1. Opportunities to change the outcomes of traumatized children (Draft Narrative) Frank Putnam, MD and William Harris, PhD OhioCanDo4Kids.Org February, 28, 2008

2. Draft Narrative This is the draft of a narrative that we are seeking to collectively construct with others. The purpose of the narrative is to inform policy makers and the public about the costs and consequences of child maltreatment. The purpose is to tell them that there are interventions and opportunities to change these personally tragic and socially costly outcomes. Feel free to use all or part of this narrative (with appropriate attribution) if helpful to advocate for children and families OhioCanDo4Kids.Org

3. Adverse Childhood Experiences Abuse and Neglect (e.g., psychological, physical, sexual) Household Dysfunction (e.g., domestic violence, substance abuse, mental illness) Impact on Child Development Neurobiologic Effects (e.g., brain abnormalities, stress hormone dysregulation) Psychosocial Effects (e.g., poor attachment, poor socialization, poor self-efficacy) Health Risk Behaviors (e.g., smoking, obesity, substance abuse, promiscuity) Long-Term Consequences Data: www.AceStudy.org, www.nasmhpd.orgwww.AceStudy.orgwww.nasmhpd.org Disease and Disability Major Depression, Suicide, PTSD Drug and Alcohol Abuse Heart Disease Cancer Chronic Lung Disease Sexually Transmitted Diseases Intergenerational transmission of abuse Social Problems Homelessness Prostitution Criminal Behavior Unemployment Parenting problems High utilization of health and social services OhioCanDo4Kids.Org

4. Developmental Cascade of Transgenerational Child Maltreatment Risk Child Adolescent Adult OhioCanDo4Kids.Org

5. Incidence and Types of Child Maltreatment NCANDS, 2004

6. Most Maltreatment is Never Reported! Random-digit dialing computerized telephone survey in North & South Carolina found that maternal- reported physical abuse was 40 times greater and sexual abuse was 15 times greater than official statistics for same period There are an estimated 8,755,000 juvenile victims of child maltreatment in the United States – that means that more than 1 of 7 children between ages of 2 and 17 have experienced maltreatment (Theodore et al., (2005) Pediatrics 115:e331-337) CDC, 2008 OhioCanDo4Kids.Org

7. “Dose-Effect” Responses for Number of Traumas in Children Copeland et al., Archives of Gen Psychiatry 2007, 64:577-584 N=1420

8. www.Acestudy.org

9. Mean Number of DSM diagnoses by Cumulative Risk Score 0 1 2 3 4 5 6 7 8 Mean Number of DSM Dx 01234+ NCS- R All Respondents N=5692 Putnam, Perry, Putnam, Harris unpublished data, 2008 OhioCanDo4Kids.Org

10. 0123456789101112 PTSD Panic Disorder Nicotine Dependence Mania Major Depressive Episode Dysthymia Drug Abuse Conduct Disorder Agoraphobia ADD Odds Ratio Males – Childhood Sexual Abuse OhioCanDo4Kids.Org Putnam, Perry, Putnam, Harris unpublished data, 2008

11. Females – Childhood Sexual Abuse 01234567891011121314 PTSD Oppositional Defiant Disorder Nicotine Dependence Mania Major Depressive Episode Intermittent Explosive Disorder Drug Abuse Bipolar I Alcohol Dependence ADD Odds Ratio OhioCanDo4Kids.Org Putnam, Perry, Putnam, Harris unpublished data, 2008

12. Childhood Trauma and Public Health Single greatest preventable cause of mental illness Single greatest preventable cause of drug and alcohol abuse in women Single greatest preventable cause of HIV high-risk behavior (IV drugs, promiscuity) Significant contributor to leading causes of death (heart disease, cancer, stroke, diabetes, suicide) OhioCanDo4Kids.Org

13. Trauma is to Mental Health as Smoking is to Cancer! Steven Sharfstein, MD

14. Neurodevelopmental Consequences of Childhood Trauma Impaired brain development –Decreased IQ –Doubled learning disabilities –Impaired emotional regulation and impulse control Dysregulated stress response systems –Dysregulation of HPA (cortisol) stress response –Increased sympathetic nervous system activation –Increased immune system abnormalities Alterations in physical growth –Doubled risk for obesity OhioCanDo4Kids.Org

15. Increasing Trauma Lowers Intelligence Koenen et al. Development and Psychology, 2003, 15:297-311

16. www.acestudy.org www.Acestudy.org

17. Cost Estimates of Child Maltreatment Alabama 1 – in 2005 dollars –Direct costs - $392 Million –Indirect costs - $129 Million –Total annual costs - $521 Million Ohio 2 – in 2007 dollars –Direct costs - $290 Million –Indirect costs - $2.1 Billion –Total annual costs – $3 Billion US 3 – in 2007 dollars –Direct costs - $33 Billion –Indirect costs - $71 Billion –Total annual costs - $104 Billion 1 – Center for Business & Economic Research, Univ of Alabama, 2007 2 – Preventing Family Violence, Anthem Foundation of Ohio, 2007 3 – Wang & Holton – Economic Impact Study, Prevent Child Abuse America, 2007 OhioCanDo4Kids.Org

18. What do we have available now. Existing networks within which to embed screening and intervention Evidence-based prevention and treatment models Replication strategies Web networking and data collection tools Prevention and quality improvement science OhioCanDo4Kids.Org

19. What can we do about it? Prevention –Meta-analysis of 21 studies found that Home Visitation programs significantly reduce child maltreatment (median reduction = 40%, range 24%-74%) (CDC, 2003) –Meta-analysis of 27 studies of school-based programs found an average effect size of (d= 1.07) (Davis & Gidycz, 2000) Screening and identification –Validated screening measures –Validated symptoms and behaviors assessments Treatment –Evidence-based treatments for different age groups, and types of trauma –Gaps remain for cultural, trauma, and family issues OhioCanDo4Kids.Org

20. Prevention, identification, and treatment can be embedded in systems that serve children Child care Education Medical Well-child Home visitation Military families Child welfare Mental health Drug and alcohol Criminal justice Immigration Faith based OhioCanDo4Kids.Org

21. What are the bottlenecks to moving ahead? OhioCanDo4Kids.Org

22. Where are the Opportunities for Prevention and Intervention in the Developmental Cascade of Transgenerational Child Maltreatment Risk? Child Adolescent Adult OhioCanDo4Kids.Org

23. Every system and piece of legislation that serves children and families should consider a “Trauma Impact Statement” OhioCanDo4Kids.Org