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Reducing all-cause mortality among children, 1-17

and young adults with child welfare involvement

(Originally published August 2021)

Most child welfare staff and other professionals who have key roles in child protection have attended one or more presentations on Adverse Childhood Experiences (ACE) research that contains the following visual representation of how ACEs have dose related potentially life-long effects on physical health and mental health.

One plausible hypothesis is that the same processes that lead from ACEs to disease, disability or early death in middle age and old age also account for increased risk of mortality in childhood and young adulthood. A study of a British adults born during a single week in 1958 found an 80% increase in mortality for women with 2 or more ACEs and a 57% increase in mortality for men with 2 or more ACEs by age 50 compared to adults with no ACEs. (Kelly-Irving, et al, 2013). Half of deaths in this birth cohort occurred prior to age 40.

A recently published study of all-cause mortality among young people with child welfare involvement in South Australia found that “CPS contact was … strongly associated with increased risk of death between ages 16 and 33 years.” The study also found that the greater the

degree of “serious maltreatment exposure” in childhood, the higher the risk of early death after controlling for covariates such as socioeconomic factors. These adolescents and young adults “were more likely to die in circumstances involving poisonings, alcohol, drugs, other substances, or mental illness … or suicide … but also natural causes … compared with children with no CPS contact.” And “The biggest absolute contributor to excess risk (of death) was suicide.” (Segal, et al, 2021)

According to the ACE pyramid, disrupted brain development leads to social, emotional and cognitive impairments, including early onset mental health conditions, which leads children and young people to engage in behaviors such as smoking and substance abuse to manage these conditions, resulting in chronic disease and sometimes early death. Many children (17-21) with child welfare involvement (especially children in foster care) experience multiple adversities, a history that cannot be undone. Chronically neglected and chronically maltreated (i.e., combinations of neglect and abuse) children have the highest ACE scores among child welfare populations. Reducing these children’s risk of early mortality requires interventions to mitigate the eects of ACEs on children’s neurodevelopment and mental health, and to discourage youth from engaging in dangerous behaviors to control their emotions and feel safe.

Child welfare systems cannot possibly reduce the risk of all-cause mortality for children with multiple ACEs unless they recognize that chronic child maltreatment has cumulative eects on development that aects both child safety and child well-being. Child welfare systems should do the following:

Take on the goal of developmental repair as a fundamental part of their child welfare mission.
Adopt a broader definition of child safety than protection of children from immediate safety threats.
Engage in developmental screening and (when called for) developmental assessment of children in chronically referring families as a standard part of family assessments.
Train foster parents and adoptive parents in trauma informed care, with a strong emphasis on skills needed to help traumatized children with emotion regulation.
Ensure that high quality mental health services are delivered at the onset of mental health disorders, rather
than several years later after the eects of these disorders on children’s social functioning becomes evident.

The importance of helping severely neglected and traumatized children to avoid “meltdowns” and calm themselves before the loss of emotional control becomes extreme cannot be overstated. Deborah Gray, the author of Nurturing Adoptions comments:

“High stress kills children’s brain cells, making them even more vulnerable in stressful events. … There is a neurotoxic eect of circulating

glucocorticoids, which are present during high stress, on the hippocampus, a structure rich in receptors for stress hormones that also plays a key role in memory.”

Proactive steps to limit the damage to neurodevelopment from ACEs must increase children’s capacity to calm themselves. Deborah Gray maintains that “Children who receive help developing calming techniques and self-refection ultimately respond much better behaviorally.

"Suggestions for children should always include calming techniques as part of interventions.”

Unfortunately, the ACE pyramid does not fully account for the factors that increase risk of all-cause mortality among children with child welfare involvement, as discussed in my two prior Sounding Boards. Adverse childhood experiences often begin in the prenatal period

(not at birth) through exposure in utero to dangerous substances (including nicotine and alcohol), lack of prenatal care and the toxic stress experienced by the mother. Children at highest risk of mortality in childhood from both child maltreatment and poor health have

compromised health and/or disabilities from birth, or extremely low birth weight. Poor birth outcomes precede the usual list of ACEs and increase the risk of child maltreatment among parents with severe functional impairments due to substance abuse, mental health

conditions and or DV.

It is not the case that children and youth’s high risk health behaviors always contribute to chronic disease or disability, per the ACE pyramid. The authors of the English study cited above comment:

"For both men and women, the probability of premature death was higher for those who had childhood pathologies."

Early onset depression often increases children’s health problems and rates of early mortality. A recently published Swedish study found that among almost 1,500,000 persons born in Sweden between 1982-1996 “Individuals with youth depression had higher relative risks for 66 of the 69 somatic diagnoses” and had almost 6 times the rate of all-cause mortality and 14 times the rate of suicide from ages, 17-31 than young people with no documented history of depression.

