The CONSEQUENCES and OUTCOMES of CORPORAL PUNISHMENT - PowerPoint Presentation

Slide1

The CONSEQUENCES and OUTCOMES of CORPORAL PUNISHMENT

George Davis, MD

Director of Psychiatry

NM Department of Children, Youth and FamiliesSlide2

Many Americans agree… “A spanking can serve as a meaningful negative consequence in cases of undesirable behavior, but it tends to be most useful — and necessary — when a child is under 3 ½ years of age…because reasoning and taking away privileges simply don't work with very young children.”

Dr. James DobsonSlide3

Corporal Punishment—any physically aversive treatment from caretakers toward children designed to modify behavior

Spanking

—the alternative term

Harsh Treatment—a research term to indicate unusually coercive and punitive verbal, emotional or physical treatment of childrenInfancy—first two yearsEarly Childhood—years two to five

DEFINITIONSSlide4

65% Americans support spanking, but…94% actually spank their toddlers

30% parents smack babies under one

Over 50% toddlers are spanked more than three times weekly

Rate of spanking toddlers has NOT declined

WHAT AMERICANS BELIEVESlide5

I was spanked and I turned out OKSpanking and abuse are two separate things

Spanking is okay as long as you aren’t angry

Talking to toddlers doesn’t work

Spanking is a last resortCOMMON PUBLIC OPINIONSlide6

Review of early brain developmentReview of neglect/abuse effects

Adverse Childhood Experiences

Research on corporal punishment

Discussion and argumentation

THE OUTLINESlide7

The brain is undeveloped at birthThe brain organizes from the

“

bottom up” - brainstem to cortex and from the inside out

Organization and functional capacity of neural systems is sequential Experiences do not have equal significance throughout development

7

Sequential Neurodevelopment

The Four Essential PrinciplesSlide8

An infant needs connection to a caregiver in order to organize the brain

’

s functions in the

moment, and to allow it to develop properly over timeFailure to receive the consistent, repetitive, positive, dependable and appropriate attention of the primary caretaker is

the premier

neurological insult

8

Brain Development and AttachmentSlide9

Caregivers of secure children respond quickly to negative emotions that are

stressful to the child,

helping to

minimize exposure to the neurotransmitters that mediate stressThe best caretakers

also enhance positive emotions through

play and social interactions,

increasing

the positive neurotransmitters that enhance neuronal

growth and brain maturation

9

Brain Development and States of ArousalSlide10

CHILD ABUSE AND NEGLECT

HOW DOES CHILDHOOD TRAUMA ALTER DEVELOPMENT?

When distress is overwhelming, or when the caregivers themselves are the source of the distress, children are unable to modulate arousal. This causes a breakdown in the capacity to process and regulate experience.

At the core of traumatic stress is a breakdown in the capacity to regulate internal

states.

(

van

der

Kolk

, 2002)Slide11

THE DISTINCTION BETWEEN DEVELOPMENTAL TRAUMA and PTSDCausation

Presentation

Treatment

Prognosis CHILD ABUSE AND NEGLECTSlide12

WHAT ARE THE SALIENT FEATURES of TRAUMA THAT CAUSES DEVELOPMENTAL DAMAGE?Repetition of Trauma

More than one Kind of Trauma

Early Age

Chronicity and Persistence Interpersonal / Intrafamilial

CHILD ABUSE AND NEGLECTSlide13

What we know for sure:Child abuse is commonThe consequences of early childhood abuse can be devastating to the brain development of the child

Although we can and do treat it, tracks of the developmental damage from abuse can be essentially permanent

CHILD ABUSE AND NEGLECTSlide14

What we know for sure:The extended effects of early child abuse cross the boundaries of attachment, affect, thought, behavior, personality and healthEarly abuse vastly increases the likelihood of depression, anxiety, aggression, sleep disturbances, delinquency and criminality

So we mistakenly call it Bipolar Affective Disorder, Attention Deficit Hyperactivity Disorder, Depression, Conduct Disorder and PTSD

CHILD ABUSE AND NEGLECTSlide15

WHAT WE DON’T KNOW FOR SURE: When does corporal punishment, including routine spanking, become abuse? And at what point does it become damaging to the development of the child? In other words, what is the difference between abuse and discipline?

