Assessing the health and wellbeing needs of children entering out of home care – necessary and sufficient?

Professor Graham VimpaniClinical Chair,

Kaleidoscope Children’s Health NetworkHead of Discipline of Paediatrics and

Child Health, University of Newcastle

What’s all the fuss about?

“Is it worth the effort and expense that would be needed to improve health needs assessment and health service access for children and young people living in out-of-home care, especially when most kids in foster care seem healthy enough on a day to day basis, and can just be taken to a doctor if they feel sick?”

Overview The case for comprehensive health

assessments on entering care What is happening in Australia now?

Does it make a difference to health and wellbeing outcomes?

Is it sufficient? What about the carers’ needs? Effective intervention has lifelong

benefits The role of epigenetics

Why children enter OOHC

What is the health status of children entering care?

“The majority of children in care are in good physical health and display improvements in psychological functioning over time” (Osborn & Bromfield, AIFS 2007)

Mental health problem 18%; disability 20%; intellectual disability 14% (Vic govt audit)

What is the health status of children entering care?South Australian study 61% (N=326 aged 6-17 yrs) in clinical range for behaviour

problems (Sawyer et al, 2007) 54% needed clinical help but only 24% got it

Proportion with clinical scores on CBCL externalising scale 6-7 times higher than general community

NSW Study 53% girls and 57% boys (N=347 aged 4-9 yrs) had at least

one scale of CBCL in clinical range (Tarren Sweeney & Hazell, 2006)

“The only non-clinical populations of children likely to have poorer relationship and behavioural functioning … are those in institutional care or late adoptees following residential care”

Kari clinic (Aboriginal and Torres Strait Islander SSW) Language delays or disorder in 63% Oral health problems in 37%

Sydney Children’s Hospital Clinic Results

94 children

Age range: 3m to 14yrs

48% (45) were under 5yrs

43% girls, 57% boys

Time in care ranged from 1 week to 5 years

45 children were in their first placement

Health Problems - 1

97% had 1 or more health issues (medical, developmental, emotional and/or behavioural problems)

Immunisations – 53% up to date

Vision – 18% (16/87) failed screen and referred

» 8 Squint

» 7 Poor Visual Acuity

» 1 Floater

12 pre-existing eye conditions

Health Problems - 2

Development

– 69% of under 5s failed screen

– 2 autistic behaviours

Speech

– 51% of under 5s speech delay

Growth

– Failure to thrive - 2

– Small stature – 7

– Overweight - 3

Health Problems - 3

Infections - 14

– Respiratory – URTI, ear

– Skin –impetigo, infected eczema, warts, fungal

Skin - 17

– Eczema

– Scars

– Nappy rash

– Impetigo

– ?Psoriasis

Health Problems -6 Behavioural and Emotional health

– Most significant issue in 54%

Significant mental health issues - 7– 2 boys depressed

– 1 boy with suicidal thoughts

– 3 children with significant grief and loss issues requiring counselling

– 3 children with symptoms of Post Traumatic Stress Disorder

– 1 boy with gender identity issues

Implications of SCH study

More than 50% - perhaps 70% - of children and young people will require a secondary level assessment because of developmental and behavioural problems

A smaller proportion may require further assessment because of physical conditions

The case for comprehensive assessments DoCS – Health MOU on Children in OOHC (NSW)

(2006) Royal Australian College of Physicians policy

(2006) Royal Australian and New Zealand College of

Psychiatrists (Faculty of Child and Adolescent Psychiatry) (2008)

Wood Special Commission of Inquiry (NSW) (2008) Keep them Safe (NSW) (2009) Development of Draft National Standards for

children in Out of Home care (FaHCSIA – 2010) NSW Standards for Statutory Out of Home care

(updated 2010)

DoCS – Health MOU (NSW, 2006)

Identifying referral points in each Area Health Service for community health, drug and alcohol services, and mental health services

Specialist medical, psychiatric and other health assessment services

Specialised medical and mental health services, including secure in-patient psychiatric acute care appropriate for children and young persons

Specialist sexual offender services for children and young persons who sexually offend.

