1. Violence and Injury Prevention Short Course National Family Safety Program, NGHA January 28 th and 29 th 2013 Presentation 4. Step 1 of the Public Health Approach to Child Maltreatment Prevention: Consequences of Child Maltreatment Presented by Alaa Sebeh, MD Ph.D. Independent International Consultant, Child Protection & Disability. alaa1234@gmail.com

2. Violence and Injury Prevention Short Course Objectives The core learning objective of this module is to provide a basic understanding of the consequences of child maltreatment – immediate and lifelong physical and mental health and social and economic consequences – which is part of step 1 of the public health model to child maltreatment prevention.

3. Violence and Injury Prevention Short Course Outline 1.Consequences of Child Maltreatment on Mental and Physical Health and Social Functioning 2.The Findings of the Adverse Childhood Experiences Studies (ACE) 3.Child Maltreatment as a Risk Factor for Other Types of Violence 4.Consequences on Human Capital Formation and Economic and Social Development 5.Summary and Conclusion

4. Violence and Injury Prevention Short Course Consequences of Child Maltreatment on Mental and Physical Health and Social Functioning

5. Violence and Injury Prevention Short Course Lifelong Consequences on Mental and Physical Health Child maltreatment can have serious immediate health impacts such as death and injury. But by far the more important are the non-injury mental and physical health consequences that manifest themselves throughout the life-course Child maltreatment is both an important health problem and a major risk factor for other serious physical and mental health problems. Child maltreatment often causes difficulties in cognitive and emotional functioning and social relations. Victims of child maltreatment are likely to cope with these difficulties by adopting health risk behaviours, such as: Smoking Excessive drinking Unsafe sexual practices Physical inactivity Child maltreatment is also associated with a higher probability of violent victimization and the perpetration of violence later in life.

6. Violence and Injury Prevention Short Course Child Maltreatment and the Substantial Burden on Mental Health Child maltreatment increases the risk of behaviour problems, including internalising (e.g. anxiety, depression) and externalising (e.g. aggression, acting out) behaviour. WHO estimates that sexual abuse experienced during childhood accounts for serious health problems in the general population including: 27% of post-traumatic stress disorders 10% of panic disorders 8% of suicide attempts 6% of cases of depression, alcohol misuse, and illicit drug abuse

7. Violence and Injury Prevention Short Course Child Maltreatment and Long-Term Deficits in Educational Achievement Prospective longitudinal studies have consistently shown that maltreated children have lower educational achievement and are more likely to receive special education. Decreases in school attendance and school performance were related to the timing of maltreatment and were cumulative. Most of these associations persisted after adjustment for family and social characteristics (e.g. ethnic origin, age, sex, and socioeconomic status).

8. Violence and Injury Prevention Short Course The Findings of the Adverse Childhood Experiences Studies (ACE)

9. Violence and Injury Prevention Short Course The Adverse Childhood Experiences Study One of the most important studies on the consequences of child maltreatment is the ACE study. This is a major American study providing primarily retrospective but also some prospective analysis based on a sample of 17,000 individuals of the effect of adverse childhood experiences during the first 18 years of life on the following outcomes: Later well-being Social function Health risks Disease burden Health care costs Life expectancy

10. Violence and Injury Prevention Short Course The Adverse Childhood Experiences ACEs is a broader concept than child maltreatment which includes the following 10 types of experiences grouped into the following three categories: Abuse Emotional - recurrent humiliation Physical - beating, not spanking Contact sexual abuse Neglect Physical Emotional Household dysfunction Mother treated violently Household member was alcoholic or drug user Household member was imprisoned Household member was chronically depressed, suicidal, mentally ill, in psychiatric hospital Child not raised by both biological parents

11. Violence and Injury Prevention Short Course The Adverse Childhood Experience Score The ACE Study uses the ACE Score, which is a count of the total number of ACE respondents reported. Graphic: WHO

12. Violence and Injury Prevention Short Course ACE and Health Risks The study has demonstrated that as the number of ACEs increases, the risk for a number of serious mental and physical health and social problems increases in a strong and graded fashion. The association with physical health problems later in life is mainly due to the adoption of health risk behaviours.

13. Violence and Injury Prevention Short Course ACE Score and Rates of Antidepressant Prescriptions 0 1 2 3 4 >=5 Prescription rate (per 100 person-years) 100 90 80 70 60 50 40 30 20 10 0 Source: Anda, R. (2009). ACE PowerPoint Presentation. Geneva, World Health Organization.

14. Violence and Injury Prevention Short Course Childhood Experiences vs. Adult Alcoholism % Alcoholic 4 2 0 4 0 6 8 10 12 14 16 ACE Score Source: Anda, R (2009). ACE PowerPoint Presentation. Geneva, World Health Organization.

15. Violence and Injury Prevention Short Course Long-Term Consequences of ACE Adoption of Health-risk Behaviors Social, Emotional, & Cognitive Impairment Early Death Adverse Childhood Experiences  Toxic Stress Disease, Disability and Social Problems Death Conception ACEs are fundamental risk factors for disease and early death Source: CDC (2010).

16. Violence and Injury Prevention Short Course Neglect and Brain Damage Left: Healthy 3-year-old child Right: 3-year-old child following total global neglect during early childhood. The brain is significantly smaller than average and has abnormal development of cortical, limbic, and midbrain structures.

17. Violence and Injury Prevention Short Course ACEs and Impairments in Social Functioning: Work Performance Absenteeism (>2 days/month) Serious Financial Problems Serious Job Problems Prevalence of Impaired Performance (%) Source: Mikton, C. (2010). ACE PowerPoint Presentation. Geneva, World Health Organization.

