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Michael Seiff Foundation Sept 10 1 Longer-term impacts of childhood adversity – considering risk and resilience and implications for practice. Antonia.

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Presentation on theme: "Michael Seiff Foundation Sept 10 1 Longer-term impacts of childhood adversity – considering risk and resilience and implications for practice. Antonia."— Presentation transcript:

1 Michael Seiff Foundation Sept 10 1 Longer-term impacts of childhood adversity – considering risk and resilience and implications for practice. Antonia Bifulco, Professor of Health and Social Care Lifespan Research Group Royal Holloway, University of London a.bifulco@rhul.ac.uk Michael Sieff Foundation: Promoting the Well-being of the Primary School Age Child: 21 & 22 September 2010

2 Michael Seiff Foundation Sept 10 2 The Lifespan Research Group We undertake academic research into lifespan and intergenerational risk factors for psychological disorders – with a focus on parents and adolescents. Using a lifespan approach with focus on key transitions (such as adolescence) in relation to parental neglect/abuse in childhood. Utilising interview measures which are sensitive to narrative and meaning, yet amenable to quantitative analyses (eg CECA and ASI) We also undertake applied research with social care and health services to aid with evidence-based practice & training in assessment.

3 Michael Seiff Foundation Sept 10 3 Aim of presentation To examine longer term effects of childhood adversity in relation to adolescent and adult psychological disorder. To examine risk and resilience models in an Attachment Framework To discuss gaps in research and methods for primary school-age children. To consider implications for health and social care practice

4 Michael Seiff Foundation Sept 10 4 Risks in UK adolescents UNICEF report (2007) Young people in UK report worse levels of well-being in Europe Mental health rates increased (Maughan, Meltzer & Goodman (2008) Teenagers in the UK have high rates of psychological disorder compared to other Western countries. These increased up to 1999. Although evidence of stabilising, teacher report of emotional disorder increasing up to 2004 Nuffield Foundation, 2009). Other risk factors teenage pregnancy, family break down, neglect/abuse, risk taking behaviour, violent environments are all common in UK youth

5 Michael Seiff Foundation Sept 10 5 Risks in UK adults High rates of family breakdown, divorce and single parenthood High rates of domestic violence High rates of depression, anxiety and substance abuse Variable treatment coverage (primary care provision, but rationed)

6 Michael Seiff Foundation Sept 10 6 What is childhood adversity? FAMILY CONTEXT Deprivation: Family context of poverty, housing difficulty, parental physical or mental illness, Conflict: domestic conflict and violence. Unstable family structure – single parent, re- constituted families BEHAVIOUR TOWARDS CHILD Poor relationships with parents (antipathy, discord, low supervision, high discipline) Maltreatment (neglect, physical abuse, sexual abuse, psychological abuse). All these factors are inter-related. Some evidence of increase.

7 Adversity for children and parents occur in the same context …. Family Deprivation Partner Conflict Child Maltreatment Family structure Poor parent- Child relationship Parent Psychological disorder Child Psychological disorder FAMILY CONTEXT BEHAVIOUR TO CHILD

8 Michael Seiff Foundation Sept 10 8 Family context, parenting and maltreatment Study of family factors, parenting and maltreatment and psychological disorder in offspring shows that maltreatment is the most significant factor. Specifically: Neglect Physical abuse Sexual abuse Psychological abuse

9 Michael Seiff Foundation Sept 10 9 Summary of Lifespan findings on CECA and psychological disorder. Community series of adult women and of adolescents.

10 Michael Seiff Foundation Sept 10 10 Lifespan Intergenerational Community Samples Community mothers (1980-5; 1990-5) registered with London GP surgeries studied prospectively to determine lifetime vulnerability to depression (i) Representative 1980-5 (n=210) (ii) Vulnerable 1990-5 (n=303) Community Offspring – to test transmission of risk to adolescent/young adult offspring (i) Sons and daughters of Representative mothers 1989-92, (n=172) (ii) Sons and daughters of Vulnerable mothers 1995-99 (n=146)

11 Michael Seiff Foundation Sept 10 11 Standardised, contextual, interview measures used Childhood Experience of Care and Abuse (CECA) (Bifulco & Moran 1998) Attachment Style Interview (Bifulco et al 2002) SCID DSM-IV for clinical disorder (First et al, 1996)

12 Michael Seiff Foundation Sept 10 12 The Childhood Experience of Care and Abuse Interview (CECA) (Bifulco & Moran, 1998) A retrospective measure of early life experience used with adolescents or adults. Covers relationship with parents, family context and neglect and abuse directed to child. Assesses severity, age at onset, duration, frequency etc of a range of negative experience before age 17. Has good reliability and validity.