DoCS (NSW) procedures prior to Keep them Safe All children and young persons should undergo a health,

developmental and mental health/behavioural assessment within 60 days of entering care.

The child/young person’s case worker is responsible for arranging these assessments which are carried out by a range of medical and allied health professionals

The physical health/medical component of the assessment should include the following:

1. completion of a medical history profile of the child and family to understand the health conditions of parents or siblings which may impact on the child’s health, welfare and well-being

2. immunisation register check 3. physical examination that checks for growth delay (eg careful

measure of weight, height and head circumference) and signs of malnutrition

4. screening for visual and hearing deficits 5. screening for signs of pathological conditions that need further

investigation (e.g. foetal alcohol syndrome, fragile X syndrome, physical abnormalities that may be related to past abuse)

6. dental health screening

DoCS (NSW) procedures prior to Keep them Safe

A developmental assessment component should also be done which covers domains such as general cognitive functioning, language and communication, gross and fine motor functioning and socialisation

The mental health/behaviour assessment may be deferred

It is the responsibility on the caseworker to obtain the child or young person’s personal health record (Blue Book), from the parents

RACP proposals Ensuring that physical, developmental and mental health

assessments are performed on all children who enter out-of-home care within 30 days;

Encouraging ongoing monitoring of needs by identified health care co-ordinators;

Ensuring appropriate timely access to therapeutic services;

Developing a transferable health record system; Improving training and support for foster carers; Coordinating a health care centred approach between all

agencies involved with this group of children, including Community Services and Education;

Encouraging governments to adequately fund the implementation of the suggested recommendations; and,

Collecting aggregated data and ensuring evaluation of programs.

Components of comprehensive health care assessment (RACP) 1 General health assessment including

a health history of the child and family physical examination growth assessment vision, hearing and dental screening immunisation register check.

The health assessment information must be documented to ensure easy access for medical professionals

Undertaken by paediatrician, GP, nurse practitioner or Aboriginal Health worker

Components of comprehensive health care assessment (RACP) 2

Developmental assessment incorporating standardised screening tools e.g. Ages and Stages or Brigance, as an

adjunct to clinical assessment, access to formalised assessment.

Local systems must be developed to fast track therapeutic developmental services to children with identified deficits.

Systems need to be established for liaison with Education representatives

Components of comprehensive health care assessment (RACP) 3

Mental health screening using accessible and validated tools e.g. Strengths and Difficulties

Questionnaire, or Achenbach Child Behaviour Checklist (CBCL).

Infants and toddlers must be assessed for attachment disorders (sic)

Local systems must be developed to provide a therapeutic response to identified needs.

Development of an individualised health plan - RACP

Based on results of comprehensive assessment and in conjunction with CPS:- Identifying a health coordinator for

each child; Promoting a follow-up health review

to occur within three months of assessment and subsequently at least on an annual basis.

Ensuring equitable health care - RACP Working with CPS, Education, Health to:-

Develop local systems to ensure that this group of children is not disadvantaged in their receipt of health care services compared to their peers;

Promote the use of fast tracking therapeutic services, given the often, small window of opportunity available due to transient care placements; and,

Ensure that such services are provided for all health needs and in particular mental health needs, utilising both public and private therapeutic services as required

Data collection - RACP Governments be encouraged to develop and

resource permanent and easily transferable health records which will be accessible to future health providers and available to parents and carers:-

Using electronic health records linked to Community Services files;

Ensuring these are stored in a safe manner while at the same time allowing them to facilitate health communication;

Recording information that includes a patient hand-held record containing past history, relevant family history, health assessment information, treatments and interventions;

Evaluating the health needs of children placed in out-of-home care and aggregating this data to monitor and identify the effective interventions.

Improved access to health records of birth parents - RACP That the College assist Community Services

workers to have access to health records of birth parents in a fashion which is consistent with privacy legislation by:-

Developing a proforma to enable these workers to collect a satisfactory health history from parents

engage with parents over consent for health treatment of their child at the point of entry into care; and,

Entering into discussions with Privacy Commissioners, or similar bodies, to explore the availability of this information to Community Service workers.

