1. Children’s mental health in the context of development Housing Provider Group Healthy Families Initiative Abi Gewirtz, Ph.D., L.P. University of Minnesota

2. Today’s topic – child maltreatment and exposure to violence Child maltreatment –definitions and statistics –Physical abuse –Neglect –Sexual abuse –Psychological abuse

3. Definitions of maltreatment Introduction –‘average expectable environment’ (Cicchetti & Lynch, 1995) –‘battered child syndrome’ –Statistics: reported cases 43 per 1000, substantiated cases 16 per 1000 or more than 1 million in 1993. Huge increases as problem uncovered. –Defining maltreatment (NICCHD, 1992) “behavior toward another person which (a) is outside the norms of conduct and (b) entails a substantial risk of causing physical or emotional harm. The behavior included will consist of actions and omissions, ones that are intentional and ones that are unintentional. They will have severe, mild or no immediate adverse consequences.” (p1033)

4. Definitions of maltreatment Types of maltreatment –Physical abuse –Sexual abuse –Neglect –Emotional abuse The developmental dimension –Effects of maltreatment will vary, depending on the child’s stage of development and the fact that maltreatment most often takes place within the family context. –Definition of maltreatment also varies by age

5. Physical abuse Injuries resulting from acts placing child’s life, health or safety in danger. –Munchausen by Proxy syndrome Prevalence: 3.5 per 1000, 23% of all reports Child characteristics: mostly young victims,difficult or with special needs

6. Physical abuse Developmental course –Cognitive development –Emotional development: attachment deficits (avoidant), devt of self –Interpersonal development: social skills Etiology: abusive parents - young, stressed, few resources/aggressive coping, low impulse control, male abusers = most fatalities Intergenerational transmission around 30% Protective factors = support, insight

7. Neglect Definition and characteristics: 49% cases, failure to thrive Developmental course –Cognitive development: most impaired –Emotional development: attachment (ambivalent) –Interpersonal development: passivity, dependent Etiology: young, single mothers living in poverty; distressed, withdrawn, lacking in social support, negative views of relationships, inappropriate expectations of children.

8. Psychological maltreatment Definition and characteristics: e.g. verbal abuse, psychological unavailability. Co- occurs with other forms of abuse Developmental course –Cognitive development –Emotional development - depression, self- injurious behavior, low self-esteem,

9. Sexual abuse Definition and characteristics Developmental course - attributions child makes are critical –Cognitive development - lower academic perf, learning problems –Emotional development - internalizing problems, depression –Interpersonal development - inappropriate sexual behavior Long-term course - depends on extent of abuse, etc Protective factors: supportive relationship with mother Controversies - false allegations, suggestibility of kids, repressed memories The sexual abuser: sex abuse may be part of pedophile pattern, 5 yrs between suspect and victim

10. Prevention and intervention programs Physical and psychological abuse and neglect –Interventions with children –Interventions for parents –Prevention programs Sexual abuse –Interventions with children –Interventions for parents

11. Children’s exposure to violence –Incidence –Effects on development –Event-related factors Community violence Domestic violence Terrorism –Posttraumatic stress disorder –Interventions

12. Impact of witnessing violence on children INFANTS AND YOUNG CHILDREN disturbances of sleep and eating inability to be soothed constant crying

13. Child Development and Trauma PRESCHOOL CHILDREN (18 months to 3 years old) disruption of expectation of a protective figures. (attachment difficulties) agitated motor behavior or extreme passivity. eating and/or sleeping disturbances inconsolable crying

14. Child Development and Trauma 4-6 years old regression: loss of previously attained milestones –nightmares –temper tantrums –toilet training difficulties –etc.

15. Child Development and Trauma School age Disillusioned with outside world (can’t keep me safe) poor academic performance Lying, stealing fighting sleep and eating disturbances clinging false bravado

16. Child Development and Trauma Early Adolescence feelings of inadequacy unrealistic feelings of guilt exaggerated preoccupation with body somatic manifestations, acting out, etc. –unsafe sex, criminal and illegal activities, illness, drugs, pregnancies, etc.