CHILD ABUSE AND NEGLECTSlide16

ADVERSE CHILDHOOD EXPERIENCES (ACE) STUDY BY CDC AND KAISER

17,337 Adult Subjects make up the Total Sample

11% Emotionally Abused

28 % Physically Abused21 % Sexually Abused27 % Exposed to Drug or Alcohol Abuse

19 % Exposed to Mental Illness

13 % Witnessed Violence Toward Their Mothers

23 % Lost a Parent due to Divorce or Separation

63 % Experienced at Least One Category of Negative Childhood Experience, and 20% had Three

ADVERSE CHILDHOOD EXPERIENCESSlide17

Emotional abusePhysical threats or physical assault

Sexual abuse (including inappropriate touch)

Emotional neglect: Often feeling unloved, unimportant OR a sense that family didn’t feel close or support each other.

Physical neglect: not enough to eat, had to wear dirty clothes, and no one to protect you OR parents too drunk/high to care for you or seek medical help.

Adverse Childhood Experiences—

Questions

Centers for Disease Control & PreventionSlide18

Parents separated or divorced

Domestic violence toward mother

or

stepmotherHousehold member a problem drinker or used street drugs.Household member depressed, mentally

ill, or attempted suicide

.

Household

member

went to

prison.

Adverse Childhood Experiences—

Questions

Centers for Disease Control & PreventionSlide19

Researchers found a strong link between adverse childhood experiences and adult onset of chronic physical illness. Those with ACE scores of 4 or more had significantly higher rates of heart disease and diabetes than those with ACE scores of zero. The likelihood of chronic pulmonary lung disease increased 390 percent; hepatitis, 240 percent; depression, 460 percent; suicide, 1,220 percent. Those with an ACE score of 6 had a 4,600 percent increase in the likelihood of becoming an IV drug user.

Adverse Childhood ExperiencesSlide20

SmokingChronic obstructive pulmonary diseaseHepatitisHeart diseaseDiabetes

Obesity

Alcoholism

Fifty or more sexual intercourse partnersOther substance abuse including IV drug useDepression and attempted suicideTeen pregnancy (including paternity)Sexually transmitted diseasesPoor occupational health and poor job performance

ADVERSE CHILDHOOD EXPERIENCESSlide21

The 17,337 people who participated in the ACE study are typical, middle-class, working Americans — 75 percent Anglo, 11 percent Latino, 7 percent Asian, and 5 percent African-American. They’re educated: 75%

attended college and

40% have

a basic or higher college education. Most of them had jobs. Half were women, half were men. All of them had good health insurance.Adverse Childhood ExperiencesSlide22

The Summary Conclusions:

The findings of the ACE Study suggest that these experiences – ACEs – are the leading causes of illness, death and poor quality of life in the United States.

Adverse Childhood ExperiencesSlide23

DOSE DEPENDENT DAMAGESlide24

WHAT WE DON’T KNOW YET—THE FIRST CLUEAccording to the clear evidence of the ACE study, adverse experiences are cumulative, and the ultimate effects are dose dependent.

This is true as much for moderately adverse experiences like an alcoholic parent or physical threats as more severe trauma like sexual or physical abuse.

If physical punishment is a stressor of any sort, then the cumulative effects are

dose dependent just as they are for any other stressor.ADVERSE CHILDHOOD EXPERIENCESSlide25

The effects of early childhood trauma and stress are not immediately apparent Neurodevelopment is progressive, with later stages depending upon earlier foundations

The changes in the brain are cumulative and make their effects felt over the course of the lifetime

Consequently, early stress and trauma is initially disguised…or nearly so

The “Time Bomb” EffectSlide26

Activation of the stress response system

Under and over activation of sensitive

neurodevelopmental

processesSensitive and critical periodsWHAT IS THE MECHANISM OF DAMAGE?Slide27

Chronic stress results in altered function and development—

eg

, changes in arousal, attachment, reward.

Which lead to maladaptive coping mechanismsWhich lead to disease, pathological behaviors, and early death

WHAT IS THE MECHANISM OF DAMAGE?Slide28

The links between actual abuse and corporal punishment: Differences in kind? Probably not…Differences in degree?

Definitely…

Differences in motivation?

