Download Findings from a 20 year prospective study of - UNC

Lessons Learned from LONGSCAN: Findings
from a 20-yr prospective study of maltreatment
antecedents and consequences. Session 2
LONGSCAN Consortium PIs
LONGSCAN: Continue our 20-Year Journey
LONGSCAN Principal Investigators
East:
• South:
• Midwest:
• Northwest:
• Southwest:
• CC:
•
Howard Dubowitz, MD, MSci
Jonathan Kotch, MD, MPH
Richard Thompson, PhD
Diana English, PhD
Alan Litrownik, PhD
Des Runyan, MD, DrPH
Other LONGSCAN Investigators
•
•
•
•
•
•
East
• Maureen Black, PhD; Steve Pitts, PhD; Raymond Starr, PhD
South
• Christine Cox, PhD; Jon Hussey, PhD
Midwest
• Patrick Curtis, PhD; Emalee Flaherty, MD; Mary Schneider, PhD;
Richard Thompson, PhD
Northwest
• Chris Graham, PhD; David Marshall, PhD
Southwest
• Laura Proctor, PhD; John Landsverk, PhD; Rae Newton, PhD
CC
• Kant Bangdiwala, PhD; Mark Everson, PhD; Wanda Hunter,
MPH; Liz Knight, MSW; Terri Lewis, PhD
LONGSCAN Overview
• 5 Independent study sites and CC
• Recruit at 4 (vary by maltreatment risk)
• Common measures and methods
• Assess every year (4 to 18)
• Extensive face-to-face interviews with
child/youth and caregiver every 2 years
• Domains assessed
• Child/Caregiver/Environment
• Multiple sources/informants
• Child/youth, caregiver, official CPS records
LONGSCAN: Role of Fathers
Howard Dubowitz, MD, MS
University of Maryland School of Medicine
Research on Fathers - Background
• Very little pertaining to child maltreatment (CM)
• Absent fathers
• Sexual abuse
• Considerable research on child development
• Less on high risk & minority children
• In general, nurturing fathers enhance child dev.
Fathers & Child Neglect
Dubowitz et al, Arch Pediatr Adoles Med. 2000;154:135-141.
Background
• Neglect
• most common form of CM
• usual focus on omissions in mother’s care
• A lack of father involvement may jeopardize
children’s basic needs being adequately met
Hypothesis
• Greater involvement of fathers
•
•
•
•
Nurturing
Living in the home
Contributing $
Helping with child care, household tasks
• …… protects children from neglect
Participants
• 244 families of 5-yr. olds
• Eastern site
• 72% had identified fathers
• 66% of them interviewed (n = 117)
Measures – Fathers’ Involvement
Reported by Fathers
•
Demographics (eg, relationship to child,
residence)
•
Who Does What (child care, household tasks)
•
Videotaped father-child interaction (nurturing)
•
Parenting Sense of Competence
Measures – Neglect
•
CPS report (age 4-6) 16%
• Child Well-Being Scales
• Home Observation Measure of the Environment
• Videotaped mother-child interaction
Neglect Index
Probable: CPS + 2 measures, no CPS + 3
Possible: CPS and < 2, no CPS + 2
Unlikely: no CPS and < 2
[N = 11]
[N = 24]
[N = 59]
Findings
• F absence alone NOT related to
neglect
• F relationship was related to neglect
• A greater sense of efficacy
• Relationship of longer duration
• Helped with household tasks
Findings
• F characteristics NOT related to neglect
• Nurturing behavior
• Residence
• Employed fathers’ $ contributions
• Biological status
Policy & Practice
Implications
• Need broad view of “father” beyond biological
status, residence, $ support
• Need to help fathers feel competent re.
parenting
• Encourage F’s involvement
• Impart parenting knowledge, skills
Are Father Surrogates a Risk
Factor for Child Maltreatment?
Does a father surrogate in the home affect the
risk of a subsequent CPS report?
