child maltreatment & child welfare critical issues

CIHR New Emerging Team CIHR New Emerging Team (NET): The impact of (NET): The impact of

childhood maltreatment on childhood maltreatment on adolescent and adult adolescent and adult

outcomesoutcomes

Child Maltreatment & Child Welfare Child Maltreatment & Child Welfare Critical IssuesCritical Issues

High Prevalence – High CostHigh Prevalence – High Cost

INCIDENCEINCIDENCE::22 out of 100022 out of 1000 childrenchildren reported to child welfare reported to child welfare

9.7/10009.7/1000 “substantiated” child abuse/neglect (CIS, 1998) “substantiated” child abuse/neglect (CIS, 1998)

INDIVIDUAL COSTINDIVIDUAL COST::22%22% adults who were abused/neglect deemed adults who were abused/neglect deemed resilientresilient (No homelessness, (No homelessness,

juvenile/adult arrests etc.) (McGloin & Widom, 2001)juvenile/adult arrests etc.) (McGloin & Widom, 2001)

SOCIETAL COSTSOCIETAL COST::OntarioOntario - - $863 million$863 million spent on child welfare (2002-2003) spent on child welfare (2002-2003)

USUS – child abuse cost $258 million/day or $94 billion/year – child abuse cost $258 million/day or $94 billion/year

Family Violence in Family Violence in CanadaCanada


Complex Problem - Complex SolutionsComplex Problem - Complex Solutions

Canadian Incidence Study of Reported Child Abuse & Neglect:Caregiver Substance Abuse

65% decreaseOR: 0.35; CI: 0.14, 0.90*

61% increaseOR: 1.61; CI: 1.17, 2.21*

155% increaseOR: 2.55; CI: 1.90, 3.42*

6% decreaseOR: 0.94; CI: 0.63, 1.41

-150%

-100%

-50%

0%

50%

100%

150%

200%

Physical abuse Sexual abuse Neglect Emotional abuse

Child Maltreatment Type

% in

crea

se/d

ecre

ase

in r

isk

for

mal

trea

tmen

t in

as

soci

atio

n w

ith

car

egiv

er s

ub

stan

ce a

bu

se

age & sex of the child + the caregiver's characteristics accounted for *p>0.05

Trend of Funds Awarded for Fetal Alcohol Syndrome (FAS) Related Research

$0

$100,000

$200,000

$300,000

$400,000

$500,000

$600,000

1998 1999 2000 2001 2002 2003 2004

Year

Fu

nd

ing

($)

Child Maltreatment Mental Health Physical Health Other

Awarded funds were searched under the CIHR and SSHRC databases and funding was distributed through each fiscal year.


Relevant Research NeededRelevant Research Needed

9090% % increase in increase in substantiated physical substantiated physical abuse: abuse: 4,200 to 8,000 4,200 to 8,000

44% decrease in 44% decrease in substantiated sexual abusesubstantiated sexual abuse: : 3,400 to 1,9003,400 to 1,900

102% increase in 102% increase in substantiated neglect: substantiated neglect: 4,400 4,400 to 8,900 to 8,900

770% increase 770% increase substantiated emotional substantiated emotional maltreatmentmaltreatment/ exposure to / exposure to DV: 1,000 to 8,700DV: 1,000 to 8,700

0

5,000

10,000

PhysicalAbuse

SexualAbuse

Neglect Emotional &DV

1993 1998

1 2 3

Differential Trends by Form of Differential Trends by Form of Maltreatment: Ontario Incidence Maltreatment: Ontario Incidence

Study 1993-1998Study 1993-1998

Publication Volume By Publication Volume By Maltreatment Type Maltreatment Type (Behl et al., 2003)(Behl et al., 2003)


Research Capacity is CriticalResearch Capacity is Critical

256

319

363 362

438

384 380 388367

389

417438 429

358

2342 34 33

51 5034 30 28 37 37 36

20 25

0

50

100

150

200

250

300

350

400

450

500

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

Year

Fre

qu

ency

(#

pu

blic

atio

ns)

US Canada

The results of the depicted graph, which shows the number of publications on a year-by-year basis, were gathered using the PsychInfo Database. Keywords used were: child abuse, child neglect, sexual abuse, emotional abuse, child maltreatment, physical abuse, child welfare, child protective services, and children's aid societies. Boolean constructs (and/not/or) were used to restrict occurrances of duplicates among the publications. The publications contain samples from the main author's country of affliation, which was also restricted amongst the two countries.