18. Violence and Injury Prevention Short Course Child Maltreatment as a Risk Factor for Other Types of Violence

19. Violence and Injury Prevention Short Course The Intergenerational Transmission of Interpersonal Violence The intergenerational transmission of interpersonal violence can occur in the following ways: 1. From victimization to further victimization in the home and community 2. From victim to child abuser in the home 3. From victim to perpetrator of violence against an intimate partner in the home; and/or from victim to perpetrator in the community

20. Violence and Injury Prevention Short Course Typology of Violence Source: Krug, E. et al. (2002). World report on violence and health. Geneva, World Health Organization.

21. Violence and Injury Prevention Short Course Child Maltreatment as a Risk factor for Other Forms of Violence: Example 1 A survey of 5,908 French women in stable relationships found that 1 in 7 of those with a childhood history of maltreatment reported serious abuse by their spouse, compared with 1 in 20 of those with no such experience in childhood.

22. Violence and Injury Prevention Short Course Child Maltreatment as a Risk factor for Other Forms of Violence: Example 2 The consensus from research is that individuals with a history of abuse in childhood are at increased risk of maltreating their own children and/or partners. Nevertheless, the majority of individuals who experienced maltreatment as a child are not violent towards their own children.

23. Violence and Injury Prevention Short Course Child Maltreatment as a Risk factor for Other Forms of Violence: Example 3 Another study reported that being physically abused or neglected as a child increased the likelihood of arrest as a juvenile and as an adult. A direct comparison of different types of maltreatment found that children who were physically or sexually abused were more likely to carry a weapon in adolescence than were neglected children because of a perceived need for self protection. Evidence that risks of youth violence cumulate when child abuse persists into adolescence suggests a need for interventions to prevent ongoing abuse.

24. Violence and Injury Prevention Short Course Consequences on Human Capital Formation and Economic and Social Development

25. Violence and Injury Prevention Short Course Economic and Social Consequences of Child Maltreatment The implications of the long-term damage to health and social functioning wrought by child maltreatment on human capital formation, the workforce, and, ultimately, social and economic development in both low-, middle-, and high-income countries have started to become much clearer. Research in economics, developmental psychology, and neurobiology show that early experiences – including child maltreatment – have a powerful influence on the development of cognitive and social skills. This has led to the conclusion that the most efficient strategy for strengthening the future workforce, both economically and neurobiologically, and improving its quality of life is to invest in the environments of disadvantaged children during the early childhood years (Knudsen et al., 2006).

26. Violence and Injury Prevention Short Course Benefits of Early Investments in an Individual’s Life Source: Heckman, J. (2008). The case for investing in disadvantaged young children. In First Focus (Ed.), Big ideas for children: Investing in our nation's future (pp. 49-58). Washington, DC: First Focus.

27. Violence and Injury Prevention Short Course Summary and Conclusion

28. Violence and Injury Prevention Short Course Summary and Conclusion This module reviewed: Consequences of Child Maltreatment on Mental and Physical Health and Social Functioning. The Findings of the Adverse Childhood Experiences Studies (ACE) Child Maltreatment as a Risk Factor for Other Types of Violence Consequences on Human Capital Formation and Economic and Social Development. Preventing rather than treating and rehabilitating the effects of injury and violence is usually more cost-effective. This is true especially given the severe and lifelong consequences that can result from child maltreatment.

29. Violence and Injury Prevention Short Course References Adverse Childhood Experiences Study. Centers for Disease Control and Prevention. Retrieved March 18, 2010, from http://www.cdc.gov/nccdphp/ACE/findings.htm Butchart, A. Phinney, A. and Furness, T. (2006). Preventing child maltreatment: A guide to taking action and generating evidence. Geneva, World Health Organization. Child Maltreatment. TEACH-VIP E-Learning. Retrieved March 17, 2010, from http://teach-vip.edc.org/course/view.php?id=23 Gilbert, R. Widom, C. Browne, K. Fergusson, D. Webb, E. Janson, S. (2009). Burden and consequences of child maltreatment in high-income countries. Child Maltreatment 1. 373 (9667), 1-14. The Future of Children. (2009) Preventing Child Maltreatment. 119(2), 3-21. Heckman, J. (2008). The case for investing in disadvantaged young children. In First Focus (Ed.), Big ideas for children: Investing in our nation's future (pp. 49-58). Washington, DC: First Focus. Jonson-Reid M, Drake B, Kim J, Porterfield S, Han L. (2004). A prospective analysis of the relationship between reported child maltreatment and special education eligibility among poor children. Child Maltreatment. 9, 382–94. Knudsen, E. Heckman, J. Cameron, J. Shonkoff, J. (2006). Economic, neurobiological, and behavioral perspectives on building America’s future workforce. Proceedings of the National Academy of Sciences. 103 (27), 10155-10162. Krug, E. et al. (2002). World report on violence and health. Geneva, World Health Organization. Mikton, C. (2010). ACE PowerPoint Presentation Geneva, World Health Organization. Pinheiro, P.S. (2006). World report on violence against children. Geneva, World Health Organization.

30. Violence and Injury Prevention Short Course Discussion: Long-Term Costs of Child Maltreatment Individually, come up with a short list of examples of the long-term costs of child maltreatment in your own workplace and community. With a partner, discuss examples of the long-term costs of child maltreatment found within your own workplaces and communities. Prepare a short list of these examples to be presented and discussed with the large group.