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Childhood maltreatment is recognized as the No. 1 preventable cause of mental illness – and some experts argue, of all stress-related diseases – yet science still has no clear answers for how to best prevent the spiral of neglect and abuse that threatens millions of infants and children in the U.S. alone.
In a report published this week, the U.S. Preventive Services Task Force (USPTF), a U.S. Public Health Service committee charged with recommending action to thwart preventable health conditions, conceded that there was “insufficient data” to recommend any particular strategy that has been tested as a means of preventing childhood maltreatment, which encompasses neglect as well as physical, psychological, or sexual abuse. Preventive interventions initiated in primary care focus on preventing maltreatment before it occurs, as opposed to identifying children who are victims of abuse or neglect.
The USPSTF report in JAMA: The Journal of the American Medical Association comes at a time of heightened awareness of the toll of childhood neglect and abuse, both in terms of the long-term neuropsychiatric effects, which set so many children on a trajectory of emotional instability and mental health disorders, and in terms of societal impact, which new estimates put at roughly $2 trillion annually in direct and indirect costs.
The Task Force reviewed 22 studies that investigated strategies for preventing child abuse and neglect, many of them home visitation programs that usually involve a professional (such as a nurse) or paraprofessional (such as peer educator or community health worker) providing periodic counseling, educational services, or support in a family’s home. Other programs studied include primary care programs designed to identify high-risk patients and refer them to community resources, parent education to improve nurturing and increase the use of positive discipline strategies, and psychotherapy to improve caregivers’ coping skills and strengthen the parent-child relationship. These interventions are variously delivered in settings such as primary care clinics, schools, and the community.
Poverty, it turns out, is an important risk factor. Children growing up in low-income households are at heightened risk of maltreatment, as are children born to adolescent mothers, parents with low levels of education, and parents who were themselves abused or neglected.
Rockefeller University neuroscientist Bruce McEwen, a Dana Alliance for Brain Initiatives member and expert on the effects of stress, is one scientist who believes that the full impact of childhood maltreatment is still under-appreciated. He argues that, together with poverty, childhood maltreatment contributes disproportionately to the societal burden of both mental and physical health – particularly the stress-related diseases such as heart disease and diabetes that are primary killers in developed nations – via the effects of toxic stress and inflammation on the brain and bodily systems.
That conviction, McEwen acknowledges, is based not on a smoking-gun causal link proved by peer-reviewed science, but rather a “chain of logic” connecting known facts to reach a conclusion. Al Race, co-director of Harvard’s Center for the Developing Child, describes the three critical links behind this logic chain:
- Maltreatment and severe deprivation are potent activators of the stress response system.
- Stress is implicated in numerous chronic illnesses, including heart disease and inflammation.
- Four of the top ten most costly diagnoses in the US are attributable at least in part to early life stress: heart conditions ($107 billion per year), mental disorders ($73 billion), diabetes ($51 billion), and hypertension ($43 billion), based on 2010 data from the Agency for Healthcare Research and Quality.
“If you connect those three dots,” Race wrote in an email, “you get a powerful case that a) maltreatment and deprivation activate the stress response system; b) severe, long-lasting stress contributes to a range of chronic health problems, and c) those health problems are among the most costly to deal with. Combined, they are THE most costly.”
For more on this topic, see our Briefing Paper: The Abused Brain: Neural Adaptation, Resilience, and Compensation in Childhood Maltreatment.