Child maltreatment and the brain

New research shows that the brain is affected by childhood maltreatment and abuse. What is fascinating about the work is that different parts of the brain are affected by different forms of abuse. The research has just been published in the American Journal of Psychiatry.The implications are the risk of life long changes that will impact a person is some specific ways.

The research was summarized is a recent Science Daily report.

The results showed a correlation between specific forms of maltreatment and thinning of the cortex in precisely the regions of the brain that are involved in the perception or processing of the type of abuse. Specifically, the somatosensory cortex in the area in which the female genitals are represented was significantly thinner in women who were victims of sexual abuse in their childhood. Similarly, victims of emotional mistreatment were found to have a reduction of the thickness of the cerebral cortex in specific areas associated with self-awareness, self-evaluation and emotional regulation.

The clinical implications are immense. The brain is changed in order to deal with the trauma but then changes how the person adapts to life and subsequent situations that may not be directly related to the abuse. This helps us to understand why people are triggered to events that my be similar in some way to the abuse. While the brain changes may have been adaptive during the abuse, they can set up maladaptive outcomes for later life in behavioral and / or health facets of the victim's life.

Reference

Christine M. Heim, Helen S. Mayberg, Tanja Mletzko, Charles B. Nemeroff, Jens C. Pruessner. Decreased Cortical Representation of Genital Somatosensory Field After Childhood Sexual Abuse. Am J Psychiatry, June 1, 2013

Depressed parents and the child welfare system - a case of presumptive bias?

There is a large body of research that says that depression negatively impacts the ability of a parent. This includes lack of emotional availability to children; physical and emotional neglect as well as some connection to child abuse. This research has created a presumptive bias that a depressed parent is likely to be a risk to a child. Child protection workers can then lean towards more intrusive interventions. The bias gets greater with other forms of mental illness such as psychosis, bipolar disorder or the more severe forms of anxiety.

It is with that background in mind that I came across a recent Australian qualitative study that looked at the capacity of parents with mental illness. Boursnell (2012) sought to understand how parents with mental illness manage it and the parenting role. She reviewed the literature which identifies that mental illness is often seen as a risk factor in child protection matters. She further acknowledges that, when it can be shown that the illness does indeed prevent a parent from meeting minimum standards, then interventions are needed that may lead to the removal of children from the family.

There is also research that suggests that children raised in families with a mentally ill parent are at greater risk for problems with school, social relationships, links to the community as well as higher risks for substance abuse problems.

However, Boursnell also notes that much of the literature considers parents with quite severe mental illness including those who have been hospitalized. What then, she explores, about the many who are managed within the community utilizing voluntary services?

In those populations, the development of a solid working relationship between a social worker and the parent can allow a more strengths based approach in which the actual capacity of the parent might be considered. This might move the worker beyond the presumptive bias. There are many parents who might be able to successfully sustain the role of parent with appropriate community supports.

Many social workers are under pressure with high caseloads making it hard to build those relationships. This makes a risk oriented view of a parent with mental illness more probable. It also acts as a deterrent for parents getting involved in support programs.

While the article does not tell us that parents with major mental illness are not a concern, it does tell us that there is a need to be cautious about presuming mentally ill parents cannot parent.

Reference:

Boursnell, M. (2012). Assessing the capacity of parents with mental illness: Parents with mental illness and risk. International Social Work, In press.  http//:dx.doi.org.10.11770020872812445197

Do interventions reduce recidivism in child protection?

The idea of writing about the impact of therapy in child protection cases seems somewhat mundane. However, a recently published study by Soloman and Asberg (2012) looked at the issues of child protection interventions and recidivism, or the revolving door. The reality is that there is not a significant research base on this topic. Thus, the contributions from these authors is welcome.

There were a couple of areas that particularly struck me. Past research tells us that isolation is a risk factor in child protection cases. These authors tells us that the creation of social support networks can help to reduce recidivism. Giving parents therapy to help them address such things as mental health, emotional issues, trauma and substance abuse also helps to reduce recidivism. While this might make intuitive sense, it is nice that research is quantifying the impact.

