Article

Special Focus Section: A Critical Look at Trauma Informed Care (TIC) Among Agencies and Systems Serving Maltreated Youth and Their Families

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  • Child Health and Development Institute
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Abstract

The past two decades have witnessed an increase in programs targeting children and youth impacted by traumatic events, with a heightened focus on ensuring that all such programs and relevant service systems are trauma informed. While such efforts are laudable, trauma-informed care (TIC) is defined in a number of ways, limiting evaluation of these initiatives, specifically as they relate to the potential for improved outcomes or reduced costs often used to advocate for TIC. Widespread interest in TIC, despite an apparent dearth of empirical research, served as the impetus for this special section. Our goal was to identify the most rigorous empirical studies available. These six papers were selected based on their inclusion of a definition of TIC, focus on at least one component of TIC in a child-serving system, and availability of empirical data demonstrating the effectiveness of their efforts. In addition to introducing these papers, we share preliminary data from a brief, anonymous survey of child-serving professionals across various systems and roles to obtain feedback about definitional and conceptual issues related to TIC. While this special section provides a representation of available empirical work, significant gaps between research and practice of TIC remain, with important implications for future work.

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... [52][53][54][55] TIC organizations strive to improve multiple practice domains: education of providers to change practice, early identification of children experiencing adversity, treatment through evidence supported and resiliency-focused services, and collaboration within and across agencies that serve children and families in the broader community. 34, [56][57][58] The Substance Abuse and Mental Health Services Administration (SAMHSA) outlines six broad principles to implement TIC (Table I). 59 These principles include safety, organizational trustworthiness and transparency, peer support, organizational collaboration amongst its members, empowerment of clients, and culturally sensitive care. ...
... 79,100,103,105 States committed to multisystem TIC approaches demonstrate the importance of working across multiple systems when developing interventions for children and families who are often involved in more than one system. 57,67,72 This 'trauma-informed systems' approach promotes shared beliefs, values, and practice approaches among organizations, some of which are multilevel interventions that provide workforce training along with policy changes, while others offer targeted services, such as child welfare screenings across multiple agencies. 72,105,110,111 In fact, with the recognition that cross-system TIC implementation may improve health, social, and educational outcomes simultaneously, numerous states have started efforts to build capacity to deliver TIC across systems serving children and their families, including child welfare, education, health and mental health systems. ...
Article
There is building evidence that Adverse Childhood Experiences without early and proper intervention leads to subsequent short- and long-term behavioral, social, physical and mental health problems. Practitioners, researchers, and healthcare systems have been implementing trauma-informed care (TIC) in a variety of health and human services settings, resulting in improvements in clinical care and prevention of illness by identifying high risk populations. This has led to positive health outcomes including improved compliance, better access to mental health services and reduced health care costs. A systematic review was conducted of studies that focused on TIC implementation in healthcare settings, statewide TIC implementation, impact of adverse childhood experiences on health outcomes, impact of TIC on health outcomes, and evaluation of TIC implementation. A search was conducted in March 2019 to identify studies in PubMed, Medline, and other online literature. We limited our search to articles published in English after 2000. This article aims to review the components of TIC phases of implementation in healthcare settings, success stories across the nation to help the readers understand the importance of a paradigm shift to improve healthcare delivery and health outcomes and to prevent illness starting from childhood with a family centered care perspective.
... A further outcome of this systematic review was that despite the slender evidence base evaluating organisation-wide, traumainformed care models, and the difficulties in evaluating organisation-wide processes, outcomes, overall, provide preliminary support for the efficacy of organisation-wide, trauma-informed care models in OoHC populations. This support concords with the extensive anecdotal evidence for trauma-informed care models (such as, Farragher & Yanosy, 2005;Gurwitch et al., 2016;Hanson & Lang, 2014). ...
