1. National Family Safety Program, NGHA
January 28th and 29th 2013
Presentation 4. Step 1 of the Public Health Approach to Child Maltreatment Prevention:
Consequences of Child Maltreatment
Presented by
Alaa Sebeh, MD Ph.D.
Independent International Consultant,
Child Protection & Disability.

2. Objectives
The core learning objective of this module is to provide a basic understanding of the consequences of child maltreatment – immediate and lifelong physical and mental health and social and economic consequences – which is part of step 1 of the public health model to child maltreatment prevention.

3. Outline
Consequences of Child Maltreatment on Mental and Physical Health and Social Functioning
The Findings of the Adverse Childhood Experiences Studies (ACE)
Child Maltreatment as a Risk Factor for Other Types of Violence
Consequences on Human Capital Formation and Economic and Social Development
Summary and Conclusion

4. Consequences of Child Maltreatment on Mental and Physical Health and Social Functioning

5. Lifelong Consequences on Mental and Physical Health
Child maltreatment can have serious immediate health impacts such as death and injury.
But by far the more important are the non-injury mental and physical health consequences that manifest themselves throughout the life-course
Child maltreatment is both an important health problem and a major risk factor for other serious physical and mental health problems.
Child maltreatment often causes difficulties in cognitive and emotional functioning and social relations.
Victims of child maltreatment are likely to cope with these difficulties by adopting health risk behaviours, such as:
Smoking
Excessive drinking
Unsafe sexual practices
Physical inactivity
Child maltreatment is also associated with a higher probability of violent victimization and the perpetration of violence later in life.   

6. Child Maltreatment and the Substantial Burden on Mental Health
Child maltreatment increases the risk of behaviour problems, including internalising (e.g. anxiety, depression) and externalising (e.g. aggression, acting out) behaviour.
WHO estimates that sexual abuse experienced during childhood accounts for serious health problems in the general population including:
27% of post-traumatic stress disorders
10% of panic disorders
8% of suicide attempts
6% of cases of depression, alcohol misuse, and illicit drug abuse

7. Child Maltreatment and Long-Term Deficits in Educational Achievement
Prospective longitudinal studies have consistently shown that maltreated children have lower educational achievement and are more likely to receive special education. Decreases in school attendance and school performance were related to the timing of maltreatment and were cumulative. Most of these associations persisted after adjustment for family and social characteristics (e.g. ethnic origin, age, sex, and socioeconomic status).

8. The Findings of the Adverse Childhood Experiences Studies (ACE)

9. The Adverse Childhood Experiences Study
One of the most important studies on the consequences of child maltreatment is the ACE study.
This is a major American study providing primarily retrospective but also some prospective analysis based on a sample of 17,000 individuals of the effect of adverse childhood experiences during the first 18 years of life on the following outcomes:
Later well-being
Social function
Health risks
Disease burden
Health care costs
Life expectancy   

10. The Adverse Childhood Experiences
ACEs is a broader concept than child maltreatment which includes the following 10 types of experiences grouped into the following three categories:
Abuse
Emotional - recurrent humiliation
Physical - beating, not spanking
Contact sexual abuse
Neglect
Physical
Emotional
Household dysfunction
Mother treated violently
Household member was alcoholic or drug user
Household member was imprisoned
Household member was chronically depressed, suicidal, mentally ill, in psychiatric hospital
Child not raised by both biological parents

11. The Adverse Childhood Experience Score
The ACE Study uses the ACE Score, which is a count of the total number of ACE respondents reported.
Graphic: WHO

12. ACE and Health Risks
The study has demonstrated that as the number of ACEs increases, the risk for a number of serious mental and physical health and social problems increases in a strong and graded fashion. The association with physical health problems later in life is mainly due to the adoption of health risk behaviours.

13. ACE Score and Rates of Antidepressant Prescriptions
100 90 80 70
(per 100 person-years)
Prescription rate 60 50 40 30 20 10
>=5
Source: Anda, R. (2009). ACE PowerPoint Presentation . Geneva, World Health Organization.

14. Childhood Experiences vs. Adult Alcoholism16 14 12 10 4
% Alcoholic 8 6 4 2
ACE Score
Source: Anda, R (2009). ACE PowerPoint Presentation . Geneva, World Health Organization.

15. Long-Term Consequences of ACE
Death
Early
Death
ACEs are fundamental risk factors for disease and early death
Disease, Disability
and Social Problems
Adoption of
Health-risk Behaviors
Social, Emotional, &
Cognitive Impairment
Adverse Childhood Experiences
Toxic Stress
Conception
Source: CDC (2010).

16. Neglect and Brain Damage
Left: Healthy 3-year-old child
Right: 3-year-old child following total global neglect during early childhood. The brain is significantly smaller than average and has abnormal development of cortical, limbic, and midbrain structures.

