Reduced orbitofrontal and temporal grey matter in a community sample of maltreated children

Background: Childhood maltreatment is strongly associated with increased risk of psychiatric disorder. Previous neuroimaging studies have reported atypical neural structure in the orbitofrontal cortex, temporal lobe, amygdala, hippocampus and cerebellum in maltreated samples. It has been hypothesised that these structural differences may relate to increased psychiatric vulnerability. However, previous studies have typically recruited clinical samples with concurrent psychiatric disorders, or have poorly characterised the range of maltreatment experiences and levels of concurrent anxiety or depression, limiting the interpretation of the observed structural differences. Methods: We used voxel‐based morphometry to compare grey matter volume in a group of 18 children (mean age 12.01 years, SD = 1.4), referred to community social services, with documented and well‐characterised experiences of maltreatment at home and a group of 20 nonmaltreated children (mean age 12.6 years, SD = 1.3). Both groups were comparable on age, gender, cognitive ability, ethnicity and levels of anxiety, depression and posttraumatic stress symptoms. We examined five a priori regions of interest: the prefrontal cortex, temporal lobes, amygdala, hippocampus and cerebellum. Results: Maltreated children, compared to nonmaltreated peers, presented with reduced grey matter in the medial orbitofrontal cortex and the left middle temporal gyrus. Conclusions: The medial orbitofrontal cortex and the middle temporal gyrus have been implicated in reinforcement‐based decision‐making, emotion regulation and autobiographical memory, processes that are impaired in a number of psychiatric disorders associated with maltreatment. We speculate that grey matter disturbance in these regions in a community sample of maltreated children may represent a latent neurobiological risk factor for later psychopathology and heightened risk taking.     

Effects of chronic maltreatment and maltreatment timing on children’s behavior and cognitive abilities

Background: Chronic maltreatment has been associated with the poorest developmental outcomes, but its effects may depend on the age when the maltreatment began, or be confounded by co‐occurring psychosocial risk factors. Method: We used data from the National Survey of Child and Adolescent Well‐Being (NSCAW) to identify four groups of children who varied in the timing, extent, and continuity of their maltreatment from birth to 9 years. Internalizing and externalizing problems, prosocial behavior, and IQ were assessed 21 months, on average, following the most recent maltreatment report. Results: Children maltreated in multiple developmental periods had more externalizing and internalizing problems and lower IQ scores than children maltreated in only one developmental period. Chronically maltreated children had significantly more family risk factors than children maltreated in one developmental period and these accounted for maltreatment chronicity effects on externalizing and internalizing problems, but not IQ. The timing of maltreatment did not have a unique effect on cognitive or behavioral outcomes, although it did moderate the effect of maltreatment chronicity on prosocial behavior. Conclusion: There is a need for early intervention to prevent maltreatment from emerging and to provide more mental health and substance use services to caregivers involved with child welfare services.     

Facial emotion expression recognition by children at familial risk for depression: high‐risk boys are oversensitive to sadness

Background: Offspring of depressed parents are at greatly increased risk for mood disorders. Among potential mechanisms of risk, recent studies have focused on information processing anomalies, such as attention and memory biases, in the offspring of depressed parents. In this study we examined another information processing domain, perceptual sensitivity to emotion cues in facial expressions, as a potential mechanism of risk that characterizes the offspring of depressed parents. Methods: The study included 64 children at familial‐risk for depression and 40 low‐risk peers between the ages 7 and 13(Mage = 9.51; SD = 2.27). Participants were presented with pictures of facial expressions that varied in emotional intensity from neutral to full‐intensity sadness or anger (i.e., emotion recognition), or pictures of faces morphing from anger to sadness (emotion discrimination). After each picture was presented, children indicated whether the face showed a specific emotion (i.e., sadness, anger) or no emotion at all (neutral) using a forced choice paradigm. We examined group differences in the intensity of emotion that suggested greater sensitivity to specific emotions. Results: In the emotion recognition task, boys (but not girls) at familial‐risk for depression identified sadness at significantly lower levels of emotional intensity than did their low‐risk peers. The high and low‐risk groups did not differ with regard to identification of anger. In the emotion discrimination task, both groups displayed over‐identification of sadness in ambiguous mixed faces but high‐risk youth were less likely to show this labeling bias than their peers. Conclusion: Our findings are consistent with the hypothesis that enhanced perceptual sensitivity to subtle traces of sadness in facial expressions may be a potential mechanism of risk among boys at familial‐risk for depression. This enhanced perceptual sensitivity does not appear to be due to biases in the labeling of ambiguous faces.     

