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Adverse Childhood Experiences (ACEs) refer to a range of potentially traumatic events that occur before the age of 18, which can significantly impact a child's development and future well-being. These experiences include various forms of abuse (physical, emotional, or sexual), neglect (physical or emotional), and household dysfunction, such as domestic violence, substance abuse, mental illness, or incarceration of a family member (Centers for Disease Control and Prevention [CDC], 2021). ACEs have been linked to a host of negative outcomes in later life, including chronic health conditions, mental health issues, and impaired social functioning. Understanding and addressing ACEs is crucial for developing effective interventions and support systems aimed at mitigating their long-term effects and promoting healthier developmental trajectories.

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Overview of adverse childhood experiences, the latest data, and CDC’s approach to prevention.

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This article explains how childhood trauma influences behavioral and emotional regulation. It highlights the concept of hyperarousal and its role in heightened sensitivity and stress, leading to impairments in executive function, learning delays, and social difficulties. Brain alterations due to trauma can significantly impact cognitive development, making it difficult for children to succeed academically and socially.

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3.3 Effects of childhood trauma on behavioural, social and emotional functioning – Trauma Informed Behaviour Support: A Practical Guide to Developing Resilient Learners

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The changes in brain structure and chemical activity caused by childhood trauma can have a wide variety of effects on children’s behavioural, social, and emotional functioning.

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The SAMHSA article on child trauma reveals that over two-thirds of children experience at least one traumatic event by age 16, such as abuse, violence, or disaster. It highlights the significant impact of trauma, including learning difficulties, increased use of health services, and long-term health problems. Signs of traumatic stress vary by age, with young children showing fear and nightmares, and older children exhibiting anxiety, depression, or substance abuse. Effective recovery involves recognizing trauma triggers, providing emotional reassurance, and seeking professional help. Supportive caregivers and trauma-informed services are crucial for helping children heal and thrive.

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Fast Facts

At least 1 in 7 children have experienced child abuse and/or neglect in the past year, and this is likely an underestimate. In 2019, 1,840 children died of abuse and neglect in the United States.

Each day, more than 1,000 youth are treated in emergency departments for physical assault-related injuries.

In 2019, about 1 in 5 high school students reported being bullied on school property in the last year.

8% of high school students had been in a physical fight on school property one or more times during the 12 months before the survey.

Each day, about 14 youth die from homicide, and more than 1,300 are treated in emergency departments for violence-related injuries.
It's important to recognize the signs of traumatic stress and its short- and long-term impact.
The signs of traumatic stress may be different in each child. Young children may react differently than older children.

Preschool Children

Fear being separated from their parent/caregiver

Cry or scream a lot

Eat poorly or lose weight

Have nightmares

Elementary School Children

Become anxious or fearful

Feel guilt or shame

Have a hard time concentrating

Have difficulty sleeping

Middle and High School Children

Feel depressed or alone

Develop eating disorders or self-harming behaviors

Begin abusing alcohol or drugs

Become involved in risky sexual behavior

The Body's Alarm System

Everyone has an alarm system in their body that is designed to keep them safe from harm. When activated, this tool prepares the body to fight or run away. The alarm can be activated at any perceived sign of trouble and leave kids feeling scared, angry, irritable, or even withdrawn.

Healthy Steps Kids Can Take to Respond to the Alarm

Recognize what activates the alarm and how their body reacts

Decide whether there is real trouble and seek help from a trusted adult

Practice deep breathing and other relaxation methods

Impact of Trauma

The impact of child traumatic stress can last well beyond childhood. In fact, research has shown that child trauma survivors may experience:

Learning problems, including lower grades and more suspensions and expulsions

Increased use of health and mental health services

Increase involvement with the child welfare and juvenile justice systems

Long-term health problems (e.g., diabetes and heart disease)

Trauma is a risk factor for nearly all behavioral health and substance use disorders.
There is hope. Children can and do recover from traumatic events, and you can play an important role in their recovery.
A critical part of children's recovery is having a supportive caregiving system, access to effective treatments, and service systems that are trauma informed.

Get Help Now
SAMHSA Behavioral Health Treatment Services Locator The National Child Traumatic Stress Network: Get Help Now Healthcare Toolbox: Basics of Trauma-Informed Care
Not all children experience child traumatic stress after experiencing a traumatic event. With support, many children are able to recover and thrive.

As a caring adult and/or family member, you play an important role.

Remember To:

Assure the child that he or she is safe.

Explain that he or she is not responsible. Children often blame themselves for events that are completely out of their control.

Be patient. Some children will recover quickly while others recover more slowly. Reassure them that they do not need to feel guilty or bad about any feelings or thoughts.

Seek the help of a trained professional. When needed, a mental health professional trained in evidence-based trauma treatment can help children and families cope and move toward recovery. Ask your pediatrician, family physician, school counselor, or clergy member for a referral.

Visit the following websites for more information:

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Recognize the signs of child traumatic stress and the impact that trauma may have on children. The infographic developed by SAMHSA's National Child Traumatic Stress Initiative (NCSTI) provides information on the prevalence and impact of traumatic events on children, and what actions can be taken to support children who experience traumatic events.

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Research published by the American Psychological Association reveals that children exposed to trauma, such as abuse or violence, exhibit biological signs of accelerated aging compared to those without such adversity. The study, led by Dr. Katie McLaughlin, found that early exposure to threat-related trauma was linked to early puberty, cellular aging markers like shortened telomeres, and reduced cortical thickness in brain regions associated with emotion processing. In contrast, deprivation-related adversities, such as poverty, did not show these biological aging signs. These findings suggest that the accelerated aging observed might have evolved as adaptive responses to dangerous environments but could lead to significant health issues later in life. The research highlights the importance of early interventions to mitigate long-term health effects and improve outcomes for traumatized children.

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WASHINGTON - Children who suffer trauma from abuse or violence early in life show biological signs of aging faster than children who have never experienced adversity, according to research published by the American Psychological Association. The study examined three different signs of biological aging-early puberty, cellular aging and changes in brain structure-and found that trauma exposure was associated with all three.

"Exposure to adversity in childhood is a powerful predictor of health outcomes later in life-not only mental health outcomes like depression and anxiety, but also physical health outcomes like cardiovascular disease, diabetes, and cancer," said Katie McLaughlin, PhD, an associate professor of psychology at Harvard University and senior author of the study published in the journal Psychological Bulletin. "Our study suggests that experiencing violence can make the body age more quickly at a biological level, which may help to explain that connection."

Previous research found mixed evidence on whether childhood adversity is always linked to accelerated aging. However, those studies looked at many different types of adversity-abuse, neglect, poverty, and more-and at several different measures of biological aging. To disentangle the results, McLaughlin and her colleagues decided to look separately at two categories of adversity: threat-related adversity, such as abuse and violence, and deprivation-related adversity, such as physical or emotional neglect or poverty.

The researchers performed a meta-analysis of almost 80 studies, with more than 116,000 total participants. They found that children who suffered threat-related trauma such as violence or abuse were more likely to enter puberty early and also showed signs of accelerated aging on a cellular level-including shortened telomeres, the protective caps at the ends of our strands of DNA that wear down as we age. However, children who experienced poverty or neglect did not show either of those signs of early aging.

In a second analysis, McLaughlin and her colleagues systematically reviewed 25 studies with more than 3,253 participants that examined how early-life adversity affects brain development. They found that adversity was associated with reduced cortical thickness-a sign of aging because the cortex thins as people age. However, different types of adversity were associated with cortical thinning in different parts of the brain. Trauma and violence were associated with thinning in the ventromedial prefrontal cortex, which is involved in social and emotional processing, while deprivation was more often associated with thinning in the frontoparietal, default mode and visual networks, which are involved in sensory and cognitive processing.

These types of accelerated aging might originally have descended from useful evolutionary adaptations, according to McLaughlin. In a violent and threat-filled environment, for example, reaching puberty earlier could make people more likely to be able to reproduce before they die. And faster development of brain regions that play a role in emotion processing could help children identify and respond to threats, keeping them safer in dangerous environments. But these once-useful adaptations may have grave health and mental health consequences in adulthood.

The new research underscores the need for early interventions to help avoid those consequences. All of the studies looked at accelerated aging in children and adolescents under age 18. "The fact that we see such consistent evidence for faster aging at such a young age suggests that the biological mechanisms that contribute to health disparities are set in motion very early in life. This means that efforts to prevent these health disparities must also begin during childhood," McLaughlin said.

There are numerous evidence-based treatments that can improve mental health in children who have experienced trauma, McLaughlin said. "A critical next step is determining whether these psychosocial interventions might also be able to slow down this pattern of accelerated biological aging. If this is possible, we may be able to prevent many of the long-term health consequences of early-life adversity," she says.

Article: "Biological Aging in Childhood and Adolescence Following Experiences of Threat and Deprivation: A Systematic Review and Meta-Analysis," by Natalie Colich, PhD, University of Washington, Eileen S. Williams, PhD, Stanford University, and Maya Rosen, PhD, and Katie McLaughlin, PhD, Harvard University. Psychological Bulletin, published online Aug. 3, 2020.

Katie McLaughlin, PhD, can be reached by email.

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Study: Experiencing childhood trauma makes body and brain age faster

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Children who suffer trauma from abuse or violence early in life show biological signs of aging faster than children who have never experienced adversity.

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Severe childhood adversity significantly increases the risk of various lifelong problems, including mental health disorders, physical health issues, and substance abuse. The ACE (Adverse Childhood Experiences) study, involving over 17,000 adults, highlighted a strong correlation between the number of adverse experiences in childhood and increased risks of behaviors and conditions such as heart disease and diabetes. Specifically, individuals with high ACE scores are more likely to develop alcohol dependence and PTSD. Studies show that childhood trauma, particularly abuse, is linked to a higher likelihood of substance use disorders, with early trauma often preceding alcohol dependence. Biological mechanisms, including alterations in stress-response systems and neurotransmitter pathways, may underlie these associations. Treatment approaches that address both trauma and substance abuse simultaneously, such as integrated cognitive-behavioral therapies, show promise in improving outcomes. However, further research is needed to refine and validate these approaches and to explore pharmacological treatments that target co-occurring PTSD and alcohol dependence.

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Kathleen T. Brady, M.D., Ph.D.

Sudie E. Back, Ph.D.

Abstract

Early-childhood trauma is strongly associated with developing mental health problems, including alcohol dependence, later in life. People with early-life trauma may use alcohol to help cope with trauma-related symptoms. This article reviews the prevalence of early-childhood trauma and its robust association with the development of alcohol use disorders and posttraumatic stress disorder. It also examines the potential biological mechanisms by which early adverse experiences can result in long-lasting changes in neurobiology underlying this vulnerability, as well as pharmacological and behavioral interventions. Recent investigations highlight the importance of assessing trauma among patients with alcohol use disorders and the positive benefits associated with the application of integrative psychosocial interventions that target both trauma-related symptoms and alcohol dependence.

Keywords: Alcohol dependence, alcohol use disorders, childhood, childhood trauma, trauma-related symptoms, posttraumatic stress disorder, coping with stress or anxiety, neurobiology, biological mechanisms, treatment, pharmacological intervention, behavioral intervention, integrative psychosocial intervention, adverse child-rearing environment

Children exposed to severe adversity early in life are at increased risk of subsequently developing mental health problems, including alcohol dependence. In general, the onset of trauma precedes the onset of alcohol dependence. Although it is impossible to establish a direct causal relationship, this temporal relationship suggests a robust and positive relationship between exposure to early-life trauma and alcohol-related problems later in life. People with trauma-related symptoms and other negative consequences of early-life trauma may use alcohol to help mitigate such symptoms. People with both a positive history of early childhood trauma and co-occurring alcohol dependence have a more severe clinical profile, as well as worse treatment outcomes when compared with those with either early trauma or alcohol dependence alone. Recent investigations highlight the importance of assessing trauma among patients with alcohol use disorders and the positive benefits associated with the application of integrative psychosocial interventions that target both trauma-related symptoms and alcohol dependence. This article reviews the prevalence of early-childhood trauma and its robust association with the development of alcohol use disorders and posttraumatic stress disorder (PTSD). It also examines the potential biological mechanisms by which early adverse experiences can result in long-lasting changes in neurobiology underlying this vulnerability, as well as pharmacologic and behavioral interventions.

Prevalence

There is little doubt that severe childhood adversity may place an individual at life-long risk for a variety of problems, including those related to mental health, physical health, employment, and legal difficulties ( Putnam 2006). In a study conducted by the Centers for Disease Control and Prevention and Kaiser Permanente (Adverse Childhood Experiences [ACE] study; Felitti et al. 1998), a sample of 17,337 adults recruited from a large health maintenance organization were surveyed concerning a range of adverse events that might occur during childhood (e.g., physical or sexual abuse, incarcerated household member, emotional neglect) and adult risk behaviors, health status, and disease. The investigators found a graded relationship between the number of adverse childhood experiences (i.e., ACE score), risk behaviors during adulthood, and leading causes of morbidity and mortality in the United States, including heart disease, diabetes, liver disease, and emphysema. It is possible that these increased rates of medical conditions are not a direct result of childhood adversity but rather the result of dysfunctional and unhealthy behaviors in which many victims of childhood abuse engage.

A number of studies also report that victims of child maltreatment are more likely to have emotional difficulties and psychiatric disorders. One of the most consistent results across these studies is the finding that childhood maltreatment is associated with an increased risk for alcohol and drug use disorders ( Enoch 2011). In a population-based sample of 1,411 female adult twins, self-reported childhood sexual abuse was positively associated with a number of psychiatric disorders, but the strongest associations were with alcohol and drug dependence ( Kendler et al. 2000). In the ACE study, the risk of alcohol dependence increased 7.2-fold, and illicit drug use increased 4.5-fold for people with four or more ACEs ( Anda et al. 2006). People with a history of childhood abuse or neglect are vulnerable to using alcohol in order to cope with stressful situations, which in turn may lead to excessive alcohol use ( Schuck and Widom 2001). An investigation by Widom and colleagues (2007) demonstrates that the increased risk of excessive alcohol use among victims of childhood abuse or neglect is consistent and stable into middle adulthood (e.g., age 40). Furthermore, research has shown that alcohol-dependent patients with a history of sexual abuse are more likely than nonabused patients to relapse to alcohol use (87.5 vs. 63.3 percent) and to relapse more quickly (median time to first drink = 60 vs. 115 days) in the first year following inpatient treatment for alcohol dependence ( Greenfield et al. 2002).

In addition to alcohol use disorders, childhood adversity is associated with an increased risk of PTSD ( Widom 1999). Data from a number of studies over the last 20 years have emphasized the high co-occurrence of PTSD and alcohol disorders. For example, among 3,768 female twins participating in the longitudinal Missouri Adolescent Female Twin Study (MOAFTS), Sartor and colleagues (2010) found that women exposed to trauma were nearly twice as likely to develop alcohol dependence (hazard ratio 1.85), and women exposed to trauma who also had PTSD were even more likely to develop alcohol dependence (hazard ratio 3.54; significantly higher than women with trauma exposure alone) when compared with women who had not experienced trauma. Studies of samples of individuals seeking treatment for alcohol use disorders also find a high prevalence of reported childhood adversity and PTSD. In a study of men and women in treatment for addictions, 62 percent reported having been victims of childhood physical or sexual abuse ( Grice et al. 1995). A review of studies of individuals seeking treatment for addictions reveals rates of PTSD as high as 50 percent or greater ( Dansky et al. 1994). In the majority of cases, the development of PTSD precedes the development of the substance use disorder.

These high rates of childhood victimization in individuals with PTSD and alcohol and other substance-related problems suggests that there is a link between childhood adversity and the development of these disorders, although it is impossible to establish a direct causal relationship. However, even when studies control for demographic differences, family discord, and parental pathology, the specific relationship between childhood abuse and the development of substance use disorders holds true. Several theoretical connections have been postulated ( Miller et al. 1993). Childhood victimization may lead to low self-esteem and the subsequent use of alcohol to deal with negative cognitions. It also is possible that victims of childhood abuse feel that their experiences make them "different" from other children and lead them to withdraw from healthier social circles toward fringe groups, where alcohol use is more accepted. In any case, given that victims of child abuse are more likely to develop alcohol use disorders as adults, early intervention, prevention, and training for parents are all important in interrupting this cycle of violence and alcohol problems.

Neurobiology

Recognizing the pervasive and detrimental effects of adverse childhood experiences on quality of life and health outcomes has led to the exploration of potential biological mechanisms by which early experiences can produce long-lasting changes. Evidence from both animal and human research suggests that early stressors can lead to neurobiological changes in systems known to be involved in the pathophysiology of depression, anxiety, and substance use disorders ( De Bellis et al. 1999; Heim and Nemeroff 2001). The hypothalamic-pituitary-adrenal (HPA) axis plays a critical role in the stress response and is involved in the pathophysiology of addictive disorders. Early stressors cause long-term increases in the stress response of the hormone cortisol ( Plotsky and Meaney 1993) as well as decreased genetic expression of cortisol receptors and increased expression of corticotropin-releasing factor in the hypothalamus, both of which may contribute to dysregulation of the HPA axis ( Ladd et al. 1996). The noradrenergic system also plays a key role in stress ( Bremner 2003), and early stressors can lead to long-term decreases in α-2 noradrenergic receptors in the locus coeruleus, which may lead to loss of feedback inhibition of noradrenergic activity with associated increases in the noradrenergic stress responses ( Caldji et al. 1998; Sanchez et al. 2001).

In addition to the long-lasting effects of early trauma on the stress response, a number of studies indicate that early trauma has specific effects on the neurotransmitter systems involved in the positive reinforcing effects of alcohol and drugs, particularly the brain pathway for dopamine (i.e., the mesocorticolimbic dopamine system) ( Meaney et al. 2002). Higley and colleagues (1991) found that adult rhesus monkeys raised in peer groups without maternal care showed increased HPA response to stress and increased alcohol consumption during periods of stress ( Higley et al. 1991). In a series of studies, Meaney and colleagues (2002) demonstrated that repeated periods of maternal separation in the early life of rats decreased dopamine transporter expression and increased dopamine responses to stress and behavioral responses to stress, cocaine, and amphetamine. These findings suggest that early-life experiences can affect the development of the mesocorticolimbic dopamine system and lead to a vulnerability to addiction in later life. Thus, in addition to effects on stress reactivity, early-life events might predispose individuals to the development of alcohol use disorders by directly influencing the reinforcing effects of alcohol. Other neurotransmitter systems involved in the pathophysiology of alcohol dependence, such as brain-derived neurotrophic factor (BDNF), serotonin, and γ-aminobutyric acid (GABA) systems also are affected by early-life trauma in ways that may influence vulnerability to the development of alcohol dependence, but the mechanistic connections in these systems are under active investigation and are not as well understood ( Enoch 2011).

Not all children exposed to early-life trauma develop alcohol dependence or other significant pathology, clearly suggesting that resilience and mediating factors play a role ( Enoch 2011). The genetic risk for alcohol and drug dependence involves multiple genes. Emerging evidence suggests that variation in some stress-related genes may determine the risk for psychopathology or resilience in people exposed to early-life trauma. In particular, it seems that there are important variations in the genes encoding the CRF system that can influence the development of alcohol dependence following an early-life trauma in a gene-by-environment interaction. One study of at-risk children found an interaction between a particular genetic variant coding for the CRF receptor (i.e., CRHR1) and sexual trauma in adolescents that predicted an earlier age of onset of drinking and heavy alcohol consumption ( Blomeyer et al. 2008). This finding is supported by animal studies demonstrating that the CRHR1 genotype and expression interact with environmental stress to reinstate alcohol-seeking in rodents ( Hansson et al. 2006), and a functional CRF promoter variant in monkeys conferred increased stress reactivity and was associated with increased alcohol consumption in animals reared under stressful conditions ( Barr et al. 2009). These findings suggest that the interaction of genetic susceptibility and environmental exposure can lead to a pathologically activated CRF system, which increases the risk for the development of alcohol dependence in some people.

Treatment

Both behavioral and pharmacological interventions are important to consider in the treatment of alcohol dependence and trauma/PTSD ( Davis et al. 2006; Weiss and Kueppenbender 2006). To date, most empirical studies of behavioral or pharmacological agents have investigated the treatment of either alcohol dependence or PTSD alone.

Psychosocial Interventions

With regard to psychosocial interventions, cognitive-behavioral therapies (CBTs) are the most widely studied and empirically valid treatments for both PTSD and alcohol use disorders. The CBTs used to treat PTSD fall into three main categories: (1) exposure-based therapies, (2) cognition-focused therapy, and (3) anxiety/stress-management therapy. Exposure-based therapies are considered the gold standard treatment for PTSD ( Institute of Medicine 2008) and involve having patients confront safe, but anxiety-provoking situations (i.e., physical location where childhood abuse occurred), known as in vivo exposure; and the memory of the traumatic experience, known as imaginal exposure ( Foa et al. 2006). With prolonged, repeated in vivo and imaginal exposure, the trauma-related anxiety is extinguished. Cognition-focused therapy includes cognitive therapy, which addresses the meaning that people assign to early-life trauma; and cognitive-processing therapy, which combines a narrative element of exposure therapy with efforts to identify and modify unhelpful cognitions related to the themes of safety, trust, power, esteem, and intimacy ( Resick and Schnicke 1992). Finally, stress inoculation training ( Meichenbaum and Novaco 1985), one of the most widely used and empirically investigated forms of anxiety management therapies, aims to provide a sense of mastery over PTSD symptoms by teaching patients a variety of coping skills. Stress inoculation training also has been incorporated into CBTs for substance use disorders and includes relaxation training, breathing retraining, thought stopping, self-instruction training, assertiveness training, cognitive restructuring, anger management, and problem solving.

Recently, integrative psychosocial interventions have been developed to address both trauma/PTSD and substance use disorders simultaneously ( Back 2010). Clinicians previously believed that trauma interventions were inappropriate until after a patient had been abstinent from alcohol or drugs for a sustained period of time (e.g., 3 months). This model, known as the "sequential" model, posits that continued alcohol use impedes therapeutic efforts to address and process the trauma, and that trauma interventions commenced before sustained abstinence would result in increased risk of relapse. Contrary to these beliefs, however, recent data reported by several different investigators in the United States and Australia show that treatment outcomes of substance dependent patients who engage in integrative CBT interventions typically experience significant improvements in both conditions and that rates of relapse are not increased by the introduction of therapy for trauma ( Brady et al. 2001; Hien et al. 2004; McGovern et al. 2009; Najavits 2002; Triffleman et al. 1999). Proponents of integrative treatments posit that unprocessed trauma-related memories and PTSD symptoms may, at least in part, drive alcohol use. Thus, attending to and treating the trauma-related symptoms early in the process of therapy may improve the chances of long-term recovery from alcohol ( Back et al. 2006; Hien et al. 2010). Although more randomized controlled trials of integrative treatments are needed, the studies to date clearly demonstrate that for the majority of alcohol-dependent patients with trauma/PTSD, the inclusion of trauma interventions confers substantial therapeutic benefits.

Pharmacological Interventions

There are several general issues to consider when treating co-occurring alcohol dependence and trauma/PTSD. When pharmacological agents are used, treatment should generally follow routine clinical practice for the treatment of PTSD. Regardless, relapse is common, and it is critical to consider the potential toxic interactions that may occur between the prescribed medication and alcohol. Given the high co-occurrence of alcohol and illicit drug use, potential toxic interactions between the prescribed medication and other substances of abuse must also be addressed. The pharmacological agent with the least abuse liability potential should be chosen for this population. Although benzodiazepines are effective in providing immediate relief of anxiety symptoms, they are generally not considered a first-line treatment for patients with alcohol dependence given the abuse potential of benzodiazepines. During the initial phase of treatment, when latency of onset of antidepressants is an issue, benzodiazepines may be considered as adjunctive medication. The amount of benzodiazepines prescribed to the patient should be limited, and the patient should be closely monitored for relapse or nonmedical use of benzodiazepines or other medications.

The use of pharmacological agents to specifically target alcohol dependence and PTSD is underexplored. Most studies to date, however, show promise and suggest that patients with co-occurring alcohol dependence and trauma/PTSD respond well to standard PTSD pharmacotherapies. Sertraline, a serotonin-specific reuptake inhibitor, has been investigated in patients with comorbid alcohol dependence and PTSD. The first study was a small ( n = 9) open-label, 12-week trial, which demonstrated significant pre-post decreases in alcohol use severity (e.g., number of drinking days, number of drinks per day), as well as PTSD symptoms of re-experiencing the trauma, avoidance, and hyperarousal ( Brady et al. 1995). A second study examined the efficacy of 12 weeks of sertraline compared with placebo in 94 patients with alcohol dependence and PTSD ( Brady et al. 2005). The primary outcome analysis indicated no significant effect of sertraline on alcohol-related outcomes and only trend-level findings for the PTSD outcomes. The sertraline-treated group showed statistical trends for greater improvement in the experience of sudden flashbacks of the traumatic event and hyperarousal symptoms (e.g., insomnia, inability to concentrate). Follow-up cluster analyses suggested that individuals with primary PTSD, compared with primary alcohol dependence, derived more benefit from sertraline treatment as evidenced by significantly less severe alcohol use. The results suggested that patients with early-onset alcohol dependence actually had worse alcohol-related outcomes with sertraline treatment compared with placebo ( Brady et al. 2005).

In another study of 254 veterans with alcohol dependence and a variety of co-occurring mood and anxiety disorders ( Petrakis et al. 2005), naltrexone, disulfiram, or a combination of both was added to treatment as usual. A high percentage (42.9 percent) of the study participants had PTSD, although data analysis for specific disorders was not conducted. Alcohol-related outcomes improved significantly in patients treated with either medication alone or with combination therapy, compared with placebo, but there was no added improvement with combination therapy when compared with monotherapy. This study strongly suggests that alcohol-dependent patients with co-occurring PTSD should receive medications targeting alcohol consumption.

There is good rationale for the exploration of a number of other compounds in the treatment of co-occurring PTSD and alcohol dependence. Prazosin blocks a specific α ₁-adrenergic receptor and has shown promise in several well-controlled trials for the treatment of PTSD, particularly in decreasing PTSD-related sleep disturbance and nightmares ( Raskin et al. 2007). In a preliminary study, prazosin decreased alcohol consumption in an alcohol-dependent population ( Simpson et al. 2009). This inexpensive and relatively safe drug warrants investigation in the treatment of co-occurring PTSD and alcohol dependence. In addition, several anticonvulsant agents, such as topirimate, have shown promise in the treatment of alcohol dependence ( Johnson et al. 2003). It is hypothesized that actions on the glutamatergic systems might be responsible for these agents' therapeutic actions. PTSD also has been associated with glutamatergic dysregulation, and anticonvulsant agents have shown promise in small-number, open-label studies in the treatment of PTSD. This is another area in which additional investigation is warranted. More research clearly is needed to help advance the behavioral and pharmacological treatment of co-occurring trauma/PTSD and substance use disorders.

