The Long-term Consequences of
Child Maltreatment:
Should we rethink Prevention??
Jennie G. Noll, PhD
Professor, Human Development and Family Studies
Director of Research & Education,
Network on Child Protection & Well-being
The Pennsylvania State University
Child Maltreatment
“ANY RECENT ACT OR FAILURE TO ACT ON THE PART OF A PARENT OR
CARETAKER WHICH RESULTS IN DEATH, SERIOUS PHYSICAL OR EMOTIONAL
HARM, SEXUAL ABUSE OR EXPLOITATION; OR AN ACT OR FAILURE TO ACT,
WHICH PRESENTS AN IMMINENT RISK OF SERIOUS HARM.”
Physical & Medical Neglect
Physical abuse
Sexual abuse
Other (Emotional, Family violence, Parent’s drug/alcohol abuse)
U.S. Department of Health and Human Services, 2012
National Prevalence Rates
6.3 MILLION CHILDREN WERE SUBJECTS OF CHILD
MALTREATMENT ALLEGATIONS
3.2 MILLION CHILDREN WERE INVESTIGATED
1.2 MILLION VICTIMS OF MALTREATMENT
17.1 victims per 1000 children (~1 in 58)
800,000 REACHED “ENDANGERED” STANDARDS
2,400 FATALITIES ATTRIBUTED TO CHILD ABUSE
The National Incidence Study of Child Abuse & Neglect , 2010
% of children involved in protective
services at least once by age 17
Year
89%
located/agreed
2017
Offspring 4-20; M=12.29
Time 8; mean age=36.47
Offspring 2-18; M=10.29
2015
Time 7; mean age=34.47
2013
2011
2009
2007
Offspring 0-9; M=4.08
Time 6; mean age=24.89
2005
96%
retained
2003
2001
Time 5; mean age=19.85
1999
Time 4; mean age=18.05
1997
1995
1993
1991
Time 3; mean age=13.42
1989
Time 1; mean age=11.06
Time 2; mean age=12.22
1987
6
10
14
18
22
26
Age
30
34
38
42
acute responses
to trauma in childhood/
early adolescence
Times 1-3 (mean ages 11, 12 & 13)
ORIGINAL CONCEPTUAL MODEL
Psychosocial
distress
Childhood
Sexual
Abuse
Competencies:
cognitive ability
family/social sup port
self-esteem
Psychopathology:
Physiological
stress
hormone
disruption
dep ression/anxiety
dissoci ation
beh avi or p roblems
outcomes in late
adolescence
Times 4 & 5
outcomes in early
adulthood
Time 6
(mean ages 18 &19)
(mean age 24)
adulthood
offspring
outcomes
wellbeing
Times 7 & 8
(mean ages 33 & 35)
(mean ages 9 & 11)
Competencies:
cognitive ability
family/social sup port
self-este em
Competencies:
cognitive a bility
family/social sup port
self-este em
edu cation atta in.
Competencies:
cognitive ability
family/social sup port
self-este em
occupational attain.*
dyadic adjustmen t*
Competencies:
cognitive ability
family/social sup port
self-este em
Psychopathology:
dep ression/anxiety
dissoci ation
deli nquency
Psycho pathology:
dep ression/anxiety
dissoci atio n
psychia tric symptoms
substan ce use
Psychopathology:
dep ression/anxiety
dissoci ation
psychiatric symptoms
substan ce ab use*
Psychopathology:
dep ression/anxiety
dissoci ation
beh avi or p roblems
Physical Heal th:
HPA dysre g/DHE A
obesity
accelerated puberty
Physica l Heal th:
HPA dysre g/DHE A
obe sity
hea lth hx
Physical Heal th:
HPA dysre g/DHE A
obe sity
developmental hx
pub erta l timing*
Psycho sexua l:
risky sex behaviors
Psycho sexua l:
risky se x beha vio rs
teen pregn ancy
Physical Heal th:
HPA dysre g/DHE A
obesity
health hx
risk for car diovascula r
disease, diabetes &
cancer*
Pub erta l
Timing
Revictimization:
victimizatio n h x
Revictimizatio n:
victimizatio n h x
intimate pa rtn er viol.
Offsprin g well being
(mean age 4):
competencies
psycho pathology
develo pme nta l hx
Psycho sexua l:
risky sex behaviors
HIV-risk*
sexual dysfunction*
Revictimizatio n:
victimization hx
domestic violence*
Par enti ng:
pare nti ng styl e*
parenti ng stress
home environment*
Childhood
Maltreatment
SES is diverse;
the majority being either working class or lower SES
Race is diverse;
49% Caucasian
46% African American
4% Hispanic
1% Asian
Comparison Families well matched on demographics
plus family constellation and non-sexual trauma hx.
