child maltreatment: how does the child’s behaviors and needs impact risk of abuse? hugh f....
TRANSCRIPT
Child Maltreatment:How does the child’s behaviors
and needs impact risk of abuse?
Hugh F. Johnston, M.D.Faculty Associate
University of Wisconsin Medical School & School of Education
Overview
• A brief overview of a systemic perspective• Recent research on childhood risk factors• An integration of research to practice• Future directions• Practical recommendations
Slide 2
First, a brief explanatory Note:This is not an exercise in “blaming the victim”
• “Causality” has complex meanings and implications–Who is at fault and can be blamed or punished
–Who is responsible and accountable
–What can be done in service of prevention
• In terms of formal logic—antecedents: –Necessary but not sufficient
–Sufficient but not necessary
–Necessary and sufficient
–Non-necessary but contributory
–Associated but not contributory
Slide 3
The role (or characteristics) of the child
• In terms of formal logic–Non-necessary, non-sufficient but contributory
antecedents
–Associated but not contributory antecedents
• In plain English
–There are no child roles/characteristics that always lead to abuse/neglect
–There are no child roles/characteristics that, by themselves, are sufficient to result in abuse and neglect
–There are child roles/characteristics that may or may not contribute to abuse
Slide 4
The role (or characteristics) of the child• In plain English
–There are no child roles/characteristics that always result in abuse/neglect
–There are no child roles/characteristics that, by themselves, are sufficient to result in abuse and neglect
–There are child roles/characteristics that cause an increase in the risk of abuse/neglect• Some of these can be modified, changed, treated
• Some of these are fixed and unchangeable
–There are child roles/characteristics that are associated with the risk of abuse/neglect, but are not causal• These have the potential to be misleading
Slide 5
Categorical vs. dimensional
• Dimensional– Obesity– Blood pressure– Acne– Child abuse/neglect
• Categorical– Cancer– Down’s syndrome– Pregnancy– Cystic fibrosis
Slide 6
Human nature, insurance, and the law try to stuff the dimensional nature of child abuse/neglect into a
categorical box—causing many problems!
Categorical
Cystic Fibrosis
Slide 7
AbnormalNormal
Per
cent
age
o f t h
e po
p ula
tion
Child Abuse is Dimensional
“Normal” familiesAbuse/Neglect
Family functioning
Slide 8
Per
cent
age
of th
e po
pula
tion
Child “At Risk Maltreatment
Better parenting Worse parenting
“Perfect” families
Complex children with no diagnosis(or with dozens of diagnoses)
Slide 9
Depression
Substance Use
Pain
Anxiety
Life Stress
Sleep
Systematic research seems to have confirmed our worst fears
• The most vulnerable children are at increased risk
– Low birth weight & poor health
– Physical disabilities
– Mental illness
– Developmental problems
– Mental retardation
– Communicative disorders
– Behavioral problems
Slide 10
Here are some recent articles Slide 11
Sidebotham P, Heron J; ALSPAC Study Team. Child Abuse Negl. 2003 Mar;27(3):337-52.
Jaudes PK, Diamond LJ. Child Abuse Negl. 1985;9(3):341-7.
McCartney JR, Campbell VA. Ment Retard. 1998 Dec;36(6):465-73.
Verdugo MA, Bermejo BG, Fuertes J. Child Abuse Negl. 1995 Feb;19(2):205-15.
Ammerman RT, Hersen M, van Hasselt VB, Lubetsky MJ, Sieck WR.J Am Acad Child Adolesc Psychiatry. 1994 May;33(4):567-76.
Sullivan PM, Brookhouser PE, Scanlan JM, Knutson JF, Schulte LE.Ann Otol Rhinol Laryngol. 1991 Mar;100(3):188-94.
Tharinger D, Horton CB, Millea S. Child Abuse Negl. 1990;14(3):301-12.
Yet, there is some skepticismSlide 12
[such findings] . . . are based on methodologically weak designs, and recent findings do not support the premise that children have a major role in the etiology of abuse.
Ammerman RT. Violence Vict. 1991 Summer;6(2):87-101
And there are dangers: Association should never be equated with cause
• Here are two glaring examples– Risk of heart disease increases with the
number of toilettes in the house• It is not the toilettes, it is the sedentary life
associated with wealth
– Risk of child abuse increases with racial minority status
• It is not a person’s race, it is the lack of advantage associated with minority status
Slide 13
A simple formula for child maltreatment
Slide 14
Parent
Child
Parent
Child
Normal At risk
= parenting capacity
= Child’s needs
less
mo
re
Parenting vs. “Childing”
• Parenting is what parents do to children– Protect from harm– Meet physical needs– Meet emotional needs
• Affection
• Teaching knowledge and skills
• Teaching social skills
• And more
• Childing is what children do to parents– Assistance in day-to-day
chores– Meet emotional needs
• Affection –unconditional
• Gratitude –for parents’ efforts
• Reflect and amplify parents’ competence
• And more
Slide 15
Parenting and childing: An interaction
Slide 16
Bad parenting Good Parenting
Good ChildingBad childing
Bad parenting
Bad parenting
Bad childing
Good Parenting
Good Parenting
Good Childing
Parenting and childing: Aberrations
Slide 17
Good Parenting
Bad childing
Bad parenting Good Parenting
The big nagging questionSlide 18
Why do high-need children so often Why do high-need children so often havehave
low capacity parents?low capacity parents?