Enhancing communication - RACP That the College … advocate increasing the

level of communication by: Facilitating effective communication channels

between health professionals, Community Services Departments and other key people in the foster child's life e.g. schools, carers and parents;

Establishing specific communication avenues such as community based inter-agency forums for more complex cases;

Listening and responding to foster children’s opinions and ideas as to how their health needs may be best met; and,

Engaging birth parents in their child’s ongoing health planning where possible.

The case for comprehensive mental health assessment and intervention (RANZCP)

Every child entering OOHC has a multimodal mental health assessment as part of the admissions to care process

Children with potential psychopathology should have a comprehensive mental health assessment within 30 days

A profile based on a developmental framework of psychopathology that identifies risk and protective factors that contribute to resilience should be documented for each child at this time

All children with intellectual disability entering OOHC should have a comprehensive mental health assessment routinely

The case for comprehensive mental health assessment and intervention (RANZCP)

Treatment plans that organise and prioritise interventions in the major areas of a child’s life should be developed with emphasis on enhancing strengths through therapy or activities that promote the child’s development. These plans may include medication to improve functioning and reduce symptoms

Children in OOHC with MH problems should be given special attention and priority access to MHS

A cost-effective process for assessing these children that does not rely solely on specialist clinicians needs to be developed

What should happen re health in KtS, National and NSW OOHC standards?

Keep them Safe (2008-2009) Proposed principles (Wood)

Children and young persons should be assisted to gain regular access to education, health and other services to meet their changing needs and to enable them to grow and develop

Restoration decisions should not take longer than six months, particularly for younger children

Greater in-depth assessment of children and young persons coming into care through more comprehensive assessment and interventions in the crucial early stages of placements should be part of agency placement and planning processes

Care arrangements for children and young persons should be based on their assessed needs, and the assessed capacity of carers to meet these needs

There should be sufficient health and specialist services including dental, psychological, counselling, speech therapy, mental health and drug and alcohol services available to meet the needs of children and young persons in OOHC

What should happen re health in KtS, National and NSW OOHC standards?

Keep them Safe (2008-2009) Proposed principles (Wood)

There should a system common to all agencies delivering services to children and young persons in OOHC that collects essential health information and monitors their health and educational outcomes. This should include an accessible, comprehensive medical record or a transferable record for children and young persons in care

Interventions for high needs children and young persons in OOHC should include strong case management, integrated multi-agency work, and highly skilled staff and carers who receive expert supervision, ongoing training and support

What should happen re health in KtS, National and NSW OOHC standards?

Keep them Safe (2008-2009) Recommendations (Wood)

Recommendation 16.3 Within 30 days of entering OOHC, all children and young

persons should receive a comprehensive multi-disciplinary health and developmental assessment. For children under the age of five years at the time of entering OOHC, that assessment should be repeated at six monthly intervals. For older children and young persons, assessments should be undertaken annually. A mechanism for monitoring, evaluating and reviewing access and achievement of outcomes should be developed by NSW Health and DoCS

Govt response: Supported. Role of GPs to be explored Recommendation 16.4 NSW Health should appoint an OOHC coordinator in each Area

Health Service and at The Children’s Hospital at Westmead.Govt response: Supported.

What should happen re health in KtS, National and NSW OOHC standards?

Keep them Safe (2008-2009) Recommendations (Wood)

Recommendation 16.6 The NSW Government has a responsibility to ensure that all children

and young persons removed from their parents and placed in its care receive adequate health treatment. Thus, there should be sufficient health services including speech therapy, mental health and dental services available to treat, as a matter of priority, children and young persons in OOHC

Govt response: SupportedRecommendation 16.7 The introduction of centralised electronic health records should be a

priority for NSW Health. Given that this is likely to take some time, an interim strategy should be developed to examine a comprehensive medical record or a transferable record for children and young persons in OOHC, which should be accessible to those who require it in order to promote or ensure the safety, welfare and well-being of the child or young person.

