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The state of science and practice in the prevention of child abuse and neglect John N. Constantino, MD 2015 Midwest Justice for Children Conference

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Seizing the Day Reducing exposure to known, modifiable causes of child psychopathology among children with highest likelihood of exposure Child Maltreatment Parental Mental Health and Substance Use Disorders Deleterious Exposures in Pregnancy and Early Childhood (As of 2014, genes are not yet on this list, except for the scenario of prenatal genetic counseling) among those at highest risk for psychopathologic consequences of exposure Family Genetic Loading for Psychopathology Relative Absence of Compensatory Features of the Village (Family /Social Environment) as one of the most urgent priorities of our branch of medicine i.e. what can be done NOW for children at risk which means re-allocating the total resource for child mental health Clinical Educational Scientific in a manner that is reasonably proportionate with the fraction of population risk for psychopathology that is directly attributable to preventable causes ( ~ 20%) Anything less is throwing away opportunity here-and-now for the public health impact of our discipline

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SPECIFIC ENVIRONMENTAL FACTORS AND THEIR INTERACTION WITH INHERITED RISK CAUSATION

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Jonson-Reid, Constantino et al., J Am Acad Child Adolesc Psychiatry 2010 Joint Effects of Maltreatment and Inherited Liability on Antisocial Development: An Official Records Study RR 6.5 for non-identical sib (DZ twin) affected and maltreated genetic environmental

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N% Conduct Disorder % Maltreated Familial Liability 2 nd deg.rel. antisocial disorder 1 st deg.rel. antisocial disorder 148 280 15.5 28.2 8.1 22.6 Income Below federal poverty level Above federal poverty level 92 336 30.4 22.0 56.6 6.9 Child Maltreatment No report Unsubstantiated Report Substantiated Report / FC 353 39 36 21.2 25.6 47.2 Gene-Environment Correlation in the Collaborative Study on the Genetics of Alcoholism (COGA): Poverty and Family Psychiatric History identify children at severe combined genetic and environmental risk Jonson-Reid, Drake, Constantino et al., J Am Acad Child Adolesc Psychiatry 2010

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STATUS OF PREVENTIVE INTERVENTION

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Date of download: 10/21/2014 Copyright 2014 American Medical Association. All rights reserved. From: Effect of Home Visiting by Nurses on Maternal and Child Mortality: Results of a 2-Decade Follow-up of a Randomized Clinical Trial JAMA Pediatr. 2014;168(9):800-806. doi:10.1001/jamapediatrics.2014.472 Survival Curves for Children in the Nurse-Family Partnership TrialA, All causes of death. B, Preventable causes of death. All 690 children who survived had at least 19.7 years of follow-up after birth. The numbers at risk of dying at 20.0, 20.5, 21.0, 21.5, and 22.0 years after randomization were 620, 369, 132, 4, and 1, respectively. Figure Legend : Earlier findings: Marked reduction in incidence of maltreatment Adolescent-limited reduction in delinquency in boys Sustained reduction in antisocial behavior in girls

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FAST TRACK: Home Visitation, social skills groups, parent-child cooperative activities with staff support

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Intervention associated with a 10% reduction in incidence of displaying at least one of the following psychiatric problems: --externalizing --internalizing --substance use

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Uncoupling gene-environment correlation

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Evid Based Child Health.Evid Based Child Health. 2013 Mar 7;8(2):318-692. Cochrane review: behavioural and cognitive-behavioural group-based parenting programmes for early-onset conduct problems in children aged 3 to 12 years Furlong M 1, McGilloway S, Bywater T, Hutchings J, Smith SM, Donnelly M. Furlong MMcGilloway SBywater THutchings JSmith SMDonnelly M This review includes 13 trials (10 RCTs and three quasi-randomised trials), as well as two economic evaluations based on two of the trials. Overall, there were 1078 participants (646 in the intervention group; 432 in the control group). The results indicate that parent training produced a statistically significant reduction in child conduct problems, whether assessed by parents (standardised mean difference (SMD) -0.53; 95% confidence interval (CI) -0.72 to -0.34) or independently assessed (SMD -0.44; 95% CI -0.77 to -0.11). When compared to a waiting list control group, there was a cost of approximately $2500 (GBP 1712; EUR 2217) per family to bring the average child with clinical levels of conduct problems into the non-clinical range. These costs of programme delivery are modest when compared with the long-term health, social, educational and legal costs associated with childhood conduct problems.

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320 DBD subjects randomized to treatment across 5 RCTs J Am Acad Child Adolesc Psychiatry 2014

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Effect of Preventive Interventions in Mentally Ill Parents on the Mental Health of the Offspring: Systematic Review and Meta-Analysis Siegenthaler et al., JAACAP 2012

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Justifying reallocation of resources Can families of highest-risk children be feasibly engaged in preventive intervention before onset of psychopathology? Do the effects of intervention extend to children at elevated inherited risk? Feasible systems for integrating intervention around the needs of families.