Deborah Gray states:

“People drift toward depression and hopelessness following early neglect and trauma experiences … Neglect steers children toward self-destruction. It is almost as if neglected people agree with the notion that they should not have been born in the first place.”

Child welfare assessments and case plans should be directed at improving the capacity of parents to engage in emotionally responsive, “Serve and Return” interactions with their young non-verbal children.

It is not enough for service plans to improve the physical care of neglected children, help parents to come to grips with substance abuse and/or chronic mental illness and DV. Children’s health and development depends on creating nurturing families and communities with the following characteristics:

Children have daily experiences of “Serve and Return’ interactions, per The Science of Neglect (2012)
Children receive spontaneous expressions of aections from caregivers.
Children’s positive behaviors are recognized and rewarded.
Children experience social inclusion at school and among friends.
Children’s cultural identity and community traditions are honored.
Children can form friendships with children outside their immediate family.

Children’s mental health services must help caregivers create nurturing environments in which developmental repair is possible. Any evidenced based program that reduces a narrow range of maltreated children’s depressive symptoms without improving the nurturing

elements of family life has missed the mark; and will not improve children’s health outcomes or reduce the risk of early mortality.

In chronically referring families, it is often maternal depression that leads directly to non-nurturing parenting. Child welfare service plans often place greater emphasis on substance abuse treatment than on co- occurring mood disorders; but this is a mistake. Restoring the

potential for nurturing parenting can often not occur until maternal depression is eectively treated.

A recent study published in JAMA Pediatrics indicates the importance of positive childhood experiences on children’s mental health. This study used a phone survey of 6,188 adults, 18 and older; “Data were weighted to be representative of the entire population of Wisconsin,”

according to the authors, (Bethell, et al, 2020). The study found a dose related association between 7 positive childhood experiences (PCEs) and rates of adult depression and or poor mental health (D/PMH) and adult reported social and emotional support, i.e., higher PCEs led to lower rates of depression and/or poor mental health and higher rates of emotional and social support. The 7 PCEs were (1) felt able to talk to their family about feelings (2) felt their family stood by them in difficult times (3) enjoyed participating in community traditions (4) felt a sense of belonging in high school (5) felt supported by friends (6) had at least 2 non-parent adults who took genuine interest in them (7) felt safe and protected by an adult in their home.

Once children with multiple ACES reach school age, service plans need to extend beyond the family to schools and community. Abused and neglected children may receive excellent care from parents, relatives or foster parents but be bullied, ostracized, belittled among

peers; and have difficulty coping with the academic demands and behavioral expectations of school. Children with troubled early histories that have led to cognitive impairments will often need adult allies and peer allies to cope with challenges in school.

Trends in youth suicide

One of the most distressing trends in recent years has been the greater than 50% increase in the U.S. youth suicide rate since 2008. Youth suicide rates vary widely among racial/ethnic groups. American Indian/ Alaskan Native youth, 10-24, have a suicide rate 2.5 times higher

than the national average; white youth have a much higher suicide rate than black youth, though the black youth suicide rate has increased during the past two decades.

Male youth commit suicide almost 3 times more frequently than females, a pattern that is consistent across all racial/ethnic groups. Male children also die from child maltreatment more often than females: the usual ratio in most studies is 58% males to 42% females. Young

boys are also more likely to die from disabilities than girls of a similar age. Male children are more biologically vulnerable than female children; and the much higher suicide rate among male youth suggests that they are more psychologically vulnerable as well.

A recent California study (Palmer, et al, 2021) of a large birth cohort found that children with CPS reports were 3-5 times more likely to commit suicide than children with no CPS reports. Another study (Palmer, et al, 2021) which used the same or similar administrative data found that adolescents with CPS reports alleging recent physical abuse or sexual abuse were at elevated risk of suicide vs. youth reported for neglect or reported in early childhood.

This study indicates that adolescent abuse can have lethal consequences even when adolescents suer minor injuries or no injuries.

I have yet to read or hear a plausible explanation for the large dierence in suicide rates between black and American Indian/Alaskan Native youth. My hypothesis is that youth suicide rates are a proxy indicator of hopelessness among adolescents regarding their

prospects for a socially valued life. According to this perspective, black youth are much more hopeful about their future (despite structural racism) than Native American youth. Past experiences, both positive and adverse, have a large eect on health outcomes and mortality, as does the future which troubled youth imagine for themselves.

The most eective antidote for hopelessness in any age group is empowerment. An inspiring experiment in youth empowerment is discussed in The Return of the Sun: Suicide and Reclamation Among Inuit in Arctic Canada by Michael Kral; he comments:

“The tipping point … for the reduction of suicide was not likely any one factor in the communities but a spread of wellness that coincided with and is directly related to community control.” And “…none of the Inuit activities and programs described here that resulted in the elimination or decreased rates of suicide were called suicide prevention. They were called by what they were: a youth center, community gatherings and … going on the land with elders or starting a sports team. There was no prescriptive program enacted across communities.”