Radhakrishna et al, Child Maltreatment, 2001;6: 281-289
Fathers & Risk for Maltreatment
• 182 high risk families
• Southern site
• Fathers
• No F in home (55%)
• Bio. F in home (29%)
• Father figure or FF (16%)
• CPS data: perpetrator NOT known
Findings
P
OR
CI
Partner vs. no male partner
.021
2.0
1.1-3.5
Partner vs. biological father
.003
2.6
1.4-4.7
Bio. father vs. single mother
ns
0.8
0.5-1.2
Policy & Practice
Implications
•
Increased risk, but most FF do NOT maltreat
•
Association with FF may be confounded by
other family circumstances, dysfunction
•
CPS needs to carefully assess and address
fathers’ roles
•
Support vulnerable mothers – less dependent
on maltreating men
Father Involvement and Children’s
Functioning at Age 6
•
Is presence of a father associated with better
child functioning?
•
Are children’s perceptions of fathers’ support
associated with better functioning?
•
Are the above associations moderated by the
father’s relationship to the child and the child’s
race and gender?
Dubowitz et al, Child Maltreatment, 2001;6:300-309
Measures
• 6 yr. olds’ perceptions of F involvement
• Child functioning
• Mental health
• Behavior
• Social competence
Findings
• Father presence associated with better
cognitive development and perceived
competence by the children
• Children reporting more F support
• Less depression
• Greater social competence, acceptance
• The associations did NOT differ by child’s
gender, race, or relationship to father figure
Policy & Practice
Implications
•
Need to convey to fathers, and mothers, how
children can benefit from fathers’ involvement
•
Need to understand what enables and impedes
fathers’ involvement
•
Need interventions to encourage men’s positive
involvement in children’s lives
- especially in high risk families
The Effect of Fathers or Father Figures
on Child Behavioral Problems in Families
Referred to CPS
Marshall et al, Child Maltreatment, 2001;6:290-299
Methods
• 182 6-year olds
• NW site
• Teacher reports, CBCL – TRF
• Aggression
• Depression
Findings
• F presence did NOT effect behavioral problems at
age 4
• F presence associated with less aggression and
depression at age 6
• In multivariate analyses, African American children
without a father
• more aggressive and depressed
Policy & Practice
Implications
•
Recognize the many influences on
children’s behavior
•
Particularly, in African American families
involved with CPS, father presence appears
important to children
•
Need ways to help fathers be positively
involved in their children’s lives.
The Involvement of Low-Income African
American Fathers in their Children’s Lives,
and the Barriers.
Objective
To describe & understand the barriers facing low-income,
African American fathers to being involved in their
children’s lives
Dubowitz et al, Ambulatory Pediatrics. 2004;4(6):505-508.
Sample
•
Eastern site
•
246 mothers of 8-year olds were asked if
fathers or father figures were involved in
their children’s life, with at least monthly
contact
•
180 (73%) of the mothers identified an
African American father or father figure
•
119 (66%) of the men were interviewed
Fathers & Father Figures
119 fathers or father figures
48% biological father
20% mother’s partner
9% stepfather
12% uncle
Method
Fathers were asked open-ended questions
about their views of fatherhood including the
barriers they perceived concerning their roles
and relationships with their children
Sample questions
“What makes it hard for you to be the father to ____
you want to be?”
“What do you like least about being a father to ____?”
Financial Limitations
(N=29)
What do you like least about being a father to your
child?
“…material things are so important, and I want to be
able to give him everything. I do provide for him the
necessities, but the accessories, that the other kids
have, it’s hard, and I don’t like not being able to do
that, and it’s hard to explain to a kid why.”
Work/Career
(N=27)
What do you like least about being a father to your
child?
“Cause of my job, I work midnight hours. Cause I
don’t see her like everybody else does. I’m usually
in bed sleeping when she gets home.”