As it turns out, things are more complicated
Research DilemmaSlide 19
Poverty
Family History
Mental Illness
Substance Ab.
Abuse Neglect
Life Stress
Dev. Disability
Sexual Abuse
Mental Illness
Comm. Dis.
Behavior Prob.
Phys. Illness
Parent Factors Child Factors
Research DilemmaSlide 20
Poverty
Family History
Mental Illness
Substance Ab.
Abuse Neglect
Life Stress
Dev. Disability
Sexual Abuse
Mental Illness
Comm. Dis.
Behavior Prob.
Phys. Illness
Parent Factors Child Factors
Familial transmission
• Genetics– In some measure, almost all mental illness has an
element of heritability– Children with faulty genes tend to have parents with
faulty genes• Environment—gene interaction
– Parents with faulty genes tend to have lower SES, lower education, decreased frustration tolerance, increased substance abuse, and unstable relationships
Slide 21
Thus, children with “low resilience” tend to find themselves in especially challenging family environments
Familial transmission (cont.)
• How important life-skills are learned . . . – We take drivers ed to learn how to drive– We take lessons to learn the piano– We study the manual to learn how to program our
VCR (or not!)• Parenting is learned differently
– Most of us do not take a course, go to lessons, or read a manual
– Instead, we mostly rely on procedural knowledge acquired from our parents during our own childhood
Slide 22
Thus, adults who have endured a troubled childhood tend to recreate that same troubled system for their own children
The triple-whammy phenomenon
• Faulty genetic endowment (child and/or parents)
• Ineffectual parenting techniques
• Deprived psychosocial environment
Slide 23
1) Any one of these factors can contribute to the risk of abuse/neglect
2) These three factors tend to run together
3) Each factor worsens the impact of the others
What’s a researcher to do?
• The good news– There is plenty of opportunity for ambitious young
researchers
• The bad news– No definitive study will ever happen– There is a potential for paralysis in the face of
complexity• Future directions –ask the right questions!
– Intervention-based research– Further studies of resilience– Use a systemic perspective
Slide 24
What’s a clinician to do?
• Embrace a systemic view—Strive for a systemic change– Child’s & parents(s) mental status– Parent(s) child rearing heritage– Socio-economic stress
• Anticipate the ineffectiveness of narrow interventions
Slide 25
Lessons in prevention fromthe study of suicide
• Risk assessment doesn’t work• Targeting at-risk populations doesn’t work• Intervening after the fact is minimally helpful
Slide 26
Office of the Surgeon General200 Independence Avenue SW.Room 714-B Washington, DC 20201
Psychiatric News July 18, 2003Volume 38 Number 14© 2003 American Psychiatric Association
Community-wide interventions have demonstrated effectiveness for
prevention of suicide!
Community-based interventionsSlide 27
• All adult therapists should be mandated to ask about children in the home– We are mandated to ask about risk of
suicide/homicide, to discuss HIPPA, etc, etc– Children are seemingly invisible– Major mental illness is often treated without regard to
children
• Criminal justice system should be mandated to consider any children in the offender’s home– Any felony-class crime should invoke a system to
evaluate & support children
Community-based interventions (cont.)
Slide 28
• Quality mental health services should be available to all children, regardless of parental wealth!
• Teen pregnancy should automatically invoke a community support system– Education on child development– Parent training– Periodic supervision
The developmental disabilities community provides a good model
A few practical tipsSlide 29
• Systemic interventions are a great idea but:– The system is full of barriers and territories– Third-party payers don’t pay
• There are a few big non-systemic possibilities – Treat childhood mood instability (~bipolar)– Treat ADHD carefully
– Remember medication rebound!
– Provide scheduled respite– Over night, weekly– NOT “as needed”
• Parent(s) mental condition must be considered– Mood disorders– Substance abuse
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Why does mental illness so impair parenting?
Wells et al. JAMA. 1989.
Slide 30
ADHD
• Children with ADHD tend to be impulsive, intrusive, and disruptive
• Children with ADHD tend to have parents who are impulsive
• Ideally, when a child is diagnosed with ADHD, first degree relatives should also be evaluated
• Treatment with stimulants is highly effective for children and adults– Beware of stimulant rebound
Slide 31
Bipolar disorder in children
• A very loosely defined diagnosis– Intense unstable mood are the hallmark
• Children with unstable and intense moods tend to have parent(s) struggling with their own moods
• Mood stabilizing medication can be dramatically helpful– This can mask important environmental issues– Mood stabilizing medications have a higher potential
for side effect & toxicity
Slide 32
Attachment disordered and under-socialized children
• Some of the most challenging children– They are very deficient in childing– Emotions are often out-of-control– They form weak emotional bonds
• Treatment is based more on lore than data– Medications to reduce intensity– Attachment therapy to help form bonds
Slide 33
Summary
• Child-factors do matter• Child-factors are related to, and
interact with, other factors• When child-factors are present, a
systemic approach is best
Slide 34
Questions