Variable… How is it experienced by the child? Think about it…CORPORAL PUNISHMENT OF CHILDREN Slide29
Slide30

23 young adults (18-25 years old) who had experienced harsh physical punishment were compared to 22 healthy controls. The subjects who had experienced harsh physical discipline had gray matter volume in the prefrontal cortex that was reduced by 19.1 %. Exposing children to harsh punishment has detrimental effects on brain development. (

Tamoda

et al,

Neuroimage, 2009)WHAT DOES THE RESEARCH SAY?Physiological EffectsSlide31

PHYSICAL PUNISHMENT IS NOT WHAT WE THINKPhysical punishment does not promote long-term, internalized compliance. 85 % of studies found physical punishment to be associated with less moral internalization (

Gershoff

, 2002)

In fact, physical punishment is positively associated with defiance (Eamon, 2004)As well as lack of empathy (Lopez and Bonenberger, 2001)

THE PHILOSOPHICAL ARGUMENTSlide32

IT DOES NOT TEACH WHAT WE WANT…Parents often use physical punishment for either aggression (hitting a sibling) or antisocial acts (stealing money) in order to communicate the seriousness of the offense. But in a meta-analysis of 27 studies, all 27 studies proved that physical punishment was associated with

more

rather than less aggression.

(Pagani, International Journal of Behavioral Development, 2004) Another study proved that 12 of 13 studies positively linked corporal punishment and antisocial behavior. (Gershoff, Psychological Bulletin, 2002)

THE PHILOSOPHICAL ARGUMENTSlide33

IT DOES NOT HAVE THE DESIRED EFFECTIt is true that many adults who were spanked as children may be well-adjusted and caring people today. However, research has shown that, when compared with children who are not spanked, children who are spanked are more likely to become adults who are depressed, use alcohol, have more anger, hit their own children, hit their spouses, and engage in crime and violence.

(Discipline Your Child, American Academy of Pediatrics, 2009)

THE PHILOSOPHICAL ARGUMENTSlide34

IT DOES NOT MAKE US STRONG OR HEALTHY Parents often employ physical punishment with their children to make sure that the children have strong social values, respect for authority and a clear mental health status. Unfortunately, a meta-analysis indicated that in 12 of 12 studies the frequency and intensity of corporal punishment was associated with poor mental health measures. Every single study saw an increase in depression, substance abuse, and general psychological maladjustment.

(

Gershoff

, Psychological Bulletin, 2002)THE PHILOSOPHICAL ARGUMENTSlide35

IT DOES NOT STRENGTHEN OUR RELATIONSHIPS Parents often endorse physical punishment in the belief that they are inculcating strong family values. And yet, child corporal punishment also impairs the relationship between parents and children. 13 out of 13 studies found that physical punishment was associated with poorer quality parent-child relationships.

(

Gershoff

, Psychological Bulletin, 2002)THE PHILOSOPHICAL ARGUMENTSlide36

SO WHAT DOES PHYSICAL PUNISHMENT TEACH CHILDREN?Physical punishment teaches children that violence and coercion are acceptable ways to settle disagreements or enforce a certain form of behavior. Research proves consistently that the more men and women are physically punished as children, they more they resort to aggression with their domestic partner.

(Straus,

Cross Cultural Research

, 2004; Douglas and Straus, European Journal of Criminology, 2006)THE PHILOSOPHICAL ARGUMENTSlide37

In the 80s and 90s evidence was beginning to accumulate that showed a simple association between physical punishment and greater levels of aggression against parents, siblings, peers and spouses. Virtually without exception this association between the two was clear and positive. But the relationship was a simple association and did not account for the possible confounding factors of pre-existing aggression.

THE META MESSAGE:

20 YEARS OF RESEARCHSlide38

The following studies throughout the 90s established the actual causative nature of the relation between corporal punishment and later aggression and delinquency.For example, one of the first and best prospective studies of 807 children controlled for the factors of socioeconomic status, gender, pre-existing aggression and home environment. Still there was a strong relationship between physical punishment and later antisocial behavior in 6-9 year olds.

(Straus,

Sugarman

et al, 1997)THE META MESSAGE:

20 YEARS OF RESEARCHSlide39

Subsequent studies controlled for every imaginable variable and still continued to demonstrate the propensity of physical punishment to cause antisocial behavior. (Gunnoe

, 1997; Grogan-

Kaylor

, 2005; Mulvaney, 2007)Treatment intervention studies established that children’s aggression and overall behavior could be improved by reducing their physical punishment.

