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Longer-term impacts of childhood adversity – considering risk and resilience and implications for practice.

Michael Sieff Foundation: Promoting the Well-being of the Primary School Age Child: 21 & 22 September 2010. Longer-term impacts of childhood adversity – considering risk and resilience and implications for practice. Antonia Bifulco, Professor of Health and Social Care Lifespan Research Group

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Longer-term impacts of childhood adversity – considering risk and resilience and implications for practice.

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  1. Michael Sieff Foundation: Promoting the Well-being of the Primary School Age Child: 21 & 22 September 2010 Longer-term impacts of childhood adversity – considering risk and resilience and implications for practice. Antonia Bifulco, Professor of Health and Social Care Lifespan Research Group Royal Holloway, University of London a.bifulco@rhul.ac.uk Michael Seiff Foundation Sept 10

  2. The Lifespan Research Group • We undertake academic research into lifespan and intergenerational risk factors for psychological disorders – with a focus on parents and adolescents. • Using a lifespan approach with focus on key transitions (such as adolescence) in relation to parental neglect/abuse in childhood. • Utilising interview measures which are sensitive to narrative and meaning, yet amenable to quantitative analyses (eg CECA and ASI) • We also undertake applied research with social care and health services to aid with evidence-based practice & training in assessment. Michael Seiff Foundation Sept 10

  3. Aim of presentation • To examine longer term effects of childhood adversity in relation to adolescent and adult psychological disorder. • To examine risk and resilience models in an Attachment Framework • To discuss gaps in research and methods for primary school-age children. • To consider implications for health and social care practice Michael Seiff Foundation Sept 10

  4. Risks in UK adolescents • UNICEF report (2007) • Young people in UK report worse levels of well-being in Europe • Mental health rates increased (Maughan, Meltzer & Goodman (2008) • Teenagers in the UK have high rates of psychological disorder compared to other Western countries. These increased up to 1999. Although evidence of stabilising, teacher report of emotional disorder increasing up to 2004 Nuffield Foundation, 2009). • Other risk factors • teenage pregnancy, family break down, neglect/abuse, risk taking behaviour, violent environments are all common in UK youth Michael Seiff Foundation Sept 10

  5. Risks in UK adults • High rates of family breakdown, divorce and single parenthood • High rates of domestic violence • High rates of depression, anxiety and substance abuse • Variable treatment coverage (primary care provision, but rationed) Michael Seiff Foundation Sept 10

  6. What is childhood adversity? FAMILY CONTEXT • Deprivation: Family context of poverty, housing difficulty, parental physical or mental illness, • Conflict: domestic conflict and violence. • Unstable family structure – single parent, re-constituted families BEHAVIOUR TOWARDS CHILD • Poor relationships with parents (antipathy, discord, low supervision, high discipline) • Maltreatment (neglect, physical abuse, sexual abuse, psychological abuse). • All these factors are inter-related. Some evidence of increase. Michael Seiff Foundation Sept 10

  7. Adversity for children and parents occur in the same context…. FAMILY CONTEXT Family structure Partner Conflict Family Deprivation Parent Psychological disorder BEHAVIOUR TO CHILD Poor parent- Child relationship Child Maltreatment Child Psychological disorder

  8. Family context, parenting and maltreatment • Study of family factors, parenting and maltreatment and psychological disorder in offspring shows that maltreatment is the most significant factor. Specifically: • Neglect • Physical abuse • Sexual abuse • Psychological abuse Michael Seiff Foundation Sept 10

  9. Summary of Lifespan findings on CECA and psychological disorder. Community series of adult women and of adolescents. Michael Seiff Foundation Sept 10

  10. Lifespan Intergenerational Community Samples • Community mothers (1980-5; 1990-5) registered with London GP surgeries studied prospectively to determine lifetime vulnerability to depression • (i) Representative 1980-5 (n=210) • (ii) Vulnerable 1990-5 (n=303) • Community Offspring – to test transmission of risk to adolescent/young adult offspring • (i) Sons and daughters of Representative mothers 1989-92, (n=172) • (ii) Sons and daughters of Vulnerable mothers 1995-99 (n=146) Michael Seiff Foundation Sept 10

