1. Double Disadvantage: The impact of childhood maltreatment and community violence exposure on adolescent mental health Charlotte Cecil Molecules of Happiness: Why Love Matters for Vulnerable Children London, 26 th September 2013

2. 1.Childhood maltreatment Background

3. Maltreatment prevalence  Affects millions of children worldwide  Difficult to estimate true prevalence  Many cases never come to light  Existing estimates vary widely  Community studies vs. official reports  UK: up to 1 in 5 experience severe maltreatment (NSPCC; Radford et al., 2011) Background

4. Maltreatment effects  Childhood  Child fatality  1 in 10 injury-related child fatalities worldwide (WHO; Pinheiro et al., 2006)  Increased risk of mental health and adjustment difficulties  Emotional, behavioural, interpersonal domains (Cicchetti & Toth, 2005)  Underpinned by biological changes in brain structure, function, and stress response (McCrory et al, 2010) Background

5. Maltreatment effects  Childhood  Child fatality  1 in 10 injury-related child fatalities worldwide (WHO; Pinheiro et al., 2006)  Increased risk of mental health and adjustment difficulties  Emotional, behavioural, interpersonal domains (Cicchetti & Toth, 2005)  Underpinned by biological changes in brain structure, function, and stress response (McCrory et al, 2010)  Adulthood  Increased susceptibility to psychiatric and medical disorders  E.g. mood and personality disorders, obesity, diabetes, chronic pain (Oswald et al., 2010)  Decreased life opportunities  E.g. education, employment, earnings (Currie & Widom, 2010) Background

6. 2. Community violence exposure (CVE) Background

7. Community Violence Exposure (CVE)  Characteristics  Acts: Chasing, threatening, robbing, beating up, shooting, stabbing, murder  Levels of exposure: Hearing about, witnessing, directly experiencing  Most chronic and prevalent form of violence exposure  Rates of exposure remain constant across years (Fowler et al., 2009)  50%+ of urban youth affected (Buka et al, 2001)  4-70% witness stabbing/shooting  1-47% witness murder  CVE impact  Mental health & behaviour (Margolin & Gordis, 2000)  PTSD, Aggression Background

8. Community Violence Exposure (CVE)  Characteristics  Acts: Chasing, threatening, robbing, beating up, shooting, stabbing, murder  Levels of exposure: Hearing about, witnessing, directly experiencing  Most prevalent and chronic form of violence exposure  50%+ of urban youth affected (Buka et al, 2001)  Rates of exposure remain constant across years (Fowler et al., 2009)  CVE impact  Mental health & behaviour (Margolin & Gordis, 2000)  PTSD, Aggression Background

9. Community Violence Exposure (CVE)  Characteristics  Acts: Chasing, threatening, robbing, beating up, shooting, stabbing, murder  Levels of exposure: Hearing about, witnessing, directly experiencing  Most chronic and prevalent form of violence exposure  Rates of exposure remain constant across years (Fowler et al., 2009)  50%+ of urban youth affected (Buka et al, 2001)  CVE impact  Mental health & behaviour (Margolin & Gordis, 2000) Background

10. FREQUENTLY CO-OCCUR

11. YET, EXAMINED SEPARATELY

13. Sample  204 inner city youth from the community  16-24 year olds, males and females  Multiple recruitment channels  50% Kids Company  50% Inner city London schools and internet websites  Matched for age, sex, ethnic background, IQ and neighbourhood deprivation Measures  Developmental adversity (self-report)  Childhood maltreatment  Current exposure to community violence  Mental health functioning (multi-rater reports)  Internalizing difficulties (anxiety, depression)  Externalizing difficulties (conduct problems, ASB)  Trauma symptoms (anger, PTSD, dissociation) Kids-Co/UCL Project

14. Sample  204 inner city youth from the community  16-24 year olds, males and females  Multiple recruitment channels  50% Kids Company  50% Inner city London schools and internet websites  Matched for age, sex, ethnic background, IQ and neighbourhood deprivation Measures  Developmental adversity (self-report)  Childhood maltreatment  Current exposure to community violence  Mental health functioning (multi-rater reports)  Internalizing difficulties (anxiety, depression)  Externalizing difficulties (conduct problems, ASB)  Trauma symptoms (anger, PTSD, dissociation) Kids-Co/UCL Project

15. Part I: Characterizing levels of exposure Part II: The impact of maltreatment and CVE Part III: The influence of individual maltreatment types Outline

16. Part I: Characterizing levels of exposure

17. Part I: Levels of exposure Childhood maltreatment

18. Part I: Levels of exposure *Statistically significant difference = p <.01 1.Childhood maltreatment: Any exposure* KIDS COMPANY: 84% KIDS COMPANY: 84% COMPARISON: 56% COMPARISON: 56% VS.