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Urban Low- Income (ULI) ULI + engagement protocol (EP) ULI + familial risk + EP ULI + Drug ULI + drug + EP N (families) 10050 10070 # home visits / yr 1.710.59.2014.6 Rate of participation of women with legal custody of infants and toddlers in home visitation, stratified by a) level of risk and b) engagement protocol (EP) Constantino et al., manuscript in preparation Group-based engagement in preventive intervention Child Abuse & Neglect, 2001 Developmental education, experience-based (hands-on), babies present, trusted site

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Dose-Response Relationship

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J Am Acad Child Adolesc Psychiatry. J Am Acad Child Adolesc Psychiatry. 2001 Feb;40(2):214-21. Evaluation of a preventive intervention for maltreated infants and toddlers in foster care. Zeanah CHZeanah CH, et al. To determine the effectiveness of an intervention designed to improve outcomes for infants and toddlers in foster care. METHOD: Records were reviewed for all children who were adjudicated as in need of care in a specific parish in Louisiana between 1991 and 1998. This period included 4 years before and 4 years after a comprehensive intervention was implemented. With regard to the same child returning in a subsequent incident of maltreatment, relative risk reduction for the intervention group ranged from 53% to 68%. CONCLUSIONS: A comprehensive preventive intervention for maltreated infants and toddlers in foster care substantially reduced rates of recidivism. Symposium 29 Friday, October 24, 2014: 8:30 AM-11:30 AM Health Promotion and Illness Prevention in Child Psychiatry

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Developmental expert consultation for infants and young children in protective custody Ph.D./M.D. (infant mental health and development is an area of discomfort/weakness for many child welfare workers, especially given pressures imposed by high caseloads) Comprehensive Assessment Child Parent Parent-Child Relationship

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Standardized, serial assessment of parent-child relationship

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What additional information is needed? Identifying/pursuing missing components of a comprehensive intervention Has there been an appropriate test of the capacity of the caregiver to succeed in parenting? Has there been an appropriate level of support for the parent to succeed in that test.

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Deliver service Secure appropriate mental health services for parent, child, and their relationship Fix what is fixable Propose and execute a reasonable plan for continued support and surveillance in the event that reunification occurs

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Issues at the interface between clinic and courts Clarifying the boundary between neglect and a level of caregiving that is good enough to reasonably support a childs reaching his/her inherited potential Calibrating good-enough parenting to the developmental needs of that parents child Recognizing the cost of not intervening by conservatively predicting developmental course

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Results 85% of referred birth families consented and materially participated in the intervention. Medically-indicated interventions not available or previously acquired by the children/families at the time of evaluation included initiation of developmental therapies for previously unrecognized/undiagnosed developmental delay (n=25), psychiatric treatment of untreated mental disorders in uninsured/under-insured birth parents (n=27), and delivery of indicated, evidence-based mental health treatments to children (trauma-focused CBT, child-parent psychotherapy, family psychotherapy, and/or psychopharmacologic intervention when indicated (n=75). Other critical services: evidence-based parent training (n=47 completed), revisions of existing Court/Social Service dispositions (n=35) serial in-clinic observations of parent-child interaction constituting key evidentiary support of viability of reunification

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Dev Psychopathol.Dev Psychopathol. 2013 Nov;25(4 Pt 2):1635-53. doi: 10.1017/S0954579413000813. Rethinking evidence-based practice and two-generation programs to create the future of early childhood policy. Shonkoff JP Shonkoff JP 1, Fisher PA 2.Fisher PA SYNCHRONY Project, cumulative results for closed cases

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Perinatal Behavioral Health Service Mission Screening, Education and Support for Maternal Mental Health Serves the mothers of infants in the Regular and Special Care Nurseries and the Neonatal Intensive Care Unit (NICU) Aims to treat perinatal mental health symptoms, particularly depression, in the early postpartum period. Services Universal screening of all mothers for postpartum depression Coordinating referrals for mental health, substance use, and nurse home visitation Psychiatric care in the Perinatal Behavioral Health Clinic Psychotherapy onsite within the NICU Evidence-Based Parenting Education Staff Directors: Cynthia Rogers, M.D. (Departments of Psychiatry and Pediatrics) 3 Staff Psychiatrists 1 Therapist 3 Patient Coordinators

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Felton J. Earls, MD

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AIDS Is No. 1 Killer Of Adolescents In Africa Kami, HIV Muppet

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J. Purnell, PhD, MPH

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Seizing the Day Reducing exposure to known, modifiable causes of child psychopathology among children with highest likelihood of exposure Child Maltreatment Parental Mental Health and Substance Use Disorders Deleterious Exposures in Pregnancy and Early Childhood (As of 2014, genes are not yet on this list, except for the scenario of prenatal genetic counseling) among those at highest risk for psychopathologic consequences of exposure Family Genetic Loading for Psychopathology Relative Absence of Compensatory Features of the Village (Family /Social Environment) as one of the most urgent priorities of our branch of medicine i.e. what can be done NOW for children at risk and re-allocating the total resource for child mental health To ensure that as many children as possible can access the effective treatments we already have And to invest in prevention at a level that is reasonably proportionate with the fraction of population risk for psychopathology (20%) that is directly attributable to preventable causes Anything less is throwing away opportunity here-and-now for the public health impact of our discipline

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Thank You constantino@wustl.edu