Mednotes

L2 Psych Med Child Maltreatment and Mental Disorders

Properties2
tagspsychmed, lecture, child-maltreatment, child-development
aliasesChild Maltreatment and Mental Disorders

14 min read

Overview

The lecture works through child maltreatment in four moves. It first sets out what healthy development requires and the holistic, contextual models used to understand it (Bronfenbrenner, Meihana, Fonofale), then applies the same nested-systems logic to maltreatment itself through the ecological model of maltreatment, which locates risk and protective factors at individual, family, community and cultural/societal levels. It then names the four types of maltreatment and their sequelae across four domains (physical, cognitive, emotional, social), showing at the biological level how persistent stress alters brain architecture and drives chronic inflammation and later disease. Finally it explains the mechanism linking maltreatment to its consequences as a cascade in which the four domains feed into one another, and closes on buffers and protective factors: maltreatment does not inevitably lead to poor outcomes.

The Psychological Medicine Vertical Module runs down through both ELM 2 and ELM 3; within ELM 2 the Psychological Medicine Block comprises Medical Psychology, Mental Disorders and Human Development. This lecture sits in the vertical module at the ELM 3 level.

Linked teaching:

  • ELM 2 Psych Med Block Module: Developmental Lectures
  • EPE 3 Block Module: Nervous System
  • Integrated Case 14: Developmental Delay
  • ELM 3 Block Module: Metabolism/RCA
  • EPE Unit 4: Family Violence and Abuse

Why maltreatment matters: Aotearoa NZ statistics (MSD)

Total substantiated abuse findings by finding type:

Finding typeF2013F2014F2015F2016F2017
Emotional abuse12,77710,4068,3188,4907,231
Physical abuse3,3433,3053,2353,0733,136
Sexual abuse1,4591,3291,2751,1671,038
Neglect5,4054,5833,6443,6643,397
Total abuse findings22,98419,62316,47216,39414,802

Key points:

  • Emotional abuse is by far the most frequent substantiated finding type in every year shown.
  • Total findings fall year on year, from 22,984 in F2013 to 14,802 in F2017.

Ingredients for healthy development

Healthy development of the whole child rests on four domains: attachment, cognitive, social and physical. Attachment is the ingredient emphasised in the deck’s build of this figure.

Models for understanding development

Three named models are used, all of which place the child in a wider context rather than treating development as an individual property.

  • Bronfenbrenner’s Ecological Systems Theory: emphasises the importance of experience and environment, and their interactions, on development. Represented as concentric rings running from the outside in: community, school, family, individual and peers, with the child at the centre. The version shown is themed around substance use (ATOD), with example influences on each ring: community (anti-ATOD messages in media, community norms, policies discouraging ATOD use, community disorganisation, cultural disenfranchisement); school (high expectations, orderly school climate, consistent discipline, truancy, school bonding, absenteeism); family (family attitudes about ATODs, family bonding, family history of ATOD use); individual and peers (antisocial behaviours, peer group norms, social competence, rewards for prosocial behaviour and positive performance, clear rule enforcement).
  • Meihana Model: a Māori model emphasising contextual and historical contributions to health and wellbeing. Depicted as a waka (double-hulled canoe) on water, with labelled currents and winds representing contextual influences such as colonisation, migration, racism and marginalisation.
  • Fonofale model: a Pasifika model emphasising holistic consideration of health and wellbeing, built as a Samoan house. Roof = culture; four supporting posts = physical, spiritual, mental, other; floor/foundation = family; the whole house sits within a surrounding frame of environment, context and time.

Transcript flags on the model slides

The Bronfenbrenner ring labels are set in very small type in a low-resolution image, so the example wording above is approximate. On the Meihana Model slide the labels within the image could not be read reliably; only the model name and the heading statement are certain.

Ecological model of maltreatment (Fisher et al. 2008)

The same nested-systems logic is applied to maltreatment: influences operate at four levels, from the individual outwards to the societal. The examples given, in order from innermost to outermost, are parents’ past history of abuse, isolation, job loss, and social norms.