Conclusions

Epidemiologic studies as well as studies in treatment-seeking populations converge to support the finding that early-life trauma is common in people with alcohol dependence. There are a number of potential mechanistic explanations for the connection between early-life trauma and the development of alcohol dependence. These include psychological and developmental issues that are affected by trauma, as well as neurobiological effects of early trauma that can lead to increased vulnerability to the development of alcohol and other substance use disorders. These explanatory hypotheses are not mutually exclusive. There is a growing literature on efficacious psychotherapeutic and pharmacotherapeutic treatments for individuals with co-occurring PTSD and alcohol dependence. Integrative psychosocial interventions combining efficacious interventions from the alcohol and PTSD fields have shown promise. Evidence suggests that agents targeting alcohol consumption (i.e., disulfiram, naltrexone) can be useful in patients with co-occurring PTSD and alcohol dependence, but additional investigation clearly is needed.

Acknowledgments

This work was supported in part by grants K24 DA-00435 (to Kathleen T. Brady) and K23 DA-021228 (to Sudie E. Back) from the National Institute on Drug Abuse.

Footnotes

Financial Disclosures
The authors declare that they have no competing financial interests.

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Articles from Alcohol Research : Current Reviews are provided here courtesy of National Institute on Alcohol Abuse and Alcoholism

# data[].attributes.attachment_link.title
Childhood Trauma, Posttraumatic Stress Disorder, and Alcohol Dependence

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Early-childhood trauma is strongly associated with developing mental health problems, including alcohol dependence, later in life. People with early-life trauma may use alcohol to help cope with trauma-related symptoms. This article reviews the prevalence ...

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The article explores the evolving understanding of how adverse childhood experiences (ACEs) and trauma, including abuse and neglect, influence not only mental health but also physical health and health behaviors. Recent literature highlights the long-term physical consequences of child abuse, such as increased risks of heart disease and cancer, and underscores the importance of addressing these issues in healthcare settings. It discusses key diagnostic advances, including the recognition of complex PTSD (cPTSD) and developmental trauma disorder (DTD), which emphasize relational trauma. The article advocates for broader screening and treatment of ACEs, emphasizing the need for trauma-informed care in clinical practice and research. These insights challenge previous psychiatric-only perspectives, broadening the scope of child abuse’s impact on overall health (Teicher et al., 2023).

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Journal of Ethics | American Medical Association

# data[].attributes.attachment_link.title
Key Updates to Understanding Roles of Childhood Trauma in Overall Health

# data[].attributes.attachment_link.description
Adverse childhood experiences and trauma influence health in ways that now garner more attention across the life-spectrum.

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Research published by the American Psychological Association reveals that children exposed to trauma, such as abuse or violence, exhibit biological signs of accelerated aging compared to those without such adversity. The study, led by Dr. Katie McLaughlin, found that early exposure to threat-related trauma was linked to early puberty, cellular aging markers like shortened telomeres, and reduced cortical thickness in brain regions associated with emotion processing. In contrast, deprivation-related adversities, such as poverty, did not show these biological aging signs. These findings suggest that the accelerated aging observed might have evolved as adaptive responses to dangerous environments but could lead to significant health issues later in life. The research highlights the importance of early interventions to mitigate long-term health effects and improve outcomes for traumatized children.

# data[].attributes.attachment_link.readable_text
WASHINGTON - Children who suffer trauma from abuse or violence early in life show biological signs of aging faster than children who have never experienced adversity, according to research published by the American Psychological Association. The study examined three different signs of biological aging-early puberty, cellular aging and changes in brain structure-and found that trauma exposure was associated with all three.

"Exposure to adversity in childhood is a powerful predictor of health outcomes later in life-not only mental health outcomes like depression and anxiety, but also physical health outcomes like cardiovascular disease, diabetes, and cancer," said Katie McLaughlin, PhD, an associate professor of psychology at Harvard University and senior author of the study published in the journal Psychological Bulletin. "Our study suggests that experiencing violence can make the body age more quickly at a biological level, which may help to explain that connection."

Previous research found mixed evidence on whether childhood adversity is always linked to accelerated aging. However, those studies looked at many different types of adversity-abuse, neglect, poverty, and more-and at several different measures of biological aging. To disentangle the results, McLaughlin and her colleagues decided to look separately at two categories of adversity: threat-related adversity, such as abuse and violence, and deprivation-related adversity, such as physical or emotional neglect or poverty.

The researchers performed a meta-analysis of almost 80 studies, with more than 116,000 total participants. They found that children who suffered threat-related trauma such as violence or abuse were more likely to enter puberty early and also showed signs of accelerated aging on a cellular level-including shortened telomeres, the protective caps at the ends of our strands of DNA that wear down as we age. However, children who experienced poverty or neglect did not show either of those signs of early aging.

In a second analysis, McLaughlin and her colleagues systematically reviewed 25 studies with more than 3,253 participants that examined how early-life adversity affects brain development. They found that adversity was associated with reduced cortical thickness-a sign of aging because the cortex thins as people age. However, different types of adversity were associated with cortical thinning in different parts of the brain. Trauma and violence were associated with thinning in the ventromedial prefrontal cortex, which is involved in social and emotional processing, while deprivation was more often associated with thinning in the frontoparietal, default mode and visual networks, which are involved in sensory and cognitive processing.

These types of accelerated aging might originally have descended from useful evolutionary adaptations, according to McLaughlin. In a violent and threat-filled environment, for example, reaching puberty earlier could make people more likely to be able to reproduce before they die. And faster development of brain regions that play a role in emotion processing could help children identify and respond to threats, keeping them safer in dangerous environments. But these once-useful adaptations may have grave health and mental health consequences in adulthood.

The new research underscores the need for early interventions to help avoid those consequences. All of the studies looked at accelerated aging in children and adolescents under age 18. "The fact that we see such consistent evidence for faster aging at such a young age suggests that the biological mechanisms that contribute to health disparities are set in motion very early in life. This means that efforts to prevent these health disparities must also begin during childhood," McLaughlin said.

There are numerous evidence-based treatments that can improve mental health in children who have experienced trauma, McLaughlin said. "A critical next step is determining whether these psychosocial interventions might also be able to slow down this pattern of accelerated biological aging. If this is possible, we may be able to prevent many of the long-term health consequences of early-life adversity," she says.

Article: "Biological Aging in Childhood and Adolescence Following Experiences of Threat and Deprivation: A Systematic Review and Meta-Analysis," by Natalie Colich, PhD, University of Washington, Eileen S. Williams, PhD, Stanford University, and Maya Rosen, PhD, and Katie McLaughlin, PhD, Harvard University. Psychological Bulletin, published online Aug. 3, 2020.

Katie McLaughlin, PhD, can be reached by email.

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Study: Experiencing childhood trauma makes body and brain age faster

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Children who suffer trauma from abuse or violence early in life show biological signs of aging faster than children who have never experienced adversity.

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This article discusses complex trauma, which arises from repeated exposure to trauma over a prolonged period, often beginning in childhood or adolescence. Unlike post-traumatic stress disorder (PTSD), complex trauma is associated with multiple forms of abuse, such as physical, sexual, and emotional, frequently perpetrated by individuals known to the victim. Dr. Shweta Kapoor of the Mayo Clinic explains that complex trauma disrupts a child’s developmental trajectory, impacting self-esteem, attachment styles, and future relationships, leading many women to enter abusive relationships as adults. Symptoms of complex trauma include dissociation, substance abuse, and physical ailments like fibromyalgia and gastrointestinal issues. Dr. Kapoor emphasizes the need for an official diagnosis for complex trauma, as current PTSD criteria may not fully capture its impact. Although treatments like trauma-informed care, medication, and psychotherapy are effective, formal recognition of complex trauma could lead to better diagnostic clarity and targeted interventions.

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Trauma and women: Untangling the complex emotional and physical consequences - Mayo Clinic Press

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At this point, you’re not sure how to help your cousin. She had a rough childhood with an abusive dad and has been struggling ever…

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Children who experience ongoing trauma, such as abuse, neglect, or violence, often face significant challenges in learning and behavior. This article highlights how trauma can manifest in the classroom, with symptoms like difficulty forming relationships, poor self-regulation, negative thinking, hypervigilance, and executive function deficits. Educators may misinterpret these signs, confusing them with disorders like ADHD. Dr. Nancy Rappaport and Dr. Jamie Howard emphasize the need for teachers to understand the emotional roots of students’ behavior, provide co-regulation support, and avoid punitive measures. Trauma-affected children require positive attention, incremental successes, and a supportive environment to counter negative self-perceptions and build trust in adults. Effective trauma-informed teaching involves recognizing emotions, helping students manage their responses, and fostering an atmosphere of kindness and patience.

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How Trauma Affects Kids in School - Child Mind Institute

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Learn how trauma from ongoing neglect, abuse, homelessness or violence causes children to have problems with learning and behavior. How to help these kids.

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Adverse Childhood Experiences (ACEs) encompass a range of stressful or traumatic events that occur during childhood and are associated with significant risks to long-term health and well-being. ACEs include various forms of abuse, neglect, and household dysfunction, such as domestic violence, substance abuse, and parental mental illness (Felitti et al., 1998). The impact of ACEs can be profound, influencing physical health, mental health, and social functioning throughout an individual's life. Research highlights that the cumulative effect of these experiences can lead to increased vulnerability to chronic diseases, behavioral problems, and difficulties in forming stable relationships. Addressing ACEs early and providing supportive interventions are crucial for mitigating their negative outcomes and promoting healthier developmental trajectories.

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Abstract

Background: The relationship of health risk behavior and disease in adulthood to the breadth of exposure to childhood emotional, physical, or sexual abuse, and household dysfunction during childhood has not previously been described.

Methods: A questionnaire about adverse childhood experiences was mailed to 13,494 adults who had completed a standardized medical evaluation at a large HMO; 9,508 (70.5%) responded. Seven categories of adverse childhood experiences were studied: psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned. The number of categories of these adverse childhood experiences was then compared to measures of adult risk behavior, health status, and disease. Logistic regression was used to adjust for effects of demographic factors on the association between the cumulative number of categories of childhood exposures (range: 0-7) and risk factors for the leading causes of death in adult life.

Results: More than half of respondents reported at least one, and one-fourth reported > or = 2 categories of childhood exposures. We found a graded relationship between the number of categories of childhood exposure and each of the adult health risk behaviors and diseases that were studied (P < .001). Persons who had experienced four or more categories of childhood exposure, compared to those who had experienced none, had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health, > or = 50 sexual intercourse partners, and sexually transmitted disease; and 1.4- to 1.6-fold increase in physical inactivity and severe obesity. The number of categories of adverse childhood exposures showed a graded relationship to the presence of adult diseases including ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease. The seven categories of adverse childhood experiences were strongly interrelated and persons with multiple categories of childhood exposure were likely to have multiple health risk factors later in life.

Conclusions: We found a strong graded relationship between the breadth of exposure to abuse or household dysfunction during childhood and multiple risk factors for several of the leading causes of death in adults.

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Adverse Childhood Experiences (ACEs) are potentially traumatic events that occur before the age of 18 and can have lasting effects on an individual's physical and mental health. These experiences include various forms of abuse, neglect, and household dysfunction, such as parental separation or incarceration (Hughes et al., 2017). Research indicates that exposure to ACEs is linked to a higher risk of developing chronic health conditions, mental health disorders, and behavioral issues later in life. The detrimental effects of ACEs often compound over time, making early intervention and support critical for mitigating their impact and fostering resilience in affected individuals.

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Bellis et al. (2014) conducted a national survey to assess the impact of Adverse Childhood Experiences (ACEs) on the health and social well-being of adults in the UK. The study highlights how ACEs, such as abuse, neglect, and household dysfunction, are prevalent and significantly associated with a range of adverse outcomes in adulthood, including physical health conditions, mental health issues, and social difficulties. The findings underscore the importance of understanding ACEs as a critical factor influencing long-term health and well-being and advocate for targeted interventions to address these early life experiences.

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BMC Medicine 12, Article number: 72 (2014) Cite this article

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Abstract

Background

Epidemiological and biomedical evidence link adverse childhood experiences (ACEs) with health-harming behaviors and the development of non-communicable disease in adults. Investment in interventions to improve early life experiences requires empirical evidence on levels of childhood adversity and the proportion of HHBs potentially avoided should such adversity be addressed.

Methods

A nationally representative survey of English residents aged 18 to 69 (n = 3,885) was undertaken during the period April to July 2013. Individuals were categorized according to the number of ACEs experienced. Modeling identified the proportions of HHBs (early sexual initiation, unintended teenage pregnancy, smoking, binge drinking, drug use, violence victimization, violence perpetration, incarceration, poor diet, low levels of physical exercise) independently associated with ACEs at national population levels.

Results

Almost half (47%) of individuals experienced at least one of the nine ACEs. Prevalence of childhood sexual, physical, and verbal abuse was 6.3%, 14.8%, and 18.2% respectively (population-adjusted). After correcting for sociodemographics, ACE counts predicted all HHBs, e.g. (0 versus 4+ ACEs, adjusted odds ratios (95% confidence intervals)): smoking 3.29 (2.54 to 4.27); violence perpetration 7.71 (4.90 to 12.14); unintended teenage pregnancy 5.86 (3.93 to 8.74). Modeling suggested that 11.9% of binge drinking, 13.6% of poor diet, 22.7% of smoking, 52.0% of violence perpetration, 58.7% of heroin/crack cocaine use, and 37.6% of unintended teenage pregnancy prevalence nationally could be attributed to ACEs.

Conclusions

Stable and protective childhoods are critical factors in the development of resilience to health-harming behaviors in England. Interventions to reduce ACEs are available and sustainable, with nurturing childhoods supporting the adoption of health-benefiting behaviors and ultimately the provision of positive childhood environments for future generations.

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Background

Non-communicable diseases (NCDs) have risen to become the greatest contributors to burden of disease globally, accounting for two thirds of all deaths (34.5 million [ 1]) and 54% of disability adjusted life years (DALYs; 1.3 billion [ 2]) in 2010. In high-income countries this proportion is typically much higher, reaching 87% in western Europe [ 3]. Two of the most common causes of NCDs, alcohol use and tobacco smoking (including second-hand smoke), are now the leading risk factors for burden of disease and injury in 15 to 49-year-olds, and globally attributed to around 800,000 and 565,000 deaths respectively in this age group in 2010 [ 4]. Obesity and drug use contributed an additional 325,000 and 107,000 deaths, respectively [ 4]. Thus, at global [ 5], regional (for example, Europe [ 6]), and national levels, tackling NCDs and the health-harming behaviors (HHBs) that cause them are health and economic priorities.

Although HHBs such as drug misuse, smoking, violence, and poor nutrition are apparent in all sectors of society, they are typically more prevalent in the poorest communities [ 7- 9]. However, even in such communities, most individuals in high-income countries do not abuse alcohol, take illicit drugs or smoke, and their diet and exercise regimens remain sufficiently balanced to at least avoid obesity (for example, in England [ 10]). Equally, although often at a lower prevalence, HHBs are far from absent in more affluent communities. Consequently, although socioeconomic gradients are strong predictors of HHBs, additional factors are required to explain the resilience and susceptibility of individuals to developing HHBs throughout the life course.

Over the past two decades, studies have begun to explore how early life experiences impact on behavior and health during adolescence and adulthood. Adverse childhood experience (ACE) studies show that adult health profiles relate to the abuse individuals experienced during childhood as well as to other childhood stressors such as parental substance misuse, incarceration, and domestic violence [ 11, 12]. The initial ACE study in the USA emerged from work identifying strong relationships between ACEs and adult obesity [ 13]. Since then, ACEs have been related to increased propensity for substance use (alcohol, tobacco, and drugs), anti-social behavior, and ultimately development of cardiovascular disease, cancer, chronic lung disease, and diabetes [ 11, 12]. Critically, studies have established that the quantity of stressors (that is, the ACE count) is an important predictor of poor behavioral and consequently poor health outcomes over the life course. Moreover, exposure to multiple stressors in childhood is also associated with subsequent unintended pregnancies [ 14], and being a victim or perpetrator of violence, including intimate partner violence [ 15]. Together, these sexual and violent behaviors create a mechanism for intergenerational passage of ACEs and their health consequences [ 16].

Through a range of evidence-based interventions, ACEs are a modifiable factor in children's lives [ 17]. However, there is currently little understanding of the potential impact of reducing ACEs independent of socioeconomic factors (for example, deprivation) that are also associated with poor health choices and anti-social behavior. Consequently, here we used a national ACE survey to measure levels of ACEs across England, calculated the prevalence of exposure to multiple ACE counts, and examined the relationships between ACE exposure and HHBs. After accounting for deprivation and other demographic effects, we modeled the impact of reduced ACE prevalence on resilience to HHBs. We considered how supportive childhoods allow individuals to resist the commercial, cultural, and environmental pressures that promote substance use, obesity, and anti-social behavior throughout the life course.

Methods

A national household survey of adults resident in England was undertaken between April and July 2013. Ethical approval was obtained from Liverpool John Moores University and the study adhered to the Declaration of Helsinki.

The study used an established survey tool [ 16] that includes questions on participant demographics, ACEs, and HHBs. ACE questions used the Centers for Disease Control and Prevention short ACE tool, which forms part of the US Behavioral Risk Factor Surveillance System [ 18]. The tool includes 11 questions on different childhood exposures to abuse and family dysfunction. These form nine distinct categories of ACE covering: physical, verbal, and sexual abuse; parental separation; exposure to domestic violence; and growing up in a household with mental illness, alcohol abuse, drug abuse, or incarceration (Table 1). The HHB outcomes examined in this study were: early sexual initiation (<16 years); unintended teenage pregnancy (<18 years); daily smoking; binge drinking; cannabis use (lifetime); heroin or crack cocaine use (lifetime); violence perpetration (past year); violence victimization (past year); incarceration; poor diet; and low levels of physical exercise (see Table 2). Although other HHBs, such as suicide attempt [ 11], have also been strongly linked to ACEs, our pilot survey [ 16] identified increased questionnaire length as detrimental to compliance, and therefore not every HHB could be included.

Questionnaires were completed by participants in their places of residence, under the instruction of a professional survey company directed by the research team. All sampled households were sent a letter providing study information and the opportunity to opt out prior to the surveyor visiting. At the door, surveyors again explained the study and its voluntary and anonymous nature, and provided a second opportunity for individuals to opt out. Participants were offered the choice of completing the questionnaire through a face-to-face interview using a hand-held computer (with sensitive questions self-completed; n = 3,852), or to self-complete using paper questionnaires (n = 158). The questionnaire took an average of 13 minutes to complete.

Sample selection

A target sample size of 4,000 was based on ACE prevalence identified in a pilot study [ 16]. Sampling used a random probability approach stratified first by region (n = 10, with inner and outer London treated as two regions) and then small area deprivation in order to provide a sample representative of the English population. Samples for each region were proportionate to their population. Within each region, lower super output areas (LSOAs; geographical areas with a population mean of 1,500 [ 19]) were categorized into deprivation deciles based on their ranking in the 2010 Index of Multiple Deprivation (IMD; a composite measure including 38 indicators relating to economic, social, and housing issues [ 20]). Two LSOAs were randomly selected from each deprivation decile in each region for sampling (n = 200 LSOAs). Within each sampled LSOA, between 40 and 120 addresses were randomly selected from the Postcode Address File ®, with 16,000 households initially sampled to allow for non-response, ineligibility, and non-compliance.

Of all sampled households, 771 (4.8%) opted out following receipt of the study letter. Household visits were made on all days of the week and between the hours of 09.30 and 20.30 hours. At least three attempted visits at differing days/times were made before an address was removed, with sampling completed once the target sample size was achieved.

Inclusion criteria for the study were: residence in a selected LSOA; age 18 to 69 years; and cognitive ability to participate in a face-to-face interview. A total of 9,852 households were visited, of which 7,773 were occupied. Of the occupied households, 2,719 (35.0%) opted out, 1,044 (13.4%) were ineligible, and 4,010 completed a study questionnaire. Thus, compliance was 59.6% across eligible occupied households visited, and 53.5% including those opting out at the letter stage.

Statistical analysis

All analyses were undertaken using PASW Statistics v18. Only individuals with complete data relating to all ACEs, age, sex, ethnicity, and IMD quintile were included in the analysis, yielding a final sample size of 3,885. Although ethnicity was initially collected through self-identified UK Census categories, these were combined into White, Asian and Other because of the small numbers within individual ethnic groups (Table 3). Where individuals did not answer all relevant questions, adjusted sample sizes are presented in the tables.

Table 3 Sample demographics and comparison with the English national population a

Owing to highly significant correlations between all ACE types (see Additional file 1: Table S1), and consistent with ACE study methodology elsewhere [ 11, 12], ACE counts were calculated for all individuals as a proxy for severity of childhood adversity and classified into four retrospective cohorts (0 ACEs, n = 2,084; 1 ACE, n = 881; 2-3 ACEs, n = 597; 4 + ACES, n = 323). Bivariate analyses used χ² tests with conditional binary logistic regression (LR) to examine independent relationships between ACE counts and HHBs of interest. Best-fit LR model parameters were used to calculate the numbers and proportions of each HHBs relating specifically to ACE count. Thus, for each HHB, model parameters for age, sex, ethnicity, and deprivation were applied to national and sample populations with ACE count parameters set to the observed values, and then with ACE count parameters set to zero ACEs.

Results

The sample was not significantly different from the overall English population for either deprivation or ethnicity. However, the ACE sample had an over-representation of females and included a higher proportion of individuals in the age category 60 to 69 years, with a corresponding underrepresentation of those aged 18 to 29 years (Table 3). Individual ACEs ranged in prevalence from 3.9% with a drug-using household member during their childhood to 22.6% experiencing parental separation or divorce. After correction to national population demographics, these prevalences increased to 4.1% and 24.3% respectively. Overall, 46.4% of the sample had experienced at least one ACE (population-adjusted 47.9%; Table 4). Higher ACE counts were associated with deprivation, and were lower in Asian ethnicity populations, males, and the oldest age group. In childhood, living with a drug user, parental separation, having a household member incarcerated, and living with an alcohol abuser all increased in prevalence with deprivation and reduced with increasing age (Table 4). Experience of physical abuse, verbal abuse, or domestic violence within the childhood household was also highest in the most deprived quintiles. For all ACEs, Asian ethnicity had the lowest prevalence while 'Other' ethnicity had the highest prevalence for each ACE except living with a household member with mental illness or alcohol abuse. Differences by ethnicity did not reach significance for any ACE type. Variations in prevalence of ACE types by gender were significant for childhood sexual and verbal abuse and having a household member with mental illness or alcohol abuse, with the prevalence being higher in females.

In bivariate analysis, the prevalence of all HHBs except low levels of physical exercise increased with ACE count (Table 5). Thus, prevalence of having had or caused unintended teenage pregnancy and all violence and criminal justice outcomes (violence perpetration, violence victimization, incarceration) was more than five times higher in those with 4+ ACEs (versus those with none). All HHBs except binge drinking were also associated with deprivation; for example, prevalence of early sexual initiation increased from 12.0% in the least deprived quintile to 22.3% in the most deprived, and prevalence of smoking increased from 12.9% to 38.1%, respectively (see Additional file 1: Table S2). After using LR models to account for the confounding effects of deprivation and other demographics, odds of all HHBs except low physical exercise were significantly higher in those with 4+ or 2 to 3 ACEs (versus none). Having one ACE (versus none) was associated with a significant increase in unintended teenage pregnancy, early sexual initiation, binge drinking, cannabis use, violence perpetration, violence victimization, and incarceration (Table 6). The impact of deprivation remained significant for unintended teenage pregnancy, early sexual initiation, smoking, binge drinking, incarceration, poor diet, and low exercise levels after accounting for relationships with ACE counts.

For each HHB, the best-fit LR models were used to calculate expected HHB prevalence in the sample and national population if no ACEs were experienced. Although causality could not be established in this study, modeling estimated that nationally 13.6% of poor diet and up to 58.7% of heroin or crack cocaine use is related to ACEs. ACEs also accounted for approximately half of all individuals experiencing violence in the past year, either as a perpetrator or a victim. At a national population level, this would account for over a million individuals being assaulted and just under 900,000 assaulting someone else at least once in the past 12 months (Table 7). Similarly, modeling suggested that nationally 37.6% of individuals who have experienced an unintended pregnancy before the age of 18 years (equivalent to 826,352 individuals) could be accounted for by ACEs.

Table 7 Modeled impact of preventing ACEs at sample and national population levels on health-harming behaviors a

Discussion

Results suggest that nearly half of all individuals in England are exposed to at least one adverse experience during childhood, and 9% experience four or more ACEs (Table 4). ACEs and HHBs were both associated with deprivation. Thus, four or more ACEs were reported by 4.3% of individuals in the most affluent quintile, rising to 12.7% of those in the most deprived. Equally, all HHBs, with the expected exception of binge drinking [ 23] increased with deprivation. However, we identified a strong relationship between ACEs and HHBs, independent of deprivation (Table 6). Modeling suggested that ACEs contributed to as many as one in six individuals smoking and one in seven with poor diet and binge drinking (Table 7). Links between such behaviors and childhood circumstances are likely to operate through the impact of ACEs on the developing brain. Thus, early life trauma can lead to structural and functional changes in the brain and its stress regulatory systems, which affect factors such as emotional regulation and fear response, and this may predispose individuals to HHBs [ 24]. Consequently, the impact of ACEs on engagement in anti-social behavior and problematic drug use appears particularly marked. Over half of cases of violence perpetration, violence victimization, incarceration, and heroin/crack cocaine use could be explained by ACEs. These HHBs represent major health, social, and economic burdens across communities, and when expressed in family environments mean subsequent generations are exposed to ACEs. Moreover, we found that ACEs accounted for around a third of individuals reporting early sexual initiation and unintended teenage pregnancy. Such pregnancies can mean that individuals are born into settings typically less prepared for the needs of children, with fewer resources for child-rearing, poorer parenting skills, and consequently greater opportunity for child abuse [ 25], again ensuring intergenerational transmission of ACEs and related harms.

Although the ACE methodology has been refined and extensively tested [ 26], it remains prone to issues associated with any cross-sectional study. Results rely on accurate recall and willingness to report ACEs even after assurances of anonymity. In older individuals especially, recollection of childhood issues may be limited, although studies elsewhere suggest that false-positive reports are rare [ 27]. Moreover, although prospective studies may allow more immediate recording of ACEs, they are ethically problematic if identification of ACEs in children does not lead to intervention [ 28]. Further, our measures of ACEs are in part subjective, with individuals having to self-identify childhood abuse and other stressors relating to household members (for example, mental health problems). However, despite definitional differences, independent comparable measures of ACEs for England are relatively consistent with this study. Thus, point estimates from national surveys have suggested that 5.9% of children in England live with an adult who is a dependent drinker, 2.8% with an adult who is drug-dependent, and 7.8% with an adult with a mental health problem [ 29]. Our estimates for exposure to these ACEs at any stage in childhood were marginally higher, at 9.7% for alcohol abuse, 4.1% for drug abuse, and 12.0% for mental illness. Our sample size (n = 3,885) and compliance (59.6% at the door and 53.5% including households withdrawing at the letter stage) were also comparable with other major national surveys (for example, British Social Attitudes Survey 2012, n = 3,248, compliance 53% [ 30]; Adult Psychiatric Morbidity Survey 2007, n = 7,353, compliance 57% [ 31]). Finally, although many individuals stated time constraints as their reason for non-participation, we could not measure whether ACEs or HHBs were of a different prevalence or displayed different relationships in non-participants.