  11. Standardised, contextual, interview measures used • Childhood Experience of Care and Abuse (CECA) • (Bifulco & Moran 1998) • Attachment Style Interview • (Bifulco et al 2002) • SCID DSM-IV for clinical disorder • (First et al, 1996) Michael Seiff Foundation Sept 10

  12. The Childhood Experience of Care and Abuse Interview (CECA)(Bifulco & Moran, 1998) • A retrospective measure of early life experience used with adolescents or adults. • Covers relationship with parents, family context and neglect and abuse directed to child. • Assesses severity, age at onset, duration, frequency etc of a range of negative experience before age 17. • Has good reliability and validity. Michael Seiff Foundation Sept 10

  13. Material neglect and indifference shown by parents and carers to child in relation to: material care (being fed, clothed); regular household routines; health & hygiene. Socialisation: neglect of friendships, school work, career options Emotional needs & support Severity determined by pervasiveness of neglect and number of areas of neglect Rated: Marked ] Severe Moderate ] Severe 3. Mild 4. Little/none Scored For each abuse by different perpetrator For changes in severity over time CECA Neglect Michael Seiff Foundation Sept 10

  14. Violence shown to child from household member. Includes severe beatings, being hit with implement, punched, kicked, burned. Potential for causing injury. Usually repeated but can be single severe attack, usually from adult, but maybe older child/young person. Severity determined by intensity of attack, type of hitting and frequency. CECA Physical abuse • Rated: • Marked ] Severe • Moderate ] Severe • 3. Mild • 4. Little/none • Scored • For each abuse by different perpetrator • For changes in severity over time Michael Seiff Foundation Sept 10

  15. Sexual behaviour to child by any adult or older child/young person. Usually sexual contact but can include verbal solicitation, observing sexual activity/ pornography. With or without force. Perpetrator can be any relationship to child or stranger. Can be single incident or repeated. Severity determined by degree of contact, repeated nature, relationship to other. Rated: Marked ] Severe Moderate ] Severe 3. Mild 4. Little/none Scored For each abuse by different perpetrator For changes in severity over time CECA Sexual abuse Michael Seiff Foundation Sept 10

  16. Rated: Marked ] Severe Moderate ] Severe 3. Mild 4. Little/none Scored For each abuse by different perpetrator For changes in severity over time Sadistic & cruel behaviour, coercive control of the child involving: humiliation, extreme rejection deprivation of basic needs or valued objects, inflicting marked discomfort/distress, Terrorising Cognitive disorientation Emotional blackmail or exploitation. Severity determined by intensity , number of categories of abuse and frequency. CECA Psychological Abuse Michael Seiff Foundation Sept 10

  17. Prevalence of maltreatment • Experiences of severe neglect, physical or sexual abuse in childhood affects around 1 in 4 individuals (Bifulco & Moran, 1998). • (Also, see Cawson 2000: with 15% severe neglect, 21% physical abuse, 18% sexual abuse and 6% psychological abuse). • Although fairly common, most individuals survive it (around two-thirds) in terms of psychological disorder. • However there is variation in the multiples of abuse and intensity which does increase risk of negative outcome Michael Seiff Foundation Sept 10

  18. Neglect and abuse experience relates to later clinical disorder • A range of negative childhood experience relates to adult depression and to a range of adolescent disorder. • The pattern is similar in both age groups although higher in adolescents. • Various dose-response effects are observable. Michael Seiff Foundation Sept 10