In Kral’s account, hope among Inuit youth regarding the future was engendered by community control and the experience of collective self-eFcacy. Kral’s book is a great resource for tribal communities developing programs to reduce youth suicide.

Two pathways to violence

The inability to “regulate stress-reactive aggressive states” is a potential precursor to violence and/or to victimization from violence when youth have not learned how to control their vulnerability to “meltdowns” prior to adolescence. Adolescents with an inability to regulate

their emotional states are headed for some type of institutional care, or early death. Trauma informed care must address this challenge head on. Deborah Gray’s, Nurturing Adoptions, Anne Gearity’s, “Developmental Repair” day treatment model and Saxe’s, et al,

Collaborative Treatment of Traumatized Children and Teens are excellent resources to guide the development of practice models. These resources also oer useful concrete strategies for helping children and youth acquire self- regulation skills. Every foster parent and unlicensed relative caregivers should receive these resources during or following training programs.

There is another pathway to violence followed by some “cross-over” youth who move from foster care or residential care to juvenile justice institutions: school failure combined with the lack of non-academic prosocial skills leads to violence as a means of self-protection and

a way of commanding respect in a peer group. Violent altercations may become enmeshed in adolescent identity formation. No enlightened (or prudent) community stands by passively as this process unfolds.

The most eective way of reversing antisocial trajectories among school age children is through investment in youths’ prosocial talents, e.g., athletics, art, music, dance, poetry or drama, computers, work with horses or other animals, farming, mountaineering, etc. Nurturing

relationships remain important at all ages; however, school age children and youth must >nd their way in the world with skills and talents, especially when school is a painful, discouraging experience. Foster parents and residential care staff should be involved in a persistent

search for children’s interests and innate strengths that can be directed into the development of talents. Philanthropies should invest in annual talent searches among low-income school age children.

Every youth deserves the opportunity to shine in activities valued by the local community.

Summary

There are two broad strategies for reducing all-cause mortality among child welfare involved children: (1) through nurturing caregiving as described above and (2) through social inclusion and belonging, community empowerment and the development of prosocial skills

among school age youth. Child welfare agencies must develop a sharper focus on children’s physical vulnerabilities from birth; and invest in services and programs that assist parents in meeting disabled and chronically ill children’s special needs. Therapeutic interventions in chronically referring families should be directed at restoring parents’ capacity for nurturing care of children, as well as ensuring adequate

physical care.

References

“American Indian Suicide Rate Increases,” National Council on Aging, inc., September 9, 2019, available online.

Bethell, C., Jones, J., Gombojav, N., Linkenbach, J. & Sege, R., “Positive Childhood Experiences and Adult Mental and Relational Health in a Statewide Sample,” JAMA Pediatrics, published online September 9, 2019.

Gearity, A., Developmental Repair: A Paradigm Change for Intervening with At-risk Young Children, (2012) Washburn Guidance Clinic, Minneapolis, Mn., available online.

Gray, D., Nurturing Adoptions: Creating Resilience after Neglect and Trauma (2007), Perspectives Press, Indianapolis, Indiana.

Kelley-Irving, M., Lepage, B., Dedieu, D., Bartley, M., Blane, D., Grosclaude, P., Lang, T. & Delpierre, C., “Adverse childhood experiences and premature all-cause mortality,”, Journal of European Epidemiology, pub. online, July 26,2013.

Kral, M., The Return of the Sun: Suicide and Reclamation Among Inuit of Arctic Canada (2019), Oxford University Press, New York

City, NY. Levine, M, Kuja-Halkola, R., Level, A., D’Onofrio, B., Larsson, H.,

Lichtenstein, P. & Bergen, S., “Association of Youth Depression with Subsequent Somatic Diseases and Premature Death,” JAMA Psychiatry, published online, December 9, 2020.

Palmer, L., Prindle, J. & Putnam- Hornstein, E., “A population-based case control study of suicide among youth reported for abuse and neglect,” Child Abuse and Neglect , 117, available online April 9, 2021.

Palmer, L., Prindle, J & Putnam-Hornstein, E., “A Population-Based Examination of Suicide and Child Protection System Involvement,”

Journal of Adolescent Health, pending publication 2021.

Saxe, G., Ellis, B. & Kaplow, J., Collaborative Treatment of Traumatized Children and Adolescents (2007), The Guildford Press, New York City and London.

Segal, L., Arm>eld, JM, Gnanamanickam, ES, et al, “Child maltreatment and mortality in young adults,” Pediatrics, 147(1), 2021.

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