In England and elsewhere, attempts to reduce financial and other inequities relating to NCDs have met with limited success [ 32]. Equally, calls to limit the promotion and sale of alcohol, unhealthy foods, and to a lesser extent, tobacco, are routinely blocked by industry [ 33]. However, resistance to commercial, cultural, and other environmental pressures to adopt HHBs appears to be related to childhood stressors, with nurturing, ACE-free childhoods increasing personal resilience [ 34]. There is a range of evidence-based interventions already available to improve parenting and support child development (for example, home visiting programs, parenting programs, social development programs). Many of these interventions have been developed and tested in North America, where they have reduced ACEs, increased child pro-social behavior, prevented HHBs, and been identified as cost-effective [ 17, 35- 37]. The evidence base is also developing for their use in the UK and elsewhere in Europe [ 17]. Thus, the relationship between child adversity, HHBs, and poor health and social outcomes identified here provides a compelling case for investing at scale in parental well-being, parenting skills, and coordinated health, education, and criminal justice services to prevent and identify child maltreatment. Moreover, measuring the benefits of such investments on such a multi-disciplinary basis strengthens the economic case for investment, with total savings potentially exceeding program costs within a year [ 38]. Critically, investing in parenting should be seen as a sustainable intervention that has the potential to break cycles of adversity, with positive parenting practices likely to be passed down through generations once established.

Conclusions

Emerging international literature is beginning to describe consistent impacts of ACEs on behavior and both physical and mental health outcomes across a variety of nations [ 16, 17, 39]. However, empirical evidence on prevention is more limited, largely to the USA [ 17]. A better understanding of the potential impact of integrated, large-scale interventions is required in countries where universal health systems already support all parents and prospective parents. Thus, brief motivational parenting interventions communicating the benefits of warm and consistent parenting are largely untested, despite the success of such approaches in other areas [ 40]. Neurobiological studies have already identified changes to the hippocampus and prefrontal cortex associated with ACEs, while epigenetic studies are exposing gene-environment interactions with negative health consequences once exposed to stressors [ 24]. Consequently, a joint research agenda between epidemiological and other sciences is required to identify the points in a child's development at which interventions to prevent ACEs are most important and when their impacts are largely immutable. Moreover, from a policy perspective, child health is typically considered to begin from conception. However, positive parenting outcomes are also impacted by spacing between siblings [ 41]. Further examination is required of how contraceptive and maternity services can better assist especially vulnerable parents with family planning. Moreover, although policies providing financial and other support for deprived parents are critical, their impact on decisions to conceive, reductions in child spacing, and consequently ACEs requires urgent attention [ 42]. Finally, measures to reduce other drivers of domestic violence and child maltreatment such as alcohol and drug use are also likely reduce childhood adversity. Although ACEs are linked with deprivation, they are by no means limited to poor communities, and consequently ACE prevention activities should be both universal and proportionate to need. Our results demonstrate that the absence of ACEs is linked with resilience to commercial and cultural pressures to binge drink, smoke, abuse drugs, adopt poor diets, engage in early and unprotected sex, and become involved in violent and criminal behavior. The importance of addressing ACEs is often hidden, along with the voices of the children affected. However, exposing the levels of ACEs experienced even in a developed country like England and investing more in their prevention makes both ethical and economic sense.

References

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Acknowledgements

We thank Katie Hardcastle and Olivia Sharples for supporting study implementation. We are grateful to all the surveyors for their time and commitment to the project and to all the individuals who participated in the study.

Author information

Affiliations

1. Centre for Public Health, World Health Organization Collaborating Centre for Violence Prevention, Liverpool John Moores University, 15-21 Webster Street, Liverpool, L3 2ET, UK

Mark A Bellis & Karen Hughes

2. Public Health Wales, Hadyn Ellis Building, Maindy Road, Cardiff, CF24 4HQ, UK

Mark A Bellis

3. Department of Academic Neonatal Medicine, Chelsea and Westminster Campus, Imperial College London, Fulham Road, London, SW10 9NH, UK

Nicola Leckenby

4. Knowledge and Intelligence Team (North West), Public Health England, 15-21 Webster Street, Liverpool, L3 2ET, UK

Clare Perkins

5. Blackburn with Darwen Borough Council, Specialist Public Health Directorate, 6th floor, 10 Duke Street, Blackburn, BB2 1DH, UK

Helen Lowey

Corresponding author

Correspondence to Mark A Bellis.

Additional information

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

MAB designed the study, analyzed the data, and wrote the manuscript. KH contributed to study design, coordination, data analysis, and manuscript writing. NL coordinated the study, formatted data, and contributed to data analysis and manuscript editing. CP contributed to study coordination and manuscript editing. HL supported study development and edited the manuscript. All authors read and approved the final manuscript.

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Bellis, M.A., Hughes, K., Leckenby, N. et al. National household survey of adverse childhood experiences and their relationship with resilience to health-harming behaviors in England. BMC Med 12, 72 (2014). https://doi.org/10.1186/1741-7015-12-72
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Keywords

Child abuse

Childhood

Alcohol

Smoking

Violence

# data[].attributes.attachment_link.title
National household survey of adverse childhood experiences and their relationship with resilience to health-harming behaviors in England - BMC Medicine

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Background Epidemiological and biomedical evidence link adverse childhood experiences (ACEs) with health-harming behaviors and the development of non-communicable disease in adults. Investment in interventions to improve early life experiences requires empirical evidence on levels of childhood adversity and the proportion of HHBs potentially avoided should such adversity be addressed.

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Santos and Papageorgiou (2020) provide a comprehensive review of recent literature examining the link between Adverse Childhood Experiences (ACEs) and adult health outcomes. The article synthesizes evidence from various studies to explore how experiences of abuse, neglect, and household dysfunction during childhood can contribute to a range of negative health outcomes in adulthood, including chronic diseases and mental health disorders. The review highlights the mechanisms through which ACEs impact long-term health and emphasizes the need for early intervention strategies to address these early life adversities effectively.

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Adverse Childhood Experiences and Adult Mental Health Outcomes

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This cohort study investigates the association of adverse childhood experiences with adult psychiatric disorders after adjusting for familial confounding.Are adverse childhood experiences (ACEs) associated with poor mental health in adulthood after adjustment…

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This resource provides an overview of Adverse Childhood Experiences (ACEs) and their long-term impact on brain development. The article emphasizes that trauma can alter brain structures like the hippocampus and prefrontal cortex, leading to emotional dysregulation, cognitive delays, and increased risk for mental health issues such as depression and PTSD. Early intervention is highlighted as crucial for mitigating these effects.

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Choice MD | The Lifelong Impact of Childhood Trauma: Understanding ACEs and Brain Development

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The Lifelong Impact of Childhood Trauma: Understanding ACEs and Brain Development

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This article focuses on diagnosing trauma in children and the challenges associated with overlapping symptoms like ADHD and anxiety. It also explores treatments like Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) and play therapy, which help children process traumatic experiences.

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Childhood Trauma in Psychology: Defining and Understanding Its Long-Term Impact

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Explore the psychological effects of childhood trauma, its neurobiological impact, and treatment approaches. Learn about diagnosis and long-term consequences.

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This article discusses how toxic stress from trauma can disrupt normal brain architecture during childhood. Chronic exposure to stress affects areas involved in emotional regulation, learning, and memory, increasing the likelihood of developmental delays, behavioral issues, and health problems in adulthood.

# data[].attributes.body
This study links childhood trauma to long-term health outcomes, including mental health disorders, substance abuse, and chronic diseases. The ACE study demonstrates that the higher the number of adverse experiences in childhood, the greater the likelihood of negative health and social outcomes in adulthood.

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This study explored how exposure to childhood trauma correlates with adult psychiatric disorders and functional outcomes, such as health, risky behavior, and financial or educational functioning. The researchers found that childhood trauma increased the risk of adult psychiatric conditions, even after controlling for childhood adversities. The study highlights the enduring psychological and social impacts of early trauma, with little variation in effects based on race or sex.

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Childhood Trauma Exposure and Adult Psychiatric Disorders and Functional Outcomes

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This cohort study examines association between cumulative childhood trauma exposure and long-term psychiatric and functional outcomes in adulthood.

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This meta-analysis examines how childhood trauma is linked to emotion regulation difficulties among youth. It emphasizes that trauma can significantly impair an individual's ability to regulate emotions, which can lead to various psychological problems. The review highlights the importance of early intervention and therapeutic strategies aimed at improving emotional regulation skills in traumatized youth​.

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Emotion regulation difficulties in traumatized youth: a meta-analysis and conceptual review - European Child & Adolescent Psychiatry

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This article provides a quantitative and conceptual review of emotion regulation difficulties in trauma-exposed young people, and informs future directions in the field. Despite long-standing interest in the influence of emotion regulation difficulties on different internalizing and externalizing psychiatric disorders in childhood, several questions remain unresolved with respect to children and adolescents with PTSD (post-traumatic stress disorder). Meta-analytic data from adult victims suggest that emotion regulation problems are associated with PTSD, but this has never been studied in children and young people. We therefore provide a conceptual review of features related to the phenomenology, assessment, severity and treatment of emotion regulation difficulties in trauma-exposed children and young people. We combine this with a meta-analysis of published literature. We searched studies in Medline, PsychINFO, and Embase databases based on pre-selected criteria. Eight hundred and eighty-six papers were identified and 41 were included. We found that children and adolescents with a diagnosis of PTSD reported more emotion regulation difficulties than those who did not develop PTSD, and that the overall association between the two symptom dimensions was moderately strong. We identify a number of research priorities: the development of instruments to assess emotion regulation difficulties in children, the design of studies that describe its prevalence in young epidemiological traumatized samples, its predictive role in the onset, severity and persistence of post-traumatic symptoms, and its relevance as a moderator, outcome or treatment target for young survivors.

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This study explores the relationships between childhood trauma, PTSD symptoms, and the roles of emotion regulation and distress tolerance. It suggests that difficulties in emotion regulation can mediate the relationship between trauma exposure and the development of PTSD. The findings emphasize the need for targeted therapeutic approaches that enhance emotion regulation skills in individuals with a history of trauma.

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Childhood Trauma and PTSD Symptoms: Disentangling the Roles of Emotion Regulation and Distress Tolerance - Research on Child and Adolescent Psychopathology

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Research documents that a history of childhood trauma increases risk for post-traumatic stress disorder (PTSD), greater emotion regulation difficulties (ERD), and reduced distress tolerance (DT). Independent lines of research implicate ERD and DT as transdiagnostic risk factors and link them to PTSD. To elucidate how such mechanisms may influence the etiology, maintenance, and treatment of PTSD, the current study investigates the distinct mediating roles of emotion regulation and DT, exploring which explains a larger indirect effect from childhood trauma to PTSD symptom severity. Participants (N = 385, aged 18–48) who endorsed a history of childhood trauma provided retrospective report of cumulative childhood trauma exposure, and of current ERD, DT, and PTSD symptom severity. Single and dual mediation analyses were used to assess indirect effects through ERD and DT in the relation between cumulative childhood trauma exposure and current PTSD symptom severity. ERD and DT were significantly and inversely related. Higher current self-ratings of PTSD symptom severity were explained by cumulative childhood trauma through ERD (B = 0.93, p < 0.001) and DT (B = 0.50, p < 0.05). The full model explained 36% of the variance in PTSD symptom severity. Current findings provide preliminary evidence of DT and emotion regulation (with specific facets identified) as distinct mechanisms in the development of PTSD. Of clinical relevance, current findings support post-trauma processing theories that contend individuals’ recovery requires accepting and learning to modulate trauma-related emotional states. Implications for methods of treatment and prevention are discussed.

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This research indicates that childhood trauma is associated with lower levels of personal mastery and greater emotional reactivity to daily stressors. The study finds that individuals with traumatic backgrounds may struggle to develop effective emotional regulation strategies, which leads to heightened sensitivity to stress and emotional fluctuations throughout adulthood​.

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Frank J. Infurna,

Crystal T. Rivers,

John Reich,

Alex J. Zautra

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Abstract

Childhood trauma is associated with premature declines in health in midlife and old age. Pathways that have been implicated, but less studied include social-emotional regulation, biological programming, and habitual patterns of thought and action. In this study we focused on childhood trauma's influence via alterations in social-emotional regulation to everyday life events, a pathway that has been linked to subsequent health effects. Data from a 30-day daily diary of community residents who participated in a study of resilience in Midlife ( n = 191, Mage = 54, SD = 7.50, 54% women) was used to examine whether self-reports of childhood trauma were associated with daily well-being, as well as reported and emotional reactivity to daily negative and positive events. Childhood trauma reports were associated with reporting lower overall levels of and greater variability in daily well-being. Childhood trauma was linked to greater reports of daily negative events, but not to positive events. Focusing on emotional reactivity to daily events, residents who reported higher levels of childhood trauma showed stronger decreases in well-being when experiencing negative events and also stronger increases in well-being with positive events. For those reporting childhood trauma, higher levels of mastery were associated with stronger decreases in well-being with negative events and stronger increases in well-being with positive events, suggesting that mastery increases sensitivity to daily negative and positive events. Our results suggest that childhood trauma may lead to poorer health in midlife through disturbances in the patterns of everyday life events and responses to those events. Further, our findings indicate that mastery may have a different meaning for those who experienced childhood trauma. We discuss social-emotional regulation as one pathway linking childhood trauma to health, and psychosocial resources to consider when building resilience-promoting interventions for mitigating the detrimental health effects of childhood trauma.

Citation: Infurna FJ, Rivers CT, Reich J, Zautra AJ (2015) Childhood Trauma and Personal Mastery: Their Influence on Emotional Reactivity to Everyday Events in a Community Sample of Middle-Aged Adults. PLoS ONE 10(4): e0121840. https://doi.org/10.1371/journal.pone.0121840

Academic Editor: Daisuke Nishi, National Center of Neurology and Psychiatry, JAPAN

Received: July 28, 2014; Accepted: February 17, 2015; Published: April 7, 2015

Copyright: © 2015 Infurna et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

Data Availability: All relevant data are within the paper and its Supporting Information files.

Funding: This work was funded by the National Institute on Aging R01 AG26006. The funders had no role in study design, data collection, and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Development is a lifelong process with experiences from childhood potentially having an impact on health and well-being throughout in midlife and beyond [ 1- 3]. Childhood trauma characterized by abuse and family conflict is one of those early life experiences that not only has detrimental effects during childhood and adolescence, but can leave a "scar" well into midlife and old age [ 4- 5]. Recent empirical evidence suggests that childhood trauma is associated with less emotional support and more strain in social relationships in adult life [ 6], lower levels of well-being [ 7], and early onset of functional limitations, disease, and premature mortality [ 8- 10].

There are several possible pathways linking childhood trauma to health in midlife, including social-emotional regulation, biological programming, and patterns of behavior [ 4, 11]. For example, chronic stress in childhood is associated with stronger pro-inflammatory cytokine response and resistance to anti-inflammatory properties of cortisol [ 12], which have long-term health consequences [ 13]. Similarly, chronic childhood stress is linked to unhealthy habits, such as smoking, alcohol dependency, and overeating [ 14, 15]. One likely pathway that has yet to be fully tested is whether childhood trauma alters day-to-day life experiences through daily well-being, and experience of and reactivity to daily negative and positive events. These components of daily life are considered a form of social-emotional regulation that has the potential to accumulate over the lifespan to shape the course of development [ 16- 19]. As is accustomed in the daily diary literature, we define well-being as one's level of negative and positive affect on days when no negative or positive daily event is reported [ 16, 19]. Social-emotional regulation is broadly defined as one's ability to effectively manage their daily emotions in the response to specific stimuli [ 20]. We conceptualize social-emotional regulation in our study as changes in positive and negative affect in response to the stimulus provided by daily negative and positive events. There may be psychosocial resources that moderate one's social-emotional regulation capacities; we examine whether mastery, a key resilience resource across the life-span, increases or decreases social-emotional regulation capacities for individuals who experienced high levels of childhood trauma. To evaluate associations between childhood trauma and social-emotional regulation, we used data from 30-day daily diaries of participants in midlife to examine (1) whether childhood trauma is associated with daily well-being, and reports of and reactivity to daily negative and positive events and (2) the role of mastery in moderating such associations.

Pathways Linking Childhood Trauma to Health

Childhood trauma in the form of emotional, physical, or sexual abuse, as well as childhood misfortune can have detrimental and long-lasting effects on development across the lifespan. For example, a meta-analysis by Wegman and Stetler [ 21] found that the effect size linking childhood abuse to negative physical health outcomes in adulthood was d = 0.42 (Confidence Interval = 0.39-0.45). Similarly, Caspi and colleagues [ 22- 23] found that child maltreatment and traumatic events early in life were associated with lower well-being and greater psychological distress in young adulthood. Despite the substantial evidence linking childhood trauma to health in midlife and old age, much less empirical research has been done on examining specific pathways that could underlie this relationship.

The ramifications of childhood trauma for development in midlife and old age are thought to be set in motion through biopsychosocial processes that unfold over time to increase risk for ill health. Miller and colleagues [ 4] reviewed evidence for several pathways, including biological programming, behavioral habits, social relationships, and social-emotional regulation (reports of and reactivity to stressors), as plausible mechanisms. We focus on exploring social-emotional regulation as one pathway through which childhood trauma can lead to differential health outcomes because childhood trauma has the potential to affect the dynamics of daily life. Day-to-day living accumulates to affect development across the lifespan through various sets of experiences, interactions, and events. For example, Charles and colleagues [ 24] found that people who were more reactive to daily stressors (i.e., stronger decline in well-being) had an increased risk for mental health disorders over 10 years of time. One might describe these experiences as being comprised of multiple components, which we have captured through use of daily diaries completed by a mid-life sample. The diary data allows us to investigate levels of and variability in daily well-being, reports of both stressors and pleasant events, and emotional reactivity to daily negative and positive events. Well-being has many definitions in the literature, but a common feature to most of those definitions is attention to both the presence of positive affective states and the relative absence of negative emotions [ 25- 27]. Following in this vein we operationalized well-being as according to one's daily levels of and variability in negative and positive affect, in addition to how negative and positive affect changes in response to daily negative and positive events. Below we set forth the assumptions upon which our investigation is based.

First, childhood trauma may be associated with reporting lower overall levels of well-being and greater fluctuations from day-to-day (i.e., variability). Childhood trauma could alter individuals' strategies for regulating their desires and emotions that are essential for interpreting and experiencing their daily lives in context [ 28- 29]. Second, childhood trauma may lead to poorer health via reporting more daily stressful events and fewer daily positive events. Daily events may be more likely to be appraised and perceived as stressful and high in severity, due to inconsistencies and growing up in an environment where behavior-event relationships were not developed due to a harsh childhood environment, e.g., contingency[ 30]. Childhood trauma could also result in being less engaged in goal-directed behaviors that are associated with daily positive events, resulting in deriving less benefit from these events in daily life. Third, childhood trauma may prime individuals to be more sensitive to their daily events or context; this is conceptualized as one's emotional reactivity and assessed via examining changes in well-being on days where daily negative and positive events are reported. In adolescence, childhood maltreatment is associated with poor self-regulation deficits when encountering social stressors [ 31], suggesting that deficits are already present early in life and likely worsen into adulthood. Similarly, previous research in adulthood shows that early life adversity and poor parental relationship quality is associated with stronger increases in negative affect to daily stressors [ 32- 34].

In sum, there are multiple social-emotional regulation pathways through which childhood trauma may play a role in creating self-regulation deficits. Accordingly, childhood trauma may lay the groundwork for such deficits extending into midlife and beyond. These sorts of outcomes indicate that such inadequate regulatory response to stress compromises resilience.

The experience of well-being.

Early life adversity may lead to increased sensitivity to ongoing stressors, but also differentially boost well-being through greater responsiveness to lasting changes that have a positive valence. This concept has been referred to in the literature as differential susceptibility, which is broadly defined as individual differences in one's response to both negative and positive social contexts [ 8, 35]. More specifically, not only does differential susceptibility refer to a heightened reactivity to adversity, "these same attributes that make an individual particularly sensitive to adversity may also make them more responsive to interventions designed to offset the effects of adversity" [ 8].

One way to assess differential susceptibility is by assessing individuals' emotional reactivity to daily social stressors and positive interactions. Despite the difficulties experienced early in life, positive daily events may provide individuals the opportunity to be engaged in their daily life and pursue goal-directed behavior, resulting in the opportunity to flourish. Most of the literature examining emotional reactivity in the context of childhood trauma has primarily focused on daily stressors, whereas emotional reactivity to daily positive events has been rarely addressed [ 19]. Positive events, such as completing a fulfilling project at work or a social interaction with family member or friend may boost well-being differentially with those who experienced childhood trauma because of being more sensitive to their context.

Mastery as a Key Resilience Factor for Confronting Childhood Trauma

The evidence provided by prior research makes clear the potential for negative consequences arising from childhood trauma. However, there is a resilience perspective on childhood adversity that is instructive insofar as it gives voice to the potential for abused persons to recover, sustain their sense of purpose and even thrive [ 36]. Masten [ 37] described the need for researchers to examine more than the effects of deficits such as early abuse; rather, to investigate how "assets, risks, and protective factors... may influence each other over time." Positive influences include access to caring adults, cognitive skills, and personal mastery [ 37, 38]. In the present study, we focus on one of these personal assets as a protective factor for individuals who experienced childhood trauma: personal mastery.

Personal mastery.

Mastery, or perceived control, has a long history in the literature of being associated with better cognitive, mental, and physical health across the lifespan [ 39- 42] and being a resource for caregivers and patient populations to protect against declines as a function of chronic stressors [ 43- 44]. For our purposes, mastery is considered a resource for individuals with childhood trauma to protect against reports of and emotional reactivity to daily negative events, and could also result in positive events being more uplifting (i.e., increase in well-being). Previous research in daily diary designs has shown that mastery is protective against declines in well-being as a function of daily stressors [ 45]. For example, Hay and Diehl [ 46] found that reporting higher levels of control on stressor days was associated with a less steep increase in negative affect [ 47]. Mastery likely serves this protective function through individuals' perceptions of higher control over the situation, using better coping or compensatory strategies, and turning to social network members to help reduce the negative effects of stressors. In contrast, much less is known regarding mastery in the context of daily positive events. Reporting more mastery may result in more uplifting or boosts in well-being with daily positive events because these events are often times engaged in or directed by the individual [ 19]. Insights on the role of mastery in the context of daily positive events may be gained through considering research on agency and self-efficacy. Bandura described self-efficacy, people's beliefs about their ability to control events, as a mechanism of agency, which may be thought of as goal-directed determination and motivation [ 48]. In the context of childhood trauma, a greater sense of agency might be highly stabilizing, resulting in greater reactivity with positive events.

The view of oneself as the effective agent of one's own life, once established and reinforced by lengthy and diverse experience, is carried forward into late life as a powerful influence on the current mastery of older adults [ 49]. However, in the context of childhood trauma, the role of mastery is less clear. We envision several scenarios regarding whether mastery will up- or down-regulate reports of and emotional reactivity to daily negative and positive events. Perceiving control over life can be potentially beneficial given early life adversity. For daily negative events, following previous research [ 45, 47], we expect that higher levels of mastery would be protective against declines in well-being when confronted with a daily negative event [ 50]. However, adults with high mastery may expect to see their world as under their control and daily stressors can effectively disconfirm those expectations, possibly giving rise to distress. Focusing on positive daily events, high mastery may result in stronger increases in well-being because positive events are often sought after and perceived as under one's own control [ 19]. The person is an active agent rather than a passive recipient in the production of positive events [ 51- 52] and this is amplified in the context of childhood trauma.

The Present Study

Early life adversity in the form of childhood trauma can have a long-term impact on health in midlife and beyond; we focus on whether childhood trauma is associated with social-emotional regulation as one potential pathway underlying this association. To do so, we use data from a 30-day daily diary of participants in midlife that permits the opportunity to examine within-person change in daily well-being and tracking within-person change in well-being as a function of daily negative and positive events.

Our first objective is to examine whether childhood trauma is associated with levels and variability of daily well-being, and reports of and emotional reactivity to daily negative and positive events. We hypothesize that childhood trauma will be associated with reporting lower levels of, and greater variability in, daily well-being. Furthermore, childhood trauma will be linked to reporting more daily negative events and less engagement in daily positive events, but stronger emotional reactivity to both daily negative and positive events. Our second research question centers on the role of mastery moderating reports of and emotional reactivity to daily negative and positive events. We hypothesize that mastery will be protective against declines in well-being with daily stressors for people with high levels of childhood trauma and stronger increases in well-being as a function of daily positive events.

Method

Participants and Procedure

We used data from the ASU Live Project, which is a large-scale study of mid-aged (aged 40-65) residents of the Phoenix metro area ( N = 800) focusing on identifying individual, familial and community factors in resilience (Resilience Processes in Individuals and Communities: R01 AG26006). A total of 800 participants were recruited for the study, with a final number of 782 participating in the initial component of the study that involved self-report questionnaires. The study was multi-modal. Participants completed self-report questionnaires about early family life, personality, traumatic and stressful events, as well as qualitative interviews about participants' most stressful life experience. One-quarter of the sample (~200) participated in an additional videotaped lab stressors component and one-quarter (~200) completed daily diaries covering a 30-day period. The laboratory stressor employed procedures for eliciting physiological and affective arousal [ 53]. Participants were given a stress-eliciting task that was videotaped and ratings of positive and negative affect were collected with the PANAS [ 27] at baseline and after each rest and task period. Saliva samples (for cortisol) were collected at baseline and following each rest and stress period.

We use data from 191 participants who completed the 30-day daily diary and provided data on our variables of interest from the self-report questionnaires. On average, participants were 54 years of age ( SD = 7.45, range 40-65), 54% were women, and 75% attended some college. The data used for the present study can be found in S1 Dataset.

Sampling and Recruitment.

The parent study employed a purposive sampling strategy, also referred to as sampling for heterogeneity [ 54, 55], to recruit eight hundred participants from 40 census tracts across the metropolitan Phoenix area between the years 2007 and 2012. This method increased the external validity of research findings through representativeness of individuals, environment and measured outcomes. Census tracts were established through a factor analysis that yielded five dimensions that together explain 80% of the variance between census tracts. The five dimensions are: (1) social status (describing income, occupation, and education); (2) the presence of school-aged children and multi-person households; (3) retirement communities; (4) residential construction growth between 1995 and 2000; and (5) Native American communities.

Potential participants were contacted in two ways: (1) through mailed recruitment letters printed in both English and Spanish, and (2) recruiters traveled to households approximately one week after letters were mailed to introduce themselves and the study, provide materials about the study, and request participation. Prior to participation, participants gave informed consent. Participants were compensated up to one hundred US dollars for participation in the main study (i.e., questionnaires, home visit, phone interview), and the 25% that was selected for the lab stressors and daily diaries were compensated up to an additional one hundred and forty US dollars. Inclusion criteria for recruitment were: (1) participant presently between the ages of 40 and 65 years, and (2) either English or Spanish speaking. Exclusionary criteria were: presence of physical, psychiatric or cognitive impairments during initial recruitment contact, as measured by the Mental Status Questionnaire [ 56]. No participants were excluded based on these criteria. Attempts were made to keep balance between genders. The study was approved by the Arizona State University Institutional Review Board. Prior to participation, participants gave written informed consent.

Daily diaries.

The daily diaries collected provided accounts of participants' daily life events near in time to the events, as they occurred. Participants were given PC tablets pre-loaded with structured questions that related to the day's most positive and negative events, and questions designed to gauge affect. They were instructed to complete the diary each evening for 30 consecutive days, 30 minutes prior to going to sleep.