A major finding is seen on p. 2316:

Overall, findings suggest that cases with at least one minority caregiver and cases in which caregiver(s) have received therapy are less likely to involve abuse or neglect recidivism, while cases in which children were temporarily taken from their caregivers' custody
are nearly nine times more likely to involve abuse or neglect recidivism. Although some studies found that neglect cases have higher recidivism rates (e.g., Hindley et al., 2006), this association was not found in the current study.

While this study has a skewed sample, it does tell us that some of the assumptions that have been held as true, may not be universally so. There may be sub samples where the assumptions prove untrue, as the above quote suggests

The point here is that each case must be considered on its own merits. It also tells us that each case should have a unique case management plan that reflects what might be done to assist families. This study does affirm that therapy is a worthwhile endeavour. The reason might well be that it helps parents deal with stress which is strongly related to the frequency of abuse. Parents who are unable to manage stress that pushes them towards their coping limits are more prone to abuse. This includes rates of neglect. Therapy can increase the coping skills which then reduces risk.  Consider what the authors states on p. 2312:

It has been found that 30% of investigated child maltreatment cases involve at least one
instance of recidivism within 3 years from the original index event (Connell et al., 2009), and these rates of re-referral to CPS seem to continue to climb as more time passes, with life-time re-referral rates upward of 40% (Connell et al., 2007; Drake, Jonson-Reid, Way,

& Chung, 2003) or 50% (English, Marshall, Brummel, &; Orme, 1999).

If therapy can reduce these recidivistic patterns, it is worth continuing to try. Children who are subject to repeated apprehensions and placement into foster care do worse. Can therapy help, this study suggests possibly so.


Reference

Soloman, D. & Asberg, K. (2012). Effectiveness of child protective services interventions as indicated by rates of recidivism. Children and Youth Services Review, 34, 2311-2318 http://dx.doi.org/10.1016/j.childyouth.2012.08.014

Oxford child sexual abuse scandal

Child protection again finds itself under scrutiny as a result of the failure to protect girls caught up in a sexual abuse ring.

Oxford gang members: (top left to right) Akhtar Dogar, Anjum Dogar, Kamar Jamil, Assad Hussain, (bottom left to right) Mohammed Karrar, Bassam Karrar and Zeeshan Ahmed who were found guilty of child sexual exploitation. Photograph: PA

Some of the girls who have come forward tell stories of classical grooming behaviours that led to them be enslaved within the power of the men who ran the ring. One of the girls gave the British newspaper, The Guardian, an exclusive interview. In it, she states:

She described how the gang began to abuse her when she was 13, plied her with crack cocaine and threatened to cut off the head of the baby she had by one of her abusers if she ever tried to escape them.

What perhaps is most disturbing about this case is that it did not occur without the knowledge of the social service and police agencies. The Guardian goes on to state:

A litany of failings by police and social services had allowed the men between 2004 and 2012 to groom young, vulnerable girls they met on the streets, outside schools and in cafes, entice them with the promise of alcohol and trinkets, and subject them over years to sexual atrocities and torture....

Girl C said her adoptive mother went to social services in 2004 to beg for help. She said: "Mum wrote to all the key people in social services, called her own case conferences, invited agencies and got them sitting around the table, but they just passed the parcel between them – and all the while, I was getting increasingly under the power and influence of the gang."

It is astonishing on one level that this could go on. There will be a Serious Case Review which may help us to better understand why. But there are some common themes arising in this matter. Perhaps the one that stands out for me is the failure of organizations to  collectively gather what was happening and build a coordinated response. Agencies are prone to see problems such as this belonging to the jurisdiction of another. There may well be shared responsibility. Silos in child protection work run directly contrary to the needs of children whose problems and situations often cross mandates of various agencies. Silos are simply dangerous for the well being of children. To illustrate this point, the Chief Constable in Oxford stated:

She said the cases were originally looked at individually. "I don't think we understood the extent that the abuse was systematic and it was organised," she said. "It was only when we sat down, pooled our information with that of the social workers, that we began to piece together the picture which explained what was happening in terms of this criminal network in Oxford."