  19. CECA experience and major depression in 12 months: 303 adult high-risk community women*

  20. CECA experience and any case disorder in 12 months – 276 young people 16-25 (representative & high risk)

  21. Males and externalising disorder:CECA experience and conduct disorder – young males 16-25, n=140

  22. Dose-Response effects (i) Multiple AbuseThe more the types of abuse the more likelihood of disorder – dose response effect (303 adult community women) % with adult depression 12 month Chronic/ recurrent 73 64 65 53 35 35 28 23 23 9 Multiple abuse < 17 Severe neglect or physical or sexual or psychological abuse

  23. Dose-response effects (ii) Severity of abuseSeverity of types of abuse and adult depression – dose response effect (303 adult community women) % depression in 12 months Severity of neglect/abuse

  24. Family context and neglect/abuse in childhood (303 adult women) X 2.4 Parental conflict X2.8 Severe neglect, physical or sexual abuse Parental Loss X2 Deprivation X3.2 Any 1 factor (Relative risks given) Bifulco & Moran, 1998

  25. Teenage linking experiences(303 Vulnerable women) Teenage pregnancy x 1.64 Lack of planning re home leaving x 1.7 Neglect or abuse <17 x 3 Teenage depression 17-20 Relative risks shown

  26. Adult risk factors and neglect/abuse in childhood (303 vulnerable women) Violent partner X2.1 X2.6 Neglect/abuse <17 Adult sexual assault X1.6 Separation partner Relative risks given

  27. Role of previous pregnancy & marital experience (303 vulnerable women)Path analysis Marital adversity .21 .33 Neglect or Abuse in childhood ADULT DEPRESSION 12 MONTHS .33 .29 ns Severe loss pregnancy Bernazzani, Bifulco et al 2003

  28. Role of insecure attachment style- adults • Adult attachment examined as mediating factor between childhood experience and later adult disorder, both anxious and avoidant active. • Adult attachment examined as mechanism in maltreatment of children and in relation to poor parenting capacity • Adolescent insecure anxious attachment style mediates between maternal poor parenting and emotional disorder. Michael Seiff Foundation Sept 10

  29. Attachment Theory Bowlby, 1969-80 Attachment and Loss trilogy. • Attachment theory provides a useful framework for investigating lifespan linkages between early interactions between parent and child and subsequent relationship style in adolescence and adulthood. • Research evidence shows insecure attachment style relates to: • childhood neglect/abuse (Crittenden 1997), • poorer support (Hazan & Shaver, 1994; Bartholomew & Horowitz 1997), • stress (Mikulciner & Florian, 1998) and • psychological disorder in adolescence (Allen, 1998) and adulthood (Mickelson & Kessler 1997) Michael Seiff Foundation Sept 10

  30. Attachment Style Interview (ASI)Bifulco et al 2002 • Assesses quality of relationship with partner and 2-3 Very Close Others. At least 2 close confiding relationships, provides good ability to make and maintain relationships and denotes Security. • Attitudes to closeness (mistrust, constraints on closeness, fear of rejection, anger) and autonomy (self-reliance, desire for company, fear of separation) all assessed. • Profile from all information provides degree of insecurity (marked, moderate, none) and type of style: • Anxious (Enmeshed or Fearful) • Avoidant (Angry-Dismissive or Withdrawn) • Secure. Michael Seiff Foundation Sept 10

  31. Adult Lifespan analysisPath analysis model(303 Vulnerable community women) .22 Poor support .18 .37 Adult depression .32 Neglect/ abuse<17 Highly Insecure Attachment style .24 .27 Teenage depression .41 .26 .30 Negative Eval- uation of self Bifulco et al, 2002 a & b SPPE

  32. Attachment style and depression – specificity of style studied prospectively(154 women seen over 3 year period) Onset depression Interview 2 ASI interview 1 Childhood experience At interview 1 Highly Enmeshed .26 ns .23 Highly Fearful .19 Neglect or Abuse < 17 (CECA) Onset Major Depression .19 .28 Highly Angry- dismissive ns ns Highly Withdrawn Tests show partial mediation for Fearful and Angry-dismissive Bifulco et al, 2006, SPPE