10-year Trend in Child Maltreatment Publications under 10-year Trend in Child Maltreatment Publications under the First Authorthe First Author


High Prevalence – High CostHigh Prevalence – High Cost Complex Problem - Complex SolutionsComplex Problem - Complex Solutions Relevant Research NeededRelevant Research Needed Research Capacity is CriticalResearch Capacity is Critical Critical Issues for Prevention & Evidence-Critical Issues for Prevention & Evidence-

Based Practice and Policy Goal AttainmentBased Practice and Policy Goal AttainmentNeed a Network ApproachNeed a Network Approach

Childhood maltreatment is a significant risk Childhood maltreatment is a significant risk

factor for Canadian healthy developmentfactor for Canadian healthy development • Child maltreatment is often an on-going, family systems problem

within complex systems (i.e. education, neighbourhood, community, youth justice, social services including public, mental health)

• 22 of every 1000 Canadian children are reported to child welfare each year - with 9.7 / 1000 of these are deemed substantiated neglect (40%), physical (31%), emotional (19%), and sexual abuse (10%)

• Reports to child welfare were estimated at 135,573 cases for 1998; and across substantiated cases, “high risk” groups were found by gender

• Intergenerational cycle of abuse and neglect has been estimated at 30%, and with such persistence of maltreatment and arrival of new cases, service delivery in child welfare is further complicated

• Literature reviews conclude that there is lack of a well-designed intervention research, a dominance of single-focus rather than integrated research agendas, inattention to service utilization models and effectiveness, and gaps in knowledge of effective dissemination and training on co-morbidities that are associated with violence in relationships

Impacts of Childhood MaltreatmentImpacts of Childhood Maltreatment• Economics and quality of life perspectivesEconomics and quality of life perspectives

• Quality of life is defined in terms of both health and standard of livingQuality of life is defined in terms of both health and standard of living• Poor overall health is predicted by single-parent and low socioeconomic status, Poor overall health is predicted by single-parent and low socioeconomic status,

low child academic status, and female genderlow child academic status, and female gender

• Effects on schoolingEffects on schooling• Child welfare-involved youth display greater residential instability and its attendant Child welfare-involved youth display greater residential instability and its attendant

interrupted schooling, higher absenteeism and drop-out rates, and limited interrupted schooling, higher absenteeism and drop-out rates, and limited vocational trainingvocational training

• Effects on labor market outcomesEffects on labor market outcomes• Low school outcomes create substantial obstacles to a better-trained workforce, Low school outcomes create substantial obstacles to a better-trained workforce,

larbor market participation, and future productivitylarbor market participation, and future productivity• Such factors, in turn, contribute to poverty, adult unemployment and further Such factors, in turn, contribute to poverty, adult unemployment and further

marginalizationmarginalization

• Effects on healthEffects on health• Injuries sustained during abuse can lead to life-long physical and cognitive Injuries sustained during abuse can lead to life-long physical and cognitive

disabilities, ranging from the less severe to the near-fatal such as chronic pain and disabilities, ranging from the less severe to the near-fatal such as chronic pain and brain injurybrain injury

New Emerging Team (NET) New Emerging Team (NET) ObjectivesObjectives

The NET has 5 key objectives:The NET has 5 key objectives:

1)1) Increase the quality, amount, and scope of maltreatment-Increase the quality, amount, and scope of maltreatment-focused, integrative research needed for a science-based public focused, integrative research needed for a science-based public health approach to violencehealth approach to violence

2)2) Bring together established researchers with maltreatment-Bring together established researchers with maltreatment-related expertiserelated expertise

