1. Wisconsin Public Psychiatry Network Teleconference (WPPNT) This teleconference is brought to you by the Wisconsin Department of Health Services (DHS) Bureau of Prevention, Treatment, and Recovery and the University of Wisconsin- Madison, Department of Psychiatry. The Department of Health Services makes no representations or warranty as to the accuracy, reliability, timeliness, quality, suitability or completeness of or results of the materials in this presentation. Use of information contained in this presentation may require express authority from a third party.

2. 2 The Impact of Childhood Trauma on Adults Wisconsin Public Psychiatry Network Teleconference Ryan Herringa, MD, PhD Assistant Professor of Child & Adolescent Psychiatry University of Wisconsin School of Medicine & Public Health

3. 3 Outline Case presentation Child maltreatment: A silent epidemic Social outcomes of childhood abuse Mental health outcomes of childhood abuse Physical health outcomes of childhood abuse Biology of childhood abuse Discussion

4. 4 Case Presentation 41 year old female, single mother of 2 Sexually abused by her father in her teens Multiple psychiatric admissions, suicide attempts Diagnoses have included bipolar disorder, borderline personality disorder, alcohol dependence, PTSD Physical health problems: smoking, overweight, diabetes

5. 5 Outline Case presentation Child maltreatment: A silent epidemic Social outcomes of childhood abuse Mental health outcomes of childhood abuse Physical health outcomes of childhood abuse Biology of childhood abuse Discussion

6. 6 Child maltreatment: A silent epidemic 2 in 3 children experiences a significant trauma Child maltreatment: – U.S. 2009 - Estimated 763,000 victims (1% of kids) – Wisconsin 2009 – 4,289 victims (0.3%) – Over 80% is perpetrated by the parent or caregiver – Only 5-10% of abused children may come into contact with child protective services – Cumulative prevalence of childhood sexual abuse: 1 in 4 girls, 1 in 6 boys U.S. DHHS; WI DCF; CDC; Gilbert et al, 2009

7. 7 What is child maltreatment? Any act of commission or omission by a parent or other caregiver that results in harm, potential for harm, or threat of harm to a child Physical abuse Sexual abuse Emotional abuse Neglect Witnessing domestic violence Gilbert et al 2009

8. 8 Risk factors for child maltreatment Parent poverty Low parent education levels Parent mental illness and substance abuse Parent maltreated as a child Family conflict and separation Family criminality Child with disability

9. 9 Outline Case presentation Child maltreatment: A silent epidemic Social outcomes of childhood abuse Mental health outcomes of childhood abuse Physical health outcomes of childhood abuse Biology of childhood abuse Discussion

10. 10 Social outcomes of childhood abuse Low educational achievement – Only 42% of maltreated children complete high school (compared to 66% in community) Lower occupational achievement – 59% vs. 42% unemployed Criminal activity – 48% arrest rate vs. 36% matched controls Perez & Widom, 1994

11. 11 Social outcomes of childhood abuse (2) Economic burden (lifetime costs) – $210,000 per nonfatal victim – $1.2 million per fatal victim – $124 billion in the US in 2008 – Over $500 billion for all estimated cases Fang et al, 2012

12. 12 Outline Case presentation Child maltreatment: A silent epidemic Social outcomes of childhood abuse Mental health outcomes of childhood abuse Physical health outcomes of childhood abuse Biology of childhood abuse Discussion

13. 13 Adverse childhood experiences (ACE) study Conducted by the CDC & Kaiser Permanente in California From 1995-1997, over 17,000 HMO participants enrolled, following prospectively Questions regarding adverse childhood experiences, and adult mental and physical health ACEs: abuse, neglect, serious household dysfunction http://www.cdc.gov/ace/index.htm

14. 14 ACE Study http://www.cdc.gov/ace/index.htm

15. 15 Mental health outcomes of childhood abuse Abuse accounts for 5-13% of mental disorders Depression (2x risk) Attempted suicide (2-5x risk, up to 20%) Self injurious behavior (sexual abuse) Personality disorders (sexual abuse) Substance abuse (7-10x risk) PTSD (20-25% prevalence) CDC; Gilbert et al, 2009; Fergusson et al, 2008

16. 16 Dube, S. R. et al. JAMA 2001;286:3089-3096 Copyright restrictions may apply. Childhood abuse and attempted suicide

17. 17 Childhood abuse and depression % Lifetime Depression 0

18. 18 Childhood abuse and IV drug use

19. 19 Outline Case presentation Child maltreatment: A silent epidemic Social outcomes of childhood abuse Mental health outcomes of childhood abuse Physical health outcomes of childhood abuse Biology of childhood abuse Discussion

20. 20 Physical health outcomes of childhood abuse Obesity (9 lb greater weight) Smoking (5x risk) Cardiovascular disease (4x risk) Lung cancer (3x risk) COPD (3x risk) Liver disease (3x risk) Teen pregnancy (up to 40%) Sexually transmitted infections (3-5x risk)

21. 21 Childhood abuse and longevity

22. 22 Dong M et al. Circulation 2004;110:1761-1766 Copyright © American Heart Association Childhood abuse and behavior change

23. 23 Outline Case presentation Child maltreatment: A silent epidemic Social outcomes of childhood abuse Mental health outcomes of childhood abuse Physical health outcomes of childhood abuse Biology of childhood abuse Discussion

24. 24 Biology of childhood abuse Dannlowski et al, 2011 ↑ Amygdala activity ↓ Hippocampus volume

25. 25 PFC Hippocampus Adapted from Phillips et al, 2008 Biology of childhood abuse (2) Amygdala Front Back

26. 26 Biology of childhood abuse (3) Child abuse leaves lasting 'scars' on DNA – Nature News Feb. 2009 McGowan et al, 2009 NeuronDNA

27. 27 Clinical Pearls A child and his/her brain adapt to survive in the environment in which they are raised This comes at a cost to childhood abuse victims (whether as a child or adult) Trust and safety are key aspects of working with childhood abuse victims Don’t be afraid to talk about their abuse

28. 28 Outline Case presentation Child maltreatment: A silent epidemic Social outcomes of childhood abuse Mental health outcomes of childhood abuse Physical health outcomes of childhood abuse Biology of childhood abuse Discussion