17. Child Development and Trauma Adolescence can act as younger children inadequate solutions that can be physically dangerous to self and others 2nd opportunity experienced as threatening

18. Child Development and Trauma Short Term Effects: Acute Disruptions in Self Regulation Eating Sleeping Toiletting Attention & Concentration Withdrawal Avoidance Fearfulness Re-experiencing /flashbacks Aggression; Turning passive into active Relationships Partial memory loss

19. Child Development and Trauma Long Term Effects: Chronic Developmental Adaptations Depression Anxiety PTSD Personality Substance abuse Lower school attainment Perpetration of violence

20. Traumatic Event Related Factors I Nature of event (fire, accident, assault) –Controllable Vs. uncontrollable –Acute Vs. chronic –Familiar Vs. unfamiliar location Proximity to event (time - place - relationship) Location: Home, school, community

21. Traumatic Event Related Factors II Child’s relationship to victim Child’s relationship to perpetrator Child’s involvement in perpetration Presence of others: e.g., alone or with caregiver

22. Traumatic Event Related Factors III Witness –nature and extent of injury –physical proximity –event after aftermath –visual vs. auditory –direct vs. media –relationship to victim

23. Traumatic Event Related Factors IV Victim –threat with injury –threat without injury –severity of injury

24. Traumatic Event Related Factors V Outcome –loss of caregiver –permanent physical injury and disability Single vs. multiple exposures (non- chronic) Violent vs. non-violent

25. Traumatic Event Related Factors VI Quality of family life; parent resources Quality of school environment Availability of supportive adults Community safety –isolated and unusual Vs. chronic, daily life Response of family members, school personnel, and community institutions

26. Post-Traumatic Stress Disorder DSM IV criteria: –Exposure to event involving actual or threatened death/injury/threat to physical integrity –Response involved fear, helplessness or horror. In children: disorganization, agitation –PTSD symptom clusters (duration > 1 month): Numbing/avoidance Intrusive memories/play/dreams etc. Increased arousal

27. Post-Traumatic Stress Disorder Reactions in Children A. Traumatic repetitions 1. Traumatic play 2. Play reenactment 3. Nightmares 4.Flashback/dissociation 5. Distress when reminded 6. Somatic complaints when reminded

28. Post-Traumatic Stress Disorder Reactions in Children B. Avoidance, Numbing, Regression 1. Avoids thinking or talking about event 2. Avoids reminders of event 3. Impaired recollection 4. New fears (e.g. Separation, toiletting, darkness) 5. Sense of a foreshortened future

29. Post-Traumatic Stress Disorder Reactions in Children C. Increased arousal 1. Night terrors 2. Difficulty falling/staying asleep 3. Decreased attention/concentration 4. Irritability/angry 5. Increased aggression 6. Hypervigilance 7. Exaggerated startle response

30. Post-Traumatic Stress Disorder Reactions in Children D. Decreased responsiveness, numbing, regression 1. Constriction of play 2. Diminished interest in activities 3. Social withdrawal/feeling of detachment 4. Restricted range of affect 5. Developmental regression

31. Resilience and Adjustment Intrapersonal factors: temperament coping Prior history – may have vulnerability or protective effects Interpersonal factors social support (parental separation)

32. Police-Mental Health Responses to Traumatized Children Results from the Child Development Community Policing Program

33. Collaborative Principles Relationships Mutual Concern for Children & Families Willingness to Share the Burden and the Responsibility Multi-problem Situations Require Multi-disciplinary Interventions

34. Shared Assumptions Therapeutic value of structure Police as benevolent authority Value of security & containment Knowledge & insight –Child development –Dynamics of human behavior –Nature of clinical intervention Awareness of child’s experience

35. Program Elements Child Development Seminars Police training for clinicians Consultation service (Acute Response) Program conference Case Conference Clinician ride-alongs

36. The role of an officer in a child’s life Positive, prosocial role model Representation of safety and security Representation of benign authority (ability to contain and set limits)

37. Cultural competence What is cultural competence? What do clients want? Matching providers and consumers of mental health services - differing views Cultural competence - not only about culture, race…