Maltreatment and mental health

Transcription

1 Maltreatment and mental health Helen Minnis

2 Lets start with a good news story Rates of violence in Scotland have reduced by about 60% in recent years because we treat our children better?

3 The way we used to treat our children Until the 1960s, children often left for months in hospital TB, polio etc. - with no parental visits

4 Adverse Childhood Experiences Felitti et al

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7 The ACES load

8 But what about maltreated children in 2015? Neglectful and/or abusive early experiences Turbulent journeys through the care system Foster carers are temporary Essentially no mental health services for children under 5 especially if maltreated

9 Disinhibited Social Engagement Disorder indiscriminate sociability with marked inability to exhibit appropriate selective attachments Maltreatment specific disorders

10 Maltreatment specific disorders Reactive Attachment Disorder Emotional withdrawal, hypervigilant or highly ambivalent and contradictory responses

11 Population prevalence of RAD and DSED together is about 1% - similar to autism

12 Of those children with RAD: ALL had at least one other diagnosis ADHD (54%) ODD (23%) 1.4% CD (31%) PTSD (15%) ASD (15%) Tics 1 child

13 Adopted children with RAD/DSED have slightly but significantly lower cortisol secretion compared to control children

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15 A complex picture And nearly all have other psychiatric disorders: 85% also had possible or likely ADHD 85% also had a possible or likely Anxiety Disorder 55% had possible or likely PTSD 75% were oppositional 85% had conduct problems Kocovska et al

16 Maltreatment-associated psychiatric problems (MAPP) Children who have experienced maltreatment in early life tend to have complex overlapping problems These can include RAD, DSED, ADHD, Conduct disorder, PTSD, anxiety, FASD Speech and language problems are common Mild cognitive problems are common A central problem in forming and sustaining intimate relationships e.g. control, emotional withdrawal, problems with regulation

17 In the context of maltreatment, certain parts of the brain suffer Most susceptible are the areas still developing long after birth And those with a high density of receptors for stress hormones Teicher, 2003, 2016 For example Hippocampus Amygdala Fronto-temporal area The course of MAPP over time

18 So can these problems be treated? Yes!

19 The most effective intervention is loving family care: Children who grew up in terrible conditions in Caucescu s Romania had psychiatric and cognitive problems that resolved almost completely once adopted to the UK O Connor and Rutter Trial evidence has shown that changes to cortisol profile can be reversed with extra nurturing care Dozier et al

20 Is introducing a mental health service for maltreated infants a cost-effective way of improving their mental health?

21 Treatment of birth family with aim to reduce future ACES apparently successful in US in non-randomised study

22 Randomised controlled trial of an infant mental health services for maltreated children Recruiting since 2012 Approx 180 participating families Represent 60% of families in Glasgow who have a pre-school child coming into foster care

23 Research Question: why do some severely maltreated children develop psychiatric disorders and some don t? We know part of the answer -children differ

24 Children differ from birth The differential susceptibility hypothesis Belsky 2004

25 Children differ from birth Temperament: present early in life strongly heritable stable over time emotionality activity levels sensation-seeking Biological rhythmicity sensitivity to changes Chess and Thomas

26 Children differ from birth Children with difficult temperaments, because they struggle with internal regulation, appear more amenable to assistance with regulation from outside direct assistance with coping (e.g., parental sensitivity) opportunity for productive activity Bradley and Corwyn, Journal of Child Psychology and Psychiatry 49:2 (2008), pp Reproduced with permission

27 Why do only some maltreated children have mental health problems? Alcohol or other prenatal insult Yes No FASD Maltreatment Yes No Orchid temperament Yes No MAPP

28 Why do only some maltreated children have mental health problems? Alcohol or other prenatal insult Yes No FASD Maltreatment Yes No Orchid temperament Yes No MAPP

29 Research Question: why do some severely maltreated children develop psychiatric disorders and some don t? -but how do children differ? Plan to follow up BeST? cohort of maltreated children as they reach age 8

30 Epigenetics Immune Functioning Areas of focus Social development Epigenetics Stress hormones and stress responsivity Immune functioning Brain development

31 High stress environment at age 0-5 Stress response system Immune system Brain x Genetic factors Neurocognitive problems, esp. executive functioning Problems with social interaction e.g. with face recognition Psychiatric disorders (mood/personality disorder)

32 Epigenetic changes High stress environment at age 0-5 x Genetic factors Ready for action physiology Stress response system Immune system Neurocognitive problems, esp. executive functioning Problems with social interaction e.g. with face recognition Psychiatric disorders (mood/personality disorder) Brain

33 A reminder of the way we used to treat our children

34 Are we slipping back?

35 Your thoughts please