Article
Trauma in early childhood has been shown to adversely affect children's social, emotional, and physical development. Children living in out‐of‐home care (OoHC) have better outcomes when care providers are present for children, physically, psychologically, and emotionally. Unfortunately, the high turnover of out‐of‐home carers, due to vicarious trauma (frequently resulting in burnout and exhaustion) can result in a child's trauma being re‐enacted during their placement in OoHC. Organisation‐wide therapeutic care models (encompassing the whole organisation, from the CEO to all workers including administration staff) that are trauma‐informed have been developed to respond to the complex issues of abuse and neglect experienced by children who have been placed in OoHC. These models incorporate a range of therapeutic techniques, and provide an overarching approach and common language that is employed across all levels of the organisation. The aim of this study was to investigate the current empirical evidence for organisation‐wide, trauma‐informed therapeutic care models in OoHC. A systematic review searching leading databases was conducted for evidence of organisation‐wide, trauma‐informed, out‐of‐home care studies, between 2002 and 2017. Seven articles were identified covering three organisational models. Three of the articles assessed the Attachment Regulation and Competency framework (ARC), one study assessed the Children and Residential Experiences programme (CARE), and three studies assessed The Sanctuary Model. Risk of bias was high in six of the seven studies. Only limited information was provided on the effectiveness of the models identified through this systematic review, although the evidence did suggest that trauma‐informed care models may have significantly positive outcomes for children in OoHC. Future research should focus on evaluating components of trauma‐informed care models and assessing the efficacy of the various organisational care models currently available.
... Trauma informed care, in which health and service providers are trained in the effects of ACEs and how to integrate compassionate care, are a growing approach to tertiary prevention. Trauma informed care is been integrated in settings such as healthcare, service agencies for high-risk families, and in correctional facilities, but few outcome evaluation studies have been conducted (27)(28)(29). ...
Article
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Aim: This article identifies the prevalence of adverse child events (ACEs) and their health outcomes, discusses how they are measured, and presents approaches to prevent ACEs and reduce their societal burden. Methods: Literature on the prevalence, outcomes, and prevention of ACEs was reviewed, including published peer-reviewed literature and ongoing research. Results: ACEs are common around the world, with approximately half of the population experiencing at least one adverse childhood event and a third experiencing three or more. ACEs have been tied to the leading causes of death and chronic disease, many health risk behaviors, and other performance measures such as employment and crime. The BECAN study that included 9 Balkan countries identified ACEs as a prevalent and important health concern for the region. A growing number of prevention and intervention approaches are emerging, especially that focus on individual and family approaches in the tertiary phase. Conclusion: Despite an increasing number of evidence-based interventions, critical gaps exist in foundational knowledge about the prevalence of ACEs, causal pathways to poor outcomes, and prevention approaches that focus on the primary phase and the societal level.
... TIC, which is being integrated in settings such as health care, service agencies for high-risk families, and in correctional facilities, help service providers become aware of the effects of ACEs and how to integrate compassionate care. Although TIC is among the most prevalent strategies to address ACEs, few outcome evaluation studies have been conducted (51,(69)(70)(71). ...
Article
Adverse Childhood Experiences (ACEs) are related to short- and long-term negative physical and mental health consequences among children and adults. Studies of the last three decades on ACEs and traumatic stress have emphasized their impact and the importance of preventing and addressing trauma across all service systems utilizing universal systemic approaches. Current developments on the implementation of trauma informed care in a variety of service systems call for the surveillance of trauma, resiliency, functional capacity and health impact of ACEs. Despite such efforts in adult medical care, early identification of childhood trauma in children still remains a significant public health need. This article reviews childhood adversity and traumatic toxic stress, presents epidemiologic data on the prevalence of ACEs and their physical and mental health impacts, and discusses intervention modalities for prevention.Pediatric Research (2015); doi:10.1038/pr.2015.197.
Article
Enthusiasm for trauma-informed practice has increased dramatically. Organizational interventions that train staff about trauma-informed practice are frequently used to promote trauma-informed systems change, but evidence about these interventions’ effects has not been integrated. A systematic review was conducted of studies that evaluated the effects of organizational interventions that included a “trauma-informed” staff training component. A search was conducted in July 2017 and studies were identified in PubMed, PsycINFO, and the Published International Literature on Traumatic Stress database, limited to articles published in English after 2000. Six hundred and thirty-two articles were screened and 23 met inclusion criteria. Seventeen studies used a single group pretest/posttest design, five used a randomized controlled design, and one used a quasi-experimental design with a nonrandomized control group. The duration of trauma-informed trainings ranged from 1 hr to multiple days. Staff knowledge, attitudes, and behaviors related to trauma-informed practice improved significantly pre-/posttraining in 12 studies and 7 studies found that these improvements were retained at ≥1month follow-up. Eight studies assessed the effects of a trauma-informed organizational intervention on client outcomes, five of which found statistically significantly improvements. The strength of evidence about trauma-informed organization intervention effects is limited by an abundance of single group, pretest/posttest designs with short follow-up periods, unsophisticated analytic approaches, and inconsistent use of assessment instruments. In addition to addressing these methodological limitations, priorities for future research include understanding intervention effects on clients’ perceptions of care and the mechanisms through which changes in staff knowledge and attitudes about trauma-informed practice influence client outcomes.