Moderation of the association between childhood maltreatment and neuroticism by the corticotropin-releasing hormone receptor 1 gene

Background: Neuroticism is a personality trait reflecting the tendency to experience negative affect. It is a major risk for psychopathology, especially depression and anxiety disorders. Childhood maltreatment is another major risk factor for psychopathology and may influence personality. Maltreatment may interact with genotype to predict developmental outcomes. Variation in three polymorphisms of the CRHR1 gene has been found to moderate the association of childhood maltreatment with depression, and we hypothesized that it would also be linked to neuroticism. Methods: Variation in three CRHR1 SNPs (rs110402, rs242924, rs7209436) was assessed in 339 maltreated and 275 demographically similar nonmaltreated children, who participated in a day camp research program. Maltreated children were further categorized based on the number of types of maltreatment they had experienced and the most severe form of maltreatment experienced. Genotype and maltreatment status were used to predict the Big Five personality traits, as assessed by camp counselors following a week of interaction with children. Results: CRHR1 genotype significantly moderated the association of maltreatment with neuroticism but none of the other traits. Having two copies of the TAT haplotype of CRHR1 was associated with higher levels of neuroticism among maltreated children relative to nonmaltreated children, with the exception of sexually abused children and children who had experienced 3 or 4 types of abuse. Effects sizes of these interactions ranged from η² = .01 (p = .02) to η² = .03 (p = .006). Conclusions: Variation in CRHR1 moderates the association of maltreatment with neuroticism. The effects of specific types of maltreatment on neuroticism are differentially moderated by CRHR1 genotype, as are the effects of experiencing more or fewer types of maltreatment.     

Risk factors for recurrence of maltreatment: a systematic review

Background

Children who have been maltreated are at increased risk of further maltreatment. Competent identification of those at highest risk of further maltreatment is an important part of safe and effective practice, but is a complex and demanding task.

Aim

To systematically review the research base predicting those children at highest risk of recurrent maltreatment.

Methods

Systematic review of cohort studies investigating factors associated with substantiated maltreatment recurrence in children.

Results

Sixteen studies met the inclusion criteria. The studies were heterogeneous. A variety of forms of maltreatment were considered. Four factors were most consistently identified as predicting future maltreatment: number of previous episodes of maltreatment; neglect (as opposed to other forms of maltreatment); parental conflict; and parental mental health problems. Children maltreated previously were approximately six times more likely to experience recurrent maltreatment than children who had not previously been maltreated. The risk of recurrence was highest in the period soon after the index episode of maltreatment (within 30 days), and diminished thereafter.

Conclusions

There are factors clearly associated with an increased risk of recurrent maltreatment, and these should be considered in professional assessments of children who have been maltreated. A comprehensive approach to risk assessment, including but not solely based on these factors, is likely to lead to interventions which offer greater protection to children.     

Training anxious children to disengage attention from threat: a randomized controlled trial

Background: Threat‐related attention biases have been implicated in the etiology and maintenance of anxiety disorders. As a result, attention bias modification (ABM) protocols have been employed as treatments for anxious adults. However, they have yet to emerge for children. A randomized, double‐blind placebo‐controlled trial was conducted to examine the efficacy of an ABM protocol designed to facilitate attention disengagement from threats, thereby reducing anxiety and stress vulnerability in children. Methods: Participants were 34 chronically high‐anxious 10‐year‐olds. An emotional attention spatial cueing task was used. In the ABM condition (n = 18), threat faces never cued the targets’ locations, such that the valid–invalid ratio was 0%/100%, respectively. The valid–invalid ratio on neutral cue trials was 25%/75%, respectively. In the control condition, the valid–invalid ratio was 25%/75% for both neutral and threat faces. Anxiety and depression were measured pre‐ and post‐training and pre‐ and post‐stress induction. Results: ABM facilitated attention disengagement from threat. In response to the stressor task, children in the ABM condition reported less state anxiety relative to controls. Conclusion: Computerized attention training procedures may be beneficial for reducing stress vulnerability in anxious children.     