Measures

Childhood trauma.

We used the childhood trauma questionnaire (CTQ) to assess the degree to which individuals experienced trauma in childhood [ 57]. The CTQ is a retrospective report that assesses the degree to which individuals experienced emotional, physical, and sexual abuse before the age of 18 ( M = 1.68, SD = 0.86, range: 1-4.8; α = 0.92). Items were answered on a 5-point Likert scale, ranging from 1 ( never true) to 5 ( very often true). Using the stem question, "when I was growing up" participants responded to 10 items. Sample items include "People in my family called me things like "stupid," "lazy," or "ugly;" "I believe that I was physically abused," and, "Someone molested me." Although the CTQ is a retrospective report, it has been used in clinical populations for guidelines for determining whether people reported significant emotional, physical, and sexual abuse during childhood [ 58]. We created a mean score across the ten items that assessed emotional, physical, and sexual abuse, with higher scores reflecting higher levels of childhood trauma. The CTQ was given in the self-report questionnaire prior to participants completing the 30-day diary.

Mastery.

Mastery was assessed using the Pearlin Mastery Scale, α = .82 [ 43]. Items asked participants to rate the extent to which they believe their life is under their own control ("I can do just about anything I really set my mind to do") using a 4-point Likert scale (1 = strongly agree to 4 = strongly disagree). Higher scores indicated more feelings of control over life circumstances. Mastery was given in the self-report questionnaire prior to participants receiving instructions on completing the 30-day diary.

Daily diary: Negative and positive affect.

Each day, participants completed the positive affect and negative affect scale, which totaled 32 items, PANAS [ 27]. The Negative Affect scale consisted of 16 items that assessed a general dimension of aversive affective states, such as feeling distressed, sluggish, hostile, and sad. The Positive Affect scale consisted of 16 items that assessed a general dimension of uplifting or positive affective states, such as feeling happy, relaxed, cheerful, and calm. Respondents indicated how often they had felt this way during the past 24 hours on a 5-point scale ranging from 1 ( very slightly/not at all) to 5 ( extremely). Consistent with the daily diary literature [ 16, 19], well-being is defined as levels of negative or positive affect on days when no negative or positive event was reported and emotional reactivity is defined as changes in negative or positive affect on days when a negative or positive event was reported.

Daily diary: Negative and positive daily events.

During completion of the daily diary each night on the Tablet, participants answered questions pertaining to daily negative and positive events. The specific wording for daily negative events was, " Think of the most stressful event that occurred today, even if it may not have been too stressful. Which category was this event in?" The categories were spouse/partner, family, friends, work, finances, health, other, and no stressful event. For daily positive events, the specific wording was, " Think of the most positive event that occurred today, even if it may not have been too positive. Which category was this event in?" The categories were spouse/partner, family, friends, work, finances, health, other, and no positive event. From these items, we created two dichotomous variables, one for negative events and one for positive events, to indicate whether or not participants reported a negative or positive event during the course of the given day. If participants reported a negative or positive event occurring in the domains of spouse/partner, family, friends, work, finances, health, or other, then the negative or positive dichotomous variable was coded as a 1, with a 0 for days indicative of no negative or positive event.

Table 1 shows the breakdown of the frequency that each of the categories was reported during the course of the 30-day daily diary. We found that, on average, participants reported a negative event on 60% of the diary days, and, on average, participants reported a positive event on 79% of the diary days. The most frequent negative events reported were in the work, family, and other domains. The most frequent positive events reported were in the family, friend, and spouse/partner domains.

Statistical Analysis

Multilevel logistic regression model.

The first set of analyses focused on the extent to which childhood trauma was associated with differences in reports of a daily negative and positive event. Ultimately, our interest was in determining whether childhood trauma increased or decreased one's likelihood of experiencing a negative or positive event over the course of the day. To do so, we used a multilevel logistic regression model, such that the log odds of the probability of reporting a negative or positive event was modeled as the outcome and childhood trauma was included as a person-level predictor. Models were estimated using SAS PROC GLIMMIX[ 59].

Multilevel linear regression model.

The first set of analyses focused on the extent to which childhood trauma was associated with differences in reports of a daily negative and positive event. Ultimately, our interest was in determining whether childhood trauma increased or decreased one's likelihood of experiencing a negative or positive event over the course of the day. To do so, we used a multilevel logistic regression model, such that the log odds of the probability of reporting a negative or positive event was modeled as the outcome and childhood trauma was included as a person-level predictor. Models were estimated using SAS PROC GLIMMIX [ 59].

Multilevel linear regression model.

In a second set of analyses, we estimated a multilevel linear regression model [ 60] to examine whether childhood trauma moderated emotional reactivity to daily negative and positive events. Models were specified as (1) where person i's level of well-being (either negative affect or positive affect) at day t, WBti, is a function of an individual-specific intercept parameter that represents levels of negative affect or positive affect on days when no negative or positive event was reported, β 0i; an individual-specific emotional reactivity slope parameter, β 1i, that captures rates of change in the outcome on days when a negative event was reported; an individual-specific emotional responsiveness slope parameter, β 2i, that captures rates of change in the outcome on days when a positive event was reported and residual error, e ti.

Following standard multilevel modeling procedures [ 60], individual-specific intercepts and slopes (βs from the Level 1 model given in Eq 1) were modeled as the Level 2 model where between-person differences were estimated (i.e., variance parameters) and are assume to be normally distributed, correlated with each other, and uncorrelated with the residual errors, e ti. The expanded model that included childhood trauma, mastery, and socio-demographics took the form

(2)

All models were estimated using SAS PROC MIXED [ 61], with incomplete data accommodated under missing at random assumptions at the within- and between-person levels [ 62].

Results

In a first step, we used the data from the 30-day daily diaries to create two aggregate measures of both negative affect and positive affect, namely a mean and standard deviation. The mean score represents one's overall levels of negative affect and positive affect and the standard deviation score represents one's fluctuations in negative affect and positive affect over the course of the 30-days. Table 2 shows the descriptive statistics for the variables included in the present study. The correlations from Table 2 suggest that reporting more childhood trauma was associated with overall higher levels of negative affect ( r = .16, p <. 05) and lower levels of positive affect ( r = −.21, p <. 05), in addition to greater variability in both negative affect ( r = .21, p <. 05) and positive affect ( r = .23, p <. 05). We also examined the association between childhood trauma and daily mean in negative and positive affect and variability in negative and positive affect using regression models. In the regression models, daily mean and variability in negative affect and positive affect were regressed on childhood trauma. We found substantively similar findings in that higher levels of childhood trauma were associated with higher negative affect, lower positive affect, and more variability in negative affect and positive affect. It is also worth noting the correlation between childhood trauma and mastery, r = −.24, p <. 05, suggesting that higher levels of childhood trauma is associated with reporting lower levels of mastery in midlife.

To examine the data further, we created two groups, low and high levels of childhood trauma, based on a median split of the CTQ and examined whether there were significant differences in the study variables of interest. Table 3 shows that individuals who reported high levels of childhood trauma, on average, were more likely to report lower levels of mastery, more negative affect, less positive affect, and more variability in both negative and positive affect, but the two groups did not differ based on age, gender, and education. These preliminary results suggest that childhood trauma is associated reporting lower overall levels of and more fluctuations in well-being from day-to-day.

Linking Childhood Trauma to Daily Negative and Positive Events

Reports of daily negative and positive events.

Table 4 shows our results from a series of analyses examining whether childhood trauma was associated with the likelihood of experiencing negative and positive events each day. Focusing on daily negative events, we found that childhood trauma was associated with an increased likelihood of reporting a negative daily event (Odds Ratio = 1.43, 95% confidence interval: 1.06, 1.94). This suggests that each one unit increase in childhood trauma is associated with a 43% increased likelihood of reporting a daily negative event on a given day. To examine this finding further, we divided our sample into two groups, people with higher levels of childhood trauma (+1 SD; n = 30) versus lower levels of childhood trauma (-1 SD; n = 64) and examined whether they differed in the percent of days where a daily negative event was reported. In comparing the two groups, we found that the high childhood trauma group, on average, experienced daily negative events on 66% of the diary days, whereas the lower childhood trauma group, on average, experienced negative events on 50% of the diary days. The inclusion of mastery and socio-demographics rendered the effect of childhood trauma no longer significant. Predictors that were associated with an increased likelihood of a daily negative event were lower mastery and more years of education. Focusing on daily positive events, childhood trauma was not associated with engagement in daily positive events (Odds Ratio = 0.78, 95% confidence interval: 0.53, 1.18). Attaining more years of education was associated with increased likelihood of engaging in daily positive events.

Emotional reactivity to daily negative and positive events.

Table 5 shows results from our multilevel linear regression model that examined whether childhood trauma moderated emotional reactivity to daily negative and positive events. First, we found that within-person daily negative events resulted in increases in negative affect (γ ₁₀ = 0.17, p <. 05) and decreases in positive affect (γ ₁₀ = −0.15, p <. 05) and that presence of a positive event was associated with decreases in negative affect (γ ₂₀ = −0.07, p <. 05) and increases in positive affect (γ ₂₀ = 0.38, p <. 05). Childhood trauma was a significant predictor of the within-person daily negative event effect, such that reporting higher levels of childhood trauma was associated with stronger increases in negative affect (γ ₁₁ = 0.03, p <. 05) and stronger declines in positive affect (γ ₁₁ = −0.07, p <. 05) on negative event days. Similarly, childhood trauma was a significant predictor of the within-person daily positive event effect, such that reporting more childhood trauma was associated with stronger increases in positive affect (γ ₂₁ = 0.11, p <. 05). ² In follow-up analyses, we examined whether emotional reactivity to stressful events differed by the source of type of event (spouse/partner, family, friends, work, finances, health, and other). For daily negative events, more childhood trauma was associated with stronger declines in well-being for negative events centered on friends and health. For daily positive events, more childhood trauma was associated with stronger increases in well-being for positive events centered on spouse/partner, family, friends, work, and other.

Fig 1 graphically illustrates the moderating effect of childhood trauma on within-person daily negative events. Compared to participants with lower levels of childhood trauma, participants who experienced more childhood trauma were more likely to report more negative affect and less positive affect on non-event days (left part of A and B in Fig 1). We see that stronger changes or steeper slopes in negative and positive affect as a function of daily negative events is indicative of people with childhood trauma being more emotionally reactive to daily negative events.

Compared to participants with lower levels of childhood trauma, participants with higher levels of childhood trauma were more likely to report more negative affect and less positive affect on non-event days (left part of A and B in Fig 1). Stronger changes or steeper slopes in negative and positive affect as a function of daily negative events is indicative of people with higher levels of childhood trauma being more emotionally reactive to daily negative events.

Fig 2 graphically illustrates the moderating effect of childhood trauma on within-person daily positive events. On days that a daily positive event was reported, people reporting higher levels of childhood trauma were more likely to show a stronger increase or boost in positive affect, suggesting that childhood trauma is associated with being more emotionally responsive to daily positive events.

On days where a positive event was not reported, participants with higher levels of childhood trauma reported higher negative affect and lower positive affect (left part of A and B in Fig 2). People with higher levels of childhood trauma were more likely to show a stronger increase or boost in positive affect on days when a positive event was reported.

In a subsequent model, we included mastery and socio-demographics to examine whether mastery up- or down-regulated emotional reactivity to daily negative and positive events. Table 6 shows results from these analyses. We found that in the context of high childhood trauma, mastery increased one's emotional reactivity to daily negative (negative affect: γ ₁₃ = 0.04, p <. 05; positive affect: γ ₁₃ = −0.003, p >. 05) and positive (negative affect: γ ₂₃ = −0.04, p <. 05; positive affect: γ ₂₃ = 0.12, p <. 05) events. Reporting more mastery in the context of high childhood trauma was associated with stronger increases in negative affect on days where a negative event was reported and stronger increases in positive affect on days when a positive event was reported. Fig 3 graphically illustrates the three-way interaction among within-person daily negative and positive events and between-person childhood trauma and mastery. Part A of Fig 3 shows that high childhood trauma and high mastery is associated with stronger decreases in positive affect on days when confronted with a negative event (dotted line, circle end points). Part B of Fig 3 shows that high childhood trauma and high mastery is associated with stronger increases in positive affect on days when confronted with a positive event (dotted line, circle end points). Our findings suggest that for people who experienced childhood trauma, mastery increases one's sensitivity to their daily event context.

Part A of Fig 3 shows that higher levels of childhood trauma and mastery is associated with stronger decreases in positive affect on days when confronted with a negative event (dotted line, circle end points). Part B of Fig 3 shows that higher levels of childhood trauma and mastery is associated with stronger increases in positive affect on days when confronted with a positive event (dotted line, circle end points). High mastery is represented by circle end points and black lines, whereas low mastery is represented by square end points and gray lines.

Discussion

The objective of this study was to examine social-emotional regulation as one potential pathway linking childhood trauma to poorer health in midlife and beyond. We were able to test multiple components of social-emotional regulation using data from a 30-day daily diary of participants in midlife. We found that childhood trauma was associated with poorer overall levels of and greater fluctuations in daily well-being. Participants who reported higher levels of childhood trauma were more likely to also report stressors each day but their rate of reporting daily positive events did not differ. Furthermore, individuals with higher levels of childhood trauma were more emotionally reactive to daily negative and positive events, evidenced by stronger declines in well-being as a function of negative events and stronger increases in well-being with positive events (e.g., increased sensitivity to context, indicative of differential susceptibility). Lastly, mastery was not protective against decreases in well-being following negative events, but actually also increased one's emotional reactivity to negative and positive events for people with childhood trauma. Our findings demonstrate how early life experiences still affect daily life in midlife and beyond. Furthermore, our results point to childhood trauma likely leading to poorer health in midlife through disturbances in the patterns of everyday life events and responses to those events.

Pathways Linking Childhood Trauma to Health

Childhood trauma was associated with lower overall levels of and higher variability in daily well-being, which are both important constructs to take into consideration. How daily well-being is experienced likely operates through our daily behaviors and health practices that have subsequent effects on physiological processes that underlie the health effects of levels and variability in well-being [ 63]. For example, Ong and colleagues [ 64] found that sleep disturbance was associated with higher daily variability in positive affect in a mid-life sample, even though stable elevations in positive affect were associated with better sleep quality. Less consistency in daily well-being has also been tied to inflammatory markers associated with ill health [ 65].

A second component from the daily diaries ascertaining whether those reporting childhood trauma were also more likely to report daily negative and positive events; there was an association with stressful events but not positive experiences. The findings pertaining to average number of days reporting a daily stressor when contrasting high versus low levels of childhood trauma are startling. Our results indicate that over the course of 30 days, those reporting high levels of childhood trauma (+1 SD) averaged one or more negative events on 20 days compared with an average of 15 days for those reporting low levels of childhood trauma (-1 SD). In extrapolating these numbers to over the course of a year, this results in 60 more days, on average, with daily negative events than those with little or no abuse in their childhoods. Evidence from other studies suggests that these small stressors can have cumulative effects on health and mental health in midlife and beyond [ 16- 17, 19].

Emotional reactivity to daily negative events.

Our findings that childhood trauma was associated with greater emotional reactivity to daily negative events is consistent with previous research on adolescents [ 31- 33]. These vulnerabilities to daily life stressors have been linked to long-term consequences in a number of recent studies [ 24, 64, 66, 67] and may be driven by underlying physiology. For example, several underlying physiological changes that occur as a result of reactivity to daily negative events include activation of the sympathetic and parasympathetic nervous system [ 68]. These physiological pathways were not testable in our dataset, but should be explored in future research [ 69]. In sum, childhood trauma may lead to daily life being, on average, more stressful and unpleasant and over years and decades, this likely accumulates to shape the course of health in midlife and beyond.

Emotional reactivity to daily positive events.

Childhood trauma was associated with greater increases in well-being on days that notable positive events occurred. This finding, coupled with showing that childhood trauma was associated with emotional reactivity to daily negative events, points to the possibility that childhood trauma makes individuals more sensitive to their daily context, otherwise known as differential susceptibility. Broadly speaking, differential susceptibility is defined as contexts through which individuals suffer with negative events and flourish with positive events [ 35, 70- 71]. Childhood adversity may differentially boost well-being through greater responsiveness to lasting changes that have a positive valence. Early life adversity can lead to higher levels of inflammation (13), but positive emotions can offset increases in inflammation and improve immune functioning [ 72]. It is important to note that greater responsivity to positive events does not mean that those with greater childhood adversity had occasions when they were happier than those without those past experiences. As Fig 2 shows they approach but do not surpass levels of well-being of those without childhood trauma. Greater sensitivity, though, does suggest that this population would respond to interventions designed to help them attain more positive social experiences.

Mastery as a Key Resilience Factor for Confronting Childhood Trauma

Before discussing the moderating role of mastery in the context of emotional reactivity to daily negative and positive events for those with childhood trauma, we note that childhood trauma and mastery were moderately correlated, r = −.24, suggesting that childhood trauma is associated with reporting lower levels of mastery. There is limited research in the childhood antecedents of mastery and this finding suggests that childhood trauma sets individuals on a developmental course of lower levels of mastery.

Our findings on the effects of mastery did not fully match our hypotheses. Mastery was associated with a stronger increase in well-being on days when a positive event was reported. However, mastery was not always protective against declines in well-being, and even in fact exacerbated emotional reactivity to negative events in some cases. For people with high levels of childhood trauma, reporting more mastery beliefs were associated with greater decreases in well-being with daily negative events. Our findings suggest that mastery, rather being a positive personality feature across the board, increases one's sensitivity to both good and bad events in everyday life.

There are several plausible reasons for this finding. First, mastery beliefs likely constitute something different for people with high levels of childhood trauma. Individuals who experienced childhood trauma and report more mastery may have John Henryism, a term coined by James and colleagues as signifying someone who believes they can do all and need no help, when in fact with difficult stressors this is less adaptive [ 73]. Similarly, those reporting high levels of mastery may be low on other important resources for managing stressors such as perceived social support. Therefore, these individuals may be too self-sufficient and fearful of relying on others. Second, daily stressors are typically events, experiences, and interactions that are largely uncontrollable [ 74] and this could be compounded for people with childhood trauma and high in mastery. Being high on mastery may result in viewing the world in general as having control over life circumstances, but when encountered with uncontrollable daily events, this clashes with one's expectations, resulting in stronger declines in well-being as a function of daily stressors.

Resilience-Promoting Interventions

Our findings that higher levels of childhood trauma are associated with increased sensitivity to daily context (i.e., differential susceptibility) may result in people being more sensitive or responsive to interventions. There are various routes researchers can take to intervene for better health in midlife and beyond for people with high levels of childhood trauma. First, researchers can focus on increasing levels of mastery. The focus of interventions targeting mastery could be controllability and uncontrollability of daily life events, particularly, negative events. People need to acknowledge that certain daily events, whether they be negative or positive, may not be controllable. For example, Zautra and colleagues in a 25-day daily intervention focused on increasing mastery beliefs through daily phone calls, with messages that focused on identifying positive and negative experiences that were under their control, and encouraging participants to take action to improve their daily lives [ 75]. They found that, although mastery beliefs remained relatively stable over the course of the intervention, the intervention resulted in significant improvements in mental health [ 75].

Second, social relationship interventions have broad-based applicability and could help people with childhood trauma reduce the toxic effects of stress on health and overall functioning [ 76- 77]. Social Intelligence concepts have been embedded within the social and behavioral sciences literature for some time [ 78], and in current writings, these concepts refers to a keen awareness of the value of sustainable social connections, the ability to take another's perspective, and the capacity to engage fully in satisfying relationships [ 79- 80]. Focusing on the plasticity of social relationships through social intelligence training has the potential to benefit people with high levels of childhood trauma through modifying key social cognitions regarding social engagement, and enhance efficacy expectations regarding performance in social situations [ 81]. The approach extends beyond cognitive models and behavioral principals to include attention to evidence of barriers to social-emotional development from adverse experiences in childhood and adult life [ 76].

Limitations and Conclusion

We note several limitations. First, our measure of childhood trauma was a retrospective self-report and people do not always report their childhood experiences, reliably. Prior studies have used the CTQ in clinical populations to obtain reliable accounts of emotional, sexual, or physical abuse in childhood [ 58]. The CTQ measure complements research from previous studies that have focused on childhood misfortune [ 3]. Second, our sample was drawn from the Phoenix metropolitan area, and though it may be fairly representative of middle-aged residents in the southwestern United States, its representativeness of midlife in other regions is unknown. Future research is needed on examine the extent to which similar associations are found in other samples of people in midlife, as well as those in young adulthood and old age. It may be that emotional reactivity to stressors is strongest for those individuals who are in young adulthood and experienced childhood trauma, as compared to people in older ages. Third, it is likely that daily well-being, and reports of and reactivity to daily negative and positive events have physiological consequences for subsequent effects on health. This is in line with research showing that stressors are associated physiological effects [ 68, 82- 83] and future research is warranted that focuses on sympathetic and parasympathetic systems to determine how the physiological changes mediate the effects of stress to eventual health declines.

Early life adversity in the form of childhood trauma has the potential to shape the course of development in midlife and beyond. We explored the extent to which daily social-emotional regulation links childhood trauma to premature declines in health, with a 30-day daily diary that allowed for probing multiple components of social-emotional regulation, such as daily level and variability in well-being, as well as experience of and reactivity to daily negative and positive events. Our findings suggest that one potential pathway linking childhood trauma to poorer overall health in midlife and beyond is through disturbances in the patterns of everyday events and responses to those events. We urge future inquiry examining specific mechanisms underlying these relationships.

Author Contributions

Conceived and designed the experiments: FJI CTR JR AJZ. Performed the experiments: CTR JR AJZ. Analyzed the data: FJI. Contributed reagents/materials/analysis tools: FJI CTR JR AJZ. Wrote the paper: FJI CTR JR AJZ.

References

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# data[].attributes.attachment_link.title
Childhood Trauma and Personal Mastery: Their Influence on Emotional Reactivity to Everyday Events in a Community Sample of Middle-Aged Adults

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Childhood trauma is associated with premature declines in health in midlife and old age. Pathways that have been implicated, but less studied include social-emotional regulation, biological programming, and habitual patterns of thought and action. In this study we focused on childhood trauma's influence via alterations in social-emotional regulation to everyday life events, a pathway that has been linked to subsequent health effects.

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This article investigates how self-esteem and emotion regulation mediate the effects of childhood trauma on adult mental health. The findings suggest that lower self-esteem and poor emotion regulation abilities can exacerbate mental health issues stemming from childhood trauma, highlighting the need for interventions that target these areas in therapeutic settings.

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The role of self-esteem and emotion regulation in the associations between childhood trauma and mental health in adulthood: a moderated mediation model - BMC Psychiatry

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Background High levels of childhood trauma (CT) have been observed in adults with mental health problems. Herein, we investigated whether self-esteem (SE) and emotion regulation strategies (cognitive reappraisal (CR) and expressive suppression (ES)) affect the association between CT and mental health in adulthood, including depression and anxiety symptoms. Methods We performed a cross-sectional study of 6057 individuals (39.99% women, median age = 34 y), recruited across China via the internet, who completed the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Childhood Trauma Questionnaire (CTQ), Self-esteem Scale (SES), and Emotion Regulation Questionnaire (ERQ). Multivariate linear regression analysis and bias-corrected percentile bootstrap methodologies were used to assess the mediating effect of SE, and hierarchical regression analysis and subgroup approach were performed to examine the moderating effects of emotion regulation strategies. Results After controlling for age and sex, we found that (1) SE mediated the associations between CT and depression symptoms in adulthood (indirect effect = 0.05, 95% confidence interval [CI]: 0.04–0.05, 36.2% mediated), and CT and anxiety symptoms in adulthood (indirect effect = 0.03, 95% CI: 0.03–0.04, 32.0% mediated); (2) CR moderated the association between CT and SE; and (3) ES moderated the association between of CT and mental health in adulthood via SE, and such that both the CT-SE and SE-mental health pathways were stronger when ES is high rather than low, resulting the indirect effect was stronger for high ES than for low ES. Conclusions These findings suggested that SE plays a partially mediating role in the association between CT and mental health in adulthood. Furthermore, ES aggravated the negative effect of CT on mental health in adulthood via SE. Interventions such as emotional expression training may help reduce the detrimental effects of CT on mental health. Trial registration The study was registered on http://www.chictr.org.cn/index.aspx and the registration number was ChiCTR2200059155.

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This article reviews evidence linking childhood trauma to difficulties in emotional regulation. It reveals that trauma can lead to maladaptive emotional responses, such as heightened emotional distress and avoidance. The study underscores the importance of addressing emotional regulation in therapeutic interventions for survivors of childhood trauma.

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Wright, Abigail C, Coman, Drew, Deng, Wisteria, Farabaugh, Amy, Terechina, Olga, Cather, Corinne, Fava, Maurizio, Holt, Daphne J

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The Impact of Childhood Trauma, Hallucinations, and Emotional Reactivity on Delusional Ideation

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AbstractBackground. A large body of evidence has demonstrated that childhood trauma increases the risk for developing a psychotic disorder. However, the pa

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This article provides a comprehensive overview of Developmental Trauma (DT) and its significant impact on children's emotional and social functioning. It emphasizes how adverse childhood experiences (ACEs), such as abuse or neglect, can disrupt normal developmental trajectories, particularly in emotional regulation and social cognition. The authors highlight that children subjected to DT often face lasting consequences, including difficulties in forming secure attachments and developing effective coping strategies. The paper discusses various diagnostic challenges and suggests future research directions for understanding DT's complex effects on mental health outcomes​.

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Frontiers | Developmental trauma: Conceptual framework, associated risks and comorbidities, and evaluation and treatment

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Children exposed to adverse childhood experiences (ACEs) and pervasive interpersonal traumas may go on to develop PTSD and, in most cases, will further under…

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This review discusses the interplay between attachment, trauma, and mentalizing. It emphasizes how attachment security can mitigate the impact of trauma and highlights recent advancements in understanding these relationships through neurobiological perspectives. The authors argue that resilience is shaped more by social environments than individual strengths, suggesting new approaches to clinical practice regarding trauma and attachment

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Attachment, Mentalizing and Trauma: Then (1992) and Now (2022)

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This article reviews the current status of research on the relationship between attachment and trauma in developmental psychopathology. Beginning with a review of the major issues and the state-of-the-art in relation to current thinking in the field of attachment about the impact of trauma and the inter-generational transmission of trauma, the review then considers recent neurobiological work on mentalizing and trauma and suggests areas of new development and implications for clinical practice.