Chapter
A history of exposure to traumatic events is the norm in youth utilizing residential care, whether it be acute or subacute inpatient care or longer-term residential placement. Studies of youth in inpatient psychiatric settings reveal traumatic exposures in over 90 % of admitted youth and rates of post-traumatic stress disorder (PTSD) from 25 to 33 % (Adam et al. 1992; Craine et al. 1988; Gold 2008; Havens et al. 2012a, b; Allwood et al. 2008; Lipschitz et al. 1999). By definition, youth placed within the child welfare system have been exposed to abuse and/or neglect. Studies in this population reveal rates of PTSD from 19 to 40 % (Kolko et al. 2010; Famularo et al. 1996). Despite these realitites, inpatient psychiatricand residential treatment settings often struggle to adeqautely identify and address trauma exposure and its mental health consequences in youth, leading to inadeqaute treatmetn planning and milieu management problems. This chapter describes the features of trauma-informed milieu settings and outlines the steps in implementing four essential component: 1) youth trauma screening processes; 2) multi-disciplinarystaff trauma training; 3) trauma skills groups for youth, and; 4) strategies for sustainability of trauma practices. Examples are provided from the authors’ experiences in implementing trauma-informed care in inpatient child and adolescent psychiatry and juvenile detneion settings
Article
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Child maltreatment is a serious public health concern, and its detrimental effects can be compounded by traumatic experiences associated with the child welfare (CW) system. Trauma informed care (TIC) is a promising strategy for addressing traumatized children’s needs, but research on the impact of TIC in CW is limited. This study examines initial findings of the Massachusetts Child Trauma Project, a statewide TIC initiative in the CW system and mental health network. After one year of implementation, Trauma-Informed Leadership Teams (TILTs) in CW offices emerged as key structures for TIC systems integration, and mental health providers’ participation in EBT Learning Collaboratives was linked to improvements in trauma informed individual and agency practices. After approximately six months of EBT treatment, children had fewer posttraumatic symptoms and behavior problems compared to baseline. Barriers to TIC that emerged included scarce resources for trauma-related work in the CW agency and few mental providers providing EBTs to young children. Future research might explore variations in TIC across service system components, as well as the potential for differential effects across EBT models disseminated through TIC.
Article
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It is reasonable to assume that individuals and families who are homeless have been exposed to trauma. Research has shown that individuals who are homeless are likely to have experienced some form of previous trauma; homelessness itself can be viewed as a traumatic experience; and being homeless increases the risk of further victimization and retraumatization. Historically, homeless service settings have provided care to traumatized people without directly acknowledging or addressing the impact of trauma. As the field advances, providers in homeless service settings are beginning to realize the opportunity that they have to not only respond to the immediate crisis of homelessness, but to also contribute to the longer-term healing of these individuals. Trauma-Informed Care (TIC) offers a framework for providing services to traumatized individuals within a variety of service settings, including homelessness service settings. Although many providers have an emerging awareness of the potential importance of TIC in homeless services, the meaning of TIC remains murky, and the mechanisms for systems change using this framework are poorly defined. This paper explores the evidence base for TIC within homelessness service settings, including a review of quantitative and qualitative studies and other supporting literature. The authors clarify the definition of Trauma-Informed Care, discuss what is known about TIC based on an extensive literature review, review case examples of programs implementing TIC, and discuss implications for practice, programming, policy, and research.