  33. Model of neglect/abuse and attachment style in adolescents (146 adolescent offspring) Mother’s neglect or Abuse <17 ,25 Offspring Emotional disorder ,46 ,47 Offspring Negative Evaluation of Self ,36 Offspring Anxious Attachment style e5 e4 Bifulco A(2008) Risk and resilience in young Londoners. In (Eds, D. Brom, R Pat-Horenczyk & J, Ford) Routledge, London, NY

  34. Risk and resilience approaches • Before 1990 most research into adolescent disorder examine the contribution of different risks – psychological and social. • After work by Garmezy, Rutter, Masten and others, the importance of ‘resilience’ was recognised i.e. protective factors explaining ‘absence’ of disorder. • Research into high risk community samples allow for investigation of both risk and resilience for disorder Michael Seiff Foundation Sept 10

  35. Resilience • Protective factors are those which are active in the presence of risk factors – to buffer or moderate the impact. • In high risk adolescents, all experienced some form of social deprivation or maltreatment and 45% had disorder – were the other’s protected? Michael Seiff Foundation Sept 10

  36. High level of social risks in sample of young people 94% had at least one of the following risk factors: • Lone mother upbringing – 52% • Lowest social class – 32% • History of domestic violence between parents – 21% • Maternal recurrent depressive disorder – 46% • Paternal disorder, including substance abuse and criminal behaviour - 52% Michael Seiff Foundation Sept 10

  37. However, positive factors were also common: 80% had at least one of the following positive factors: Support from friend age 16 - 56% Positive peer group age 16 - 68% Positive school characteristics age 16 - 66% High academic attainment age 16 - 51% High felt competence as student age 16 - 66% Clearly Secure attachment style at interview - 30% Markedly high self acceptance at interview - 14% Michael Seiff Foundation Sept 10

  38. Model of positive factors for emotional disorder Logistic regression – outcome emotional disorder 12 months Marked self acceptance and secure attachment style provide the Best model in relating to absence of disorder -Goodness of fit 71.7%

  39. Protective effect of secure attachment or marked self acceptance % Case emotional disorder No positive psychological Positive psychological

  40. Model of emotional disorder Logistic regression – outcome internalising disorder 12 months Secure attachment and marked self acceptance add to the model in Producing lower disorder in the presence of neglect/abuse Goodness of fit 74.7%

  41. Implications for practice • Assessment: Need standardised assessment tools for reliable and valid measurement of child and families experience. • Analysis: Important to assess severity of neglect or abuse using standardised criteria. Need to assess multiples of abuse to estimate risk. Some risk factors more damaging than others. • Attachment Frameworks need to assess attachment style in adolescence and childhood to determine impacts of adversity and resilience. Michael Seiff Foundation Sept 10

  42. Ongoing Lifespan collaborations with services. • St Christopher’s residential care services – assessing attachment style in young people in care prior to social learning intervention. • Kingston Safeguarding services – using CECA scoring framework to rate case information to aid with classification and analysis of neglect/abuse of children. Michael Seiff Foundation Sept 10

  43. Trainings offered for social workers and psychologists • Childhood Experience of care and abuse – for forensic psychologists and social workers in safeguarding. • Attachment Style Interview for parents • Attachment Style Interview for adolescents • Parenting role Interview • www.cecainterview.com • www.attachmentstyleinterview.com Michael Seiff Foundation Sept 10

  44. Research implications: studying primary school age children • Measurement – need for intensive contextualised measures which can be used in younger age groups. • Gap in primary school group for attachment measures and face-to-face direct assessments. • Need to amplify Attachment Frameworks to include social adversity and biological variables. Michael Seiff Foundation Sept 10

  45. Research implications: studying primary school age children • Need to re-use social lifespan and stress models. Importance of life events in younger age groups. • Neglect/abuse variables in adult summarise long periods of childhood. When asking children we need to break the experience into events and difficulties using a timeframe (eg Sandberg & Rutter, 1993 - PACE ). . Michael Seiff Foundation Sept 10

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