Govt response: Supported. Interim - Blue book to have OOHC modules

What should happen re health in KtS, National and NSW OOHC standards?

Keep them Safe (2008-2009) Recommendations (Wood)

Recommendation 16.11 A common case management framework for children and

young people in OOHC across all OOHC providers, should be developed, following a feasibility study on potential models including the Looking After Children system

Govt response: Supported – CS will undertake a feasibility study with a new model to be introduced in 3-5 years

Recommendation 16.13 There should be sufficient numbers of care options for

children and young persons with challenging behaviours that include specialised models of therapeutic foster care

Govt response: Supported – CS will develop new models of care

What should happen re health in KtS, National and NSW OOHC standards?

Draft National OOHC standards (2010) Standard 4. A comprehensive health assessment is

provided to children and young people entering care, with ongoing medical needs attended to in an appropriate and timely way, and children and young people have their own written health record which moves with them if they change placements.

Standard 5. Children and young people entering into care receive timely and appropriate therapeutic assessment and support as needed.

Standard 13. Each child and young person has a case plan developed that details their health, education and other needs, which is implemented and reviewed regularly, with the children and young people supported to participate in both the development and updating of their plan.

What should happen re health in KtS, National and NSW OOHC standards?

NSW standards (2010)

3. Children and young people’s wellbeing is actively safeguarded

8. Children and young people are cared for in placements which meet their specific emotional, social and behavioural needs

9. Children and young people’s health and developmental needs are addressed

11. Children and young people have initial assessments based on their best interests and are placed according to their identified needs and where relevant, the Aboriginal and Torres Strait Islander Placement Principles

14. Children and young people have effective behaviour support and management plans where necessary

What is happening now (NSW) 20% of children entering care had a

health assessment in 60 days (NSW audit)

Fragmented information systems and poor access to personal and family health information (Wood)

No standard or consistent approach to the collection of data for health screening and assessment (Wood)

Activity in Other States Queensland – Child Health Passport to facilitate

placement and annual checks Victoria – health plans under LAC reviewed every 6

months or annually plus comprehensive intake assessment by GP, paediatrician, mental health professional

WA - children and young persons in OOHC have health and education assessments and plans covering physical, mental and dental care. It is envisaged that the assessment model chosen would review physical growth, progress towards developmental milestones and psychological/emotional development.

SA - Health Standards for Children and Young People under the Guardianship of the Minister. This involves an agreement between the Department of Families and Communities and the Department of Health that Health will provide a comprehensive paediatric assessment upon entry into care

Does health assessment make a difference to outcomes?

Outcome of SCH health assessments N=100

75% received 4 or more recommendations

– Medical review 59%

– Dental review 52%

– Immunisation 44%

– Counselling/psychological service 42%

– Ear, nose and throat review 42%

In 43 children’s cases, DOCS did not know if one or more recommendations had been implemented

Health benefits - SCH

Of the 363 recommendations where a recordable health benefit was applicable, almost 50% were unknown by the caseworker.

Examples of health benefits

Of 26 children referred by the clinic for further formal developmental assessment, 12 were found to have significant delays, and relevant educational interventions were in progress

14 of the 24 children referred for speech assessment had so far been screened, of whom nine were currently receiving speech therapy and making significant language improvements.

There were also examples of children who had undergone major dental work and of children prescribed glasses.

Status of SCH recommendations

Reasons for Recommendations non-completion

Systems Issues

Frequent change of carer

High turnover of caseworker and delays in reassignment of a new caseworker

Poor record keeping

Lack of knowledge regarding service providers

Reluctance to place children on waiting lists until the courts had finalised placement decisions

Caseworkers themselves commented on their own lack of time and resources

– for accessing the recommended allied health services

– and for tracking the child’s ongoing progress through the health system

Lack of services

Counselling

Peer and carer support,

Public dental services

Long waiting lists for allied health services

– e.g occupational and speech therapy.