Electrocortical reactivity to emotional faces in young children and associations with maternal and paternal depression

Background: The late positive potential (LPP) is an event‐related potential component that indexes selective attention toward motivationally salient information and is sensitive to emotional stimuli. Few studies have examined the LPP in children. Depression has been associated with reduced reactivity to negative and positive emotional stimuli, including reduced LPPs in response to emotional faces. The current study sought to identify the time course and scalp distribution of the LPP in response to emotional faces in young children and to determine whether reduced reactivity is observed among children at risk for depression. Methods: Electrocortical reactivity to emotional faces was examined in a large sample of young children and as a function of maternal and paternal depression. Results: In the overall sample, emotional faces were associated with increased positivities compared to neutral faces at occipital sites 200–600 ms after stimulus onset and at parietal sites 600–1,000 ms after stimulus onset. Children of mothers with a history of depressive disorders exhibited reduced differentiation in the early occipital LPP for emotional compared to neutral faces. Conclusions: Results suggest that children as young as 6 years exhibit LPPs to emotional faces, and patterns of electrocortical reactivity to emotional stimuli may be associated with vulnerability to depressive disorders.     

Neural activation to emotional faces in adolescents with autism spectrum disorders

Background: Autism spectrum disorders (ASD) involve a core deficit in social functioning and impairments in the ability to recognize face emotions. In an emotional faces task designed to constrain group differences in attention, the present study used functional MRI to characterize activation in the amygdala, ventral prefrontal cortex (vPFC), and striatum, three structures involved in socio‐emotional processing in adolescents with ASD. Methods: Twenty‐two adolescents with ASD and 20 healthy adolescents viewed facial expressions (happy, fearful, sad and neutral) that were briefly presented (250 ms) during functional MRI acquisition. To monitor attention, subjects pressed a button to identify the gender of each face. Results: The ASD group showed greater activation to the faces relative to the control group in the amygdala, vPFC and striatum. Follow‐up analyses indicated that the ASD relative to control group showed greater activation in the amygdala, vPFC and striatum (p < .05 small volume corrected), particularly to sad faces. Moreover, in the ASD group, there was a negative correlation between developmental variables (age and pubertal status) and mean activation from the whole bilateral amygdala; younger adolescents showed greater activation than older adolescents. There were no group differences in accuracy or reaction time in the gender identification task. Conclusions: When group differences in attention to facial expressions were limited, adolescents with ASD showed greater activation in structures involved in socio‐emotional processing.     

Recognizing and managing long-term sequelae of childhood maltreatment

Childhood maltreatment is a serious public health problem and represents a significant challenge to pediatricians. Maltreated children present with a variety of emotional and behavioral problems. Pediatricians should screen for risk factors associated with maltreatment and psychiatric sequelae associated with maltreatment. Because of the complexity of psychiatric sequelae in childhood maltreatment, children who have been maltreated will likely require multidisciplinary treatment in mental health care settings. Therefore, pediatricians need to be knowledgeable about mental health services in their communities and actively assist the family in obtaining services. Although we are gaining a more sophisticated understanding of the impact that maltreatment has on the mental health of children and adolescents, much remains to be done. It is critical for pediatricians to work within their professional organizations and their individual communities to address the systemic issues that create barriers to care for patients who have suffered maltreatment. It is also critical for pediatricians to encourage their professional organizations to establish good working relationships with other organizations in areas where they share interest, need, and commitment. Such collaborative relationships at local, state, and national levels can facilitate governmental policy changes that are needed to protect and care for children and adolescents. Only through such efforts can we bring about lasting changes that will support the health and well-being of children and adolescents.     

Gender, power, and violence in the family

Attributions for parent-child relationship outcomes were assessed as a function of childhood maltreatment history. In Study 1, the attributions of maltreated children were compared with those of nonmaltreated children from a similar background. Maltreated girls (but not boys) werefound to be more likely than nonmaltreated girls to attribute lower power or control to self than to parents. Effects of maltreatment on children's attributions were found for physical but not sexual abuse. In Study 2, the attributions of parents with a history of abuse as children were compared with those of parents who had not been abused. Women (but no men) with a history of abuse attributed less power or control to self than to children. Implications are drawn for gender differences in the role of biased attributions as a consequence of physical abuse.     

