse M Main and R Goldwyn (1984) Child Abuse and Neglect v8:203-17. • This is just one of the several important things that FWWI does. FWWI helps people remember their story.

  26. Family Wellness Warriors Initiative • Created in 1998 by Alaska Native and American Indian Peoples • Goal: To end child abuse and neglect in this generation. • Method: Helping people to tell their story in 3-5 day gatherings that integrates spiritual and cultural renewal with evidence-based psychology.

  27. Family Wellness Warriors Initiative • Over 1,300 have attended • Research findings show that in follow-up with participants of Beauty for Ashes and Arrigah House the association between “real family” and “ideal family” is much closer (p=.00039). • Q. If parents start telling their story in the months before and/or after birth of their child does this result in a greater level of prevention?

  28. Childhood Mental Health and Long Term Health:The CDC-ACE StudyEarly Childhood Mental Health InstituteUniversity of Alaska – May 11-13, 2009Mark Erickson, MDSouthcentral Foundation

  29. Leveraging Nature Landmark Study: (Klaus, Kennel et al. 1972) • 1. Half of mothers received hospital care as usual – (separation) • 2. The remaining mothers roomed in with infant until discharge Key findings: • At one month mothers who roomed in with infant were • more responsive to infants cry • more reluctant to leave infant • more direct eye contact • more affectionate • At one year mothers who roomed in still doing better. M Klaus, J Kennell, et al. (1972) NEJM, v286:460-463 J. Kennel et al. (1974) Dev. Med. Child Neur. v16:172-79

  30. Leveraging Nature: Breastfeeding • 6,621 mother-infant pairs followed over 15 years (Australia) • Mothers who breastfed more than 4 months were 4.8x less likely to maltreat child. • After controlling for 18 potential confounding variables still 2.6x less neglect L Strathearn et al (2009). Pediatrics v123:483-93.

  31. Leveraging Nature: Dena A Coy Mothers at Dena A Coy are extremely high risk. Yet, of approximately 50 mothers who initially planned to give their baby up for adoption, less than 10 have. (Personal communication, Carolee Kukahindin, 2008) Q. Is the pre- and post-partum support for the highest risk mothers at Dena A Coy leveraging maternal bonding and reducing abandonment?

  32. Leveraging Nature: SCF/ANMC: • 1400 births per year at ANMC. • 800 Anchorage area births per year. • 46% (~370) of local mothers are at-risk (e.g., homeless, single, inadequate income, abused as children). • Average maternity admit = 2.1 days. • Risk for abandonment, neglect and abuse entering next generation is high. • Q. Should we create a maternal post-partum home to offer to risk mothers?

  33. Teaching Parenting Skills: SCF Nutaqsiivik • Nutaqsiivik - started in 1994 to reduce SIDS deaths and in this regard has been successful. • Program has similarities to evidence based nurse-family partnership model. • Nutaqsiivik nurses visit mother during pregnancy and mother and child for first year – in Olds’ model two years. • Nurses teach mother about infant health, maternal care and provide support as in Olds’ model. • Nutaqsiivik may be preventing child maltreatment - but we haven’t measured it - measuring may be possible through collaboration with AK State Dept. Epidemiology.

  34. Preventing Child Maltreatment • Leveraging Nature: The Biology of Parental Bonding. - Dena A Coy • Teaching Parenting Skills and Providing Support. - Nutaqsiivik • The Power of Story: FWWI and Inter-generational Healing. - Beauty for Ashes, Arrigah House **No prevention study has ever used more than one of the above types of preventative intervention.

  35. Costs of Child Abuse: USA $104 billion spent annually for the direct costs of child abuse. An additional $69.5 billion spent for indirect costs including special education, mental and physical health care and juvenile delinquency. Cost per maltreated child ~$182,000 C Wang and J Holton (2007) Economic Impact Study funded by Pew Charitable Trusts, and S. Fromm (2001) Total estimated costs of child abuse and neglect in the United States: Statistical evidence, http://member.preventchildabuse.org/site/ PageServer?pagename=research_child_abuse; )

  36. CDC Study concluding comment “The mind-body dichotomy that persists in Western medical training may lead clinicians away from understanding the role that childhood trauma and stress has on the health of their adult patients.…understanding the role of these childhood experiences on adult health will become increasingly important in making decisions about prognosis, diagnosis and treatment.” CDC research group (2008) BMC Public Health 8:198.

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