Article
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To present new estimates of the average lifetime costs per child maltreatment victim and aggregate lifetime costs for all new child maltreatment cases incurred in 2008 using an incidence-based approach. This study used the best available secondary data to develop cost per case estimates. For each cost category, the paper used attributable costs whenever possible. For those categories that attributable cost data were not available, costs were estimated as the product of incremental effect of child maltreatment on a specific outcome multiplied by the estimated cost associated with that outcome. The estimate of the aggregate lifetime cost of child maltreatment in 2008 was obtained by multiplying per-victim lifetime cost estimates by the estimated cases of new child maltreatment in 2008. The estimated average lifetime cost per victim of nonfatal child maltreatment is $210,012 in 2010 dollars, including $32,648 in childhood health care costs; $10,530 in adult medical costs; $144,360 in productivity losses; $7,728 in child welfare costs; $6,747 in criminal justice costs; and $7,999 in special education costs. The estimated average lifetime cost per death is $1,272,900, including $14,100 in medical costs and $1,258,800 in productivity losses. The total lifetime economic burden resulting from new cases of fatal and nonfatal child maltreatment in the United States in 2008 is approximately $124 billion. In sensitivity analysis, the total burden is estimated to be as large as $585 billion. Compared with other health problems, the burden of child maltreatment is substantial, indicating the importance of prevention efforts to address the high prevalence of child maltreatment.
Article
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This study examined the prevalence of a history of various combinations of childhood maltreatment types (physical abuse, sexual abuse, and witnessing of maternal battering) among adult members of a health maintenance organization (HMO) and explored the relationship with adult mental health of the combinations of types of childhood maltreatment and emotional abuse in the childhood family environment. A total of 8,667 adult members of an HMO completed measures of childhood exposure to family dysfunction, which included items on physical and sexual abuse, witnessing of maternal battering, and emotional abuse in the childhood family environment. The adults' current mental health was assessed by using the mental health scale of the Medical Outcomes Study 36-item Short-Form Health Survey. The prevalences of sexual abuse, physical abuse, and witnessing of maternal violence were 21.6%, 20.6%, and 14.0%, respectively, when the maltreatment types were considered separately. Among respondents reporting any of the maltreatment types, 34.6% reported more than one type of maltreatment. Lower mean mental health scores were associated with higher numbers of abuse categories (mean=78.5, 75.5, 72.8, and 69.9 for respondents with no, one, two, and three abuse types, respectively). Both an emotionally abusive family environment and the interaction of an emotionally abusive family environment with the various maltreatment types had a significant effect on mental health scores. Childhood physical and sexual abuse, as well as witnessing of maternal battering, were common among the adult members of an HMO in this study. Among those reporting any maltreatment, more than one-third had experienced more than one type of maltreatment. A dose-response relation was found between the number of types of maltreatment reported and mental health scores. In addition, an emotionally abusive family environment accentuated the decrements in mental health scores. Future research examining the effects of childhood maltreatment on adult mental health should include assessments of a wide range of abusive experiences, as well as the family atmosphere in which they occur.
Article
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Background: We examined the relationship of the number of adverse childhood experiences (ACE score) to six health problems among four successive birth cohorts dating back to 1900 to assess the strength and consistency of these relationships in face of secular influences the 20th century brought in changing health behaviors and conditions. We hypothesized that the ACE score/health problem relationship would be relatively "immune" to secular influences, in support of recent studies documenting the negative neurobiologic effects of childhood stressors on the developing brain. Methods: A retrospective cohort study of 17,337 adult health maintenance organization (HMO) members who completed a survey about childhood abuse and household dysfunction, as well as their health. We used logistic regression to examine the relationships between ACE score and six health problems (depressed affect, suicide attempts, multiple sexual partners, sexually transmitted diseases, smoking, and alcoholism) across four successive birth cohorts: 1900-1931, 1932-1946, 1947-1961, and 1962-1978. Results: The ACE score increased the risk for each health problem in a consistent, strong, and graded manner across four birth cohorts (P < 0.05). For each unit increase in the ACE score (range: 0-8), the adjusted odds ratios (ORs) for depressed affect, STDs, and multiple sexual partners were increased within a narrow range (ORs: 1.2-1.3 per unit increase) for each of the birth cohorts; the increase in risk for suicide attempts was stronger but also in a narrow range (ORs: 1.5-1.7). Conclusions: Growing up with ACEs increased the risk of numerous health behaviors and outcomes for 20th century birth cohorts, suggesting that the effects of ACEs on the risk of various health problems are unaffected by social or secular changes. Research showing detrimental and lasting neurobiologic effects of child abuse on the developing brain provides a plausible explanation for the consistency and dose-response relationships found for each health problem across birth cohorts, despite changing secular influences.