A novel differential susceptibility gene: CHRNA4 and moderation of the effect of maltreatment on child personality

Background: The differential susceptibility hypothesis states that some genetic variants that confer risk in adverse environments are beneficial in normal or nurturing environments. The cholinergic system is promising as a source of susceptibility genes because of its involvement in learning and neural plasticity. The cholinergic receptor gene CHRNA4 has been linked to characteristics related to the personality traits Neuroticism and Openness/Intellect. Methods: The effects of interaction between CHRNA4 genotype and maltreatment status on child personality were examined in a well matched sample of 339 maltreated and 275 non‐maltreated children (aged 8–13 years). Results: Variation in CHRNA4 interacted with childhood maltreatment to predict personality in a manner indicating differential susceptibility. The interaction of CHRNA4 and maltreatment status predicted Neuroticism and Openness/Intellect. Maltreated children with the rs1044396 T/T genotype scored highest on Neuroticism and showed no effect of genotype on Openness/Intellect. Non‐maltreated children with this genotype scored lowest on Neuroticism and highest on Openness/Intellect. Conclusion: Variation in CHRNA4 appears to contribute to personality by affecting degree of developmental sensitivity to both normal and adverse environments.     

A prospective analysis of the relationship between reported child maltreatment and special education eligibility among poor children

This study presents data from the first large-scale longitudinal study to track the involvement of children reported for maltreatment in both the special education and child welfare systems. A range of state and local administrative databases were combined and cross-sector service histories were established for 7,940 children who had received Aid to Families With Dependent Children between 1993 and 1994. The authors address the following questions: (a) Is maltreatment associated with entry into special education after controlling for other factors? (b) among maltreated children, does maltreatment type or child welfare service use predict special education eligibility? and (c) what is the relationship between maltreatment type and type of educational disability? Results indicate that child maltreatment system involvement generally predates special education entry and is predictive of entry even after controlling for other factors. A range of other associations between factors such as child and maternal characteristics, services received, maltreatment type, and special education classification are detailed.     

Modulation of attentional blink with emotional faces in typical development and in autism spectrum disorders

Background: The attentional blink (AB) phenomenon was used to assess the effect of emotional information on early visual attention in typically developing (TD) children and children with autism spectrum disorders (ASD). The AB effect is the momentary perceptual unawareness that follows target identification in a rapid serial visual processing stream. It is abolished or reduced for emotional stimuli, indicating that emotional information has privileged access to early visual attention processes. Methods: We examined the AB effect for faces with neutral and angry facial expressions in 8‐ to 14‐year‐old children with and without an ASD diagnosis. Results: Children with ASD exhibited the same magnitude AB effect as TD children for both neutral and angry faces. Conclusions: Early visual attention to emotional facial expressions was preserved in children with ASD.     

Recognizing and treating uncommon behavioral and emotional disorders in children and adolescents who have been severely maltreated: dissociative disorders

Children who have experienced severe maltreatment may use dissociation as a strategy to cope with the ongoing trauma of their maltreatment. Although dissociation may help children cope with maltreatment, it can become maladaptive if it is used in other contexts. This article explores the symptoms of dissociate disorders and the ways that maladaptive dissociation can develop in maltreated children. Strategies for distinguishing dissociative disorders from other disorders in children are reviewed and treatment strategies for children and adolescents with maladaptive dissociation, and their families, are explored.     

Suicidal ideation among 8-year-olds who are maltreated and at risk: findings from the LONGSCAN studies

Suicidal ideation was examined among 1,051 8-year-old children identified as maltreated or at risk for maltreatment. Of these children, 9.9% reported suicidal ideation. Many variables, including maltreatment, had bivariate associations with suicidal ideation. Severity of physical abuse, chronicity of maltreatment, and the presence of multiple types of maltreatment strongly predicted suicidal ideation. In multivariate analyses of the domains of proximity, only ethnic background remained significant among demographic variables, only witnessed violence and maltreatment remained significant among family or contextual variables, and only child psychological distress, substance use, and poor social problem solving remained significant among child variables. The effects of ethnicity, maltreatment, and witnessed violence on suicidal ideation were mediated by child functioning. There were few interactions between maltreatment and other factors to predict suicidal ideation. Children who are maltreated and those exposed to community and domestic violence are at increased risk of suicidal ideation, even by age 8.     