Not Living with Child
(N=16)
What would you change in your relationship with your
child?
“The thing I would change is his living environment.
If I was able I would take him into my own home or
provide him with more positive role models. Him
being in his living environment with his aunts and
uncles is a negative environment.”
Relationship with Child’s Mother
(N=24)
What makes is hard to be the father you want to be?
“Right now, it is the wife, her mother. We don’t get
along as good as we could. It is mainly because of
her in my opinion. I do not want to go into details.
It is kind of personal. If things were not the way
they are, things would be a whole lot better for me.”
Not Being Child’s Biological Father
(N=9)
What makes it hard to be the father you want to be?
“Trying to compare to his real father, my brother. I
am not there to knock my brother out of the picture or
anything like that, it’s just hard trying to compete. I
won’t ever be his real father and he knows that.”
Substance Use/Health Problems
(N=4, 3)
What would you change in your relationship with your
child?
“Like drinking in front of her, I would love to
change that…I don’t like smoking in front of her.”
No Barriers
(N=25)
What makes it hard to be the father you want to be?
“I guess I am the father I want to be. I really don’t
have a problem. No one’s perfect, you know, but
right now I don’t think I am doing a bad job.”
Policy & Practice
Implications
•
•
•
•
Reduce poverty to help address barriers
facing low income fathers
Flexible work policies
Help parents recognize what’s in their
child’s best interests
Better access to health care and substance
abuse treatment
Thank You
[email protected]
LONGSCAN: Longitudinal Health and
Behavioral Outcomes
Richard Thompson, PhD
Juvenile Protective Association, Chicago
and
Jonathan Kotch, MD, MPH
The University of North Carolina at Chapel Hill
Aggression: Methods
Examined at ages 4, 6, and 8; caregiver report.
• Delinquent/violent behavior and substance use assessed
at 12 & 14; youth self-report
• Model: effects of different forms of maltreatment on
repeated measures or trajectories.
• Controls for demographics, caregiver depression, other
risk factors
•
48
Aggression (early):
Maltreatment Effects
Little overall effect of maltreatment on aggression
through age 8.
• Disaggregating timing and type of maltreatment
improves prediction.
• Specific effect of early (before age 2) reports of
neglect.
• No significant effect of early or recent physical abuse,
or of more recent (after age 2) neglect.
•
49
Aggression (early): Regression of timing
and type of maltreatment
PREDICTOR
Estimate (SE)
p
Early Neglect
1.29 (0.46)
<.01
Early Abuse
0.66 (0.68)
.33
Recent Neglect
0.14 (0.34)
.68
Recent Abuse
0.53 (0.39)
.18
Source: Kotch et al. (2008). Importance of early neglect for childhood aggression.
Pediatrics, 121, 725-731.
50
Aggression (teen):
Maltreatment Effects
Main effects of physical abuse and neglect on
aggression and risk-taking at ages 12 and 14
• Evidence for gender-specific models:
•
• Boys: a strong effect of physical abuse on risk, no effect of
neglect
• Girls: a strong effect of neglect, no effect of physical abuse.
51
Aggression:
Caveats/Future Directions
•
Moderators:
• At age 12, effects of neglect are moderated by neighborhood
social capital
• Early services may reduce risk of aggressive behavior.
•
Consistency between aggression and risk taking
• Significant links between early aggression and teen
violent/delinquent behavior and substance use.
•
Other risk factors:
• No significant effect of witnessed violence.
• Need to examine how maltreatment interacts with other risk
factors.
52
Suicidal Ideation:
Methods
•
•
•
•
•
•
Examined at age 8, 12, 16 (thus far)
Youth self-report on ideation.
Models adverse experiences, identifying unique
predictors.
Adverse experiences are mediated by depression/
psychological distress.
In LONGSCAN sample, suicidal ideation is roughly
10% of the sample at each age
Modest continuity of ideation over time.