19. Part I: Levels of exposure *All group differences statistically significant = p <.01 1.Childhood maltreatment: Any exposure*

20. Part I: Levels of exposure 1.Childhood maltreatment: Severe-Extreme* KIDS COMPANY: 38% KIDS COMPANY: 38% COMPARISON: 8% COMPARISON: 8% VS. *Statistically significant difference = p <.001

21. Part I: Levels of exposure 1.Childhood maltreatment: Severe-Extreme* *All group differences statistically significant = p <.01

22. Part I: Levels of exposure Community violence exposure

23. Part I: Levels of exposure 2. Community violence exposure: Any exposure* KIDS COMPANY: 98% KIDS COMPANY: 98% COMPARISON: 95% COMPARISON: 95% VS. *Difference not significant

24. Part I: Levels of exposure 2. Community violence exposure: Any exposure* *Group differences for witnessing and victimization statistically significant = p <.01 n.s.

25. Part I: Levels of exposure 2. Community violence exposure: Severe acts* * All group differences statistically significant = p <.001

26. Part I: Levels of exposure Single vs. Multi-type

27. Part I: Levels of exposure 3. Single vs. Multi-type: Childhood maltreatment Participants with experience of maltreatment (68% of sample; N = 139)

28. Part I: Levels of exposure 3. Single vs. Multi-type: Community violence exposure Participants with experience of community violence (92% of sample; N = 187)

29. Part I: Levels of exposure Degree of overlap

30. Part I: Levels of exposure Maltreatment (68% of sample)

31. Part I: Levels of exposure 97% No CVE CVE Maltreatment (68% of sample)

32. Part I: Levels of exposure 97% Maltreated youth typically experience a DOUBLE DISADVANTAGE No CVE CVE Maltreatment (68% of sample)

33. Summary 1.Alarming levels of exposure 2.Multi-type exposure ‘norm’ 3.Maltreatment and CVE frequently co-occur Part I: Levels of exposure

34. Summary 1.Alarming levels of exposure 2.Multi-type exposure ‘norm’ 3.Maltreatment and CVE frequently co-occur Part I: Levels of exposure

35. Summary 1.Alarming levels of exposure 2.Multi-type exposure ‘norm’ 3.Maltreatment and CVE frequently co-occur Part I: Levels of exposure

36. Part II: The impact of maltreatment and CVE

37. Part II: Maltreatment & CVE impact Aim  What are their independent effects?  What are their combined effects? ??

38. Part II: Maltreatment & CVE impact 1.Independent effects: Childhood maltreatment CHILDHOOD MALTREATMENT TRAUMA SYMPTOMS (Anger, PTSD, dissociation) TRAUMA SYMPTOMS (Anger, PTSD, dissociation) INTERNALIZING (Anxiety, depression) INTERNALIZING (Anxiety, depression) EXTERNALIZING (Conduct problems, ASB) EXTERNALIZING (Conduct problems, ASB) * * * * Effects statistically significant = p <.001

39. Part II: Maltreatment & CVE impact 1.Independent effects: Community violence exposure COMMUNITY VIOLENCE EXPOSURE * Effects statistically significant = p <.01 * * TRAUMA SYMPTOMS (Anger, PTSD, dissociation) TRAUMA SYMPTOMS (Anger, PTSD, dissociation) INTERNALIZING (Anxiety, depression) INTERNALIZING (Anxiety, depression) EXTERNALIZING (Conduct problems, ASB) EXTERNALIZING (Conduct problems, ASB)

40. Part II: Maltreatment & CVE impact 2. Combined effects: Additive

41. Summary 1.Both maltreatment and CVE have serious consequences for mental health 2.Children who experience both forms of adversity are at particularly high risk for mental health problems Part II: Maltreatment & CVE impact

42. Summary 1.Both maltreatment and CVE have serious consequences for mental health 2.Youth who experience double disadvantage are at particularly high risk for mental health problems Part II: Maltreatment & CVE impact

43. Part III: The influence of individual maltreatment types

44. Aim Part III: Maltreatment types Emotional Abuse Physical Abuse Sexual Abuse Physical Neglect Emotional Neglect Similar or different effects?

45. Findings 1.All maltreatment types have negative effect* Driven by what is common to all types Part III: Maltreatment types *(std. B =.14 –. 69; significant at least p <.05)

46. Findings 1.All maltreatment types have negative effect Driven by what is common to all types FEELING UNSAFE AND VULNERABLE? Part III: Maltreatment types

47. Findings 2. Emotional abuse* Unique predictive power, over and above all other types Part III: Maltreatment types *(std. B =.29 –. 76; significant at least p <.01, except externalizing difficulties)

48. Findings 2. Emotional abuse Unique predictive power, over and above all other types FEELING UNLOVED AND UNSUPPORTED? Part III: Maltreatment types

49. Conclusions

50. 1.Inner city youth are highly vulnerable to violence exposure 2.Maltreatment and CVE are key developmental risk factors 3.Emotional abuse unique predictive power Key findings

51. NEED TO TAKE ACTION! Increase awareness Invest in prevention Improve access to effective interventions Implications

52. Funding: Kids Company charity Collaborators: Dr Eamon McCrory Prof Essi Viding Dr Ted Barker Dr Jo Guiney Thank you to all of the young people, teachers, key workers who have taken part in this research Acknowledgments