This raises another area of concern which is looking only at cases in isolation as opposed to looking for the trends.

A fundamental principle of social work is to see the person within an environmental context. That means looking at not only the facts of the particular case but also the context in which the person is operating. In this case, a troubled girl (as she would be in prostitution and drug addiction) but those behaviours do not exist in isolation.

One hopes that the various authorities did not just see a troubled girl and a mother who wasn't an effective parent. Hopefully, the inquiry will also look beyond such possibly narrow views and see why the systems failed these girls.

Finally, one has to ask about leadership. Uncoordinated work such as appears to exist in these cases, will too often be the result of weak leadership both locally and beyond. This includes managers who are not giving the strength of supervision needed for cases like this but also funding and policy issues that make co-ordinating this work challenging. Limited resources tend to narrow the focus of workers to what can and must be done immediately. This is not an excuse but should encourage those that will do the SCR to look beyond the local issues. That too requires leadership.

 

 

Post partum depression as a child protection issue

Post partum depression (PPD) occurs in about 20 - 25% of women after giving birth. Some level of the "baby blues" might well occur in larger numbers. The risks of PPD are that women can then go on to experience longer term depression or, in a small number of cases, go on to post partum psychosis. The latter can often be quite dangerous as it can include risks of suicide and homicide. It tends to be a psychiatric emergency.

PPD has the potential to interfere with the attachment process between mother and child. It can reduce the mother's desire to interact with the baby and to provide stimulation (physical and emotional).

The good news is that it is highly treatable. A review by The Cochrane Library has shown that some very simple interventions can make a significant difference.

The piece of their extensive review showed that one intervention that is simple to manage and effective is peer support. Simply having someone touch base and ask, "How are you doing?" makes a difference. In essence, it is someone who just cares, is there and allows for the expression of a mother's true feelings. This can be a major preventative tool that reduces PPD. The Cochrane review found this to be the case.

The research also found that home visits by such people as community nurses are beneficial. Interpersonal psychotherapy was also valuable.

When we reduce PPD, we improve the situation for families which in turn will reduce the need for child protection intervention. What is most appealing about the results of this research is that we do not need to build new and elaborate programs. Peer or lay support by phone works. Keeping up with nursing post delivery visits work. And, when needed, access to basic mental health support.

Alcohol and Pregnancy

Anyone who works in child protection knows that Fetal Alcohol Spectrum Disorder is a prevalent and devastating disorder that brings life long implications. The effects can range from profound to minor. Much depends upon what was consumed in what quantity during which periods of the pregnancy.

There are many things that can be toxic to a foetus which can include alcohol, tobacco and other drugs.

A recently published longitudinal study has suggested that minor amount of alcohol are not harmful to the foetus or the child as she develops. A study of more than 10,000 children followed to age 7 found that there were no indications of increased odds for mental or cognitive deficits. Light drinking was defined as 1-2 drinks per week.

What the study did not do is identify what level of alcohol consumption was safe and that which was not safe. That, of course, is a defining issue.

The challenge with this study is that, while it truly helps to advance the debate, it can easily be misinterpreted. It can be seen as a license to drink in pregnancy. While this is an impressive study, it still leaves many question unanswered.

The advice still should be to not drink in pregnancy but to also not encourage panic when a mother announces that she had a drink at a party. In addition, we should likely be paying a lot of attention to the issue of smoking in pregnancy as well.

The true experience of being falsely accused

We hear stories of people being falsely accused of sexual abuse. In the wake of Jimmy Savile, Jerry Sandusky, Theoren Fleury, Sheldon Kennedy, The Los Angeles Catholic Church Diocese and a myriad other Catholic Church sexual abuse stories, The Boy Scouts of America and numerous other high profile cases, it is hard to remember that, rare as they are, false accusations do occur. For those so accused, the impact is hard.

Recently, in the United Kingdom, the Guardian newspaper has published a first person account of a couple who went through the world of false accusation. It is compelling reading and can be read by clicking this link.