13 Michael Seiff Foundation Sept 10 13 CECA Neglect Material neglect and indifference shown by parents and carers to child in relation to: material care (being fed, clothed); regular household routines; health & hygiene. Socialisation: neglect of friendships, school work, career options Emotional needs & support Severity determined by pervasiveness of neglect and number of areas of neglect Rated: 1.Marked ] Severe 2.Moderate ] Severe 3. Mild 4. Little/none Scored For each abuse by different perpetrator For changes in severity over time

14 Michael Seiff Foundation Sept 10 14 CECA Physical abuse Violence shown to child from household member. Includes severe beatings, being hit with implement, punched, kicked, burned. Potential for causing injury. Usually repeated but can be single severe attack, usually from adult, but maybe older child/young person. Severity determined by intensity of attack, type of hitting and frequency. Rated: 1.Marked ] Severe 2.Moderate ] Severe 3. Mild 4. Little/none Scored For each abuse by different perpetrator For changes in severity over time

15 Michael Seiff Foundation Sept 10 15 CECA Sexual abuse Sexual behaviour to child by any adult or older child/young person. Usually sexual contact but can include verbal solicitation, observing sexual activity/ pornography. With or without force. Perpetrator can be any relationship to child or stranger. Can be single incident or repeated. Severity determined by degree of contact, repeated nature, relationship to other. Rated: 1.Marked ] Severe 2.Moderate ] Severe 3. Mild 4. Little/none Scored For each abuse by different perpetrator For changes in severity over time

16 Michael Seiff Foundation Sept 10 16 CECA Psychological Abuse Rated: 1.Marked ] Severe 2.Moderate ] Severe 3. Mild 4. Little/none Scored For each abuse by different perpetrator For changes in severity over time Sadistic & cruel behaviour, coercive control of the child involving: humiliation, extreme rejection deprivation of basic needs or valued objects, inflicting marked discomfort/distress, Terrorising Cognitive disorientation Emotional blackmail or exploitation. Severity determined by intensity, number of categories of abuse and frequency.

17 Michael Seiff Foundation Sept 10 17 Prevalence of maltreatment Experiences of severe neglect, physical or sexual abuse in childhood affects around 1 in 4 individuals (Bifulco & Moran, 1998). (Also, see Cawson 2000: with 15% severe neglect, 21% physical abuse, 18% sexual abuse and 6% psychological abuse). Although fairly common, most individuals survive it (around two-thirds) in terms of psychological disorder. However there is variation in the multiples of abuse and intensity which does increase risk of negative outcome

18 Michael Seiff Foundation Sept 10 18 Neglect and abuse experience relates to later clinical disorder A range of negative childhood experience relates to adult depression and to a range of adolescent disorder. The pattern is similar in both age groups although higher in adolescents. Various dose-response effects are observable.

19 CECA experience and major depression in 12 months: 303 adult high-risk community women* CECA dichotomy – peakOdds ratio P< Relationship with parent Antipathy mother 1.94.07 Antipathy father 2.93.05 Lax control 1.78.10 Maltreatment i) Neglect 3.18.001 ii) Physical abuse 3.00.001 iii) Sexual abuse 7.00.001 iv) Psychological abuse 2.85.007 INDEX i-iv NEGLECT OR ABUSE 3.96.001

20 CECA experience and any case disorder in 12 months – 276 young people 16-25 (representative & high risk) CECA dichotomy – marked or moderate severity Odds ratioP< Relationship parents Antipathy mother 3.16.001 Antipathy father 2.49.01 Lax control 1.57NS Maltreatment i) Neglect 5.27.0001 ii) Physical abuse 5.03.0001 iii) Sexual abuse 7.88.0001 INDEX (i-iii) NEGLECT OR ABUSE 5.00.001