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This article explores how various types of childhood trauma influence adult attachment styles. Main discusses the impact of caregiver behavior on attachment strategies, emphasizing that trauma does not automatically lead to insecure attachments; rather, protective caregiving can promote secure attachments even in traumatic contexts. The article also elaborates on how attachment strategies affect processing trauma in therapeutic settings

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This study investigates the effects of parental separation during childhood on adult attachment security and PTSD. The findings indicate that such separations can have long-lasting impacts on attachment styles, influencing both emotional regulation and interpersonal relationships in adulthood. The authors suggest that early trauma experiences must be addressed in therapeutic settings to foster secure attachments

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Separation from parents during childhood trauma predicts adult attachment security and post-traumatic stress disorder | Psychological Medicine | Cambridge Core

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Separation from parents during childhood trauma predicts adult attachment security and post-traumatic stress disorder - Volume 47 Issue 11

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This article examines the links between childhood trauma, attachment styles, and the development of complex PTSD symptoms in adults. It highlights how insecure attachment can impact emotional regulation and coping strategies, influencing the long-term emotional health of individuals who experienced trauma in childhood. Understanding these connections can inform therapeutic approaches for affected individuals

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Childhood trauma, attachment orientation, and complex PTSD (CPTSD) symptoms in a clinical sample: Implications for treatment | Development and Psychopathology | Cambridge Core

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Childhood trauma, attachment orientation, and complex PTSD (CPTSD) symptoms in a clinical sample: Implications for treatment - Volume 34 Issue 3

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This article highlights how traumatic experiences, particularly in childhood, can disrupt the development of secure attachment styles. It emphasizes that trauma can lead to various attachment issues, such as anxiety and avoidance, affecting relationships throughout life. The article also discusses the importance of recognizing these patterns for effective therapy and healing.

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Frontiers | The Influence of Attachment Styles and Personality Organization on Emotional Functioning After Childhood Trauma

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Background: Current literature suggests a tenuous link among childhood trauma, personality organization, adult attachment, and emotional functioning in vario…

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TeachTrauma examines the correlation between trauma and different attachment styles, particularly focusing on disorganized attachment. This resource outlines how experiences of abuse or neglect can lead to disorganized behaviors in children, which may predispose them to later psychological difficulties. The article explains that disorganized attachment can stem from inconsistent caregiver behaviors, contributing to the development of dissociative disorder issues in adulthood.

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Attachment
According to attachment theory created by John Bowlby [19], attachment patterns are "formed in the context of early experiences with caregivers and maintained by later interpersonal relationships in adulthood" [4].

Over time, attachment patterns become internalized and shape how individuals see the self and others in close relationships, which in turn influence how individuals perceive and cope with stress through the lifespan [4].

A researcher named Mary Ainsworth identified three categories of infant attachment styles: secure, insecure avoidant, and insecure ambivalent/resistant [20].

Securely attached babies and children "feel confident that the attachment figure will be available to meet their needs. They use the attachment figure as a safe base to explore the environment and seek the attachment figure in times of distress" [21].

Insecure avoidant children "do not seek contact with the attachment figure when distressed. Such children are likely to have a caregiver who is insensitive and rejecting of their needs. The attachment figure may withdraw from helping during difficult tasks and is often unavailable during times of emotional distress" [21].

Insecure ambivalent/resistant children fail to "develop any feelings of security from the attachment figure. When distressed they are difficult to soothe and are not comforted by interaction with the attachment figure. This behavior results from an inconsistent level of response to their needs from the primary caregiver" [21].

Research has also shown that trauma involving caregivers may significantly disrupt caregiver-child attachment, leading to insecure or disorganized attachment.

Insecure Attachment and Trauma

Inconsistent or unavailable caregivers disrupt children's formation of secure attachments and promote reliance on ineffective emotion regulation strategies, leading to the formation of insecure attachment [26].

Early life traumatic events, such as child maltreatment by caregivers, can disrupt the formation of secure attachment [4].

Longitudinal research suggests that insecure attachment may increase over time among individuals with severe trauma histories and disrupt the developmental process [27].

Insecure parental attachment may lead to negative consequences including increased levels of stress hormones, negative views of themselves and others, and poor regulation of emotion and and/or behavior [1].

Inconsistent and inadequate attachment relationships may also lead to externalizing behaviors (e.g., aggression, bullying) that are linked with subsequent conduct problems [1].

As a result of insecure attachment, feelings of fearfulness and helplessness are generally pervasive through the lifespan and are commonly demonstrated in infant and child behavior [16].

Research shows that fearfully attached individuals are more likely to perceive and interpret events as stressful, which in turn increases their vulnerability to experience adverse psychological symptoms and develop severe psychopathology [25].

The effects of trauma may also be transmitted within relational exchanges that occur between parents and children:

If a parent has untreated trauma, when the parent re-experiences states of terror or rage, the children may be traumatized by the parent's traumatized state and feel frightened by the parent, rather than soothed by them. Consequently, the children may become traumatized themselves [2].

Children may exhibit a tendency to block out or constrict feelings of vulnerability and painful experiences as modeled by attachment figures; over time, children may develop problems identifying and managing their own feelings [16].

Adult survivors of childhood maltreatment are more likely to have insecure rather than secure attachment styles [14]. Trauma survivors with insecure attachment report more trauma-related symptomatology in adulthood [4].

Insecure attachment predicts avoidance of memories of the abuse and avoidant, dependent, self-defeating, and borderline personality disorders in adulthood among incest survivors [12] [13].

Insecurely attached individuals also show higher depression, distress, and posttraumatic stress symptoms than traumatized people who exhibit secure-based attachment [4] [13].

Additionally, older adults who experienced their worst trauma in childhood or adolescence report a higher number of traumatic events through their lifespan compared to older adults who encountered their worst trauma in adulthood [24].

Disorganized Attachment, Trauma, and Dissociation

A fourth category of attachment style was later identified as the "disorganized/disoriented" type [22]. Children exhibiting disorganized behaviors did not fit into the other categories of attachment.

Behaviors coded as disorganized/disoriented included overt displays of fear of the caregiver, contradictory behaviors or affects, misdirected or jerky movements, or freezing and apparent dissociation when approaching the caregiver [23].

This classification has been found to be a risk factor for later developmental problems and tends to be associated with experiencing trauma such as maltreatment during infancy or childhood [23].

In normal, middle class families, about 15% of infants develop disorganized attachment behavior; however, in unhealthy social contexts and in clinical groups this percentage is 2 or even 3 times higher [15].

A meta-analysis revealed that 48% of infants classified as disorganized were assessed by social services as having experienced abuse or neglect [23].

Disorganized caregiver-child attachment is associated with increased vulnerability to later psychological difficulties, especially dissociative experiences [2].

Many dissociative patients may have had disorganized attachment with at least one attachment figure in childhood [8].

Longitudinal research demonstrates that disorganized attachment in infancy specifically predicts dissociation in childhood and early adulthood [7].

Experiencing trauma in infancy also has an enduring impact on the maturation of the right side of the brain [11].

Disorganized attachment may result from parental abuse, neglect, and/or frightening, intrusive, or insensitive behaviors [7].

Parental "frightened and/or frightening behavior" experienced in infancy also leads to an increased vulnerability to dissociative disorders [8].

Dissociative and helpless or withdrawing behaviors in parents have also been found to predict infants' disorganized attachment behaviors [23].

Parents' ongoing experiences of anxiety disorders or forms of social and economic disadvantage have additionally been found to predict disorganized attachment behaviors [23].

Although childhood abuse contributes to the development of dissociative identity disorder (DID), attachment difficulties also likely play a central etiological role in many cases [5].

Blizard (1997) states, "When a child is dependent for survival on a parent or caregiver who is abusive, the child faces an extraordinary dilemma in finding a way to preserve attachment to the caregiver while trying to survive terrifying abuse" [6].

Furthermore, parental loss or other severe life events within the first 2 years of a child's life are also risk factors for the development of dissociative disorders [10].

Severe life events may affect the parental relationship in the crucial period when attachment develops, and contribute to disorganized attachment, which may increase the likelihood of dissociation in later life [10].

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# data[].attributes.attachment_link.title
Trauma's Impact on Attachment - TeachTrauma

# data[].attributes.attachment_link.description
Children who are traumatized are at risk for developing complications with attachment. Attachment According to attachment theory created by John Bowlby [19], attachment patterns are "formed in the context of early experiences with caregivers and maintained by later interpersonal relationships in adulthood" [4]. Over time, attachment patterns become internalized and...

# data[].attributes.body
The APT is a professional organization dedicated to promoting the value of play therapy. Their website offers numerous resources, including research articles, guidelines, and training materials that emphasize the effectiveness of play therapy in addressing childhood trauma and supporting emotional healing.

# data[].attributes.body
This meta-analysis evaluates the effectiveness of play therapy across various populations and settings. The authors found that play therapy significantly improves behavioral and emotional outcomes in children. They discuss various therapeutic modalities and emphasize the importance of play in helping children express feelings and cope with trauma.

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[PDF] The Efficacy of Play Therapy With Children: A Meta-Analytic Review of Treatment Outcomes | Semantic Scholar

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A meta-analysis of 93 controlled outcome studies conducted to assess the overall efficacy of play therapy revealed that effects were more positive for humanistic than for nonhumanistic treatments and that using parents in play therapy produced the largest effects.

# data[].attributes.body
Landreth presents the principles and techniques of play therapy, emphasizing the therapeutic relationship between child and therapist. The book discusses how play can serve as a medium for children to communicate their thoughts and feelings, particularly in processing trauma and emotional distress.

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Play therapy: The art of relationship, 3rd ed.

# data[].attributes.attachment_link.description
This text is the newest edition of Garry Landreth’s comprehensive graduate-level textbook on creating therapeutic relationships with children through play. It details his Child-Centered Play Therapy model, which stresses the importance of understanding the child’s world and perspective. Additionally, it facilitates the play therapy process while allowing therapist and client to fully connect. Professors who have taught courses based on the previous editions will be pleased to find the core message intact with an excellent balance between the classic text and new material. The third edition of Play Therapy: The Art of the Relationship is improved by: an expanded chapter on short-term play therapy; a new, extensive chapter on research with child-centered play therapy; new sections on supervising play therapists, legal and ethical issues, and multicultural principles; photographs, case vignettes, and sample dialogue, bringing the material to life; and, online instructor resources. Both educators and trainers who have relied on previous editions of this text as well as students and practitioners reading if for the first time will find it to be an invaluable guide. (PsycINFO Database Record (c) 2018 APA, all rights reserved)

# data[].attributes.body
This article highlights the essential role of play in child development and parent-child relationships. The authors discuss how play therapy can address various psychological issues in children, particularly those who have experienced trauma. They advocate for integrating play into therapeutic practices to enhance emotional healing and resilience.

# data[].attributes.attachment_link.title
The therapeutic powers of play and play therapy.

# data[].attributes.attachment_link.description
Play is as natural to children as breathing. It is a universal expression of children, and it can transcend differences in ethnicity, language, or other aspects of culture. Play is perhaps the most developmentally appropriate and powerful medium for young children to build adult-child relationships, develop cause-effect thinking critical to impulse control, process stressful experiences, and learn social skills. Play can provide a child the sense of power and control that comes from solving problems and mastering new experiences, ideas, and concerns. Play is not only essential for promoting normal child development, but it has many therapeutic powers as well. Play is used in therapy by play therapists and child clinicians as a means of helping children deal with emotional and behavioral issues. Through the specially chosen toys, games, and materials for their therapeutic and neutral stimulus qualities, the child can reveal unconscious conflicts through the defense mechanisms of projection, displacement, and symbolization. Play has also been found to facilitate the positive emotional bond between parent and child. In play, children can get immediate substitute gratification of their wishes. Frequent engagement in pretend play allows children for better discrimination between reality and fantasy. This chapter has briefly highlighted the various therapeutic change mechanisms within play that can help clients overcome their psychosocial difficulties. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

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This article reviews existing literature on Child-Centered Play Therapy (CCPT) and its efficacy in addressing childhood trauma. It highlights the therapeutic benefits of CCPT, particularly for children experiencing adverse childhood events (ACEs). The authors emphasize the need for further research to validate the efficacy of CCPT across different populations and settings.

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Parker, Maggie M; Hergenrather, Kenneth; Smelser, Quinn; Kelly, Catherine T.

# data[].attributes.attachment_link.title
Exploring child-centered play therapy and trauma: - ProQuest

# data[].attributes.attachment_link.description
Explore millions of resources from scholarly journals, books, newspapers, videos and more, on the ProQuest Platform.

# data[].attributes.body
This article outlines a developmental approach to treating traumatized children, with play therapy as a central component. The authors discuss the stages of child development and how trauma affects children at different ages. They emphasize the importance of play in facilitating healing and helping children regain a sense of safety and trust.

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This article emphasizes the importance of caregiver involvement in trauma treatments for children, particularly when behavioral problems arise. It advocates for including caregivers in therapy for young children (ages 3–6) to foster emotional healing.

# data[].attributes.attachment_link.readable_text
Abstract

This narrative review aims to identify caregiver factors that influence children's trauma treatment process and outcomes and to explore areas for future research. It reviews 29 studies published between 1996 and 2018 identified based on a search of the PsycINFO database and reference review and organizes identified caregiver factors into factors that influence treatment engagement, treatment process, and treatment outcomes in a conceptual model. The results suggest caregiver motivation and caregivers' influences on the child's symptom presentation may impact initial treatment engagement. Treatment process appears to be impacted by caregiver demographics; caregiver trauma exposure; caregiver functioning; caregiver participation in treatment; and the therapeutic relationship. Treatment outcomes appear to be impacted by caregiver support of the child during treatment and caregiver functioning. Caregiver factors, as measured in the extant literature base, generally seem to have the potential to positively impact children's trauma treatment. Exceptions to this are when caregivers experience challenges supporting their child or their child's treatment. Additionally, several limitations are noted in the current literature. Namely, there is a lack of consistent operationalization of caregiver factors and types of caregiver participation, and the role of culture and diversity variables in caregivers' engagement in children's trauma treatment is understudied.

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References

Cohen, J. A., Mannarino, A. P., & Deblinger, E. (2017). Treating trauma and traumatic grief in children and adolescents (2nd ed.). Guilford Press.

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Author notes

Courtney A. Clark

Present address: Community Health Center, Inc, Middletown, CT, USA

Authors and Affiliations

1. Ferkauf Graduate School of Psychology, Yeshiva University, New York, USA

Courtney A. Clark

2. Graduate School of Applied and Professional Psychology, Rutgers University, 152 Frelinghuysen Road, Piscataway, NJ, 08854, USA

Erum Nadeem

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Correspondence to Erum Nadeem.

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Clark, C.A., Nadeem, E. Caregiver Factors in Children's Trauma Treatment: A Review of the Literature. Child Adolesc Soc Work J 40, 773-786 (2023). https://doi.org/10.1007/s10560-021-00812-6
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# data[].attributes.attachment_link.title
Caregiver Factors in Children's Trauma Treatment: A Review of the Literature - Child and Adolescent Social Work Journal

# data[].attributes.attachment_link.description
This narrative review aims to identify caregiver factors that influence children's trauma treatment process and outcomes and to explore areas for future research. It reviews 29 studies published between 1996 and 2018 identified based on a search of the PsycINFO database and reference review and organizes identified caregiver factors into factors that influence treatment engagement, treatment process, and treatment outcomes in a conceptual model.

# data[].attributes.body
CPP focuses on strengthening the caregiver-child relationship as a protective factor in helping children process traumatic experiences. It highlights moments of caregiver attunement as crucial for recovery.

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The history of psychotherapy with young children and their caregivers has now been nearly 75 years in the making. A long list of eminent theorists, clinicians, and researchers have contributed to the establishment of dyadic psychotherapy has a respected treatment intervention. The birth of this new form of psychotherapy is rooted in many factors, including a flourishing interest in early determinants of personality organization; cultural practices and historical events that allowed for the study of early childhood separation from primary caregivers; and an expansion of psychoanalytic and child development paradigms.

The pioneer infant-parent intervention was developed by Selma Fraiberg and colleagues, in 1975, in the USA. Evolving alongside psychoanalytic theories on the role of maternal fantasy in the formation of the infant psyche, this model, which became identified with the metaphor "ghosts in the nursery", illustrated the intergenerational transmission of psychopathology through the parents' reenactment with their baby of unresolved conflicts from their own childhood. Roughly at the same time, schools of psychodynamic parent-infant treatment were developed in Europe, by Serge Lebovici, Leon Kreisler and Michel Soule in Paris and by Bertram Cramer in Geneva. Since then, the understanding and integration of multiple constructs in early childhood mental health intervention has increased impressively. One of the, although apparently simple, overriding notion achieved is that very young children exist in a relational context. Therefore, the relationship is a core target of therapeutic intervention.

Child-parent psychotherapy (CPP) is a more recent and empirically validated form of dyadic psychotherapy. Key components of CPP have their origin in infant-parent psychotherapy as developed by Fraiberg and colleagues, namely, the underlying psychoanalytic conceptualization of intergenerational trauma transmission and the intervention techniques of developmental guidance, concrete assistance, and insight-oriented interpretation. As research and theory have advanced over time, CPP has integrated additional paradigms, both theoretical (attachment theory, trauma theory, developmental psychology, psychoanalytic theory and developmental psychopathology) and of intervention (derived from social work, social learning theory, and cognitive-behavioural therapy). Most recently, CPP has incorporated an innovative concept: "angels in the nursery", seeking to recall (or create) benevolent internal models of positive, responsive, and nurturing care.

As a child-centred treatment, CPP prioritizes the goal of a healthy development across all domains. As a relationship-based treatment that locates the mental health of the young child within the relationship with the primary caregiver, the goal of CPP is to strengthen and support that relationship, building qualities of mutuality, reciprocity, communication, and understanding/empathy. CPP fosters security of attachment, the reestablishment of the caregiver as a source of protection and safety, and caregiver-child mutually constructed meanings as opposed to individually held misperceptions about self and other. Additional goals are child cognitive growth, positive conflict-resolution skills, and accurate reality testing.

These aims are pursued through joint child-parent sessions, in which the therapist uses strategies designed to promote an age-appropriate, goal-corrected partnership between parent and child. A variety of intervention modalities are used in response to different clinical needs, such as translating behavioural meanings using play, physical contact, and language; offering unstructured reflective developmental guidance; modelling appropriate protective behaviour; promoting insight-oriented interpretation; addressing traumatic reminders; retrieving benevolent memories; providing emotional support; and offering crisis intervention, case management and concrete assistance. The concept of "ports of entry" refers to the variety of elements in the parent-child relationship system that may be used as the starting point for an intervention. The choice of which "port" to enter is determined by what is happening in the moment, and the clinician's judgment of what will be most effective in that moment; it is not a singular overall treatment strategy nor a single focus of clinical attention throughout the whole of a given session. Possible ports include the individual behaviour of the child or parent, interactive exchanges between the parent and child, mental representations held by the child of self or of parent, mental representations held by the parent of self or of child, the relationship between the parent and therapist, the relationship between the child and therapist, or the parent-child-therapist relationship.

For these reasons, there are no "typical" CPP cases, and therapeutic strategies are tailored to the specific characteristics of the child and the parents. In general, the match between the therapist's therapeutic strategies and the parent's and the child's receptiveness is the best predictor of treatment outcome. The timing of questions, suggestions, and interpretations is a crucial element in fostering treatment motivation. The therapist needs to cultivate a careful balance between addressing the relevant clinical issues and remaining tactfully alert to the parent's and child's ability to tolerate and make use of these interventions.

Some unique aspects that confront the infant mental health clinician undertaking dyadic therapy must be pinpointed: accurate identification of symptoms in the context of rapid developmental change and a limited repertoire of behaviours; inference of the young child's subjective experience; assessment of symptoms in light of the ongoing interaction between child development and the caregiving environment; mastery of an expanded range and breadth of competencies (the clinician, ideally, should have knowledge of: infant and early childhood development, including brain development and developmentally salient anxieties; adult development; psychopathology and diagnostic categories ranging from infancy to adulthood; psychodynamic therapy including child-play therapy; attachment theory; trauma theory; and current research regarding parent-child interaction); management of multiple simultaneous actual and transferential relationships (the clinician must be attuned to the parent's transference to the child, the parent's transference to the therapist, the child's transference to the therapist, and the therapist's own countertransferential responses to parent, child, and the parent-child relationship-noting that both transference and countertransference reactions can be of a positive or negative cast); tolerance of intense sensory, affective, and cognitive stimulation in the treatment room (working with both parent and child together means having to simultaneously attend to feeling states, behaviours, interactional patterns, play themes and content, and specific trauma material, as they are presented both individually and in interaction); and knowing when to strategically "not intervene" (for example, in the case of a crying, distressed infant and a parent who is either nonresponsive or hostile, the clinician must maintain self-regulation, remain mindful of countertransferential reactions, recall that the infant's best interests may not be well served if it is the clinician who offers comfort, and determine a course of intervention that promotes repair within the dyad).

CPP is indicated in the presence of factors that affect the dyadic relationship in such a manner that symptoms emerge (or are at risk of emerging) in the infants, toddlers, and pre-schoolers (i.e. birth-5years). These factors include:

Traumatic stressors (e.g. domestic violence, community violence, physical abuse, sexual abuse, neglect, serious medical illness with instrumentation, prolonged or repeated separation from primary attachment figure). For the very young child, any threat (or perception of threat) to the primary caregiver is experienced as a potential annihilation of the self. Also, whether the traumatic event occurred to the child alone or to the caregiver and child jointly, it is necessary to treat the dyad, as the primary caregiver may either exacerbate or mitigate the child's trauma, which is, in fact, the most important determinant of the child's subsequent adjustment. Additionally, dyadic intervention may be used as a preventive care strategy, in advance of potentially traumatic life stressors that may present a significant risk for psychiatric or developmental disturbance in the infant or young child (e.g impending death of a parent from a terminal illness, or an imminent separation from a military parent).

Constitutional challenges in the child (e.g. developmental delay, autism spectrum disorder, sensory processing disorder, affect regulation disturbance, prematurity). These circumstances do not necessarily engender problematic reactions in the caregiver, but these can rise. Parental responses such as withdrawal, unrealistic expectations, grief and mourning, overprotection, or hostility can be normative initial reactions but they may also become fixed instead of evolving into a more integrated stance, thereby compromising the optimal development of the individual child and the parent-child relationship. In such situations, dyadic psychotherapeutic intervention is of great benefit. The paradigm of "goodness of fit" (referring to the fit, or lack thereof, between the infant's temperament and the demands of the surrounding environment, including parental temperament) also applies here. In cases of mismatched dyads, dyadic psychotherapy can often improve the developmental trajectory of the caregiver-child relationship.

Disturbances in caregiving (e.g. parental mental illness (including schizophrenia, bipolar disorder, personality disorder, major depression, anxiety disorder, PTSD), parental substance abuse, adolescent parenthood, parental history of trauma). These situations may pose a significant risk to the parent-child relationship given that: 1) caregiver self-regulation is compromised and, therefore, the caregiver's capacity to regulate the child is compromised and 2) caregiver disturbances lend themselves to distortions and misattributions in their perception of the child's feelings, thoughts, and intentions. Maladaptive parenting practices, including externalizing problems (e.g., excessive controlling, punitiveness, self-endangerment and aggression) and internalizing problems, such as emotional constriction and social withdrawal, are also included here.

CPP efficacy has been empirically documented in randomized controlled trials including more than 500 racially/ethnically diverse children in households ranging from poverty to middle-class backgrounds and populations of maltreated infants, toddlers, and pre-schoolers in the child welfare system and pre-schoolers exposed to an average of five traumatic events. These studies have demonstrated this approach results in reductions in both maternal and child posttraumatic stress symptoms, decreased child diagnosis of traumatic stress disorder, improvements in the mother-child relationship and child quality of attachment, positive shifts in child attributions regarding self, mother, and relationships, as well as improved child cognitive functioning. CPP groups had significantly better outcomes than comparison groups posttreatment and at follow-up 6 months, 1 year, and 9 years later.

"A method of child-rearing is not - or should not be - a whim, a fashion or a shibboleth. It should derive from an understanding of the developing child, of his physical and mental equipment at any given stage, and, therefore, his readiness at any given stage to adapt, to learn, to regulate his behaviour according to parental expectations." Selma Fraiberg

"Parents and children help each other to grow. In raising their children, parents are also raising themselves. Child rearing gives parents the chance to redo their own childhood and to improve on it." Alicia F. Lieberman

1. "Psychotherapy with Infants and Young Children: Repairing the Effects of Stress and Trauma on Early Attachment", by Alicia F. Lieberman and Patricia Van Horn, published in 2008. This book describes the conceptual framework underpinning CPP and illustrates complex concepts and intervention modalities using rich case examples.

2. "Losing a Parent to Death in the Early Years: Guidelines for the Treatment of Traumatic Bereavement in Infancy and Early Childhood", by Alicia F. Lieberman, Patricia Van Horn, Nancy Compton, and Chandra Ghosh Ippen, published in 2003. This book was written shortly after 9-11 in an effort to help more people understand how babies, toddlers, and pre-schoolers respond to loss and ways to support them. Rich clinical vignettes illustrate manifestations of traumatic bereavement and intervention strategies.

CPP has been manualized since 2005, with the publication, "Don't Hit My Mommy: A Manual for Child-Parent Psychotherapy with Children Exposed to Violence", by Alicia F. Lieberman and Patricia Van Horn. The 2nd edition was updated in 2015 to include new sections on the phases of treatment and CPP fidelity to support implementation.

The CPP Training materials also include two books with clinical case studies:

However, clinicians are not considered to be certified practitioners until they have received formal CPP training and supervision.

CPP is disseminated mainly in the USA, through the Early Trauma Treatment Network, a centre of the Substance Abuse and Mental Health Services Administration (SAMHSA) National Child Traumatic Stress Network (NCTSN) that involves the collaboration of four university-based programs: University of California, San Francisco Child Trauma Research Program as lead program; Child Witness to Violence at Boston Medical Centre; Child Violence Exposure Program at Louisiana State University Health Sciences Centre; and the Infant Team at Tulane University School of Medicine.

The training of clinicians in CPP is conducted within the NCTSN learning collaborative model, which combines didactic teaching with competence training through case-focused consultation for 18 months. Trainings incorporate the following areas: (1) foundational knowledge of early childhood development; (2) specialized trauma knowledge; (3) knowledge and competencies specific to the learners' roles; (4) ongoing practice; (5) evaluation of professional practice; (6) engaging supervisors and key administrators to develop leadership; (7) interdisciplinary training to address intersystem fragmentation; and (8) consultation and support to promote sustainability.
http://childparentpsychotherapy.com/
In addition to learning collaboratives, CPP is taught through internships and fellowships for master's, doctoral, and postdoctoral students.

International outreach includes implementation-level trainings in Australia, Colombia, Israel, and the Scandinavian countries.

Further information is available on the Child Parent Psychotherapy official website ( http://childparentpsychotherapy.com/providers/training/).

Filipa Martins Silva & Ana Filipa Lopes (Child and Adolescent Psychiatry Trainees in Centro Hospitalar Universitário do Porto)

Revised by: Vânia Martins & Graça Fernandes (Child and Adolescent Psychiatrists in Centro Hospitalar Universitário do Porto)

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Lieberman AF, Dimmler MH, Ghosh Ippen CM. Child-Parent Psychotherapy: A Trauma-Informed Treatment for Young Children and Their Caregivers (2019). In: Zeanah CH, editor. Handbook of infant mental health. 4rd edition. New York: Guildford Press; p. 471-485.

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Lieberman, A. F., Weston, D., & Pawl, J. H. (1991). Preventive intervention and outcome with anxiously attached dyads. Child Development, 62, 199-209.

Pickreign Stronach, E., Toth, S., Rogosch, F., & Cicchetti, D. (2013). Preventive interventions and sustained attachment security in maltreated children. Development and Psychopathology, 25(4, Pt. 1), 919-930.