The leader lines pairing each example to its ring are faint at the available resolution, so this innermost-to-outermost pairing is inferred from the printed order and position of the callouts rather than read directly. The rings carry no printed level names on that slide.

The fuller version of the figure lists risk and protective factors at each level:

Cultural/societal

  • Risk: social norms, laws and policies that increase the risk of negative outcomes for children and families
  • Protective: social norms, laws and policies that promote the wellbeing of children and families

Community

  • Risk: unemployment; chronic poverty; lack of safe housing; lack of informal support
  • Protective: safe, stable and cohesive neighbourhoods; access to adequate health care, quality education and employment services

Family

  • Risk: unhealthy parent/child interactions; parental stress; parental discord; isolation from family; domestic violence
  • Protective: availability of caring and supportive family, friends, siblings, teachers and neighbours; presence of adult role models; parenting skills; social network of relatives and friends; marital harmony; healthy bonds between parent and child

Individual

  • Risk: lack of parenting skills or capacities; lack of child development knowledge; past history of abuse; substance abuse; mental illness
  • Protective: availability of a supportive, helpful person at the birth of the child; social network of relatives and friends; knowledge of child development; emotionally satisfying relationships; parental resilience

Types of child maltreatment

Four types:

  • Physical abuse
  • Emotional abuse
  • Sexual abuse
  • Neglect

A discussion exercise asks which type(s) of abuse appear in each of three fairy tale stories: Cinderella with her stepmother, Rapunzel/Tangled, and Disney’s The Princess and the Frog. No answers are given on the slide.

Sequelae of child maltreatment

Sequelae fall into four domains: physical, cognitive, emotional and social.

Physical: brain architecture

Persistent (toxic) stress changes brain architecture. Three paired comparisons make the point, all sourced to the Center on the Developing Child (developingchild.harvard.edu):

  1. Neurons of the prefrontal cortex and hippocampus: the normal neuron is typical with many connections, whereas the toxic-stress neuron is damaged with fewer connections.
  2. Brain scans of two 3-year-old children: the normal brain versus the extreme neglect brain, the latter visibly smaller with enlarged ventricles and wider sulci.
  3. Brain activity maps: the typically developing brain shows extensive high-signal areas, whereas the severely disrupted brain shows predominantly low signal.

Together: persistent stress produces fewer neuronal connections, reduced brain growth and reduced activity.

Physical: body and chronic inflammation

Acute or temporary inflammation is a normal, time-limited response comprising the stress response (fight or flight) and the immune response (infection fighting and wound healing). Under persistent stress this shifts to chronic inflammation, which carries increased risk for asthma, heart disease, diabetes, insulin resistance, depression, obesity, arthritis, gastrointestinal disorders, autoimmune diseases, some types of cancer, and dementia.

Risk factors for adult heart disease are embedded in adverse childhood experiences. The odds ratio rises stepwise with the number of adverse experiences: roughly 1 at zero adverse experiences, about 1.2 at one, 1.3 at two, 1.5 at three, 1.6 at four, 1.9 at five to six, and about 3.2 at seven to eight (Dong et al. 2004).

Those bar values were read off the chart; they are not printed as numbers on the slide.

Cognitive, emotional and social sequelae

Cognitive

  • Executive functions: attention, working memory, flexibility, impulse control
  • Processing speed
  • Visual-spatial abilities
  • Motor skills
  • Language
  • Learning
  • IQ

Emotional

  • Emotion dysregulation
  • Mental health disorders
  • Alcohol and substance use
  • Suicide and non-suicidal self injury
  • Identity and adjustment: shame, self-esteem, guilt

Social

  • Attachment disorders
  • Transactional sexual behaviour
  • Interpersonal relationships
  • Family violence
  • Antisocial peers
  • Social withdrawal
  • Bullying and aggression

No physical heading or list appears on this slide; the physical domain is covered by the brain architecture and body slides. The bottom of the emotional list is cut off at the slide edge in the handout and was recovered from the PDF text layer, ending at "guilt".