21 Males and externalising disorder: CECA experience and conduct disorder – young males 16-25, n=140 CECA dichotomy (marked or moderate severity vs some, little/none)– peak Odds ratioP< Antipathy mother 5.0.002 Antipathy father 11.0.00001 Lax control 1.5NS i) Neglect 8.3.01 ii) Physical abuse 7.0.003 iii) Sexual abuse 10.0.05 Index i-iii: Neglect/abuse index 4.1.03

22 Dose-Response effects (i) Multiple Abuse The more the types of abuse the more likelihood of disorder – dose response effect (303 adult community women) % with adult depression Multiple abuse < 17 9 23 28 35 64 12 month Chronic/ recurrent 23 35 53 65 73 Severe neglect or physical or sexual or psychological abuse

23 Dose-response effects (ii) Severity of abuse Severity of types of abuse and adult depression – dose response effect (303 adult community women) Severity of neglect/abuse % depression in 12 months

24 Family context and neglect/abuse in childhood (303 adult women) Parental conflict Parental Loss Deprivation Any 1 factor X 2X 2 X 2.8 X 2.4 Severe neglect, physical or sexual abuse (Relative risks given) X 3.2 Bifulco & Moran, 1998

25 Teenage linking experiences ( 303 Vulnerable women) Neglect or abuse <17 Teenage pregnancy Lack of planning re home leaving Teenage depression 17-20 x 1.64 x 1.7 x 3 Relative risks shown

26 Adult risk factors and neglect/abuse in childhood ( 303 vulnerable women ) Neglect/abuse <17 Violent partner Adult sexual assault Separation partner X 2.1 X 2.6 X 1.6 Relative risks given

27 Role of previous pregnancy & marital experience (303 vulnerable women) Path analysis Neglect or Abuse in childhood ADULT DEPRESSION 12 MONTHS Severe loss pregnancy Marital adversity ns.29.33.21 Bernazzani, Bifulco et al 2003

28 Michael Seiff Foundation Sept 10 28 Role of insecure attachment style- adults Adult attachment examined as mediating factor between childhood experience and later adult disorder, both anxious and avoidant active. Adult attachment examined as mechanism in maltreatment of children and in relation to poor parenting capacity Adolescent insecure anxious attachment style mediates between maternal poor parenting and emotional disorder.

29 Michael Seiff Foundation Sept 10 29 Attachment Theory Bowlby, 1969-80 Attachment and Loss trilogy. Attachment theory provides a useful framework for investigating lifespan linkages between early interactions between parent and child and subsequent relationship style in adolescence and adulthood. Research evidence shows insecure attachment style relates to: childhood neglect/abuse (Crittenden 1997), poorer support (Hazan & Shaver, 1994; Bartholomew & Horowitz 1997), stress (Mikulciner & Florian, 1998) and psychological disorder in adolescence (Allen, 1998) and adulthood (Mickelson & Kessler 1997)

30 Michael Seiff Foundation Sept 10 30 Attachment Style Interview (ASI) Bifulco et al 2002 Assesses quality of relationship with partner and 2-3 Very Close Others. At least 2 close confiding relationships, provides good ability to make and maintain relationships and denotes Security. Attitudes to closeness (mistrust, constraints on closeness, fear of rejection, anger) and autonomy (self-reliance, desire for company, fear of separation) all assessed. Profile from all information provides degree of insecurity (marked, moderate, none) and type of style: Anxious (Enmeshed or Fearful) Avoidant (Angry-Dismissive or Withdrawn) Secure.

31 Adult Lifespan analysis Path analysis model (303 Vulnerable community women) Neglect/ abuse<17 Highly Insecure Attachment style Adult depression Teenage depression Poor support Negative Eval- uation of self.22.24.37.30.27.41.18.32.26 Bifulco et al, 2002 a & b SPPE

32 Attachment style and depression – specificity of style studied prospectively (154 women seen over 3 year period) Onset Major Depression Highly Enmeshed Highly Fearful Highly Angry- dismissive Highly Withdrawn.23.19.26 ns Neglect or Abuse < 17 (CECA).19.28 ns Tests show partial mediation for Fearful and Angry-dismissive Bifulco et al, 2006, SPPE ASI interview 1 Onset depression Interview 2 Childhood experience At interview 1