53
Suicidal Ideation:
Maltreatment Effects
•
•
•
•
•
Maltreatment predicts suicidal ideation strongly.
Especially true of physical abuse
Psychological abuse also predicts suicidal ideation at
age 16.
Multiple types predicts ideation
More recent maltreatment strongly predicts
ideation.
54
Suicidal Ideation: Regression predicting
Ideation at age 16
Predictor
OR (CI)
Physical abuse
2.62 (1.29 – 5.32)
Sexual Abuse
0.98 (0.39 – 2.46)
Psychological Abuse
3.65 (1.80 – 5.73)
Neglect
0.60 (0.19 – 1.80)
Source: Thompson et al. (2010). Suicidal ideation in adolescence: Examining the role of
recent adverse experiences. Under Review.
55
Suicidal Ideation:
Caveats/Future Directions
•
Other risk factors:
• Witnessed violence (family and community)
• Transitions in living situation
• Pessimism
• Poor social skills (age 8)
•
Ideation vs. attempts
• Maltreated girls
•
Integrating different adversities
• Cumulative risk vs specific adversities
• Age-specific risk profiles
56
Depression/Anxiety: Methods
Trajectories from age 4 to age 10
• Mother reports of child behavior (CBCL)
• Effects of early official reports of maltreatment
• Normative for child anxiety/depressive symptoms to
increase slightly over this period
•
57
Anxiety/Depression:
Maltreatment Effects
Early maltreatment strongly predicts trajectory of
depression/anxiety symptoms.
• Children with maltreatment history start at age 4
with similar levels of symptoms to those without
such history.
• By age 10, dramatic differences between the groups.
•
58
Anxiety/Depression: Trajectories
Source: Thompson & Tabone (2010). The impact of early maltreatment on behavioral
trajectories. Child Abuse and Neglect, 34, 907-916.
59
Anxiety/Depression:
Caveats/Future Directions
•
Other risk factors:
• Low family income
• Mother depressive symptoms
Effects of early services?
• Parents often have trouble detecting internalizing
problems in children.
• Need to examine other adverse experiences (family
violence, instability, family functioning)
•
60
Future Expectations:
Methods
Assessed at age 14 (and later)
• Youth report on how likely they think that they will have
outcomes in the future:
•
• Academic: e.g., graduate from high school, go to college
• Career: e.g., get a job I want, lose a job
• Social: e.g., have a child w/o getting married, get divorced
61
Future Expectations:
Maltreatment Effects
•
Maltreatment predicts:
• lower expectations of educational success
• Higher expectations of employment instability
Stronger effects of more recent maltreatment.
• Stronger effects of more severe maltreatment.
• Little effect of maltreatment on social outcomes.
•
62
Future Expectations:
Caveats/Future Directions
•
Other risk factors:
• Community violence
• Caregiver instability
Do future expectations mediate effects of
maltreatment on long-term outcomes?
• Self-fulfilling prophecy or accurate assessment of
opportunities?
•
63
Physical Health
•
Two approaches
• History of child maltreatment and child’s self-
reported gastro-intestinal symptoms at age
12
• Adverse childhood experiences and child’s
self-reported health at age 12
64
Maltreatment and GI symptoms
•
Methods (n=845)
• Maternal reports of GI symptoms ages 4, 6, 8, and 12
(CBCL)
• CPS reports of maltreatment
• Child reports (YSR) at age 12 of
• GI symptoms
• Maltreatment (phys/sex/emotional abuse)
• Psych distress (anxious/depressed subscale of YSR)
Source: Van Tilburg M et al. Unexplained gastrointestinal symptoms after abuse
in a prospective study of children at risk for abuse and neglect. Ann Fam Med
2010;8:134-140.
65
Maltreatment effects
•
Lifetime CPS allegations of sexual abuse were
associated with abdominal pain at age 12 years.
• Sexual abuse occurred before or with abdominal pain
significantly more often than after it.