Pathways and mechanisms: the developmental cascade

The four domains of sequelae are not independent. They are arranged in a continuous loop around the child, running emotional to physical to cognitive to social and back to emotional, so that a consequence in one domain feeds into the next. This cascade is the mechanism by which a single experience of maltreatment produces wide-ranging and self-sustaining consequences.

Buffers and protective factors

Protective factors operate across the nested levels of the ecological model (the same concentric-circle figure is reused here):

  • Stable, supportive adult relationship
  • Self-efficacy and perceived control
  • Self regulation
  • Connection to community/culture
  • Access to services
  • Higher cognitive ability
  • Success at friendships
  • Positive parenting behaviours

Summary points

  • Child development occurs within and between systems of influence, and through transactions between the child and their environment.
  • Maltreatment can have adverse consequences, but it does not inevitably lead to poor outcomes.
  • The presence of protective factors and resources may diminish negative outcomes and promote positive ones, through positive cascades and interactions.

References given in the lecture

  • Center on the Developing Child. InBrief: The Impact of Early Adversity on Children’s Development.
  • Child Welfare Information Gateway (2019). Long-Term Consequences of Child Abuse and Neglect.
  • Collinge, M. R. (2006). The Relationship Between Childhood Abuse and Delusions: An Investigation Based on Delusional Content. Doctoral thesis, University College London.
  • Kisely, S., Abajobir, A. A., Mills, R., Strathearn, L., Clavarino, A., & Najman, J. M. (2018). The British Journal of Psychiatry, 213, 698-703.
  • Hubka, D., Hovdestad, W., & Tonmyr, L. (2009). Child maltreatment in Disney animated feature films: 1937-2006. The Social Science Journal, 46(3), 427-441.

Self-test

  1. List the four ingredients for healthy development of the whole child.
  2. State what Bronfenbrenner’s Ecological Systems Theory emphasises, and list its levels from the outside in.
  3. Describe the structure of the Fonofale model and what each part represents.
  4. Distinguish the Meihana Model from the Fonofale model in terms of what each emphasises.
  5. List the four levels of the ecological model of maltreatment (Fisher et al. 2008) and give one example influence at each.
  6. List the risk factors at the family level of the ecological model of maltreatment.
  7. List the protective factors at the individual level of the ecological model of maltreatment.
  8. List the four types of child maltreatment.
  9. Using the MSD substantiated findings data, describe which finding type is most frequent and what happened to the total number of findings between F2013 and F2017.
  10. Describe the three changes in brain architecture demonstrated for children exposed to persistent stress or extreme neglect.
  11. Explain how acute inflammation differs from chronic inflammation in this model, including the two components of the acute response.
  12. List the conditions for which chronic inflammation carries increased risk.
  13. Describe the relationship between the number of adverse childhood experiences and the odds ratio for adult heart disease.
  14. List the executive functions named among the cognitive sequelae of maltreatment.
  15. List the emotional sequelae of maltreatment, including the three aspects of identity and adjustment.
  16. List the social sequelae of maltreatment.
  17. Describe the developmental cascade linking the four domains of sequelae, including the direction of the loop.
  18. Explain why maltreatment in one domain rarely produces an isolated consequence.
  19. List the buffers and protective factors given in the lecture.
  20. A 3-year-old has been raised in conditions of extreme neglect. Predict what the lecture’s evidence would suggest about their brain size, neuronal connections and brain activity, and explain the underlying mechanism.
  21. A child experiences maltreatment but has a stable, supportive adult relationship, good self-regulation and strong connection to their culture. Explain what the lecture would predict about their outcome and why.
  22. Integrative: explain how the ecological model of maltreatment, the four domains of sequelae and the developmental cascade fit together into a single account of why some maltreated children have poor outcomes and others do not.

Answers

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