Conclusion from SCH study

Benefits of health assessment uncertain

Routine comprehensive health screens clearly improve detection of previously unmet or unrecognised health issues

Screening provides a baseline record of the child’s current health and well-being.

Reasonable to assume that the information and advice provided to carers and caseworkers by the clinic was likely to improve a child’s access to appropriate health services.

Agencies should have systems to ensure better communication and collaboration between the health and community services systems.

Regular medical reviews while a child remains in care and improved inter-agency liaison over implementation of the child’s health plan may improve health outcomes for these children

Is health assessment of children entering OOHC sufficient to improve outcomes?

Benefits of comprehensive assessments Are there risks from not having a

comprehensive health/mental health assessment?

“Children with hidden emotional distress are a particular risk of not being referred or picked up by services. They...have a relationship style that tends to hide their needs from view.” “Closed book children” “Too good to be true”

(Schofield et al 2000; Crittenden 2009)

Benefits of comprehensive assessments “The prevalence, scale and complexity of mental health difficulties

experienced by these populations are so great, that delineation between primary and specialist levels of care for these children is blurred.

They require universal, comprehensive clinical/psychosocial-developmental assessments following entry into care or adoption. These assessments identify risks and casework-related issues that may contribute to future mental health difficulties, or detract from their development or well-being in other ways. This applies as much to children who enter care with few mental health difficulties.

Universal, comprehensive assessment by specialist clinicians following entry into care is thus preferable to mental health screening, because it is designed for prevention of future difficulties as much as detection of present ones.

Furthermore, mental health screening alone does not identify critical influences on children’s development that have a bearing on other psychosocial-developmental outcomes (that could be remedied if detected early enough). Beyond initial assessment, there remains a need for a primary care (i.e. population-wide) approach to provision of specialist mental health services, equating to a primary–specialist care nexus.”

( Tarren Sweeney, 2010)

What others have said…– Children who have experienced long-term foster care do

not benefit from the receipt of outpatient mental health services (Bellamy et al 2010)

– “there is little empirical basis for the notion that a higher frequency of services necessarily translates into improved outcome” (James et al 2004)

– “coordination of care studies suggest that increased use of formal child mental health treatment does not translate into fewer behavioural or emotional difficulties” (Bickman et al 1995, 1997, 2000)

– Often improve without treatment anyway (Burns et al 2004; Lambert et al 2004)

Why?

Untested treatments with questionable effectiveness

– Treatment programs based on dialectical-behaviour therapy, cognitive-behavioural, cognitive-analytical have yet to be evaluated on their specificity and effectiveness (Chanen et al 2008 James et al 2008)

Poor client engagement

Lax intervention fidelity

Health assessments – Necessary but Insufficient

Do health assessments need to occur earlier in a child’s child protection trajectory?– Children placed in care before the age of 7 months had fewer

attachment and behaviour problems than those placed later (Tarren- Sweeney 2008)

– Children placed late may find it difficult to form secure attachments (Rushton et al 2003)

Is it possible to identify children at risk of chronic maltreatment so that they can be placed in care earlier?

– “The challenges are correctly identifying this group so that children are not wrongly separated from their biological parents and predicting which parents are capable of making substantial improvement in their care-giving”

(RANZCP 2008)

Need for whole of government responses

No single agency can meet the needs of children in OOHC

Coordinated interagency commissioning, planning and service delivery are required – requires committed management

Agreed care pathways and protocols are needed

Multimodal programs integrated with existing service systems that address children’s safety and basic needs, quality of care, carers’ skills and children’s emotional needs

Training and consultative activities for front-line staff

Specialised service within mainstream teams could help develop skills and expertise eg Redbank House (Vostanis, 2010, Chambers et al 2010,Golding 2010)

Need for managers to be committed

“A commitment to making integrated services and teams work requires a management structure that is prepared to give time to team and service development as well as ensuring that team members are getting the job done. Time is needed for building a team identity, shared vision and ethos and for reflection and the building of relationships. It is easy to give such tasks a lower priority in the face of high need, but ultimately without this, misunderstanding, and miscommunication will weaken service delivery.”