Toth, S. L., Maughan, A., Manly, J. T., Spagnola, M., & Cicchetti, D. (2002). The relative efficacy of two interventions in altering maltreated preschool children's representationa models: Implications for attachment theory. Developmental Psychopathology, 14, 877-908.

Toth, S. L., Rogosch, F. A., Manly, J. T., & Cicchetti, D. (2006). The efficacy of toddler-parent psychotherapy to reorganize attachment in the young offspring of mothers with major depressive disorder: A randomized preventive trial. Journal of Consulting and Clinical Psychology, 74(6), 1006-1016.

Willheim, E. (2013). Dyadic Psychotherapy with Infants and Young Children: Child-Parent Psychotherapy. Child and Adolescent Psychiatric Clinics of North America, 22(2), 215-239.

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The history of psychotherapy with young children and their caregivers has now been nearly 75 years in the making. A long list of eminent theorists, clinicians, and researchers have contributed to the establishment of dyadic psychotherapy has a respected treatment intervention.

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This study emphasizes the lasting effects of interpersonal trauma experienced during childhood, including difficulties with emotional regulation, behavior, and cognition. It also highlights the importance of supportive, attuned caregiving relationships to mitigate the impact of trauma and promote healing. Proper trauma-informed diagnoses and interventions can improve caregiver-child relationships, which are crucial for helping children develop healthy emotional and behavioral responses.

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Understanding interpersonal trauma in children: why we need a developmentally appropriate trauma diagnosis - PubMed

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Childhood exposure to victimization is prevalent and has been shown to contribute to significant immediate and long-term psychological distress and functional impairment. Children exposed to interpersonal victimization often meet criteria for psychiatric disorders other than posttraumatic stress dis …

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This article provides an overview of how trauma affects children’s development and the key role caregivers play in helping children recover. It explains how supportive, consistent caregiving can help children manage trauma-related symptoms and rebuild trust and emotional stability.

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This article offers a resource guide for caregivers and foster parents, detailing how caregiving can be essential to a child's recovery from trauma. The guide explains how attachment, routine, and supportive caregiving can help children regain a sense of safety and stability.

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Caring for Children Who Have Experienced Trauma: A Workshop for Resource Parents | Children’s Mental Health Network

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Many children in foster or kinship care have a history of exposure to trauma. Caring for Children Who Have Experienced Trauma: A Workshop for Resource Parents (RPC) is a PowerPoint-based training curriculum designed to be taught by a mental health professional and foster parent as cofacilitator…

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This article discusses how early caregiving relationships shape brain development and how supportive, nurturing environments are critical for recovery from early trauma. It emphasizes the caregiver’s role in fostering resilience and healthy brain development in children who have experienced adversity.

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Center on the Developing Child at Harvard University

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InBrief: The Impact of Early Adversity on Children's Development

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providing stable, responsive, nurturing relationships in the earliest years of life can prevent or even reverse the damaging effects of early life stress.

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This guide from the Substance Abuse and Mental Health Services Administration (SAMHSA) outlines the principles of trauma-informed care (TIC) and its implementation in various settings, including education. It emphasizes the importance of understanding the impact of trauma on behavior and learning and provides strategies for creating a supportive environment for students.

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This manual helps behavioral health professionals understand the impact of trauma on those who experience it. The manual discusses patient assessment and treatment planning strategies. These strategies support recovery and the development of a trauma-informed care workforce.

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TIP 57: Trauma-Informed Care in Behavioral Health Services

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This manual helps behavioral health professionals understand the impact of trauma on those who experience it. The manual discusses patient assessment and treatment planning strategies. These strategies support recovery and the development of a trauma-informed care workforce.

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This resource discusses the role of schools in supporting children who have experienced trauma. It outlines the NCTSN's framework for trauma-informed practices in educational settings, emphasizing the need for training staff and implementing policies that promote a safe and supportive learning environment.

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The National Child Traumatic Stress Network

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Creating, Supporting, and Sustaining Trauma-Informed Schools: A System Framework

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Presents a tiered approach to creating a trauma-informed school environment that addresses the needs of all students, staff, administrators, and families who might be at risk for experiencing the symptoms of traumatic stress.

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This report from the National Association of School Psychologists (NASP) provides an overview of how trauma affects students’ learning, behavior, and social-emotional well-being. It discusses the importance of trauma-informed practices in schools to enhance academic and behavioral outcomes for affected students.

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National Association of School Psychologists (NASP)

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Trauma is a serious problem that can increase the risk for psychological, behavioral or emotional problems (depression or PTSD), substance abuse, low occupational attainment or academic failure, socia...

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This article stresses the importance of trauma-informed approaches in schools to support students affected by trauma. It defines trauma-informed education as recognizing trauma's impact on learning and emphasizes principles like safety, trust, collaboration, and empowerment. The article advocates for practical strategies, such as fostering positive relationships and integrating social-emotional learning, while also calling for professional development for staff to effectively implement trauma-informed practices.

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The principal of an internationally recognized trauma-informed school explains what this form of education is-and what it isn't.

ACEs (adverse childhood experiences) have made their way into the mainstream over the past couple of years, even showing up in a segment that Oprah did for 60 Minutes. And because ACEs have a profound effect on children, the concept has been taken up in the world of education. Approaching education with an understanding of the physiological, social, emotional, and academic impacts of trauma and adversity on our students is driving changes in our systems.

However, these changes are not coming without misconceptions. As the principal of Fall-Hamilton Elementary, an internationally recognized trauma-informed school, I've encountered many misconceptions about trauma-informed education over the past five years. As educators move toward understanding the impact of trauma, including ACEs, and how creating and maintaining positive relationships can serve as a buffer to the negative impacts of trauma, it's vitally important to understand what trauma-informed education is and is not.

6 Misconceptions About Trauma-Informed Education

1. Trauma-Informed education is solely about a student's ACE score: The ACE study conducted by Kaiser Permanente and the CDC is credited with increasing public awareness of the potential negative health outcomes of adults based on their adverse childhood experiences.

That increased awareness is good, but trauma-informed education is not solely concerned with students' ACE score. We should use the ACE study as a catalyst to look deeper into understanding the broad scope of adversity that children are experiencing but that the study did not include. Trauma-informed education includes examining the influence and impact on students in our schools of factors such as racism (explicit, implicit, and systematic; and microaggressions) as well as poverty, peer victimization, community violence, and bullying.

2. Educators must know a student's ACE score to successfully intervene: It is not imperative to know a child's ACE score or specific traumatic experience to provide effective interventions. Being trauma-informed is a mindset with which educators approach all children.

Research indicates that strong, stable, and nurturing relationships foster a feeling of belonging that is essential for all students but is absolutely imperative for healing with students who have experienced trauma. Karen Treisman, a clinical psychology specialist, says, " Every interaction is an intervention." As educators, we must understand the impact of daily positive interactions and affirmations for our students.

3. Trauma-informed education is about fixing kids: Our kids are not broken, but our systems are. Operating in a trauma-informed way does not fix children; it is aimed at fixing broken and unjust systems and structures that alienate and discard students who are marginalized.

If we view our trauma-informed approach as fixing kids, that creates a deficit mindset. Many kids are doing the best they can in the moment. We must meet all students where they are while supporting them with strong, stable, and nurturing relationships.

4. Trauma-informed educators don't give students consequences for inappropriate behavior: There needs to be a clear understanding of the difference between consequences and punishment. Consequences by definition are designed to teach, while punishment relates to personal suffering.

It's important to set clear boundaries and expectations and then to support students into success. When students do not meet expectations or disregard boundaries, it is imperative to teach and reteach the expectations through consistent consequences.

5. Sometimes you have to escalate a confrontation with a student to calm them down: Co-regulation is the idea of keeping calm in order to help calm a student who is experiencing anger, frustration, or fear. A dysregulated adult cannot regulate a dysregulated child. Raising our level of intensity is not a strategy that works.

We should instead use strategies that honor the student's emotions and need for space while also getting their systems to calm in a safe way. This can be accomplished through first making sure that we really are calm and then by validating the student's experiences and emotions in order to get to the root of what is causing those emotions.

This doesn't mean excusing any poor choices the student may have made-it means ensuring that they're in a state where they can understand and accept any consequences, which is necessary if they are to learn from the experience.

6. I'm a teacher, not a therapist-this isn't my job: As educators explore the complexities of being trauma-informed, we need to remember that trauma-informed work is a journey and not a destination. It doesn't mean that teachers need to do the work of professional therapists. Our part in helping students with trauma is focusing on relationships, just as we do with all of our students. The strong, stable, and nurturing relationships that we build with our students and families can serve as a conduit for healing and increasing resilience.

Becoming trauma-informed in our daily practice is truly a process of learning and adjustment, but it is a worthwhile process.

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The principal of an internationally recognized trauma-informed school explains what this form of education is-and what it isn't.

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This article explains the core principles of trauma-informed care (TIC) and its significance in various settings, including healthcare and education. TIC is defined as an approach that recognizes the prevalence of trauma and its effects on individuals' lives, emphasizing safety, trustworthiness, and collaboration in interactions. The article outlines six key principles: understanding trauma's impact, prioritizing safety, fostering trust, encouraging peer support, promoting empowerment, and integrating cultural, historical, and gender considerations. By implementing TIC, organizations can create environments that support healing and recovery for individuals who have experienced trauma.

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There are a number of benefits to using a trauma-informed approach, not only for patients but also for providers and staff. Many patients with trauma have difficulty maintaining healthy, open relationships with a health care provider. For patients, trauma-informed care offers the opportunity to engage more fully in their health care, develop a trusting relationship with their provider, and improve long-term health outcomes. Trauma-informed care can also help reduce burnout among health care providers, potentially reducing staff turnover.

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Learn about how trauma-informed care shifts the focus from "What's wrong with you?" to "What happened to you?"

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This source outlines strategies and resources to support trauma-informed schools, highlighting the critical role that schools play in addressing the needs of students who have experienced trauma. It emphasizes the importance of creating safe and supportive environments, which can improve student well-being and academic outcomes. The brief presents key strategies, including training staff in trauma-informed practices, implementing social-emotional learning programs, and fostering strong relationships between students and educators. Additionally, it provides resources for schools to effectively integrate trauma-informed approaches and better position students for success.

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Stephanie Frieze explores the significant effects of trauma on students' mental health, behavior, and academic performance. Children exposed to traumatic experiences, such as violence or abuse, often exhibit academic struggles, poor school attendance, behavioral issues, and symptoms related to mental health conditions like anxiety and depression. Frieze highlights that trauma impacts children's ability to focus, form relationships, and feel safe within school environments. She suggests that educators should use a combination of everyday support, such as building strong, empathetic teacher-student connections, and structured interventions, including trauma-focused programs. These approaches aim to address the unique needs of students impacted by trauma, providing them with coping strategies and tools for resilience in educational settings.

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In their study, Lecy and Osteen examine how childhood trauma impacts college completion rates, utilizing data from the National Longitudinal Study of Adolescent to Adult Health. Their findings indicate that childhood trauma acts as a significant mediating factor between demographic variables—such as race, gender, and first-generation college status—and college completion rates. For instance, being female or a continuing-generation student generally correlates with a higher likelihood of graduation, while childhood trauma often impedes educational outcomes by diminishing cognitive and emotional capacities necessary for academic success. This research underscores the importance of integrating trauma-informed approaches within higher education to better support students who have experienced childhood trauma, addressing a gap in existing educational support systems and informing future policy and program development to enhance educational outcomes for these students.

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The Effects of Childhood Trauma on College Completion

Abstract

This study uses the National Longitudinal Study of Adolescent to Adult Health to examine the effect of childhood trauma experiences on college graduation rates. A longitudinal mediation path analysis with a binary logistic regression is performed using trauma as a mediator between race, gender, first-generation status and college completion. The analysis reveals that being female and a continuing-generation student are both associated with greater likelihood of graduating college and that trauma mediates the relationship between race, gender, first-generation status and college completion. The authors explore the implications for these findings for policy, practice, and future research.

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Introduction

Earning a college degree remains one of the most reliable paths to economic, health, and social stability (Marmot & Wilkinson, 2006; Sing-Manoux et al., 2010; Steptoe et al., 2011; U.S. Department of Education, 2018; World Health Organization, 2003). Despite increasing college enrollment rates in the United States, the social-class achievement gap has actually widened (Page et al., 2019; Stephens et al., 2014). First-generation students are distinctly disadvantaged while attempting to access and navigate the system of higher education (Stephens et al., 2014). Given the disproportionate graduation rates of first-generation students, further research is warranted in exploring the factors which contribute to this phenomenon; including the effects of childhood trauma.

Incipient research continually unveils the expansive net trauma casts on later functioning in life (Metzler et al., 2016; Shonkoff & Garner, 2012). Experiencing childhood trauma correlates with diminished social, emotional, and economic stability into adulthood (Metzler et al., 2016; Sansone et al., 2012; Zielinski, 2009). Despite the budding focus on the effects of childhood trauma on socioemotional outcomes in adults, there is a vast gap in knowledge on the role childhood trauma plays on college achievement rates. This study aims to explore the effect of childhood trauma experiences on later college completion rates among first-generation status, gender, and race.

First-Generation Students and Higher Education

First-generation students are defined as students without a parent having a college degree, versus continuing-generation students who have at least one parent with a college degree (Stephens et al., 2014). First-generation students comprise between two-fifths and three-fifths of all college students (Cataldi et al., 2018; Skomsvold, 2015). First-generation students are more likely to come from lower-socioeconomic households and are more likely to be a racial minority than their continuing-generation counterparts (Horn & Nunez, 2000; Jack, 2019; Sandoz et al., 2017). These students can face a plethora of obstacles while attempting to navigate higher education. They are more likely to be working part- or full-time jobs, be enrolled in less credits, feel unwelcome on college campuses, and struggle to create connections with both faculty and their continuing-generation peers (Beegle, 2003; Sandoz et al., 2017; Tate et al., 2015; Wilson & Gibson, 2011; Wilson et al., 2012).

Obtaining a college degree increases positive outcomes in nearly every facet of life including economic stability, occupational stability, physical health, and mental health (Tate et al., 2015). In regards to health, the benefits of a college degree are vast. Health disparities are wide for college graduates compared to high school graduates; those without college degrees having increased risk for heart disease, diabetes, stroke, cancer, and increased infant mortality rates (World Health Organization, 2003; Zimmerman et al., 2015). Average life expectancy is increased by nine years for college graduates compared to high school graduates (Zimmerman et al., 2015).

Not surprisingly, income and education level are highly correlated (Sandoz et al., 2017). The median income for high school graduates is $31,800, compared to $50,000 for college graduates and $64,000 for those with graduate degrees (U.S. Department of Education, 2018). Obtaining a college degree improves wages and increases access to careers which support higher quality of life with great access to health insurance, increased benefits such as retirement plans, and friendlier work environments (Bloom, 2009). Considering the myriad of health, economic, and social benefits a higher education provides, it is important that students from all backgrounds have equal access and chances of graduating. Unfortunately, first-generation students remain disadvantaged while striving towards the great equalizer of a college degree (Jack, 2019).

Race and Higher Education

White privilege provides pervasive advantages throughout American culture including our systems of higher education (Diangelo, 2018; Fischer, 2010; Jack, 2019). Racial disparities in higher education are evident by viewing the lower rates at which students of color apply, enroll, and graduate from college (Jones & Howard, 2020; NCES, 2019). Black, Hispanic, and Indigenous students may experience increased barriers while attending college and are at greater risk for dropping out compared to their White counterparts (Fischer, 2010; NCES, 2019). Achievement gaps for students of color, especially Black students, are worsened when attending predominately white institutions (Beasely et al., 2016). Stereotype threat, social life satisfaction, and campus racial climates have been identified as contributors toward racial disparities in higher education (Fischer, 2010).

In order to address systemic inequalities embedded in education, it would be fruitful to uncover additional contributing factors to their college completion rates. According to the CDC ( 2019), people of color are more likely to experience adverse childhood experiences at higher rates than their White counterparts. This raises the question on whether childhood trauma could contribute to college graduation rates by race.

Gender and Higher Education

Women increasingly enroll, attend, and graduate from college at higher rates than their male counterparts (NCES, 2013). Roughly, they comprise 60% of college students across the United States (NCES, 2013) and exceed this proportion among Black and American Indian students (Conger & Dickson, 2017; NCES, 2013). Women tend to have higher grade point averages during high school and are more responsive to supportive services such as financial aid, case management, and mentoring (Conger & Dickson, 2017). The growing gender imbalance leaves academic institutions in a unique position to determine how to better support their male students. Female representation in academic settings have been steadily growing since the 1970s (Conger & Dickson, 2017) but the shift to explicitly creating male preference during college recruitment and retention is nuanced. In an attempt to better understand the dwindling rates of college completion among males, it would be helpful to understand what qualities or experiences contribute to their success or failure. Pertinent to this discussion is unveiling the role of childhood adversities on college graduation rates by gender.

Childhood Trauma

Emerging research is illuminating the ruminating effects of experiencing childhood trauma on outcomes well into adulthood. This research reveals a negative impact on health, social, mental health, and employment outcomes (Metzler et al., 2016; Sansone et al., 2012; Zielinski, 2009). Surprisingly, little research on childhood trauma and its effect on higher education outcomes exists. Given the alarming rates children in the United States are exposed to trauma, it appears an essential area to explore.

The Centers for Disease Control and Prevention estimate that two out of three U.S. children experience at least one potentially traumatic event prior to their 18th birthday with approximately a quarter of those children experiencing two or more potentially traumatic events prior to the age of 18 (CDC, 2019). Experiencing trauma during childhood has a titanic impact on one's later ability to live a healthy, fulfilling adult life. Exposure to childhood trauma links to poorer physical health, poorer mental health, and greater risky behaviors in later life (CDC, 2019; Metzler et al., 2016).

The landmark study of Adverse Childhood Experiences (ACEs), authored by Felitti et al. ( 1998) and carried out by the Centers for Disease Control and Kaiser Permanente, created awareness around the prevalence of adverse childhood experiences while also shedding a light on the lifelong toll of childhood trauma (CDC, 2019). Since the Felitti et al. ( 1998) study revealing the complexity of the long-term health impacts stemming from childhood trauma, research in this area continues to emerge. Through this budding research we are at the threshold of understanding the lingering presence of childhood trauma pervasive in multiple domains of adult life. Areas influenced by childhood trauma include attaining a high school degree, employability, earnings, health outcomes, and interpersonal relationships (Metzler et al., 2016).

Trauma and Health Outcomes

The impact of multiple childhood traumas is staggering. The exponential negative impact on long-term health outcomes is known as the dose-response relationship (Flaherty et al., 2013; Metzler et al., 2016). For example, those who experience exposure to four or more different types of trauma have a 12-fold risk increase for depression, suicide attempts, and substance use disorders compared to those without such exposure (Felitti et al., 1998). Childhood exposure to multiple traumas also increases a person's risk for sexually transmitted diseases, smoking, obesity, heart disease, cancer, liver disease, skeletal fractures, involvement in abusive relationships, and premature mortality by 19 years of age (Brown et al., 2009; Felitti et al., 1998; Gilbert et al., 2010).

Trauma's Impact on the Brain

In addition to illuminating the impact of ACEs on health outcomes, research connects the impact early trauma has on brain development (Brown et al., 2009; Felitti et al., 1998; Gilbert et al., 2010; Shonkoff & Garner, 2012). Early childhood traumas and exposure to chronic stress impact how the brain develops, often blocking the development of neuropathways from the limbic system to the prefrontal cortex (Babcock, 2014; Shonkoff & Garner, 2012). The inability to form neuropathways to the prefrontal cortex impacts a range of functions, including planning, task execution, memory, attention span, the ability to learn new skills, and the ability to anticipate events (Shonkoff & Garner, 2012; Shonkoff et al., 2009). Diminished executive functioning skills affect one's ability to function in all areas of life, which can include impairment in interpersonal relationships, parenting, career stability, educational attainment, and financial planning (Babcock, 2014).

Socioeconomic Outcomes

The ability to obtain and retain employment correlates to childhood trauma exposure (Sansone et al., 2012). Adults with childhood trauma experiences are twice as likely to be unemployed compared to adults without childhood trauma (Metzler et al., 2016; Zielinski, 2009). Experiencing childhood trauma puts individuals at a higher risk for having economic instability as an adult (Zielinski, 2009). This includes a greater risk of being in households in which other adults are likely to lose their jobs (Zielinski, 2009). Experiencing childhood trauma also increases one's later risk as an adult to live below the poverty line and to be without health insurance (Zielinski, 2009). Since these studies are correlational, it is difficult to pinpoint the cause of economic instability. However, given that childhood trauma experiences impair physical health, mental health, and brain development, it is possible the weight of these factors contributes to the inability to flourish after experiencing multiple childhood traumas. While research consistently demonstrates that childhood trauma negatively impacts adult employability, some speculate that different types of trauma have different effects on individual functioning. For example, some research indicates that experiencing sexual abuse and witnessing violence have a greater negative effect on employability than experiencing physical abuse or neglect as a child (Sansone et al., 2012). Research has not yet isolated the mechanisms behind those connections.

Additionally, children who experience childhood trauma are less likely to graduate from high school than their counterparts (Metzler et al., 2016). Risk of high school non-completion correlates with the number of adverse childhood experiences experienced (Metzler et al., 2016). The more categories of childhood trauma experienced, the less likely a person is to have graduated from high school (Metzler et al., 2016). Unfortunately, research on the effects of childhood trauma past high school is limited. Considering the vast effects childhood trauma can have on later outcomes, particularly the executive functioning skills of the brain, there is suggestive evidence that increased childhood trauma could correlate with college completion. Given the tremendous benefits of earning a college degree, it would be helpful to better understand the relationship between childhood trauma and college graduation rates.

Need for Current Research

Emerging research on the effects of childhood trauma throughout the lifetime is linking trauma with poorer social, emotional, and health outcomes. A connection between childhood trauma and decreased high school graduation rates has been demonstrated (Metzler et al., 2016). Surprisingly, little research has explored the relationship of childhood trauma with outcomes in higher education. Considering the pervasiveness of experiencing childhood adversities, it appears crucial to understand its effects on college degree attainment. Exploring these factors could provide valuable insight into the longer-term obstacles created by childhood trauma.

Gaining information on the effects of childhood trauma on higher education outcomes will provide insight into developing interventions to increase successful college outcomes. If a connection between childhood trauma and college outcomes exist, it could warrant the bridging of trauma informed approaches with environments of higher education. Budding research suggests primary and secondary education environments utilizing trauma-informed approaches increase educational outcomes (Herrenkohl et al., 2019; SAMSHA, 2014). If rates of childhood adversities correlate with later college graduation rates by generational status, race, or gender it would contribute to the knowledge base on how to strategically target supports for each subset.

Method

The present study aims to increase understanding on how experiencing childhood trauma affects college completion. This study aims to answer the questions: (1) Are race, gender, first-generation status, and trauma predictors of college outcomes? (2) Does trauma mediate the relationships between race, gender, first-generation status, and college graduation? To answer these questions, data from the National Longitudinal Study of Adolescent to Adult Health was selected because of its robust information provided from multiple timepoints over the course of fourteen years (more information below).

Study Procedures

This current study used data from the National Longitudinal Study of Adolescent to Adult Health (AAD Health) which was a nationally representative sample of U.S. youth beginning in the 1994-1995 school year when they were in grades 7-12. The original AAD Health study followed the youth through three more waves including Wave II in 1996, Wave III from 2001-2002, and Wave IV in 2008. The AAD Health study gathered social, emotional, health, and economic data from youth, their parents, and their schools. During Wave I, more than 90,000 students in 7th through 12th grades completed in-school surveys. The researchers then selected a random sample of 20,745 from those 90,000 students for in-home interviews. Their primary parent/guardian also completed an in-home interview; school administrative data also was provided. Wave IV (n = 15,701, current ages 24-32) consisted of an in-home interview, supplemented by lab tests. All respondents who participated in the original Wave I in-home interviews were eligible for Wave IV in-home interviews. Eighty percent of the eligible participants participated in the final Wave IV in-home interviews. For full details of this longitudinal study, see Harris and Udry ( 2018).

This dataset is well-suited to answer the research questions outlined above due to the comprehensive nature of the AAD Health dataset including topics related to race, gender, childhood trauma, and college attainment. It also offers advantages over one-time cross-sectional surveys since it captured participant data at four separate time points using a mix of surveys, in-home participant interviews, parental interviews, and administrative data.

Participants

The present study consisted of data collected in Waves I, II, III, and IV. For the present study, the authors limited participants to those who completed each wave of the interviews (Wave I, II, III, and IV) (n = 5114). The sample was further narrowed to include participants who entered four-year colleges. Additionally, only participants who identified as Black or White were included in the final sample. Race was originally assessed as White, Black or African American, American Indian or Native American, Asian or Pacific Islander, or Other (Harris & Udry, 2018). However, American Indian, Native American, and Asian/Pacific Islander groups did not have sufficient sample sizes for subgroup analysis and were thus removed, bringing the final sample to n = 2917. Among the participants who entered college, 58.3% identified as female and 41.7% as male. Regarding race, 77.6% of the participants identified as White or Caucasian and 22.4% indicated their primary identification as Black or African American. First-generation students comprised 49.2% of the sample and 50.8% were considered continuing-generation students. In the final interview, the age range was from 24 to 32 years-old (M = 26.9 years).

Model Variables

The primary outcome, college completion, was defined by the authors as whether participants graduated from a four-year-college. This information was obtained from participants during Wave IV, in-home interviews. This variable was transformed into a binary variable with the categories defined as did not complete college = 0; or completed college  = 1.

Childhood trauma was defined as adverse experiences experienced by the participant prior to the age 18. All four waves of AAD Health assessed different trauma experiences, and a total of 17 questions assessed the experiences prior to the age of 18. Questions included assessments of home life such as whether their parents were depressed, mentally ill, or suicidal, whether the participant experienced neglect or abuse. Trauma questions also included experiences that could be external to the home, such as experiencing an assault, or witnessing violence. Sample items include: "Before your 18th birthday, how often did a parent or adult caregiver hit you with a fist, kick you, or throw you down on the floor, into a wall, or down a stairs?", "Have you saw a shooting/stabbing of person?", and "Had a knife/gun pulled on you?". If participants indicated they experienced any dose of the event, they were provided a score of one for that response. Responses were summated with higher numbers indicating more trauma experiences. Trauma questions were selected to mirror CDC's ( 2019) framework around Adverse Childhood Experiences and their Behavioral Risk Factor Surveillance System (CDC BRFSS, 2021). Trauma scores were summed to capture the dose-response relationship demonstrated in previous research, which suggests multiple childhood traumas have an exponential negative impact on long-term outcomes (Flaherty et al., 2013; Metzler et al., 2016).

Gender, generational status, and race are the primary predictors in the model. Gender was a binary category coded as female = 0 or male = 1. First-generation was a binary category coded to include participants who had at least one parent graduate from college (continuing-generation) = 0 versus participants who didn't have a parent who graduated from college (first-generation) = 1. Race was originally assessed as White, Black or African American, American Indian or Native American, Asian or Pacific Islander, or Other (Harris & Udry, 2018). Race was recoded into a binary category of White = 0 or Black = 1 because all other categories did not have sufficient sample sizes for subgroup analyses.

