Children’s mental health Children’s mental health in the context of in the context of

developmentdevelopment

Children’s mental health Children’s mental health in the context of in the context of

developmentdevelopment

Housing Provider GroupHousing Provider Group

Healthy Families InitiativeHealthy Families Initiative

Abi Gewirtz, Ph.D., L.P.Abi Gewirtz, Ph.D., L.P.

University of MinnesotaUniversity of Minnesota

Today’s topic – child maltreatment and exposure

to violenceChild maltreatment – definitions and statistics– Physical abuse– Neglect– Sexual abuse– Psychological abuse

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)

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

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

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

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.

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,

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

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

Children’s exposure to violence

• Children’s exposure to violence– Incidence– Effects on development– Event-related factors

• Community violence• Domestic violence• Terrorism

– Posttraumatic stress disorder– Interventions

Impact of witnessing violence on children

INFANTS AND YOUNG CHILDREN

• disturbances of sleep and eating

• inability to be soothed

• constant crying

Child Development and TraumaPRESCHOOL 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

Child Development and Trauma 4-6 years old• regression: loss of previously attained

milestones– nightmares– temper tantrums– toilet training difficulties– etc.

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

Child Development and TraumaEarly 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.

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

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

Child Development and Trauma Long Term Effects:

Chronic Developmental Adaptations

• Depression• Anxiety• PTSD• Personality • Substance abuse• Lower school attainment• Perpetration of violence

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

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

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

Traumatic Event Related Factors IV

• Victim– threat with injury– threat without injury– severity of injury

Traumatic Event Related Factors V

• Outcome – loss of caregiver – permanent physical injury and disability

• Single vs. multiple exposures (non-chronic)

• Violent vs. non-violent

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

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

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

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

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

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

Resilience and Adjustment

Intrapersonal factors:

temperament

coping

Prior history – may have vulnerability or protective effects

Interpersonal factors

social support (parental separation)

Police-Mental Health Police-Mental Health Responses to Responses to Traumatized Traumatized

ChildrenChildren

Police-Mental Health Police-Mental Health Responses to Responses to Traumatized Traumatized

ChildrenChildrenResults from the Child Results from the Child

Development Community Development Community Policing ProgramPolicing Program

Collaborative Principles

• Relationships• Mutual Concern for Children &

Families• Willingness to Share the

Burden and the Responsibility• Multi-problem Situations

Require Multi-disciplinary Interventions

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

Program Elements• Child Development Seminars• Police training for clinicians• Consultation service (Acute

Response)• Program conference• Case Conference• Clinician ride-alongs

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)

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…