Regulating emotion in parent-child and peer relationships: a comparison of sexually maltreated and nonmaltreated girls

This study examined emotion regulation skills in 22 sexually maltreated girls and 22 nonmaltreated girls between 6 and 12 years of age to determine how the experience of sexual maltreatment might interfere with normative emotional development. Findings indicated that sexually maltreated girls, compared to nonmaltreated peers, reported different goals (i.e., inhibiting emotion to avoid conflict vs. displaying emotion to rectify, a situation) for managing their emotional expressivity with their parents. They also reported expecting less support and more conflict from parents in response to emotional displays. Finally, maltreated girls expected less practical assistance from all social partners (i.e., mother, father, best friend) following their emotional displays. Surprisingly, however, there were no group differences in girls' ability to generate effective strategies for coping with emotionally arousing situations. Findings are discussed from the functionalist approach to emotional development, emphasizing the importance of social context (i.e., maltreating, nonmaltreating) in the development of children's emotion regulation skills.     

Barriers to physician identification and reporting of child abuse

Physicians systematically underidentify and underreport cases of child abuse. These medical errors may result in continued abuse, leading to potentially severe consequences. We have reviewed a number of studies that attempt to explain the reasons for these errors. The findings of these various studies suggest several priorities for improving the identification and reporting of child maltreatment: Improve continuing education about child maltreatment. Continuing education should focus not only on the identification of maltreatment but also on management and outcomes. This education should include an explanation of the role of CPS investigator and the physician's role in an investigation. The education should provide physicians with a better understanding of the overall outcome for children reported to CPS to help physicians gain perspective on the small number of maltreated children they may care for in their practice. This education should emphasize that the majority of maltreated children will benefit from CPS involvement. New York is the only state that mandates all physicians, as well as certain other professionals, take a 2-hour course called Identification and Reporting of Child Abuse and Maltreatment prior to licensing. Cited studies in this article suggest that such a mandate might be expected to improve identification and reporting, thereby encouraging other states to adopt similar regulations. Give physicians the opportunity to debrief with a trained professional after detecting and reporting child abuse. The concept of child abuse and the gravity of the decision to report can be troubling to the reporter. The debriefing could include discussions of uncomfortable feelings physicians may experience related to their own countertransference reactions. Provide resources to assist physicians in making the difficult determination of suspected maltreatment. The role of accessible telephone consultation should be evaluated, along with formalized collaborations with local Emergency Departments with pediatric expertise. Improve the relationship between CPS and medical providers. For example, CPS workers should systematically inform the reporting physician about the progress of their investigation and the outcome for the child and family. Several past reports have made specific suggestions to improve the working relationship. Warner and Hanson recommended that positive outcomes be programmed into the reporting process. They suggested that CPS have special phone lines staffed by well-trained employees for mandated reporters to call. Finkelhor and Zellman proposed a more radical change to improve the working relationship between CPS and mandated reporters. They suggested that certain professionals, with demonstrated expertise in the recognition and treatment of child abuse and registered as such, should have "flexible reporting options." Options include the ability to defer reporting, if there are no immediate threats to a child, or to make a report in confidence and defer the investigation until necessary. Finkelhor and Zellman emphasized that this model would improve physician-reporting compliance and enhance the role of CPS while reducing the work burden for CPS. Improve interaction with the legal system. Child abuse pediatric experts who have courtroom experience could provide education and support to physicians who have little preexisting experience with the legal system. Reimbursement for time spent supporting legal proceedings should be equitable and may reduce physician concerns about lost patient revenue. Retrospective studies and vignette analyses provide much information about some of the barriers to child maltreatment reporting and describe many of the reasons why physicians do not identify and report all child maltreatment. Future prospective examinations of physician decision-making may further explain the physician's decision-making process and the barriers he or she faces when identifying and reporting child abuse.     

A descriptive survey of Swedish child health nurses' awareness of abuse and neglect. II. Characteristics of the children

AIM: To determine whether children considered by child health nurses to be at risk of abuse or neglect differed from the general population in gender, age and health status, and whether such child characteristics were related to nurses' perceptions of case seriousness, or to reporting to the child protection services (CPS). METHODS: Questionnaires were sent to nurses in the preventive Child Health Services, 951 of whom identified a total of 6044 children aged 0 to 6 y as suspected of risk of maltreatment. RESULTS: Boys and older children were over-represented among the identified children, possibly because the attention of the nurses was attracted by salient symptoms in older boys. Children with health problems and boys exposed to disturbed parenting/neglect were perceived as more serious cases than other children. Children aged 4-6 y were more likely to be reported to the CPS than children under 3 y of age. CONCLUSION: The findings raise the question whether possibly maltreated children who are very young, female or in good health run a particularly high risk of non-detection, of being considered non-serious cases and of not being reported to the CPS. The risk of going unnoticed may be higher for some children at risk of maltreatment than for others.