Analyses

A longitudinal binary logistic regression mediation path analysis, a subset of structural equation modeling, was performed using Mplus statistical software (version 8.3; Muthén & Muthén, 1998-2017) using maximum likelihood estimation with robust standard errors (MLR). The model was tested using race, gender, and first-generation status as primary predictors of college completion, and trauma as the mediating variable. The model was just-identified and demonstrated perfect fit to the data.

Results

The study sample was predominantly female (58.3%), and White (77.6%). Generational status was closely distributed with first-generation students representing 49.2% of the sample and 50.8% continuing-generation students. Females graduated at higher rates compared to their male counterparts (52.5% and 46.8% respectively). In the sample, 44.4% of Black students completed college, compared to 51.2% of White students. A starker disproportionality was observed based on generational status, with only 38.0% of first-generation students graduating compared to 68.0% of continuing-generation students (Table 1).

Table 1 Sample characteristics

Trauma experiences ranged from 0 to 9 ( Mean = 1.63, SD = 1.56). On average, males reported 1.67 ( SD = 1.58) trauma experiences compared to 1.60 ( SD = 1.55) for females. White students had an average of 1.45 ( SD = 1.49) trauma experiences, whereas Black students reported an average of 2.10 ( SD = 1.69) trauma experiences. First-generation students reported more trauma experiences ( Mean = 1.91, SD = 1.64) than their continuing-generation students ( Mean = 1.31, SD = 1.40) (Table 2).

Results for College Completion

Odds ratios were calculated for direct effects only. To ensure comparisons of direct and indirect effects, our reporting focuses on the linear regression coefficients. For clarity of interpretation regarding odds ratios, negative linear regression coefficients less than one indicate a decreased likelihood of this event happening. Odds ratio of more than one indicates an increased likelihood of this event happening.

Direct Effects

Whether the student identified as White or Black was not a statistically significant predictor of whether they graduated from college (b =  − 0.01, p = 0.824). Students' gender was a statistically significant predictor of whether the student graduated from college. Male students were less likely to graduate from college than their female counterparts (b =  − 0.07, p = 0.002). Whether the student was a first-generation student or a continuing-generation student was a statistically significant predictor of whether they would graduate from college. First-generation students were less likely to graduate from college than their continuing-generation counterparts (b =  − 0.31, p ≤ 0.001). Experiencing childhood trauma was a statistically significant predictor of whether they would graduate from college (b =  − 0.29, p ≤ 0.001). The higher the number of trauma events experienced, the less likely the participant was to graduate from college.

Indirect Effects

There was a statistically significant indirect effect of race on college completion through childhood trauma experiences corresponding to a full mediation of the relationship between race and college completion (b =  − 0.03, p ≤ 0.001). This indicates that trauma serves as a full mediator between the relationship of race and college completion, suggesting this relationship is expressed by Black students' stronger connection to childhood trauma than White students. There was a statistically significant indirect effect of gender on college graduation through childhood trauma experiences (b =  − 0.02, p = 0.006). Trauma serves as a partial mediator between gender and college completion, indicating that a portion of this relationship is manifested in the gender-trauma connection. This means that the reduced likelihood of college completion for males is partially explained by their stronger connection to trauma than females. There was a statistically significant indirect effect of generational status on college graduation through childhood trauma experiences. Trauma serves as a partial mediator to the relationship between generational status and college completion, indicating that a portion of this relationship is manifested in the first-generation-trauma connection (b =  − 0.02, p = 0.001). This means the reduced likelihood of college completion for first-generation students is partially explained by their stronger connection to trauma than continuing-generation students (see Table 3; Fig. 1). Direct and indirect effects can be combined to obtain an estimate of the total effect between race, gender, generational status, and childhood trauma experiences and college graduation. Based on the results of the model, the total effect is 20.2% (R ²  = 0.202, p < 0.001).

Table 3 Model for predicting college completion

The Mediation of College Completion (standardized coefficients and 95% CI's)

Discussion

The findings from the present study suggest experiencing childhood trauma plays a powerful role in college outcomes. The findings suggest that first-generation, male, and Black students experience worse outcomes in higher education as their childhood trauma experiences increase. Considering first-generation, Black, and male students are at increased risk of dropping out of college than their peers (CFFGSS, 2018; NCES, 2019), it is useful to uncover contributing barriers to their success and it appears that childhood trauma may play an important role in their academic trajectories.

First-generation students vary greatly in their demographics and experiences. On average, they tend to graduate at rates 14-15% lower than their continuing-generation counterparts (DeAngelo et al, 2011; Postsecondary National Policy Institute, 2021). First-generation students are more likely to be older, have dependents, identify as a student of color, work more hours, have less income, and attend school part-time compared to their continuing-generation peers (CFFGSS, 2018; NCES, 2019). Academic literature has long focused on a variety of obstacles contributing to the college trajectory of first-generation students but thus far, the effects of childhood trauma has been underexamined. This study indicates the reduced likelihood of college completion for first-generation students is partially explained by their stronger connection to trauma than continuing-generation students.

Students of color, especially Black students, face substantial obstacles to successfully navigating higher education. Black students face greater barriers in accessing higher education than Whites, including a greater likelihood of living in poverty (Kaiser Foundation, 2017). Once enrolled in college Black students may experience difficulties establishing a sense of belonging, forming social networks, and overcoming racism (Fischer, 2010). Analyzing graduation rates through childhood trauma experiences was especially pertinent for Black students, who did not have statistically significant differences in graduation rates compared to their White counterparts when examining direct effects. However, when using childhood trauma experiences as a mediator, the results indicate trauma serves as a full mediator between the relationship of race and college completion, suggesting this relationship is expressed by Black students' stronger connection to childhood trauma than White students. In order to address the racial disparities pervasive in many systems of higher education, it is essential to uncover potential contributors toward achievement gaps. The full mediation demonstrated in this study between race, trauma experiences, and graduation rates, indicates a need for the development of policies and interventions addressing the deleterious effects of childhood traumas among Black students on college completion.

Childhood trauma experiences also affect college graduation rates among male students, indicating the reduced likelihood of college completion for males is partially explained by their stronger connection to trauma than females. Overall, female students represent a growing number of the college population with females representing approximately 60% of college campuses (Jacobs, 2002). This gender imbalance is a growing concern as college graduation rates for males continue to lag (Jacobs, 2002). Research evaluating support services aimed at increasing retention and graduation rates indicate females are more likely to take advantage of both mentoring and financial assistance programs (Angrist et al., 2009). Our findings demonstrating the confounding effect of trauma on male graduation rates, warrants further concern on why these students may be left behind. The development of interventions aimed at addressing the negative outcomes of childhood adversity should consider ways to increase engagement among male students.

Limitations

The present study utilized data from the National Longitudinal Study of Adolescent to Adult Health to examine the effect of childhood trauma experiences on college graduation rates. This database is extensive and includes a wide breadth of data points from middle-school into adulthood. However, using any secondary dataset creates limitations regarding which research questions can be asked and results should be interpreted within the context of the limitations of the dataset.

One of the limitations is the grouping of the variable "race". The original AAD Health dataset categorized race as White, Black or African American, American Indian or Native American, Asian or Pacific Islander, or Other (Harris & Udry, 2018). Due to smaller subgroup sizes among American Indians and Asian/Pacific Islanders, they were excluded from the analyses, resulting in a binary variable for race comparing Black versus White students. Postsecondary graduation rates can vary greatly for students in different racial and ethnic groups (NCES, 2019) and it would be beneficial for future research to explore differences experienced across racial groups. However, despite limitations the present study still offered insight into the experiences of Black and White students in regards to the differing role of childhood trauma on their college graduation rates. It was important to explore the relationship between race, childhood trauma, and college graduation rates because people of color often experience childhood adversities at higher rates than Whites (CDC, 2019).

Another consideration to the present study was the ability to capture childhood trauma experiences. AAD Health did have an extensive set of questions throughout the course of the study that captured a variety of childhood trauma experiences. However, the questions were not standardized or based upon any specific measurement tools. Fortunately, many of the questions paralleled those of the more prominent Adverse Childhood Experiences (ACEs) questionnaire with the present study also including some experiences that could happen outside of the family (witnessing or experiencing violence).

Implications

The findings from this study increase our knowledge base on the effects of gender, race, first-generation status, and childhood trauma on later college degree completion. The present study indicates that first-generation students, male students, and those who experienced increased childhood trauma are at higher risk of not completing college once enrolled. Experiencing childhood trauma increases the risk of dropping out of college for first-generation students, males, and Black students. These findings suggest targeting interventions which better support increased graduation rates among these groups could be fruitful and have a considerable economic payout long-term. If greater rates of first-generation, Black, and male students graduated college, their earning potential would increase and they would likely experience better physical, social, and emotional well-being.

Future research should explore whether existing school environments are successfully supporting the retention of these students and which interventions are effectually increasing their retention and graduation rates. In order to target future policy and practice efforts, it would be helpful to better understand the experiences of these student groups and what perceived barriers exist. Further, it would be advantageous to better understand if there are existing academic environments or programs supporting these students to thrive and what mechanisms are increasing graduation rates.

This study was one of the first exploring the effects of childhood trauma on later college completion. Considering the results, more research is merited to explore the relationship between childhood trauma and college completion rates. Germane to this idea is the newly emerging research on the effectiveness of using trauma-informed approaches for primary and secondary academic settings (SAMSHA, 2014). Currently, research on the implementation of trauma-informed approaches targeting college level students appear nonexistent. Considering approximately 66% of the population experiences at least one traumatic event prior to their 18th birthday (CDC, 2019), utilizing trauma-informed approaches in higher education settings would be useful in supporting the vast majority of students.

A trauma-informed approach is not a program but more of a philosophy encouraging school-wide systemic changes. Trauma-informed approaches could be adapted into campus settings in a variety of ways including trauma specific interventions, classroom adaptations, or more broadly incorporated into organizational culture. Basic tenets of a trauma-informed approach include (1) fostering an environment of safety, (2) being trustworthy and transparent, (3) utilizing peer support, (4) collaborating and working toward mutually agreed upon goals, (5) empowerment, voice, and choice, and (6) consideration of cultural, historical, and gender issues (SAMSHA, 2014). Embracing this framework may seem foreign to academics, however, tenets of trauma-informed care already parallel common frameworks used in education settings such as learner-centered theory. Learner-centered theories have been implemented in education settings with the hopes of fostering conducive mentoring between educators and students (Boyer, 2016; Cornelius-White, 2008). Core components of learner-centered theory emphasize sharing control and choice between educators and students, shifting the focus towards the learner (as opposed to the teacher), and mutual endorsement of learning projects (Cornelius-White, 2008).

This study shed light on the negative effects of childhood trauma on college graduation rates, especially for first-generation, male, and Black students. While considering potential policies and strategies to better support students, it would be beneficial to utilize trauma-informed frameworks which promote safety and authentic learning, encouraging all students to actualize their full potential. Since experiencing childhood adversities are widespread and their effects far-reaching, implementing cultural shifts and multi-pronged approaches in higher education to combat their negative lifelong effects would be advantageous (SAMSHA, 2014). Bearing in mind the multitude of benefits of earning a college degree, investing in strategies which increase college graduation rates for these populations would strengthen the economic fibers of our country.

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Natalie Lecy & Philip Osteen

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Lecy, N., Osteen, P. The Effects of Childhood Trauma on College Completion. Res High Educ 63, 1058-1072 (2022). https://doi.org/10.1007/s11162-022-09677-9
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# data[].attributes.attachment_link.title
The Effects of Childhood Trauma on College Completion - Research in Higher Education

# data[].attributes.attachment_link.description
This study uses the National Longitudinal Study of Adolescent to Adult Health to examine the effect of childhood trauma experiences on college graduation rates. A longitudinal mediation path analysis with a binary logistic regression is performed using trauma as a mediator between race, gender, first-generation status and college completion.

# data[].attributes.body
This article explains how childhood trauma disrupts learning by altering brain function, often causing children to struggle with memory, focus, and emotional regulation. Trauma activates survival responses, leading to an overactive amygdala, which heightens stress and anxiety, and a weakened hippocampus, which can impair memory. In school, these neurological effects may manifest as behavioral issues, difficulty concentrating, and challenges in forming relationships. Trauma-sensitive environments and therapeutic approaches, such as Cognitive Behavioral Therapy (CBT), can support children in coping and engaging more effectively in learning.

# data[].attributes.attachment_link.readable_text
Trauma can affect a child's learning and behavior in many ways. With trauma-informed care, you can help them cope in the classroom.

From an elementary student who has outbursts of anger during class to a teenager who freezes up and can't focus on exams, there are many ways that trauma can manifest and impact the learning process.

Rather than thinking of these as disruptive behaviors, trauma-informed care offers another perspective: What happened to these children, and how can we help them?

Childhood adversities and trauma (CAT) can stem from a variety of circumstances. In short, it's a natural response to anything that feels too overwhelming for a child's developmental state.

Types of trauma include:

When a child experiences trauma, the brain's stress response becomes activated, which takes up a lot of emotional bandwidth.

Out of necessity, learning may take a backseat, explains Andrew Gerber, MD, PhD, president and medical director of Silver Hill Hospital in New Canaan, Connecticut.

"Trauma puts the child's mind and the body into fight-or-flight mode and redirects energy away from more sophisticated developmental needs, like well-tuned emotion regulation, cognitive processes (such as attention), and high-level social cognition like identity and relationship formation," he says.

Trauma can also lead to the freeze response (shutting down to avoid threats) and the fawn response (focusing on the needs of others and neglecting yourself).

As a result of these prolonged stress responses, research - including a 2019 study - shows that childhood trauma literally changes the structure of the brain in two main areas:

hippocampus: learning, memory, spatial relationships

prefrontal cortex: attention, emotional regulation, problem-solving

There are many signs of childhood trauma.

These can often mirror the symptoms of other diagnoses, explains Carlea Dries, PsyD, a psychologist and school neuropsychologist in Paramus, New Jersey.

Trauma-related behaviors may look similar to:

"For example, a child in a 'fight response' may demonstrate impulsive decision-making, engage in risky behaviors, and have difficulty self-regulating. A child in a 'freeze response' might withdraw from others, appear to zone out, or be incapable of making decisions," says Dries.

"Any of these signs can limit the amount of learning the individual can access, as well as have a negative influence on interpersonal relations," she adds.

Cognitive and learning-related signs of trauma in the classroom include:

difficulty concentrating in class

being easily distracted

test anxiety

trouble adapting to changes

reduced memory capacity

Behavioral signs that might show up in class include:

angry outbursts

avoiding peers and teachers

conflict with peers

hypervigilance

lowered grades

trouble with eye contact

Emotional signs of trauma that can interfere with learning include:

Somatic (body-based) signs include:

Trauma-informed practices switch the emphasis from what's "wrong" with a child, to what the child may have experienced.

"Focusing on the behaviors can deter us from the underlying issue of trauma. Encouraging and promoting emotional intelligence - the ability or willingness to look beyond a behavior - is important, since anxiety and trauma can show up as disruptive behaviors," says Albert Nguyen, LCSW, a licensed psychotherapist in Palo Alto, California.

Trauma-informed care may help children:

feel safe in their physical environment

avoid being retraumatized

connect with educators

improve school performance

stay in school

"At the end of the day, it's about relationships," says Nguyen. "Rapport is the single-strongest indicator of success in therapy, and it's no different in a classroom. Fostering positive reinforcement and strength-based strategies is key."

Childhood trauma can have far-reaching impacts in the classroom - and in life.

The more that parents, caregivers, and educators can help mitigate some of these effects, the better-prepared children will be for success.

There are many resources about how to provide trauma-informed care:

You may also find it helpful to delve into a few books on this subject. Some useful titles include:

"Trauma Through a Child's Eyes: Awakening the Ordinary Miracle of Healing" by Peter A. Levine, PhD, and Maggie Kline, LMFT

"Trauma-Informed Social-Emotional Toolbox for Children & Adolescents" by Lisa Weed Phifer, NCSP, and Laura K. Sibbald, CCC-SLP

"Healing Developmental Trauma: How Early Trauma Affects Self-Regulation, Self-Image, and the Capacity for Relationships" by Laurence Heller, PhD, and Aline LaPierre, PsyD

"The Body Keeps The Score" by Bessel van der Kolk, MD

# data[].attributes.attachment_link.keywords[]
how does childhood trauma affect learning

# data[].attributes.attachment_link.title
How Does Childhood Trauma Affect Learning and Education?

# data[].attributes.attachment_link.description
Trauma can affect a child's learning and classroom behavior in many ways. Trauma-informed school systems can help them cope.

# data[].attributes.body
This article explains how trauma significantly impacts academic achievement, often leading to lower grades, reduced standardized test scores, and increased absenteeism. Students affected by trauma are also more likely to be placed in special education or disciplinary programs due to difficulties with attention, memory, and language. Additionally, trauma can reduce students' motivation and interest in learning, which may lead to disengagement and apathy in school. Creating trauma-informed educational environments is essential to support these students in overcoming academic challenges.

# data[].attributes.body
The systematic review Buffering the Effects of Childhood Trauma within the School Setting examines trauma-informed and trauma-responsive interventions aimed at supporting trauma-affected youth. It identifies strategies, such as creating safe, inclusive classroom environments, providing social-emotional learning, and fostering strong teacher-student relationships, that help mitigate trauma's impact on students. The review emphasizes that integrating these approaches can improve academic and social outcomes by addressing trauma's root effects on cognitive and emotional development.

# data[].attributes.attachment_link.readable_text
Childhood trauma exposure is a highly pervasive and significant public health problem associated with physical and psychological consequences across the lifespan. Recent population-based estimates suggest that almost two thirds of children in the United States experience at least one traumatic event before age 16, with approximately 674,000 children affected by maltreatment in 2017 (Copeland et al., 2007, McLaughlin et al., 2013, U.S. Department of Health Human Services, 2019). Traumatic experiences differ from stressful experiences in that they involve exposure to actual or threatened death, serious injury, or sexual violence via directly experiencing or witnessing an event, learning that the event happened to a close friend or family member, or experiencing repeated or significant exposure to aversive details of the event (American Psychiatric Association, 2013). More specifically, childhood trauma exposure may involve maltreatment, which refers to experiences of abuse (physical, sexual, or emotional) and/or neglect (Barnett et al., 1993, Cicchetti and Valentino, 2006). Childhood trauma exposure may also involve loss or community violence (Fowler, Tompsett, Braciszewski, Jacques-Tiura, & Baltes, 2009), human-made disasters (e.g. terrorism, war, displacement; Dirkzwager, Kerssens, & Yzermans, 2006), parental separation (Pesonen et al., 2008), household dysfunction (e.g., parental incarceration, household substance use; Felitti et al., 1998), traumatic medical experiences (e.g., burns; Kazak, Boeving, Alerfer, Hwang, & Reilly, 2005), mass shootings (Orcutt, Bonanno, Hannan, & Miron, 2014), political violence (Cummings, Merrilees, Taylor, & Mondi, 2017), and natural disasters (Fu & Underwood, 2015). Thus, childhood trauma exposure refers to a range of experiences that may be acute or chronic. Polyvictimization is common, with a significant portion of children experiencing multiple types of traumatic events (Finkelhor, Omrod, & Turner, 2007).

An extensive body of literature demonstrates that childhood trauma exposure is associated with a range of deleterious emotional, behavioral, and biological sequelae across the lifespan (Felitti et al., 1998; (Dube et al., 2003). Although not all individuals who experience trauma go on to develop post-traumatic symptoms, national prevalence estimates suggest that 7% of girls and 3-4% of boys experience posttraumatic stress disorder (PTSD; Kilpatrick et al., 2003, McLaughlin et al., 2013), with a much larger number experiencing subclinical levels of traumatic symptoms such as avoidance, hyperarousal, and intrusions (Copeland et al., 2007). Beyond PTSD, trauma exposure is associated with a range of other psychological consequences, with up to 20% of trauma-exposed youth exhibiting behavioral problems that may interfere with functioning in other domains as compared to 10% of youth who report no history of trauma exposure (Copeland et al., 2007).

In particular, childhood trauma exposure disrupts academic functioning and negatively predicts educational achievement (e.g. Hardaway, Larkby, & Cornelius, 2014). For example, Perfect, Turley, Carlson, Yohanna, and Saint Gilles (2016) concluded that children exposed to trauma tend to have impairments in cognitive, socioemotional, and academic domains (e.g., grade retention and lower grades) in comparison to their peers without trauma histories (see also Romano, Babchishin, Marquis, & Frechette, 2015). In addition, students with trauma histories are often rated by their teachers as demonstrating more externalizing (e.g., aggression, hyperactivity, and defiance) and more internalizing (e.g., sadness, depression, anxiety, low self-esteem) behaviors compared with students who have not been exposed to trauma (Perfect et al., 2016). Further, children affected by trauma are more likely to be punished within the school setting for displaying problematic behavior. Specifically, the experience of maltreatment is associated with more school suspensions and referrals for disciplinary action within the schools setting (e.g. Eckenrode et al., 1993, Fantuzzo et al., 2011, Shonk and Cicchetti, 2001).

The negative effects of trauma within the school setting have lifelong implications, reaching far beyond the academic setting. For instance, the negative school outcomes associated with trauma for children are often referenced as the start point for the 'school-to-prison pipeline' wherein students who are affected by trauma are more likely to receive exclusionary consequences for behaviors within the school setting (such as suspension) and thus more likely to become associated with the juvenile justice systems (e.g. Kupchik, 2014). Further, exclusionary disciplinary measures, are associated with lasting negative effects including greater odds of being the victim of a crime, participating in criminal activity, and being incarcerated as an adult even after controlling for academic performance and achievement (Wolf & Kupchik, 2017).

Given the widespread effects of trauma exposure on children within the educational system, school-based interventions could have positive life-long implications for trauma-affected youth. Further, the school setting provides an opportune locale in which broad scale approaches and more targeted interventions to trauma exposure can be delivered to a wide range of students who might not have the means to access services otherwise. Specifically, there has been recent, substantial interest in adopting a trauma-informed approach throughout educational systems to address the impacts of childhood trauma exposure that goes beyond providing intervention in response to trauma that has already occurred and includes prevention services at universal and targeted levels (e.g. Overstreet and Chafouleas, 2016, Wiest-Stevenson and Lee, 2016, Walkley and Cox, 2013). For instance, the Substance Abuse and Mental Health Services Administration (SAMHSA, 2014) put forth a model that calls for the integration of trauma-sensitive care and practices within the broader structure of an organization (i.e., trauma-informed approach) rather than employing specific interventions in response to a particular traumatic event (i.e. trauma-specific interventions). Importantly, trauma-specific interventions may play a critical role in contributing to a broader trauma-informed approach, but when taking a trauma-informed approach, trauma-specific interventions are delivered in concert with other services such as more broad skill-building programs for youth who are at-risk for trauma exposure. As such, papers based on the SAMHSA model for trauma-informed schools typically discuss prevention and intervention efforts within the school setting as integrated across three tiers of service (see Fig. 1). Rather than existing as separate constructs, in a trauma-informed approach, the three tiers are meant to build upon one another and seek to offer more intense and individualized services with each higher tier (e.g. Franklin et al., 2017).

Several papers have detailed potential models for the infusion of trauma-informed approaches within school systems and have included recommendations for schools at multiple levels of service (e.g. administration level, student level; e.g. Wiest-Stevenson and Lee, 2016, Walkley and Cox, 2013). At the administration level, examples of trauma-informed approaches include creating policies for how to handle disciplinary procedures for youth affected by trauma that are sensitive to their trauma exposure such as not removing school resources for problematic behavior. Examples of applying trauma-informed approaches within the student level involve delivering intervention and prevention programs for students that are sensitive to their level of trauma exposure and symptomatic presentation. These intervention and prevention programs are often classified into three tiers of services based on student's experiences with trauma, with increasing trauma exposure across the tiers.

In particular, Chafouleas, Johnson, Overstreet, and Santos, (2016) classified the tiers with the following distinctions (see Fig. 1). supports include programs seeking to help children develop social, problem-solving, and coping skills targeting all students, regardless of whether or not they have been exposed to trauma or are at-risk (i.e. at the universal level). As such, these programs are more prevention-based, and incorporate skill-based learning to buffer the potential effects of trauma in the future for those who have not experienced traumatic events. Examples of these programs include classroom-based group instruction on socioemotional learning concepts. programs seek to intervene for students who are at-risk for trauma exposure or impact and include strategies and interventions that provide psychoeducation about trauma, reinforce social support systems, and strengthen self-regulation skills, as well as some group-based therapy protocols. Examples of these interventions include group-based cognitive behavioral skill building. Finally, programs provide interventions to select students who have experienced significant trauma and/or have been severely affected including facilitating cognitive-behavioral therapy, community-based services, and wrap-around care. Examples of these interventions include more intensive group-based cognitive behavioral therapy or individualized therapy via trauma-focused cognitive behavioral therapy. Importantly, these three tiers are organized in such a way that students receiving the higher tiers of services also receive programs within the lower tiers (i.e. a student receiving Tier 3 supports also receives supports from Tiers 2 and 1).

The tiers described above closely align with the Multi-Tiered System of Supports (MTSS) often used as an organizing framework by schools providing interventions across domains (Stephan, Sugai, Lever, & Conners, 2015)For instance, the state of Florida's use of MTSS to deliver interventions describes Tier 1 programs as supports provided to all students, Tier 2 programs as supports provided to some students and Tier 3 programs as provided to few students typically provided in small groups or to individual students (MTSS Implementation Components: Ensuring common language and understanding). Similar to the three-tier SAMHSA framework guiding in the current review, increasing intensity is an additional factor of the MTSS that differentiates the services provided between tiers. Although the organization of the MTSS is similar to the SAMHSA approach, it is important to note that the MTSS system is a broader framework that may be used to organize all mental health supports within schools, not just those that are specific to trauma.

The purpose of the current paper is to systematically review empirical research detailing relevant interventions to the integration of trauma-informed practices within schools. In considering the distinctions between the tiers as described in the previous two paragraphs, it is important to note that there is a difference between how these programs have been delivered in published literature and how they could be delivered in future studies. That is, previous operationalizations of the differences between the tiers of services have focused on both the students targeted and also the intensity/individualization of the services provided. Within the current review, we have classified primary articles into tiers based on how they were delivered, focusing on the group of students they sought to provide services for based on trauma symptom assessments. Thus, Tier 1 supports are provided to all students, Tier 2 programs are provided to students who have been exposed or who are at elevated risk for trauma-exposure without requiring a specific level of trauma-symptoms to participate, and Tier 3 programs are provided to students who had to be sufficiently affected by trauma. This distinction is important to detail, as previous more global concept articles have often focused on the mode of delivery (e.g. group vs. individual) as the main differing factor in dividing Tiers 2 and 3 but have not typically considered how these programs were actually delivered. Thus, programs described as "Tier 3" within the current article could be provided as Tier 2 interventions, but had not been tested in this way as described in the primary research articles.