3)3) Extend current projects and launch new research to benefit from Extend current projects and launch new research to benefit from NET expertiseNET expertise

4)4) Identify priority research areasIdentify priority research areas

5)5) Mentor new researchersMentor new researchers

CCanadian anadian CChild hild WWelfare elfare RResearch esearch NetNetwork (CCWRNet)work (CCWRNet) Objectives Objectives

The CCWRNet has 5 key objectives:The CCWRNet has 5 key objectives:

1)1) Increasing the amount, quality, and breadth of child welfare and Increasing the amount, quality, and breadth of child welfare and related researchrelated research

2)2) Increasing the relevance of and uptake by the child welfare and Increasing the relevance of and uptake by the child welfare and related systemsrelated systems

3)3) Increasing research capacity in leadership, student, practitioner Increasing research capacity in leadership, student, practitioner rolesroles

4)4) Improving the quality of life for child welfare-involved families Improving the quality of life for child welfare-involved families through establishing empirically-validated cost-effective through establishing empirically-validated cost-effective interventions with known positive impactsinterventions with known positive impacts

5)5) Reducing child maltreatment through efficacious prevention Reducing child maltreatment through efficacious prevention interventions and social innovation initiativesinterventions and social innovation initiatives

Focus on The Maltreatment Focus on The Maltreatment Adolescent Pathways (MAP) Adolescent Pathways (MAP)

StudyStudy

Maltreatment and Adolescent Maltreatment and Adolescent Pathways (MAP) ProjectPathways (MAP) Project

Research Questions:Research Questions: Childhood maltreatment has been linked to health risk Childhood maltreatment has been linked to health risk

behavioursbehaviours How at-risk is a child-welfare population of youth? How at-risk is a child-welfare population of youth?

Over time? Over time? What is the underlying process that mediates the What is the underlying process that mediates the

impact of childhood maltreatment on adverse outcome impact of childhood maltreatment on adverse outcome in adolescence?in adolescence?

Is an epidemiological study feasible in a child welfare Is an epidemiological study feasible in a child welfare sample?sample?

MAP Feasibility Study & MAP Longitudinal StudyMAP Feasibility Study & MAP Longitudinal Study

MAP Feasibility StudyMAP Feasibility StudyFunded by CIHR/CAHRFunded by CIHR/CAHR

Christine Wekerle, Ph.D., Principal InvestigatorChristine Wekerle, Ph.D., Principal InvestigatorAnne-Marie Wall, Ph.D.,Co-Principal InvestigatorAnne-Marie Wall, Ph.D.,Co-Principal Investigator

Harriet MacMillan, MD., Co-InvestigatorHarriet MacMillan, MD., Co-InvestigatorNico Trocme, Ph.D., Co-InvestigatorNico Trocme, Ph.D., Co-Investigator

Michael Boyle, Ph.D., Co-InvestigatorMichael Boyle, Ph.D., Co-InvestigatorRandall Waechter, M.A., Project ManagerRandall Waechter, M.A., Project Manager

In Collaboration WithIn Collaboration WithChildren’s Aid Society of TorontoChildren’s Aid Society of Toronto (Deb Goodman) (Deb Goodman)

Advisory Board:Advisory Board: Dan Cadman, Rob Ferguson, Heidi Kiang, Joanne Filippelli, Franz Dan Cadman, Rob Ferguson, Heidi Kiang, Joanne Filippelli, Franz Noritz, Ron Smith, Rhona DelisleNoritz, Ron Smith, Rhona Delisle

Catholic Children’s Aid SocietyCatholic Children’s Aid Society (Bruce Leslie) (Bruce Leslie)Advisory Board:Advisory Board: Jim Langstaff, Sean Wyers, Coreen Van Es, Jim Langstaff, Sean Wyers, Coreen Van Es,

Mario Giancola, Tara Nassar, Kate SchumakerMario Giancola, Tara Nassar, Kate SchumakerJewish Family and Child ServiceJewish Family and Child Service (Yosi Derman) (Yosi Derman)

Examines 4 indexes of poor developmental health among the child Examines 4 indexes of poor developmental health among the child welfare youth population (across community, in care status):welfare youth population (across community, in care status):

(1)(1) Mental Health Mental Health

(2)(2) Substance Abuse Substance Abuse

(3)(3) Dating ViolenceDating Violence

(4)(4) Risky Sexual PracticesRisky Sexual Practices

What is the MAP Feasibility What is the MAP Feasibility StudyStudy??