THE META MESSAGE:

20 YEARS OF RESEARCHSlide40

Following studies starting in 2000 expanded the list of negative effects of early corporal punishment to include mental health, greater risk of physical injury, conflicted interpersonal relationships, spouse abuse, emotional delays, poor academic performance and lower intelligence.

THE META MESSAGE:

20 YEARS OF RESEARCHSlide41

MORE EVIDENCE…From the very beginning of research into child maltreatment, studies have always indicated that child physical abuse begins with an attempt to correct children’s behavior or to “teach them a lesson.”(

Coontz

and Martin, 1988; Gil, 1973;

Kadushin, 1981; Margolin, 1990)The Canadian Incidence Study of Reported Abuse and Neglect of 2003 confirmed that three quarters of substantiated child abuse started with physical discipline.

THE META MESSAGE:

20 YEARS OF RESEARCHSlide42

Gradually, the assumed distinction between physical abuse and physical punishment has been erased in the literature.It was established that 75% of established physical abuse happened during episodes that started and were intended as physical punishment. (

Trocme

, Fallon et al, 2005)

Another study found that children who were physically punished were 7 times more likely to be physically abused.(Clement and Bouchard, 2000)THE META MESSAGE:

20 YEARS OF RESEARCHSlide43

“When society condones spanking as discipline, it has the effect of dramatically increasing the incidence of child abuse in our culture.” M. Marshall, PhD

GATEWAY BEHAVIORSSlide44

Almost never has any finding been proved so substantially and definitively—almost against the wishes of public opinion. Seldom has there been more reticence within in the scientific establishments like the American Academy of Pediatrics and the American Academy of Child and Adolescent Psychiatry to weigh in on the side of overwhelming research findings.

THE PHILOSOPHICAL ARGUMENTSlide45

At long last, the American Academy of Pediatrics has weighed in at the late date of 2011 to oppose corporal punishment for children, noting that corporal punishment “

is harmful emotionally to both parent and child. Not only can it result in physical harm, but it teaches children that violence is an acceptable way to discipline or express anger.”

Professional Organization’s RecommendationsSlide46

Even the Child Psychiatrists eventually took a stand, claiming that: “Extensive research demonstrates that although corporal punishment may have a high rate of immediate behavior modification, it is ineffective over time and is associated with increased aggression and decreased moral internalization of appropriate behavior.”

(

Policy Statement on Corporal Punishment, American Academy of Child and Adolescent Psychiatry, July 2012)American Academy of Child and Adolescent PsychiatrySlide47

When a child hits a child, we call it aggressionWhen a child hits a child, we call it aggression

When a child hits an adult, we call it hostility

When an adult hits an adult, we call it assault

When an adult hits a child, we call it discipline Haim Ginott

all it hostility

When an adult hits an adult, we call it assault

When an adult hits a child, we call it discipline

Haim

GinottSlide48

ENDSlide49

TREATMENTSlide50

COMMONLY APPLIED INTERVENTIONS

Medication

Verbal / Insight Therapies

Cognitive / Behavioral InterventionsCoercive Contingent InterventionsCorrectional Interventions

HospitalizationSlide51

Relational (with another human

)

Relevant

(developmentally-matched)Repetitive (patterned)

Rewarding

(

pleasurable

)

Rhythmic

(

resonant with neural patterns

)

Respectful

(child, family, culture)

Core Elements of Positive Developmental Experience

Bruce D Perry © 2010Slide52

Since the earliest trauma damages the more basic and regulatory parts of the brain, there is evidence that non-verbal or somatic therapies may be of more use in the treatment of early or pre-conscious trauma.

COMPLEX DEVELOPMENTAL TRAUMASlide53

THE FUNDAMENTAL PRINCIPLES“Therapeutic activities will be most effective if they are provided in the sequence that reflects normal development—from the brainstem up.”