17. ACEs and Impairments in Social Functioning: Work Performance
Prevalence of Impaired Performance (%)
Absenteeism
(>2 days/month)
Serious Financial
Problems
Serious Job
Problems
Source: Mikton, C. (2010). ACE PowerPoint Presentation. Geneva, World Health Organization.

18. Child Maltreatment as a Risk Factor for Other Types of Violence

19. The Intergenerational Transmission of Interpersonal Violence
The intergenerational transmission of interpersonal violence can occur in the following ways: 1. From victimization to further victimization in the home and community 2. From victim to child abuser in the home 3. From victim to perpetrator of violence against an intimate partner in the home; and/or from victim to perpetrator in the community

20. Typology of Violence
Source: Krug, E. et al. (2002). World report on violence and health. Geneva, World Health Organization.

21. Child Maltreatment as a Risk factor for Other Forms of Violence: Example 1
A survey of 5,908 French women in stable relationships found that 1 in 7 of those with a childhood history of maltreatment reported serious abuse by their spouse, compared with 1 in 20 of those with no such experience in childhood.

22. Child Maltreatment as a Risk factor for Other Forms of Violence: Example 2
The consensus from research is that individuals with a history of abuse in childhood are at increased risk of maltreating their own children and/or partners. Nevertheless, the majority of individuals who experienced maltreatment as a child are not violent towards their own children.

23. Child Maltreatment as a Risk factor for Other Forms of Violence: Example 3
Another study reported that being physically abused or neglected as a child increased the likelihood of arrest as a juvenile and as an adult. A direct comparison of different types of maltreatment found that children who were physically or sexually abused were more likely to carry a weapon in adolescence than were neglected children because of a perceived need for self protection. Evidence that risks of youth violence cumulate when child abuse persists into adolescence suggests a need for interventions to prevent ongoing abuse.

24. Consequences on Human Capital Formation and Economic and Social Development

25. Economic and Social Consequences of Child Maltreatment
The implications of the long-term damage to health and social functioning wrought by child maltreatment on human capital formation, the workforce, and, ultimately, social and economic development in both low-, middle-, and high-income countries have started to become much clearer. Research in economics, developmental psychology, and neurobiology show that early experiences – including child maltreatment – have a powerful influence on the development of cognitive and social skills. This has led to the conclusion that the most efficient strategy for strengthening the future workforce, both economically and neurobiologically, and improving its quality of life is to invest in the environments of disadvantaged children during the early childhood years (Knudsen et al., 2006).

26. Benefits of Early Investments in an Individual’s Life
Source: Heckman, J. (2008). The case for investing in disadvantaged young children. In First Focus (Ed.), Big ideas for children: Investing in our nation's future (pp ). Washington, DC: First Focus.

27. Summary and Conclusion

28. Summary and Conclusion
This module reviewed:
Consequences of Child Maltreatment on Mental and Physical Health and Social Functioning.
The Findings of the Adverse Childhood Experiences Studies (ACE)
Child Maltreatment as a Risk Factor for Other Types of Violence
Consequences on Human Capital Formation and Economic and Social Development.
Preventing rather than treating and rehabilitating the effects of injury and violence is usually more cost-effective.
This is true especially given the severe and lifelong consequences that can result from child maltreatment.

29. References
Adverse Childhood Experiences Study. Centers for Disease Control and Prevention. Retrieved March 18, 2010, from Butchart, A. Phinney, A. and Furness, T. (2006). Preventing child maltreatment: A guide to taking action and generating evidence. Geneva, World Health Organization. Child Maltreatment. TEACH-VIP E-Learning. Retrieved March 17, 2010, from Gilbert, R. Widom, C. Browne, K. Fergusson, D. Webb, E. Janson, S. (2009). Burden and consequences of child maltreatment in high-income countries. Child Maltreatment (9667), The Future of Children. (2009) Preventing Child Maltreatment. 119(2), Heckman, J. (2008). The case for investing in disadvantaged young children. In First Focus (Ed.), Big ideas for children: Investing in our nation's future (pp ). Washington, DC: First Focus. Jonson-Reid M, Drake B, Kim J, Porterfield S, Han L. (2004). A prospective analysis of the relationship between reported child maltreatment and special education eligibility among poor children. Child Maltreatment. 9, 382–94. Knudsen, E. Heckman, J. Cameron, J. Shonkoff, J. (2006). Economic, neurobiological, and behavioral perspectives on building America’s future workforce. Proceedings of the National Academy of Sciences. 103 (27), Krug, E. et al. (2002). World report on violence and health. Geneva, World Health Organization. Mikton, C. (2010). ACE PowerPoint Presentation Geneva, World Health Organization. Pinheiro, P.S. (2006). World report on violence against children. Geneva, World Health Organization.

30. Discussion: Long-Term Costs of Child Maltreatment
Individually, come up with a short list of examples of the long-term costs of child maltreatment in your own workplace and community. With a partner, discuss examples of the long-term costs of child maltreatment found within your own workplaces and communities. Prepare a short list of these examples to be presented and discussed with the large group.