(Golding 2010)

What about the carers?

Improved support and training for foster carers - RACP

Ensuring the provision of therapeutic foster placements by providing adequate support and training for foster carers and

ensuring that foster placements are not overcrowded or in other ways unable to meet the needs of the child; and,

Developing optimal permanency planning for children in alternative care.

What should happen re carer support in KtS, National and NSW OOHC standards?

Keep them Safe (2008-9) Proposed principles (Wood) Interventions for high needs children and young persons in OOHC should

include strong case management, integrated multi-agency work, and highly skilled staff and carers who receive expert supervision, ongoing training and support

Care arrangements for children and young persons should be based on their assessed needs, and the assessed capacity of carers to meet these needs

Carers should be provided with timely information about those in their care, their needs, and the type of support they need to flourish in their care

Foster, kinship and relative carers should be supported in caring for children and young persons, including managing those with challenging behaviours, to improve the stability of placements. This should include access to regular and planned respite care, behavioural management support, and other evidence based specialist services

Interventions for high needs children and young persons in OOHC should include strong case management, integrated multi-agency work, and highly skilled staff and carers who receive expert supervision, ongoing training and support

What should happen re carer support in KtS, National and NSW OOHC standards?

Keep them Safe (2008-2009) Recommendations (Wood)

Recommendation 16.13 There should be sufficient numbers of care options for

children and young persons with challenging behaviours that include specialised models of therapeutic foster care

Govt response: Supported – CS will develop new models of care

What should happen re carer support in KtS, National and NSW OOHC standards?

Draft National OOHC standards (2010) Standard 6. Children, young people and

carers are able to access objective advice, ask for help, have their concerns listened to, and have information and access to review mechanisms

Standard 12. Carers are assessed and receive relevant ongoing training, development and support.

What should happen re carer support in KtS, National and NSW OOHC standards?

NSW standards (2010)17. Appropriately skilled and experienced

carers and staff are selected through fair and consistent processes

18. Carers and staff have appropriate training for their role and are provided opportunities for further professional development

19. Carers and staff have supervision and support which is useful and timely to facilitate better outcomes for children and young people

Quality of first relationships (Rees, 2010)

Alternative parenting alone is an insufficient remedy but is the principal tool of recovery

Recovery from inadequate early care involves carers managing the consequences of ineffective early regulation

Ineffective parenting influences programming of stress regulation systems probably influencing gene expression at an epigenetic level with lifelong and potentially intergenerational implications

A professional priority is to equip carers through information, advice, support and adequate respite to facilitate this

Recovery rarely follows an orderly sequence Easing forward rather than fixing

Recovery through therapeutic relationships (Rees, 2010)

“Supporting recovery from abuse and neglect is a long-term multi-professional task, requiring a broad perspective, initiative, pragmatism and attention to detail. It involves bridging gaps between professional groups, particularly between CAMHS and paediatricians.”

Difficulties relating to abuse and neglect are multifactorial in cause, manifestation, consequences and management.

They are fundamentally problems of relationships; recovery is essentially achieved through relationships.”

Tasks to be achieved for competent adulthood (Rees, 2010)

Understanding of relationships Understanding of the value, safety, reliability and

predictability of relationships Effective strategies for using relationships Appropriate concepts of normal behaviour, roles and

responsibilities Effective verbal and non-verbal communication

Intuitive attunement to others’ feelings; empathy Understanding of pragmatics, nuance, words for feeling,

facial expression Understanding of self

Good self esteem; coherent life story; healthy identity Awareness of personal strengths and limitations; valued

roles and responsibilities; ability to exercise choice Safe personal boundaries

Tasks to be achieved for competent adulthood (Rees,

2010)

Understanding of the world Awareness of danger; ability to judge and manage

risk Education; practical independence skills Parenting skills

Adaptability and resilience Safe coping and stress-regulation strategies Tolerance of change; ability to relinquish control Effective executive function: planning, concentration,

learning from experience Ability to regulate emotion, anxiety, temper, mood Ability to ‘reframe,’ accept and learn from difficult

experiences Ability to use services effectively

Evidence-based interventions for foster carers (Rees, 2010)