Youth report of ever having been psychologically,
physically, or sexually abused was significantly
associated with both abdominal pain and
nausea/vomiting.
• When adjusting for psychological distress, most
effects became insignificant except for the relation
between physical abuse and nausea/vomiting.
•
66
Caveats/Future directions
•
Limitations
• Self-reports were retrospective
• Validity of parent reports and child self-reports of GI
symptoms is unknown
•
Future research
• More studies are needed on how unexplained GI
symptoms can develop as a consequence of
childhood abuse.
•
Implications for clinicians
• Could recognizing abuse early modify the course of
GI symptoms?
• Treatment recommendations for abused youth with
GI symptoms need to be developed.
67
Adverse childhood experiences
•
Methods
• 805 caregiver/child dyads completed an interview when
the child was age 4 or age 6, as well as interviews at age
8 and 12.
• 8 categories of childhood adversity
1. psychological maltreatment
2, 3, 4. physical abuse, sexual abuse, child neglect
5. caregiver’s substance/alcohol use
6. caregiver’s depressive symptoms
7. caregiver’s being treated violently
8. criminal behavior in the household
• Child health at age 12 (both child and caregiver report)
Source: Flaherty EG et al. Adverse childhood exposures and reported child
health at age 12. Academic Pediatrics 2009;9:150–6.
68
Adversity’s effects
•
Greater adversities during the child’s first 6 years of life were
associated with the caregiver’s and child’s age 12 report of
• somatic complaints
• any poor health outcome
•
Childhood adverse exposures during the second 6 years of
life were associated with
•
•
•
•
•
any health complaint
child reports of poor health
child and caregiver reports of child somatic complaints
illness requiring medical attention
Increased adverse exposures during the child’s second 6
years of life were strongly associated with
• illness requiring a doctor
• any complaint of poor health
69
Caveats/Future directions
•
Limitations
• High risk sample (not representative)
• Attrition
• Not all adversities (e.g., illicit drug use) were assessed at all
ages
• Maltreatment (CPS reports) may be underestimated
•
Future research
• Population-based sample
• More consistent assessment of adversities
•
Clinical implications
• A comprehensive assessment of children’s health should
include a careful history of exposure to adversity and
maltreatment.
• Psychosomatic symptoms always require probing for possible
triggers.
70
Early Sexual Initiation
•
Methods
• n=637 at age 14, 493 at age 16
• 411 youth are included in both samples
• Measures
• Maltreatment: CPS records and youth self-report
at age 12
• Psych distress: TSC at age 12
• Sexual intercourse: youth self report at ages 14
and 16
Black MM et al. Sexual intercourse among adolescents maltreated before age 12:
A prospective investigation. Pediatrics 2009(3);124:941-49.
71
Maltreatment effects
•
Maltreatment before age 12 is significantly
associated with early initiation of sexual
intercourse at ages 14 and 16.
• Same results for sexual abuse alone, and for all
maltreatment other than sexual abuse combined
•
Gender differences
• These relationships are the same for males and females
for sexual abuse, psychological abuse and neglect.
• The relationship between physical abuse before age 12
and sexual intercourse at ages 14 and 16 is less strong
for boys.
•
Emotional distress mediates these relationships
at age 14, but not 16.
72
Caveats/Future directions
•
Limitations
• Self reports can lead to measurement bias.
• Emotional distress was not evaluated against
published norms.
•
Future research
• Older ages
• Consequences of early initiation, e.g., unplanned
pregnancy, STIs
•
Clinical implications
• Primary prevention of maltreatment might lead to
less emotional distress and delay sexual intercourse.
• Sexually active adolescents should be evaluated for
possible maltreatment.