Special Features of the MAP:Special Features of the MAP: Random sampling of 14 to 17 year-old youth from child-Random sampling of 14 to 17 year-old youth from child-

welfare populationwelfare population Maltreatment is tracked via youth self-report (CTQ, Maltreatment is tracked via youth self-report (CTQ,

CEVQ) CEVQ) as well asas well as caseworker report caseworker report Youth anonymity is maintained via self-generated ID Youth anonymity is maintained via self-generated ID

numbers across multiple testing pointsnumbers across multiple testing points Measures are synchronized with large-scale population Measures are synchronized with large-scale population

studies (e.g. OSDUS, NLSCY), making comparison studies (e.g. OSDUS, NLSCY), making comparison between community and child-welfare samples possiblebetween community and child-welfare samples possible

Longitudinal arm tracks the trajectories of different Longitudinal arm tracks the trajectories of different measures over time, and thus provides an opportunity measures over time, and thus provides an opportunity for examining the chain of causal mechanism of for examining the chain of causal mechanism of maltreatment-teen health risk relationshipmaltreatment-teen health risk relationship

Childhood Maltreatment

Mediator:Post-traumatic stress

symptomatology

Poor Mental HealthDating violenceRisky sexual behaviorSubstance abuse

Mediators:Mediators: Causal Factors Preceding Target ChangeCausal Factors Preceding Target Change

The identification of mediator provides target for cost-The identification of mediator provides target for cost-effective intervention and ground for evidence-based effective intervention and ground for evidence-based policy decision.policy decision.

Mediators:Mediators: Causal Factors Preceding Target ChangeCausal Factors Preceding Target Change PTSD symptomatology as mediator (DeBellis, 2001)PTSD symptomatology as mediator (DeBellis, 2001)

Teens most frequently endorse intrusive memories, Teens most frequently endorse intrusive memories, numbness, reminders are distressing, dissociative numbness, reminders are distressing, dissociative response, efforts to forget about event, hypervigilance, response, efforts to forget about event, hypervigilance, reliving the eventreliving the event

a significant proportion of adults diagnosed with alcohol a significant proportion of adults diagnosed with alcohol dependence experience clinically significant levels of dependence experience clinically significant levels of PTSD symptomatologyPTSD symptomatology

individuals who suffer resultant PTSD as a result of individuals who suffer resultant PTSD as a result of childhood maltreatment childhood maltreatment maymay use alcohol as a means of use alcohol as a means of copingcoping

MAP Feasibility Study: Research ProcessMAP Feasibility Study: Research Process Mean Age of tested youthMean Age of tested youth: 15 years (data on n=87; 50 females, 37 males): 15 years (data on n=87; 50 females, 37 males)

Ineligibility RateIneligibility Rate: Overall 31% : Overall 31% (Case closed, AWOL, Discharged, mental (Case closed, AWOL, Discharged, mental health issues, developmental delay, In custody, Not identified client)health issues, developmental delay, In custody, Not identified client)

Refusal RateRefusal Rate: : OverallOverall 30% (Community: 55%, In-care: 17%; Males: 39%; 30% (Community: 55%, In-care: 17%; Males: 39%; Females: 19%)Females: 19%)

Reasons given for RefusalReasons given for Refusal: : “Just not interested”/ no reason“Just not interested”/ no reason: 65%: 65%(Parental Refusal: 14%; “Too busy”: 8%;“Not comfortable sharing”: (Parental Refusal: 14%; “Too busy”: 8%;“Not comfortable sharing”: 5%;Other: 8%)5%;Other: 8%)

