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Rates of violence in Scotland have reduced by about 60% in recent years
…because we treat our children better?
Lets start with a good news story…
The way we used to treat our children
• Until the 1960s,
children often left for
months in hospital –
TB, polio etc. - with no
parental visits
Adverse Childhood Experiences
Felitti et al
The ACES load…
• Neglectful and/or abusive early experiences
• Turbulent journeys through the care system
• Foster carers are “temporary”
Essentially no mental health services for children under 5 –
especially if maltreated
But what about maltreated children in 2015?
Disinhibited Social
Engagement Disorder
indiscriminate sociability
with marked inability to
exhibit appropriate
selective attachments
Maltreatment specific disorders
Reactive Attachment
Disorder
Emotional withdrawal,
hypervigilant or highly
ambivalent and contradictory
responses
Maltreatment specific disorders
Population prevalence of RAD and DSED together is about 1% - similar to autism
1.4%
Of those children with
RAD:
•ALL had at least one
other diagnosis
•ADHD (54%)
•ODD (23%)
•CD (31%)
•PTSD (15%)
•ASD (15%)
•Tics – 1 child
Adopted children with RAD/DSED have slightly but significantly lower cortisol secretion compared to control children
And nearly all have other psychiatric disorders:
•85% also had possible or likely ADHD
•85% also had a possible or likely Anxiety Disorder
•55% had possible or likely PTSD
•75% were oppositional
•85% had conduct problems
Kocovska et al
A complex picture
Maltreatment-associated psychiatric problems (MAPP)
• Children who have experienced
maltreatment in early life tend to have
complex overlapping problems
• These can include RAD, DSED, ADHD,
Conduct disorder, PTSD, anxiety, FASD
• Speech and language problems are
common
• Mild cognitive problems are common
• A central problem in forming and
sustaining intimate relationships e.g.
control, emotional withdrawal, problems
with regulation
In the context of maltreatment, certain parts of the brain suffer…
•Most susceptible are the areas still developing long after birth•And those with a high density of receptors for stress hormones
Teicher, 2003, 2016
The course of MAPP over time
For example•Hippocampus•Amygdala•Fronto-temporal area
So can these problems be treated?
Yes!
The most effective intervention is loving family care:
•Children who grew up in terrible conditions in Caucescu’s Romania had psychiatric and cognitive problems that resolved almost completely once adopted to the UK
O’Connor and Rutter
•Trial evidence has shown that changes to cortisol profile can be reversed with “extra nurturing” care
Dozier et al
Is introducing a mental health service for maltreated infants a cost-effective way of improving their mental
health?
Treatment of birth family with aim to reduce future ACES
–apparently successful in US in non-randomised study
• Randomised controlled trial of an infant mental health services for maltreated children
• Recruiting since 2012
• Approx 180 participating families
• Represent 60% of families in Glasgow who have a pre-school child coming into foster care
We know part of the answer
Research Question: why do some severely maltreated children develop psychiatric disorders and some don’t?
-children differ
The differential susceptibility
hypothesis
Belsky 2004
Children differ from birth
Temperament: present early in life…strongly heritable…stable over time
Chess and Thomas
Children differ from birth
emotionalityactivity levels
sensation-seeking
Biological
rhythmicity
sensitivity to
changes
Bradley and Corwyn, Journal of Child Psychology and
Psychiatry 49:2 (2008), pp 124–131
“Children with difficult temperaments, because
they struggle with internal regulation, appear
more amenable to assistance with regulation
from outside”
• direct assistance with coping (e.g.,
parental sensitivity)
• opportunity for productive activity
Reproduced with permission
Children differ from birth
Yes
Yes
No
No
FASD
Yes No
MAPP
Why do only some maltreated children have mental health
problems?
Alcohol or other
prenatal insult
Maltreatment
“Orchid” temperament
Yes
Yes
No
No
FASD
Yes No
MAPP
Why do only some maltreated children have mental health
problems?
Alcohol or other
prenatal insult
Maltreatment
“Orchid” temperament
Plan to follow up BeST? cohort of maltreated children as they reach age 8
Research Question: why do some severely maltreated children develop psychiatric disorders and some don’t?
-but how do children differ?
Epigenetics
Immune Functioning
Areas of focus• Social development
• Epigenetics
• Stress hormones and stress responsivity
• Immune functioning
• Brain development
High stress
environment
at age 0-5
Neurocognitive problems, esp.
executive functioning
Problems with social interaction
e.g. with face recognition
Psychiatric disorders
(mood/personality disorder)
Stress
response
system
Immune system
Brain
Genetic
factors
x
“Ready for action” physiology
High stress
environment
at age 0-5
Neurocognitive problems, esp.
executive functioning
Problems with social interaction
e.g. with face recognition
Psychiatric disorders
(mood/personality disorder)
Stress
response
system
Immune system
Brain
Genetic
factors
x
Epigenetic
changes
A reminder of the way we used to treat our children…
Are we slipping back?
Your thoughts
please…