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Does stress damage the brain? Studies of adults with posttraumatic stress disorder have demonstrated smaller hippocampal volumes when compared with the volumes of adults with no posttraumatic stress disorder. Studies of children with posttraumatic stress disorder have not replicated the smaller hippocampal findings in adults, which suggests that smaller hippocampal volume may be caused by neurodevelopmental experiences with stress. Animal research has demonstrated that the glucocorticoids secreted during stress can be neurotoxic to the hippocampus, but this has not been empirically demonstrated in human samples. We hypothesized that cortisol volumes would predict hippocampal volume reduction in patients with posttraumatic symptoms. We report data from a pilot longitudinal study of children (n = 15) with history of maltreatment who underwent clinical evaluation for posttraumatic stress disorder, cortisol, and neuroimaging. Posttraumatic stress disorder symptoms and cortisol at baseline predicted hippocampal reduction over an ensuing 12- to 18-month interval. Results from this pilot study suggest that stress is associated with hippocampal reduction in children with posttraumatic stress disorder symptoms and provide preliminary human evidence that stress may indeed damage the hippocampus. Additional studies seem to be warranted.
Article
This study systematically examined child-service providers' conceptualizations of trauma-informed practice (TIP) across service systems, including child welfare, juvenile justice, mental health, and education. Eleven focus groups and nine individual interviews were conducted, totaling 126 child-service providers. Conventional content analysis was used to analyze the qualitative data with interrater reliability analyses indicating near perfect agreement between coders. Qualitative analysis revealed that child-service providers identified traumatic stress as an important common theme among children and families served as well as the interest in TIP in their service systems. At the same time, child-service providers generally felt knowledgeable about what they define TIP to be, although they articulated wide variations in the degree to which they are taught skills and strategies to respond to their traumatized clients. The results of this study suggest a need for a common lexicon and metric with which to advance TIP within and across child-service systems.
Article
Effective strategies that increase the extent to which child welfare professionals engage in trauma-informed case planning are needed. This study evaluated two approaches to increase trauma symptom identification and use of screening results to inform case planning. The first study evaluated the impact of training on trauma-informed screening tools for 44 child welfare professionals who screen all children upon placement into foster care. The second study evaluated a two-stage approach to training child welfare workers on case planning for children's mental health. Participants included (a) 71 newly hired child welfare professionals who received a 3-hr training and (b) 55 child welfare professionals who participated in a full-day training. Results from the first study indicate that training effectively increased knowledge and skills in administering screening tools, though there was variability in comfort with screening. In the second study, participants self-reported significant gains in their competency in identifying mental health needs (including traumatic stress) and linking children with evidence-based services. These findings provide preliminary evidence for the viability of this approach to increase the extent to which child welfare professionals are trauma informed, aware of symptoms, and able to link children and youth with effective services designed to meet their specific needs.
Article
Exposure to childhood trauma is a major public health concern and is especially prevalent among children in the child welfare system (CWS). State and tribal CWSs are increasingly focusing efforts on identifying and serving children exposed to trauma through the creation of trauma-informed systems. This evaluation of a statewide initiative in Connecticut describes the strategies used to create a trauma-informed CWS, including workforce development, trauma screening, policy change, and improved access to evidence-based trauma-focused treatments during the initial 2-year implementation period. Changes in system readiness and capacity to deliver trauma-informed care were evaluated using stratified random samples of child welfare staff who completed a comprehensive assessment prior to (N = 223) and 2 years following implementation (N = 231). Results indicated significant improvements in trauma-informed knowledge, practice, and collaboration across nearly all child welfare domains assessed, suggesting system-wide improvements in readiness and capacity to provide trauma-informed care. Variability across domains was observed, and frontline staff reported greater improvements than supervisors/managers in some domains. Lessons learned and recommendations for implementation and evaluation of trauma-informed care in child welfare and other child-serving systems are discussed.
Article
Adjudicated youth in residential treatment facilities (RTFs) have high rates of trauma exposure and post-traumatic stress disorder (PTSD). This study evaluated strategies for implementing trauma-focused cognitive behavioral therapy (TF-CBT) in RTF. Therapists (N = 129) treating adjudicated youth were randomized by RTF program (N = 18) to receive one of the two TF-CBT implementation strategies: (1) web-based TF-CBT training + consultation (W) or (2) W + 2 day live TF-CBT workshop + twice monthly phone consultation (W + L). Youth trauma screening and PTSD symptoms were assessed via online dashboard data entry using the University of California at Los Angeles PTSD Reaction Index. Youth depressive symptoms were assessed with the Mood and Feelings Questionnaire-Short Version. Outcomes were therapist screening; TF-CBT engagement, completion, and fidelity; and youth improvement in PTSD and depressive symptoms. The W + L condition resulted in significantly more therapists conducting trauma screening (p = .0005), completing treatment (p = .03), and completing TF-CBT with fidelity (p = .001) than the W condition. Therapist licensure significantly impacted several outcomes. Adjudicated RTF youth receiving TF-CBT across conditions experienced statistically and clinically significant improvement in PTSD (p = .001) and depressive (p = .018) symptoms. W + L is generally superior to W for implementing TF-CBT in RTF. TF-CBT is effective for improving trauma-related symptoms in adjudicated RTF youth. Implementation barriers are discussed.