Attachment and biobehavioural catch-up (Dozier ’06)

Targets infants and toddlers Intervention targets dysregulation by helping

foster carers create an environment that enhances regulatory capabilities

Caregivers learn to follow child’s lead Caregivers appreciate value of touching, cuddling

and hugging their child Caregivers create conditions that allow children to

express, learn to recognise and understand emotions Children in intervention group had lower

cortisols and fewer behaviour problems

Evidence-based interventions for foster carers (Rees, 2010)

Fisher’s Multidimensional Treatment Foster Care for Preschoolers (Fisher ’05)

Targets 3-5 year olds Emphasises importance of supporting caregivers to

respond consistently and contingently to positive and negative behaviour

By supporting foster-child carer relationship adverse effects of early stress on HPA axis and related neural systems will be reversed leading to improvements in psychosocial functioning

Children in intervention group had improvements in attachment security and decreases in avoidant attachment and fewer permanent placement failures

Evidence-based interventions for foster carers (Vostanis, 2010)

Preventive Intervention for maltreated children in OOHC (Zeanah et al, 2001)

Intensive attachment based programs for maltreated children and carers that increased likelihood of adoption

Relational treatment for maltreated children and their carers (Sprang, 2009)

A relational program for maltreated children and their foster carers that specifically targeted the regulation of the carers’ behaviour and affective attunement that resulted in positive carer and child outcomes.

Programs build on parent training – combine social learning and attachment theory – enable carers to make links between children’s experiences of trauma and their emotions and behaviours

Effective interventions have lifelong benefits Child abuse and neglect is a public health issue

with lifelong consequences US Centers for Disease Control and Prevention, 2008

Statutory child protection services present a compelling and underused approach for addressing the immediate and long-term consequences of severe stress in early childhood.

(Forensic) evaluations at the time of abuse need to be augmented by comprehensive developmental (and mental health) assessments and provision of appropriate intervention by skilled professionals

Shonkoff, Boyce & McEwen, 2009

Stress and epigenetics

What’s the difference?

Rat studies showing persistent effects of early maternal behaviour

Summary (Michael Meaney 2010)

“The results of these (rat) studies suggest that the behaviour of the mother toward her offspring can program stable changes in gene expression that then serve as the basis for individual differences in behavioural and neuroendocrine responses to stress in adulthood. The maternal effects on phenotype are associated with sustained changes in the expression of genes in brain regions that mediate responses to stress and form the basis for stable individual differences in stress reactivity…..

Summary

“These findings provide a potential mechanism for the influence of parental care on vulnerability/resistance to stress-induced illness over the lifespan.”

Summary “Variations in mother-infant interaction modify

the epigenetic marks on regions of DNA that affect the regulation of the HPA response to stress. These marks are stable, enduring well beyond the period of maternal care, and thus provide a molecular basis for a stable maternal effect on the phenotype of the offspring.

Thus the behaviour of the mother directly alters cellular signals that then actively sculpt the epigenetic landscape of the offspring, influencing the activity of specific regions of the genome (our genetic code) and the phenotype of the offspring”

So what does this mean for humans?1. We know that severe adversity in childhood

is linked to markedly increased responsiveness of the HPA (hypothlamus-pituitary-adrenal) axis to stress, depression and suicide attempts

2. We have begun to identify the factors that contribute to differential vulnerability to adverse experience – for example, variants in the gene encoding serotonin reuptake transporter influence the risk of depression in response to stress

3. Human parallels to the rat study….

Adverse experience produces epigenetic modification of genes

Nr3C1 gene expression in hippocampus and total glucocorticoid expression was reduced in suicide victims who had been abused as children, but not in suicide victims who had not been abused nor in those who had died suddenly of causes other than suicide

Reduced glucocorticoid expression resulted in higher cortisol levels, enhancing effects of stress in adulthood and vulnerability to mood disorders.