The Stress of
Childhood Sexual
Abuse
Stress Response; HPA axis
Chronic
Stress/Abuse
Hypothalamus
+
CRH
-
Anterior
Pituitary
+
ACTH
Adrenal
Glands
+
Cortisol
Your Brain….on Stress
Ventral Prefrontal Cortex
Dorsolateral Cortex
Orbital
Prefrontal
Cortex
Anterior Cingulate
Amygdala
Review in Science Vol 289, p 592
200
Lower
peak and slower acquisition of
vocabulary
160
PPV T scores
Lower overall:
-graduation rates
-educational attainment
120
-occupational viability
Comparison Linear
Abused Linear
80
Comparison Quadratic
Abused Quadratic
Group X intercept interaction p<.01
Group X linear time interaction p<.01
40
Noll, et al. (2010) Pediatrics
Age
32
30
28
26
24
22
20
18
16
14
12
10
8
6
Income and education attainment dynamically controlled
Neurocognitive effects of chronic stress

Chronic stress may result in more prefrontal dopamine than is
functionally necessary causing impaired functioning (inattention,
hypervigilance, social / learning problems)

Prefrontal cortex; executive functioning, decision making, working
memory, activated in novelty or danger

Chronic stress “turn off” frontal inhibition impairing these functions

Implications for adolescent risk-behaviors; substance use, risky sexual
behaviors
Split-Second Decisions and Judgment
Activate the Anterior Cingulate
WJ Gehring & AR Willoughby, Science 295, March 2002
Neurocognitive mechanisms for
Alcohol and Substance Abuse
Outcomes:
Alcohol, tobacco
substance use
Maltreatment
HPA axis
dysregulation
Brain
maldevelopment
High-risk Social/
Emotional
functioning
Neurocognitive
impairment
Psychological Mechanisms for Alcohol and
Substance Use
PTSD
Reexperiencing
symptoms
Avoidant
symptoms
Alcohol and
Substance Abuse
Trauma
Numbing
symptoms
Arousal
symptoms
Psychological Mechanisms for
Alcohol and Substance Use
Substance abuse can develop from untreated trauma
PTSD avoidant and numbing symptoms
Trauma-focused therapies not as effective for SUD
patients
SUD treatments not as effective for trauma victims
Alcohol and Substance
Abuse Findings
Substance Abuse Disorder (P<.01)
Abused = 19%
Comparison = 5%
Alcohol Use Disorder (P<.05)
Abused = 13%
Comparison = 3%
Noll et al. (2007) Journal of Interpersonal Violence
Main Effect Findings
Childhood:
↑childhood depression
↑PTSD symptoms
↑externalizing behavior problems
↑somatic complaints
↓family cohesion
↑depressed mothers
↓school performance
Adolescence:
↑earlier pubertal timing
↑depressive symptoms
↑PTSD symptoms
↓cognitive abilities
↓age at first voluntary intercourse
↑teen pregnancy rates
↑self harm
↑sleep problems
↑revictimization
↑substance use
Early Adulthood:
↑persisting PTSD
↑psychiatric diagnoses
↑clinical depression
↑alcohol & drug abuse
↑suicide attempts
↑inter-partner violence
↑sexual violence / rapes
↑obesity
Trickett, PK., Noll, JG, & Putnam, FW. The impact of sexual abuse on female development: lessons
from a multigenerational, longitudinal research study. Development and Psychopathology 2011; 23:453-476.
Offspring Outcomes (T6)
Intergenerational Transmission??
Offspring Outcomes (T6)
• Born Preterm (gestational age <37 wks)
– Abused group: 19.4%
– Comparison group: 10.1%
p<.01
Both pre-pregnancy cortisol levels and
prenatal alcohol use were predictors
Noll et al. (2007) Journal of Pediatric Psychology
Offspring Outcomes (T6)
Cognitive Ability Scores
– Abused group: 87.47*
– Comparison group: 94.48
Bayley Infant Development
PPVT-scores
WJ-R scores
Noll et al. (2007) Journal of Interpersonal Violence
Offspring Outcomes (T6)
• Child Protective Service (CPS) Involved
– Abused group: 17%
– Comparison group: 1%
p<.01
majority neglect
4 physical abuse
1 sexual abuse
40% permanent removal from mom
4 deaths (all born to abused mothers)
Noll et al. (2007) Journal of Interpersonal Violence
CPS-involved Offspring
20
17%*
offspring born to sexually
abused mothers
offspring born to
comparison mothers
10
CPS involved offspring
born to a teenage mom
%
5
< 1%
Noll, JG (2003) Journal of Consulting and Clinical Psychology
Noll, JG SRA, 2006
* =abused vs. comparison
difference at p<.01
High-risk Pathways to Teen Pregnancy
Outcome
High-risk Behaviors/
Attitudes and
Psychosocial Difficulties
High-risk Behaviors (non-sexual):
Behavior Problems/Delinquency
Substance
Use
PTSD
→ Substance
Use
High-risk Partner Affiliation
High-risk Attitudes:
Sexual Distortion
Pregnancy Desire
Pregnancy-vulnerable Cognitions
Contextual Factors
Young age at Menarche