(Perry, 2006)

Begin with regulation of the most primitive regulatory functions that are located in the brainstem and diencephalon

Somatic and pre-verbalTapping, drumming, dance, music, massage and movementPatterned, repetitive and rhythmic

COMPLEX DEVELOPMENTAL TRAUMASlide54

THE FUNDAMENTAL PRINCIPLESAfter addressing the most primitive regulatory functions of the primitive brain, the most significant therapies are relational, social and interpersonal

Canine and equine contact, reflective and responsive interactions with consistent caretakers

Strong child-centered interventions that are relational and non-confrontational

COMPLEX DEVELOPMENTAL TRAUMASlide55

THE FUNDAMENTAL PRINCIPLESAfter the most basic reflective and supportive aspects of interpersonal interactions are offered, the next steps toward socially integrative and expressive activities are encouraged

Play and play therapy

Drama role-play

Narrative and story telling

COMPLEX DEVELOPMENTAL TRAUMASlide56

THE FUNDAMENTAL PRINCIPLESIn a sequential movement toward the higher cortical functions, more verbal and cognitive behavioral functions are introduced

Education

Relational / Interactional therapies like groups

Verbal and insight therapies

COMPLEX DEVELOPMENTAL TRAUMASlide57

ENDSlide58

Harsh physical punishment is associated with increased odds of mood disorders, anxiety disorders, alcohol and drug dependence, and several personality disorders even after adjusting for family dysfunction and socioeconomic variables.

Approximately 2-5% of Axis I and 4-7 % of Axis II disorders were attributable to harsh physical punishment.

(

Afifi, Mota et al, American Academy of Pediatrics, 2012)WHAT DOES THE RESEARCH SAY? Mental Health ProblemsSlide59

1,966 children were studied to determine the relationship between spanking before age two and later behavior problems when entering the school system at age six. Children who were spanked before age two had substantially more behavior problems at age six. (Slade and Wissow

, Journal of the American Academy of Pediatrics, 2004)

WHAT DOES THE RESEARCH SAY?

Behavior ProblemsSlide60

2,461 children were studied to determine the long term effects of spanking before 3 years of age. The study determines that “even minor forms of corporal punishment, such as spanking, increase the risk for increased child aggressive behavior. Importantly, these findings cannot be attributed to possible confounding effects of other maternal parenting risk factors

.”

(Taylor et al, Journal of the American Academy of Pediatrics, 2010)

WHAT DOES THE RESEARCH SAY?AggressionSlide61

The combined results of four separate studies conclude that spanking and other forms of corporal punishment are associated with risky and masochistic sexual practices. (Strauss, Presentation at the American Psychological Association Summit on Violence and Abuse in Relationships, 2008, Bethesda, MD)

WHAT DOES THE RESEARCH SAY?

Sexual DysfunctionSlide62

17,404 university students from 32 different countries were surveyed. The analysis found a lower average IQ in countries where spanking is more prevalent. (Straus, 2009)The linkage between decreased IQ and CP is chronic childhood stress

WHAT DOES THE RESEARCH SAY?

IntelligenceSlide63

806 children between 2-4 and 704 children between 5-9 were studied to determine how spanking might influence a child’s IQ over the course of four years. Children who were spanked had IQs between 2.8 and 5 points lower than children who were not. Those in the study who were spanked more showed a greater delay in cognitive development. (Murray Straus, 14

th

International Conference on Violence, Abuse and Trauma, San Diego, CA, 2009)

WHAT DOES THE RESEARCH SAY?IntelligenceSlide64

63 West African children in kindergarten and first grade were studied to determine the effect of school corporal punishment on intelligence. Children in the school with corporal punishment performed significantly worse on tasks involving executive functioning—such as planning, abstract thinking and delayed gratification. (

Talwar

and Lee,

Social Development, 2011)WHAT DOES THE RESEARCH SAY?Executive FunctionSlide65

A West African study of 3-4 year old children in two different school settings, one of which employed corporal punishment and the other did not, suggests that “a punitive environment not only fosters increased dishonesty but also children’s abilities to lie to conceal their transgressions.”

(

Talwar

and Lee, Child Development, 2011)WHAT DOES THE RESEARCH SAY?DishonestySlide66

Different types of negative caretaker interactions with children interact and compound the negative effects of each other. “Children’s behavior problems were significantly greater when both verbal hostility and physical punishment were used.” (Hamai

, Isbell and Ku,

Encephalon

, 2011)WHAT DOES THE RESEARCH SAY?Compound TraumaSlide67

23 young adults (18-25 years old) who had experienced harsh physical punishment were compared to 22 healthy controls. The subjects who had experienced harsh physical discipline had gray matter volume in the prefrontal cortex that was reduced by 19.1 %. Exposing children to harsh punishment has detrimental effects on brain development. (

Tamoda

et al,

Neuroimage, 2009)WHAT DOES THE RESEARCH SAY?Physiological EffectsSlide68

The effects of “subtle forms of infant maltreatment” are not as well researched or documented. “Infants who received frequent corporal punishment (eg

, spanking) showed high hormonal reactivity to stress

.” Both corporal punishment and frequent emotional withdrawal by the mother resulted in elevated baseline levels of

cortisol. (Bugental, Martorell, et al. 2002)

WHAT DOES THE RESEARCH SAY?