33 Offspring Emotional disorder Offspring Anxious Attachment style Mother’s neglect or Abuse <17 Offspring Negative Evaluation of Self e5e4 Model of neglect/abuse and attachment style in adolescents (146 adolescent offspring),25,46,36,47 Bifulco A (2008) Risk and resilience in young Londoners. In (Eds, D. Brom, R Pat-Horenczyk & J, Ford) Routledge, London, NY

34 Michael Seiff Foundation Sept 10 34 Risk and resilience approaches Before 1990 most research into adolescent disorder examine the contribution of different risks – psychological and social. After work by Garmezy, Rutter, Masten and others, the importance of ‘resilience’ was recognised i.e. protective factors explaining ‘absence’ of disorder. Research into high risk community samples allow for investigation of both risk and resilience for disorder

35 Michael Seiff Foundation Sept 10 35 Resilience Protective factors are those which are active in the presence of risk factors – to buffer or moderate the impact. In high risk adolescents, all experienced some form of social deprivation or maltreatment and 45% had disorder – were the other’s protected?

36 Michael Seiff Foundation Sept 10 36 High level of social risks in sample of young people 94% had at least one of the following risk factors: Lone mother upbringing – 52% Lowest social class – 32% History of domestic violence between parents – 21% Maternal recurrent depressive disorder – 46% Paternal disorder, including substance abuse and criminal behaviour - 52%

37 Michael Seiff Foundation Sept 10 37 However, positive factors were also common: Support from friend age 16 - 56% Positive peer group age 16 - 68% Positive school characteristics age 16 - 66% High academic attainment age 16 - 51% High felt competence as student age 16 - 66% Clearly Secure attachment style at interview - 30% Markedly high self acceptance at interview - 14% 80% had at least one of the following positive factors:

38 Model of positive factors for emotional disorder Variable ORWaldDfP< Positive school character 0.730.511NS Positive peer group 0.650.911NS Marked self acceptance 0.053.791.05 Secure attachment style 0.207.341.007 Marked self acceptance and secure attachment style provide the Best model in relating to absence of disorder -Goodness of fit 71.7% Logistic regression – outcome emotional disorder 12 months

39 Positive psychological Protective effect of secure attachment or marked self acceptance % Case emotional disorder No positive psychological

40 Model of emotional disorder Variable ORWaldDfP< Neglect/abuse from mother 1.634.631.03 Secure attachment 0.226.821.009 Marked self acceptance 0.133.731.05 Secure attachment and marked self acceptance add to the model in Producing lower disorder in the presence of neglect/abuse Goodness of fit 74.7% Logistic regression – outcome internalising disorder 12 months

41 Michael Seiff Foundation Sept 10 41 Implications for practice Assessment: Need standardised assessment tools for reliable and valid measurement of child and families experience. Analysis: Important to assess severity of neglect or abuse using standardised criteria. Need to assess multiples of abuse to estimate risk. Some risk factors more damaging than others. Attachment Frameworks need to assess attachment style in adolescence and childhood to determine impacts of adversity and resilience.

42 Michael Seiff Foundation Sept 10 42 Ongoing Lifespan collaborations with services. St Christopher’s residential care services – assessing attachment style in young people in care prior to social learning intervention. Kingston Safeguarding services – using CECA scoring framework to rate case information to aid with classification and analysis of neglect/abuse of children.

43 Michael Seiff Foundation Sept 10 43 Trainings offered for social workers and psychologists Childhood Experience of care and abuse – for forensic psychologists and social workers in safeguarding. Attachment Style Interview for parents Attachment Style Interview for adolescents Parenting role Interview www.cecainterview.com www.attachmentstyleinterview.com

44 Michael Seiff Foundation Sept 10 44 Research implications: studying primary school age children Measurement – need for intensive contextualised measures which can be used in younger age groups. Gap in primary school group for attachment measures and face-to- face direct assessments. Need to amplify Attachment Frameworks to include social adversity and biological variables.

45 Michael Seiff Foundation Sept 10 45 Research implications: studying primary school age children Need to re-use social lifespan and stress models. Importance of life events in younger age groups. Neglect/abuse variables in adult summarise long periods of childhood. When asking children we need to break the experience into events and difficulties using a timeframe (eg Sandberg & Rutter, 1993 - PACE )..


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