High-risk Parenting
Psychosocial Difficulties:
Poor Cognitive Functioning
Psychological Distress
Low Perceived Support
Psychological Dysregulation
Teen
Parenthood
Teen
Pregnancy
High-risk Sexual
Behaviors
Childhood
Maltreatment
Key:
High risk pathways for all adolescents
Child maltreatment amplifies these risks
Unique pathways for maltreated adolescents
Outcome moderators
PI: Noll, JG: R01 HD052533
514 abused and non-abused
adolescent females assessed yearly
from age 14 through age 19
Results: Teen Motherhood Rates
20.30%
20%
neglected
9.43%
physically
abused
10%
4.20%
0%
National
Average
(2007)
Noll, & Shenk., Pediatrics, 2013
sexually
abused
3.43%
National
Average
(2010)
Comparison
Females
Maltreated
Females
The Estimated Costs of Child
Maltreatment
Miller, Cohen, & Wierseman (1996) calculated $90.6 billion*
Fromm (2001) calculated $152.1 billion*
Wang & Holton (2007) calculated $167.9 billion*
Fang, Brown, Florence, & Mercy (2012) calculated $134.6 billion*
*Converted to 2013 dollars using Inflation Calculator from DaveManuel.com
Costs of other Childhood Maladies
Child Maltreatment:
$134.6 billion
Lead Exposure:
$43.4 billion (Landrigan et al., 2002)
Autism:
$35 billion (Ganz, M.L., 2007)
Childhood Obesity:
$14.1 billion (Trasande, 2009)
Cancer:
$6.6 billion (Landrigan et al., 2002)
Asthma:
$1.2 billion (NIH, 2007)
$100.3 billion
Estimates based on:
HOSPITALIZATIONS
SYSTEMS: CHILD WELFARE, FOSTER CARE, CRIMINAL JUSTICE
SHORT-TERM MENTAL HEATH NEEDS
LOST WAGES
TRUNCATED EARNING POTENTIALS
IMMEDIATE INTERVENTION REQUIREMENTS
LONGER-TERM THERAPEUTIC AND PHARMACOLOGIC
TREATMENTS
SPECIAL EDUCATION NEEDS
Estimates do NOT include:
S
S
NEUROBIOLOGICAL AND BRAIN MALDEVELOPMENT
TEEN PREGNANCY
OBESITY
SUBSTANCE DEPENDENCIES
DOMESTIC VIOLENCE
PREMATURE DELIVERY
S
What is child maltreatment prevention?
Primary – prevent maltreatment BEFORE it happens
Secondary – prevent another problem that stems
from child maltreatment (Intervention)
Targeted – prevent child maltreatment from
occurring in an at-risk group
Embedded – prevent other public health problems
by embedding primary prevention programs
within child welfare
Thinking about “Embedded Prevention”
within the child welfare system?
Abused children are at high risk for a host of
conditions of grave public health concern:
-teen pregnancy (Noll & Shenk, 2013
-obesity (Noll, et al, 2007)
-substance use (Fergusson, 2010)
Children already in the child welfare system
are prime targets for primary prevention of
other public health problems
PSU’s Network on Child Protection
and Well-being
Director Research & Education:
Jennie Noll
Director Policy & Administration:
Margaret Gray
Co-fund 12 New Faculty members in a 5 college cluster-hire
Multidisciplinary research to address important gaps in the field;
impact, detection, prevention, treatment, dissemination, translation
University Park Campus
Children, Youth & Families Consortium
Social Science Research Institute
Network
On Child
Protection
Faculty Co-fund
College
of Liberal
Arts
College
of Health
& Human
Dev’l
Hershey
College of Medicine / Department of Pediatrics
Division of Child Abuse
Pediatrics
College of
Education
Center for the Protection
of Children(CPC)
Transforming Lives of
Children (TLC) Clinic
-Forensic Evaluation
-Mental Health
-Medical Home
-Advocacy
-Research
PSU’s Network on Child Protection
and Well-being
Four Broad Areas of Impact:
Basic Science
biologic substrates of early trauma and chronic stress abuse
promote optimal heath for victims
prevalence, epidemiology
Prevention
Primary prevention
Secondary prevention programs
Targeted prevention program (integrated data research)
PSU’s Network on Child Protection
and Well-being
Four Broad Areas of Impact:
Treatment & Translation
personalized, evidence-based treatment approaches
dissemination and implementation science
-breaking down barriers to service
-increasing family engagement
-enhancing access for rural families
-reduce costs
-education and awareness for community providers
PSU’s Network on Child Protection
and Well-being
Four Broad Areas of Impact:
Engagement
Collaboration with stakeholders, including families, community
groups, and state, federal and international organizations
Serve as PSU’s clearinghouse for information and resources
Provide interdisciplinary educational opportunities to promote
awareness and understanding
-annual conference series
-undergraduate minor