Physiological EffectsSlide69

The use of violence toward children varies widely. The prevalence of violence ranged from 40% in Mongolia to 1% in Ukraine. (Lansford and Deater-Deckard, 2012)

The legal prohibition of physical punishment of children appears to have gained a foothold in popular cultural values toward child rearing.

(Lansford and

Deater-Deckard, 2012) WHAT DOES THE RESEARCH SAY?PrevalenceSlide70

There is more discrepancy between beliefs and behavior in countries where attitudes toward children are shifting. Eg, in one study in America 54% of mothers reported that in over half the time they used corporal punishment they believed it was the wrong response to have used

.

(

Straus, 1996)But in Ghana, 46% believe that corporal punishment is acceptable and 50% use it. In this case physical punishment is used more instrumentally and with less anger and emotion. (Lansford and Deater-Deckard, 2012)

WHAT DOES THE RESEARCH SAY?

PrevalenceSlide71

Violence toward children is less common in countries with a higher index of living and more educational opportunities, just as the same relation proves to be true among subgroups within the US. (Lansford and Deater

-Deckard, 2012)

WHAT DOES THE RESEARCH SAY?

PrevalenceSlide72

Most physical abuse takes place in the context of physical punishment (Durrant, 2004)

Fewer caregivers believed that it is necessary to physically punish children than actually do so. For example, only 5% of caregivers in Montenegro believed that using physical punishment is necessary, but 47% report that they or someone in their household has spanked the child in the last month

(Lansford and

Deater-Deckard, 2012.) which indicates that it is done in the heat of the moment.

WHAT DOES THE RESEARCH SAY?

Links With AbuseSlide73

8 out of 8 studies proved that the same childhood mental health problems that initially result from corporal punishment persist into adulthood and become lifetime issues. (Turner and Muller, Journal of Family Issues, 2004)

WHAT DOES THE RESEARCH SAY?

Duration of EffectsSlide74
Slide75

Politics and personal choiceThe comparison to spouse abuseThe minimizations and justificationsOpen hand

Instruments

No marks were left

Parental discretionTHE PHILOSOPHICAL ARGUMENTSSlide76
Slide77

"It is not necessary to beat the child into submission; a little bit of pain goes a long way for a young child. However, the spanking should be of sufficient magnitude to cause the child to cry genuinely."[47]

James DobsonSlide78
Slide79
Slide80

WHAT DOES THE RESEARCH SAY?Slide81
Slide82

THE SOCIAL BRAIN

LEARNING AND THE REWARD CIRCUIT

Learning and Reward

Mastery and RewardApproval and AcceptanceThe Social Aspects of LearningSlide83

THE NEW PARENTING MODEL

NEUROLOGICALLY INFORMED

What makes a healthy brain?

What does the research say?OUTCOME BASED Eventual, not immediateCharacter, not complianceSlide84

PARENTING MODELS

POSITIVE DISCIPLINE IN EVERYDAY PARENTING

Joan

Durrant, PhDLook Beyond the Immediate Behavior Toward the Long Term Childrearing GoalsProviding Warmth and Structure

Understanding How Children Think and Feel

Problem SolvingSlide85

NOTES TO CONSIDER:This is not substitution of another form of punishmentPositive Praise>CriticismThe fulfillment of these Four Principles changes with Developmental Age

PARENTING MODELSSlide86

Childhood Adversity

-number

-type

Genetics

Age

Brain Development

Medical Disorders

Psychiatric Disorders

Risky Sex

Addictions

Cognition

Depression

Antisocial behavior

Smoking

Domestic Violence

Martin

Teicher

, MDSlide87

Individuals with four adverse childhood experiences were more than five times as likely to suffer from alcoholism.Slide88

Individuals with six adverse childhood experiences were almost three times as likely to smoke.Slide89

Individuals with four adverse childhood experiences were almost four times as likely to suffer from chronic depression.Slide90

Individuals with four adverse childhood experiences were more than thirteen times as likely to suffer from intravenous drug use .Slide91

Notice anything similar about these graphs?