Recruitment RateRecruitment Rate: Overall : Overall 70% (Community: 45%; In-care: 83%;Males: 70% (Community: 45%; In-care: 83%;Males: 61%; Females: 81%) 61%; Females: 81%)

Reasons given for participationReasons given for participation: Money: 59%;“No reason given”: 32%; : Money: 59%;“No reason given”: 32%; Other: 9%Other: 9%

Average testing timeAverage testing time: 2.8 hrs (Range = 2.0 to 4.5 hrs): 2.8 hrs (Range = 2.0 to 4.5 hrs) Avg. Cost/Ss/TestingAvg. Cost/Ss/Testing: $133.11 – Youth paid ON minimum wage/4hrs: $133.11 – Youth paid ON minimum wage/4hrs

Home ($70.21) + $28.00 = $98.21 (>80% youth selected testing at residence)Home ($70.21) + $28.00 = $98.21 (>80% youth selected testing at residence)CAMH ($1.90) + $28.00 = $29.90CAMH ($1.90) + $28.00 = $29.90(+$5.00 food/refreshment cost)(+$5.00 food/refreshment cost)

MAP Feasibility MAP Feasibility StudyStudy: Preliminary Result: Preliminary Result

90% of female adolescents had experienced either one or more forms of sexual 90% of female adolescents had experienced either one or more forms of sexual abuse, and almost 80% of male had experience either one or more forms of abuse, and almost 80% of male had experience either one or more forms of physical abuse.physical abuse.

The severity and duration of maltreatment experience is associated with the number The severity and duration of maltreatment experience is associated with the number and acuteness of PTSD symptomatologyand acuteness of PTSD symptomatology

While in general PTSD symptomatology is associated with the four indicators of poor While in general PTSD symptomatology is associated with the four indicators of poor developmental health in maltreated adolescents, there are stark gender differences: developmental health in maltreated adolescents, there are stark gender differences: PTSD symptomatology in maltreated female adolescents is associated with: 1) PTSD symptomatology in maltreated female adolescents is associated with: 1)

internalizing symptoms, 2) victimization in dating violence, 3) risky sexual behavior – illicit internalizing symptoms, 2) victimization in dating violence, 3) risky sexual behavior – illicit drug-use as part of their sexual activity, 4) experienced difficulty in stopping drug and drug-use as part of their sexual activity, 4) experienced difficulty in stopping drug and alcohol even if they wanted toalcohol even if they wanted to

PTSD symptomatology in maltreated male adolescents is associated with: 1) PTSD symptomatology in maltreated male adolescents is associated with: 1) externalizing behaviors, 2) perpetration externalizing behaviors, 2) perpetration and and victimization in dating violence, 3) victimization in dating violence, 3) risky sexual behavior – un-protected sexual activities, 4) more illicit drug userisky sexual behavior – un-protected sexual activities, 4) more illicit drug use


PTSD Symptomatology



PTSD Symptomatology


MAP Feasibility Study: Preliminary ResultMAP Feasibility Study: Preliminary Result

Testing the full mediation model:Testing the full mediation model: Feasibility has small sample size, not enough statistical Feasibility has small sample size, not enough statistical

power – awaits MAP Longitudinal Studypower – awaits MAP Longitudinal Study Only partial mediation of PTSD symptomatology in the Only partial mediation of PTSD symptomatology in the

relationship between childhood maltreatment and relationship between childhood maltreatment and internalizing symptom in female, and between maltreatment internalizing symptom in female, and between maltreatment and victimization in dating violence in the combined sample.and victimization in dating violence in the combined sample.

Encourages continued research on PTSD symptomatology Encourages continued research on PTSD symptomatology as a key mediator of diverse teen outcomesas a key mediator of diverse teen outcomes

No current maltreatment-specific PTSD intervention for No current maltreatment-specific PTSD intervention for teens exists; may need gender-specific interventionteens exists; may need gender-specific intervention

child maltreatment & child welfare critical issues

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