Article
An essential but often overlooked component to promoting trauma-informed care within the child welfare system is educating and empowering foster, adoptive, and kinship caregivers (resource parents) with a trauma-informed perspective to use in their parenting as well as when advocating for services for their child. In this first evaluation of the National Child Traumatic Stress Network's trauma-informed parenting workshop (Caring for Children who Have Experienced Trauma, also known as the Resource Parent Curriculum), participant acceptance and satisfaction and changes in caregiver knowledge and beliefs related to trauma-informed parenting were examined. Data from 159 ethnically diverse resource parents were collected before and after they participated in the workshop. Results demonstrate that kinship and nonkinship caregivers showed significant increases in their knowledge of trauma-informed parenting and their perceived self-efficacy parenting a child who experienced trauma. Nonkinship caregivers increased on their willingness to tolerate difficult child behaviors, whereas kinship caregivers did not show a significant change. Participants also demonstrated high levels of satisfaction with the workshop. Although these preliminary results are important as the first empirical study supporting the workshop's effectiveness, the limitations of this study and the directions for future research are discussed.
With the recognition that large numbers of men and women receiving services in the mental health and addictions systems are the survivors of sexual and physical abuse, practitioners need to become informed about the dynamics and the aftermath of trauma.
Article
The relationship of health risk behavior and disease in adulthood to the breadth of exposure to childhood emotional, physical, or sexual abuse, and household dysfunction during childhood has not previously been described. A questionnaire about adverse childhood experiences was mailed to 13,494 adults who had completed a standardized medical evaluation at a large HMO; 9,508 (70.5%) responded. Seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned. The number of categories of these adverse childhood experiences was then compared to measures of adult risk behavior, health status, and disease. Logistic regression was used to adjust for effects of demographic factors on the association between the cumulative number of categories of childhood exposures (range: 0-7) and risk factors for the leading causes of death in adult life. More than half of respondents reported at least one, and one-fourth reported > or = 2 categories of childhood exposures. We found a graded relationship between the number of categories of childhood exposure and each of the adult health risk behaviors and diseases that were studied (P < .001). Persons who had experienced four or more categories of childhood exposure, compared to those who had experienced none, had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health, > or = 50 sexual intercourse partners, and sexually transmitted disease; and 1.4- to 1.6-fold increase in physical inactivity and severe obesity. The number of categories of adverse childhood exposures showed a graded relationship to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. The seven categories of adverse childhood experiences were strongly interrelated and persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life. We found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.
Article
We sought to assess the difference in a preference-based measure of health among adults reporting maltreatment as a child versus those reporting no maltreatment. Using data from a study of adults who reported adverse childhood experiences and current health status, we matched adults who reported childhood maltreatment (n = 2812) to those who reported no childhood maltreatment (n = 3356). Propensity score methods were used to compare the 2 groups. Health-related quality-of-life data (or "utilities") were imputed from the Medical Outcomes Study 36-Item Short Form Health Survey using the Short Form-6D preference-based scoring algorithm. The combined strata-level effects of maltreatment on Short Form-6D utility was a reduction of 0.028 per year (95% confidence interval=0.022, 0.034; P<.001). All utility losses for the childhood-maltreatment versus no-childhood-maltreatment groups by age group were significantly different: 18-39 years, 0.042; 40-49 years, 0.038; 50-59 years, 0.023; 60-69 years, 0.016; 70 or more years, 0.025. Persons who experienced childhood maltreatment had significant and sustained losses in health-related quality of life in adulthood relative to persons who did not experience maltreatment. These data are useful for assessing the cost-effectiveness of interventions designed to prevent child maltreatment in terms of cost per quality-adjusted life years saved.
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