73
Risky Sexual Behavior
•
Methods (n=844)
• Exposure
• Trajectories of CSA, emotional abuse, physical
abuse and neglect (two year intervals from 2 birth
to age 12) based on CPS reports
• Witnessed violence as reported by caregiver
• HIV/AIDS risk behavior at age 14 (A-CASI)
• Sexual intercourse (Adolescent Sexual
Experiences, Knight et al., 2008)
• Alcohol use (DISC)
Jones DJ et al. Trajectories of childhood sexual abuse and early adolescent
HIV/AIDS risk behaviors: the role of other maltreatment, witnessed violence,
and child gender. J Clin Child & Adolesc Psychology 2010;39(5):667–680.
74
Maltreatment effects
History of CSA associated with the
development of risky behavior.
• Physical and emotional abuse, but not
neglect or witnessed violence, each
contributed to risky behavior (alcohol use and
sexual intercourse combined) over and above
the role of CSA.
• Child gender did not moderate the findings.
•
75
Caveats
•
Limitations
• Sample predominantly high risk youth.
• Alcohol use and sexual intercourse were
examined at only a single time point.
• CSA experiences not explicitly excluded from
questions about sexual activity.
76
Future directions
• Consider whether variation in reporter changes the
pattern of associations between
maltreatment/witnessed violence trajectory groups
and risky behavior outcomes.
• Determine whether specific maltreatment and
witnessed violence trajectories predispose youth for
specific risky behavior trajectories across
adolescence and into adulthood.
• Other moderators to consider
• other child, family, and community risks
• protective factors
77
Clinical implications
• Knowledge of maltreatment history in
general, and CSA history in particular, may be
useful for identifying vulnerable youth prior
to their engagement in risky behaviors.
• Similar maltreatment experiences predict the
development of HIV/AIDS risk behaviors for
both boys and girls.
78
Brain function-fMRI
•
•
Total 12 subjects
•
Four kinds of behaviors
• 3 victims
• Standards (squares)
• 3 witness
• Neutral distractors
• 6 controls
• Targets (circles)
Method
• Each subject has 8-10 runs
• Press a button upon
detecting a circle and
another button for all
other stimuli.
• Aversive distractors
•
Four contrasts
• Neutral – Standard
• Target – Standard
• Aversive – Standard
• Aversive – Neutral
Analysis
Used linear modeling to test contrasts in
brain activity in response to visual stimuli
between
control group and victim group, and
• control group and witness group
•
80 80
Results
Significant case/control differences in contrasts in brain activity between
viewing aversive images compared with viewing standard or neutral
images for three anatomical regions (n=12)
Test 1:
Control vs. victim
Test 2:
Control vs. witness
Active Region (P value, Pct)
Active Region (P value, Pct)
Aversive vs. diPFC1 (0.003, 86.81%)
standard
vPFC2 (0.0, 60.85%)
PMF3 (0.0, 81.92%)
diPFC (0.0028, 58.87%)
vPFC (0.0024, 37.48%)
PMF (0.00078, 56.71%)
Aversive vs. diPFC (0.0026, 59.10%)
neutral
vPFC (0.0, 47.82%)
PMF (0.0023, 51.41%)
diPFC (0.00059, 43.20%)
vPFC (0.0043, 33.28%)
PMF (0.002, 38.85%)
1
diPFC = Bilateral dorsolateral prefrontal cortex
vPFC = Ventral prefrontal
3 PMF = Posterior middle frontal gyrus
2
81
Regional differences in brain activity in the bilateral dorsolateral prefrontal cortex between cases and
controls for the aversive vs. neutral contrasts (n=12)
3.5
0
-3.5
8282
Future directions
•
•
Scan larger number of subjects and controls
Link fMRI results to
• Executive functioning
• Saliva cortisol (stress hormone)
• Adverse behaviors
• Risky sexual behavior
• Criminal justice involvement
• Substance abuse
83
Questions & Comments
•
Website:
http://www.iprc.unc.edu/longscan
•
National Data Archive on Child Abuse &
Neglect
http://www.ndacan.cornell.edu