Prevention programs falling into Tier 1 may be conceptualized as broad or trauma specific. Regarding broad prevention programs, there are several programs, and existing reviews of those programs, that provide details of prevention programs that fit into Tier 1 supports (e.g. Sullivan and Simonson, 2016, Reinbergs and Fefer, 2017). Tier 1 supports involve efforts seeking to prevent psychopathology for all students and include programs seeking to build social and emotional learning (SEL) or to increase positive behaviors in the school setting. Specifically, such programs seek to increase students' core competencies in five specific areas: self-awareness, self-management, social awareness, relationship skills, and responsible decision making (Collaborative for Academic, Social, and Emotional Learning, 2005). For example, a recent review and meta-analysis identified 213 primary articles examining the effects of school-based SEL skill-building on child outcomes (e.g. Durlak, Weissberg, Dymnicki, Taylor, & Schellinger, 2011). In their review, authors detailed that the primary research articles consisted of samples from elementary school through high school and represented work from diverse socioeconomic settings. The results of the meta-analysis indicated that, as a whole, school-based SEL programs significantly increased SEL skills and positive social behaviors and decreased conduct problems and emotional distress when compared to control groups. Further, their analyses suggested that teacher-delivered programs were just as, and in some cases more, effective as programs delivered by other school personnel, including mental health professionals. Importantly, the SEL programs reviewed typically consisted of unique program plans (i.e. did not follow a standardized protocol) but effectiveness of these programs was moderated by whether they included four dimensions: sequenced activities, provided students a chance to learn the skills by actively practicing, involved a component on social skills, and targeted specific SEL skills such that programs that included these components were more effective.

As opposed to broad prevention programs, a search for research evaluations of Tier 1 prevention programs specific to trauma symptoms yield no results. Given our goal of systematically reviewing primary research articles that include empirical data detailing interventions delivered in the school setting in response to or in anticipation of exposure to trauma during childhood (preschool through 12th grade), only Tier 2 and Tier 3 programs are reviewed. Whereas other papers have provided reviews of some pertinent interventions (e.g. Black et al., 2012, Yohannan and Carlson, 2019), existing reviews have not provided a fully comprehensive list of interventions with implications for trauma-informed schools. Further, as part of the systematic review, this paper calculates individual effect size estimates for each study when possible. Providing a systematic review of these interventions accomplishes two primary objectives. First, this review provides schools with a list of empirically supported options for interventions for students who have been exposed, are at risk for being exposed, or are currently experiencing trauma. Second, this review provides researchers with information regarding the current state of the evidence for available trauma-informed interventions and highlights areas in which more work needs to be done. Both of these objectives will aid in providing an empirical framework for the provision of a trauma-informed approach to school settings.

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Buffering the effects of childhood trauma within the school setting: A systematic review of trauma-informed and trauma-responsive interventions among trauma-affected youth

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Exposure to trauma during childhood is highly prevalent. This review seeks to evaluate the current state of the literature in regard to trauma-informe...

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The article Understanding and Responding to the Effects of Trauma in the Classroom: A Primer for Educators provides educators with foundational knowledge on how trauma impacts students and outlines strategies for fostering supportive, trauma-sensitive classroom environments. It emphasizes interventions like building strong, positive relationships, incorporating social-emotional learning, and adapting classroom practices to address trauma’s effects on behavior and learning.

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Abstract

Although nearly half of U.S. students have experienced a potentially traumatic event (Bethell et al., 2017), educators are not routinely trained in trauma or trauma-informed practices (Hobbs et al., 2019; Koslouski & Stark, 2021; National Council of State Education Associations, 2019). Yet, trauma can have profound negative impacts on students' social, emotional, and behavioral needs. Thus, this primer introduces educators to the prevalence of trauma in PreK-12 students' lives, the effects of trauma on students' development, and proactive and responsive strategies that adults can use to support students who have experienced trauma. We provide several vignettes to help educators understand varied presentations of trauma and the range of trauma-informed practices that can benefit students. We also address educators' relationships with caregivers and describe strategies for mitigating the toll secondary traumatic stress (Figley, 1995) can take on educators. Throughout, we aim to build educators' understanding, empathy, and agency for their work supporting students affected by trauma.

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Understanding and responding to the effects of trauma in the classroom: A primer for educators

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Although nearly half of U.S. students have experienced a potentially traumatic event (Bethell et al., 2017), educators are not routinely trained in tr...

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This source discusses how factors such as supportive family relationships, a positive school environment, and community connections help children recover from trauma. It emphasizes the importance of resilience-building environments where children feel safe and valued.

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This resource outlines the various traumatic experiences children may face and stresses that recovery can be significantly influenced by positive environmental factors, including access to supportive caregivers, schools, and communities.

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Fast Facts

At least 1 in 7 children have experienced child abuse and/or neglect in the past year, and this is likely an underestimate. In 2019, 1,840 children died of abuse and neglect in the United States.

Each day, more than 1,000 youth are treated in emergency departments for physical assault-related injuries.

In 2019, about 1 in 5 high school students reported being bullied on school property in the last year.

8% of high school students had been in a physical fight on school property one or more times during the 12 months before the survey.

Each day, about 14 youth die from homicide, and more than 1,300 are treated in emergency departments for violence-related injuries.
It's important to recognize the signs of traumatic stress and its short- and long-term impact.
The signs of traumatic stress may be different in each child. Young children may react differently than older children.

Preschool Children

Fear being separated from their parent/caregiver

Cry or scream a lot

Eat poorly or lose weight

Have nightmares

Elementary School Children

Become anxious or fearful

Feel guilt or shame

Have a hard time concentrating

Have difficulty sleeping

Middle and High School Children

Feel depressed or alone

Develop eating disorders or self-harming behaviors

Begin abusing alcohol or drugs

Become involved in risky sexual behavior

The Body's Alarm System

Everyone has an alarm system in their body that is designed to keep them safe from harm. When activated, this tool prepares the body to fight or run away. The alarm can be activated at any perceived sign of trouble and leave kids feeling scared, angry, irritable, or even withdrawn.

Healthy Steps Kids Can Take to Respond to the Alarm

Recognize what activates the alarm and how their body reacts

Decide whether there is real trouble and seek help from a trusted adult

Practice deep breathing and other relaxation methods

Impact of Trauma

The impact of child traumatic stress can last well beyond childhood. In fact, research has shown that child trauma survivors may experience:

Learning problems, including lower grades and more suspensions and expulsions

Increased use of health and mental health services

Increase involvement with the child welfare and juvenile justice systems

Long-term health problems (e.g., diabetes and heart disease)

Trauma is a risk factor for nearly all behavioral health and substance use disorders.
There is hope. Children can and do recover from traumatic events, and you can play an important role in their recovery.
A critical part of children's recovery is having a supportive caregiving system, access to effective treatments, and service systems that are trauma informed.

Get Help Now
SAMHSA Behavioral Health Treatment Services Locator The National Child Traumatic Stress Network: Get Help Now Healthcare Toolbox: Basics of Trauma-Informed Care
Not all children experience child traumatic stress after experiencing a traumatic event. With support, many children are able to recover and thrive.

As a caring adult and/or family member, you play an important role.

Remember To:

Assure the child that he or she is safe.

Explain that he or she is not responsible. Children often blame themselves for events that are completely out of their control.

Be patient. Some children will recover quickly while others recover more slowly. Reassure them that they do not need to feel guilty or bad about any feelings or thoughts.

Seek the help of a trained professional. When needed, a mental health professional trained in evidence-based trauma treatment can help children and families cope and move toward recovery. Ask your pediatrician, family physician, school counselor, or clergy member for a referral.

Visit the following websites for more information:

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Recognize the signs of child traumatic stress and the impact that trauma may have on children. The infographic developed by SAMHSA's National Child Traumatic Stress Initiative (NCSTI) provides information on the prevalence and impact of traumatic events on children, and what actions can be taken to support children who experience traumatic events.

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This resource discusses how integrated student supports, such as those offered by CIS, can mitigate the lifelong effects of Adverse Childhood Experiences (ACEs). By providing mental health resources and promoting emotional well-being, schools can reduce the impact of trauma on students.

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Child Trends highlights the importance of trauma-informed care (TIC) in building resilience among children who have experienced trauma. This approach focuses on educating those who interact with children, such as educators and caregivers, on the effects of trauma and strategies to foster recovery in various environments, including the home and school.

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Despite its focus on trauma, TIC is inherently a strengths-based perspective that emphasizes resilience instead of pathology.[50] TIC has been defined and implemented in a number of ways, but the Substance Abuse and Mental Health Services Administration has identified four key elements-the Four Rs (see description of each "R" below)-that can be used broadly across programs, institutions, and services.[51]

Applying TIC to real-world settings begins with a child's first contact with a program, institution, or service system. It requires a comprehensive and multi-pronged effort involving the many adults in children's lives. For example, in a school or afterschool program, TIC means increasing trauma-related knowledge and skills among program facilitators, school administrators, bus drivers, food service workers, classroom assistants, administrative staff, volunteers, teachers, leadership, special education professionals, school social workers and psychologists, families, and anyone else who comes into contact with children. However, increasing trauma knowledge is only one aspect of TIC, which also means that the individuals who care for children must be able to:

1. Realize the widespread nature of childhood trauma and how it impacts the child's emotional, social, behavioral, cognitive, brain, and physical development, as well as their mental health. In addition, adults must be aware of the influence of trauma on family members, first responders, service providers, and others who may experience secondary stress (trauma-related reactions to exposure to another person's traumatic experience).[52],[53] In some instances, adults endure the same traumatic events or circumstances as the child (e.g., a natural disaster, community violence, death of a community member) and may benefit from similar supports.

2. Recognize the symptoms of trauma, including how trauma reactions (i.e., symptoms of posttraumatic stress) vary by gender, age, type of trauma, or setting. In addition, the adults in children's lives must understand that a child's challenging behaviors are normal, self-protective, and adaptive reactions to highly stressful situations, rather than viewing that child as intentionally misbehaving. Children's trauma reactions are understood to be adaptive efforts to protect themselves in response to traumatic events. For example, a child may be hypervigilant to an adult's anger or disapproval because, in the past, he or she experienced physical abuse by a parent. Or, a child may disassociate or daydream as a learned response that enables them to avoid feeling or thinking about a traumatic experience.[54] In addition, TIC means recognizing that trauma may influence a child's engagement in activities and services, interactions with peers and adults, and responsiveness to rules and guidelines.[55]

3. Respond by making necessary adjustments, in their own language and behavior, to the child's environment; and to policies, procedures, and practices to support the child's recovery and resilience to trauma.[56]

4. Resist re-traumatization by actively shaping children's environments to avoid triggers (sounds, sights, smells, objects, places, or people that remind an individual of the original trauma) and protect children from further trauma, which can exacerbate the negative impacts of trauma and interfere with the healing process.[57],[58]

Training and professional development on child trauma is an important first step in TIC. Providing adults (staff, leadership, families, and community partners) with training and professional development on childhood trauma is an important component of implementing TIC.[59] It is essential that adults become aware of the prevalence and impact of trauma, and learn to apply a "trauma lens" (i.e., gain the capacity to view children's difficulties in behavior, learning, and relationships as natural reactions to trauma that warrant understanding and sensitive care).[60] In addition, adults can learn key strategies to manage trauma-related problems in childhood. These include creating environments that feel physically and emotionally safe; teaching children self-regulation, language and communication skills, and how to build healthy relationships; learning each child's trauma triggers and how both the child and adults can limit, anticipate, and cope with them; and supporting the development of healthy attachments with parents and other caregivers, as well as positive relationships with peers. Evaluations of TIC initiatives also indicate that when parents, service providers, and programs share a common language and view of trauma, they are better able to work together to meet children's needs.[61]

Training and professional development opportunities are also important for increasing the capacity of adults to attend to other aspects of TIC, including family engagement; practices that are responsive to culture, gender, and sexual orientation; collaboration with community service providers (e.g., mental health providers who can screen for childhood trauma and provide evidence-based treatment); developing and integrating emergency and crisis response protocols; and establishing trauma-informed policies that support positive youth development despite exposure to trauma. Building capacity and maintaining an ongoing commitment to TIC efforts are critical to sustainability.[62], [63] However, although it is a critical component of TIC, training staff and parents on the impact of childhood trauma is not sufficient and does not in and of itself constitute TIC. TIC must also include comprehensive, ongoing professional development and education for parents, families, school staff, out-of-school program staff, and community service providers on jointly addressing childhood trauma.

Parents and service providers who work with children who experience trauma require self-care to prevent and mitigate the effects of secondary traumatic stress. TIC also means attending to the psychological and physical safety and well-being of the adults who care for children who have experienced trauma.[64], [65] Professionals, parents, and other caregiving adults may suffer secondary traumatic stress (trauma-related reactions to exposure to another person's traumatic experience).[66],[67] Psychoeducation (helping others understand the impact of trauma, both on affected individuals and on their service providers, as well as pathways toward recovery),[68] skills training, high-quality supervision, and self-care (e.g., rest, exercise, social support, mindfulness and other stress reduction activities, engaging in pleasurable activities and hobbies, psychotherapy) are critical to ensuring adult well-being and providing sufficient personal resources to work effectively with children who are exposed to trauma. See Figure 4 for specific strategies recommended by the National Child Traumatic Stress Network to combat secondary traumatic stress and reduce related staff burnout and turnover.[69]

Further research is needed on TIC in child-serving programs, institutions, and systems to develop a sufficient evidence base to inform policy and practice. TIC is a relatively new framework for working with individuals who experience trauma, and the evidence base in support of its effectiveness is in the early stages of development. However, a number of promising TIC initiatives in early care and education, schools, child welfare, and behavioral health have demonstrated improvements in trauma-related knowledge and skills among service providers, foster parents, and family members; reductions in children's posttraumatic stress symptoms and problem behaviors; and increases in children's strengths and protective factors.[70],[71],[72],[73],[74] In addition, a growing number of clinical treatment models-including Trauma-Focused Cognitive Behavioral Therapy,[75],[76] Child-Parent Psychotherapy,[77],[78] Attachment and Biobehavioral Catch-up,[79],[80] and Parent-Child Interaction Therapy,[81],[82] -have undergone rigorous evaluation and shown positive outcomes for children from infancy to late adolescence. However, TIC is not limited to mental health professionals. Each child-serving program, institution, or service system can play a role in TIC, including referral to clinical treatment and follow-up with families.

Conclusion

Trauma-informed programs, institutions, and service systems are critical to promoting and fostering resilience in all children, and particularly those who have experienced trauma. TIC requires comprehensive, multi-pronged support from adults in all aspects of children's lives. It includes increasing adults' knowledge of childhood trauma and helping them recognize the symptoms, as well as giving them the resources to support and refer children who have experienced trauma to appropriate services. Additionally, as programs make their services more trauma-informed, it is important that they promote self-care to prevent or address secondary trauma among adults working with children who have experienced trauma.
Endnotes
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[2] Enlow, M., Blood, E., & Egeland, B. (2013). Sociodemographic risk, developmental competence, and PTSD symptoms in young children exposed to interpersonal trauma in early life. Journal of Traumatic Stress, 26(6), 686-694.

[3] Lieberman (2004). Traumatic stress and quality of attachment: Reality and internalization in disorders of infant mental health. Infant Mental Health Journal, 25(4), 336-351.

[5] Substance Abuse and Mental Health Services Administration. SAMHSA's concept of trauma and guidance for a trauma-informed approach. HHS publication no. (SMA) 14-4884. Rockville, MD: Substance Abuse and Mental Health Services Administration.

[10] National Survey of Children's Health. (2011/12). Data query from the Child and Adolescent Health Measurement Initiative, Data Resource Center for Child and Adolescent Health website. Retrieved June 8, 2018 from www.childhealthdata.org.

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How to Implement Trauma-informed Care to Build Resilience to Childhood Trauma - Child Trends

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Despite its focus on trauma, TIC is inherently a strengths-based perspective that emphasizes resilience instead of pathology.[50] TIC has been defined and implemented in a number of ways, but the Substance Abuse and Mental Health Services Administration has identified four key elements-the Four Rs (see description of each "R" below)-that can be used broadly across programs, institutions, and services.[51] Applying TIC to real-world settings begins with a child's first contact with a program, institution, or service system.

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Child Trauma Academy focuses on understanding the impact of trauma within different contexts, including the home, school, and broader community. The source highlights the necessity of providing a safe, supportive environment to children who have experienced trauma, emphasizing the roles of caregivers, educators, and community programs in fostering healing.

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ABOUT CTA

With a long history of working with high-risk children through education, research and the dissemination of innovation, CTA's insight remains online as a shared resource.

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During its long tenure, a major activity of the CTA was to translate emerging findings about the human brain and child development into practical implications for the ways we nurture, protect, enrich, educate and heal children. The "translational neuroscience" work of the CTA resulted in a range of innovative programs in therapeutic, child protection and educational systems.

Etienne Wenger, a leading social learning theorist, defines communities of practice as groups of people who share a concern or a passion for something they do and learn how to do it better as they interact regularly. This model has been discussed as optimal for promoting social change in our current complex world. The CTA worked to create these collaborative working relationships between organizations and individuals to most effectively promote positive change for children.

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The CTA started as a typical center of excellence in an academic setting, initially at The University of Chicago and later at Baylor College of Medicine. Over time however, it was clear that the problems of abuse and neglect in children were much more complex and multi-dimensional in ways that our medical model was unable to address.

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A medical school centered work group investigating and solving physiological problems in humans makes sense. Solving problems which involve parenting, education, the law, child protection systems, mental health, law enforcement and a host of related systems across every professional discipline is more challenging. In response to this challenge we created this collaborative, interdisciplinary virtual Center of Excellence, The ChildTrauma Academy.​

THE HISTORY OF OUR MISSION & STRATEGY

The ChildTrauma Academy set out to help improve the lives of traumatized and maltreated children - by improving the systems that educate, nurture, protect and enrich these children. We focused our efforts on education, program consultation, research and disseminating innovations in the field.

Essential to this process was the collaboration of all sectors of society. As such, we engaged in a continuous process of identifying key partners, drawn from academia, the corporate world, private organizations and public sector systems. While each partnership had a distinct focus- identifying best practices in child protection, evaluating the latest research in child development, defining optimal ways to provide resources to parents or creating a novel therapeutic approach with traumatized children- all engaged in the continuous process of testing, refining and distributing innovations that can improve children's lives.

OUR EVOLUTION

In late 2018, the Neurosequential Network was formed to develop a whole host of online trainings for front-line professionals working in education, mental health, coaching, early childhood and research. The new entity continues to serve professionals from around the world at www.neurosequential.com.

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ABOUT CTA With a long history of working with high-risk children through education, research and the dissemination of innovation, CTA's insight remains online as a shared resource. ​ During its long tenure, a major activity of the CTA was to translate emerging findings about the human brain and child development into practical implications for the ways we nurture, protect, enrich, educate and heal children.

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National Center on Safe Supportive Learning Environments (NCSSLE) This resource offers a comprehensive understanding of trauma and its impact on students, families, and school environments. It provides training tools for educators, helping them understand how trauma affects children and how schools can become trauma-sensitive. Key elements of trauma-sensitive schools include creating safe, supportive, and culturally competent environments that foster emotional well-being and resilience in students.

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Understanding Trauma and Its Impact

Educating all school staff on trauma and its effects on students, families, and staff is an essential first step towards becoming a trauma-sensitive school. The resources included in the Understanding Trauma and Its Impact component of the Training Package are designed to provide all school and district staff with a shared awareness and understanding of the prevalence and impact of trauma and implications for schools. Resources include an interactive e-resource and a companion slide presentation and activity packet for in-person training.

1. Understanding Trauma and Its Impact E-Resource for Educators

This interactive resource provides all staff with information about what trauma is and who is affected; how the brain and body respond to stress and threat; the impact of exposure to trauma; and how schools are affected by trauma. The e-resource is designed to be viewed independently by school staff on their preferred electronic device (computer or tablet).

2. Understanding Trauma and Its Impact

This slide presentation and activity packet parallel the e-resource content and are designed for in-person training to reinforce concepts from the e-resource and encourage group discussion and learning. These resources can be used in their entirety or divided into shorter training segments depending on time available for professional development. The activity packet includes pre- and post-knowledge surveys and a training satisfaction survey for assessing impact.

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Educating all school staff on trauma and its effects on students, families, and staff is an essential first step towards becoming a trauma-sensitive school. The resources included in the Understanding Trauma and Its Impact component of the Training Package are designed to provide all school and district staff with a shared awareness and understanding of the prevalence and impact of trauma and implications for schools.

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This resource highlights the wide-ranging impact of parental substance abuse on children, including emotional, behavioral, and academic challenges. It discusses how substance abuse disrupts family structures, creating instability and unpredictability, which hinders emotional well-being and attachment. Additionally, it emphasizes the role of pediatricians and community support in addressing these issues and mitigating long-term damage to children’s development.

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Child Psychiatry Today - latest on child and adolescent mental health

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latest on child and adolescent mental health

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This publication provides an evidence-based overview of how parental substance use affects children across various domains, such as emotional regulation, educational performance, and social connections. It also examines how professional support systems, like child welfare and educational programs, can help mitigate these negative outcomes. The briefing emphasizes the importance of creating tailored interventions to address the unique needs of children affected by such environments.

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Supporting evidence-informed practice with children and families, young people and adults | Research in Practice

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This review explores the wide-ranging impacts of parental substance abuse, including academic, emotional, and social challenges faced by children. It highlights that children of substance-abusing parents are more likely to encounter behavioral problems, disrupted education, and emotional instability. The review also examines interventions targeted at mitigating these adverse outcomes, emphasizing the importance of tailored support programs for affected families. Long-term follow-ups demonstrate that effective interventions can significantly improve children's resilience and well-being. The review concludes with recommendations for better service integration and early intervention strategies.

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Stacy Calhoun, 1,2 Emma Conner, ² Melodi Miller, ³ Nena Messina ¹

1UCLA Integrated Substance Abuse Programs, Los Angeles, CA, USA; ²Department of Criminology, Law and Society, University of California, Irvine, CA, USA; 3Social Solutions International, Inc., Silver Spring, MD, USA

Abstract: Substance abuse is a major public health concern that impacts not just the user but also the user's family. The effect that parental substance abuse has on children has been given substantial attention over the years. Findings from the literature suggest that children of substance-abusing parents have a high risk of developing physical and mental health and behavioral problems. A number of intervention programs have been developed for parents who have a substance abuse problem. There have also been a number of interventions that have been developed for children who have at least one parent with a substance abuse problem. However, it remains unclear how we can best mitigate the negative effects that parental substance abuse has on children due to the scarcity of evaluations that utilize rigorous methodologies such as experimental designs. The purpose of this study is to review randomized controlled trials of intervention programs targeting parents with substance abuse problems and/or children with at least one parent with a substance abuse problem in order to identify programs that show some promise in improving the behavioral and mental health outcomes of children affected by parental substance abuse. Four randomized controlled trials that met our eligibility criteria were identified using major literature search engines. The findings from this review suggest that interventions that focus on improving parenting practices and family functioning may be effective in reducing problems in children affected by parental substance abuse. However, further research utilizing rigorous methodologies are needed in order to identify other successful interventions that can improve the outcomes of these children long after the intervention has ended.

Keywords: RCT, family, interventions

Introduction

Substance abuse is a major public health concern that has impacts not only on the user but also the user's family. This is especially true for children exposed to parental substance abuse in the home environment. Findings from the 2009 National Survey on Drug Use and Health (NSDUH) showed that a little over 8.3 million children under the age of 18 years have lived with at least one parent who abused illicit drugs or alcohol during the 12 months prior to being interviewed for the survey. These children are at increased risk for a variety of problems, such as abuse and neglect, which can negatively impact their physical and emotional well-being. In addition, parental substance abuse has been linked to ongoing behavioral problems, such as adolescent drug use. Thus, it is important to find ways to mitigate the negative impact that parental substance abuse has on the developmental outcomes of the children affected by this issue. The purpose of this review is to identify interventions targeting parents with a substance abuse problem and/or children who have at least one parent with a substance abuse problem that have been shown to improve at least one child outcome (eg, drug use, mental health, and behavioral problems) in a randomized controlled trial. A brief overview of the research outlining the consequences that parental substance abuse can have on children is provided, followed by a review of the promising interventions that appear to improve outcomes of children affected by parental substance abuse. We conclude the paper by discussing areas that need further research and potential interventions drawn from the Blueprint registry of evidence-based programs that may be effective in reducing problems among children of substance-abusing parents.

Prenatal effects of parental substance use

It has been estimated that approximately 225,000 infants are prenatally exposed to their mothers' use of illicit substances each year, and exposure to these substances is often the first point in which children experience the negative effects of parental substance abuse. Physiological manifestations of this exposure may include low birth weight, feeding difficulties, increased irritability by the infant, and stunted cognitive and physical development. The severity and nature of these manifestations vary depending on the illicit substance used, as well as the frequency and duration of use. For example, children exposed to methamphetamine use have been found to be at increased risk of being small for their gestational age and exhibit low arousal, poor quality of movement, and increased physiological stress. In contrast, prenatal opioid use has been shown to lead to neonatal abstinence syndrome, in which infants experience opioid withdrawal symptoms after birth as a result of no longer being exposed to the substance. Problems resulting from prenatal exposure to other drugs may not manifest themselves until later in the child's development. For example, prenatal cocaine exposure has been associated with poor language development, emotional problems (eg, social withdrawal, anxiety, and depression), and negative behavioral manifestations (eg, delinquency, aggressiveness, and pre-teen substance abuse).

Parental substance abuse in the home

The impact of parental substance abuse on the functioning of the family can be particularly severe, especially as it relates to parenting practices and the care of children. Studies have shown a strong association between improper parenting practices and subsequent negative behavioral manifestations such as delinquency. These improper parenting practices take the form of harsh discipline such as spanking or threatening a child in response to problematic behavior. The evidence further suggests that parents who engage in substance abuse are also more likely to engage in these problematic parenting practices than those who do not. Hien and Honeyman found that among a sample of low-income mothers receiving treatment at a public hospital, those who abused crack or cocaine were significantly more likely than mothers who did not to endorse the use of harsh disciplinary practices, which included the use of corporal punishment techniques (eg, hitting the child with a belt). Similarly, Fals-Stewart et al found that fathers who engaged in substance abuse had lower scores on the Parental Monitoring Scale and were more likely to engage in more dysfunctional disciplinary practices as measured by the Parenting Scale than fathers who did not. Additionally, in a study that examined the relationship between specific parenting practices in families with at least one substance-abusing parent, Stanger et al found that inconsistent application of discipline predicted rule breaking, aggression, and attention problems.

Parental substance abuse can leave children at risk of being neglected whereby the parents fail to take care of their basic needs, such as being fed and properly clothed. Findings from the literature suggest that children of methamphetamine users and manufacturers are especially vulnerable to neglect. Messina and Jeter examined 99 cases of children who were removed from home-based methamphetamine labs in Los Angeles County from 2001-2003, and found that 94% of the allegations of child neglect among this sample were substantiated by a Child Protective Services case worker. Children who live in homes where methamphetamine labs exist are not only exposed to the drug itself, but often live in unsanitary environments characterized by the presence of animal feces, ticks, cockroaches, garbage, and drug paraphernalia, and are at high risk of ingesting food that is spoiled, rotten, or contaminated with chemicals.

The association between child neglect and problematic behaviors has been well-established. However, establishing the underlying mechanisms that explain the nature of this relationship is difficult due to the fact that families with at least one parent who abuses drugs often experience a range of problems (eg, mental illness or chronic unemployment) that can undermine the parent's ability to care for their children and increase their risk of becoming involved with child welfare services. Child neglect is the most common reason for involvement with child welfare services, and it has been estimated that 50%-80% of children removed from homes due to neglect and involved in the child welfare system have at least one substance-abusing parent. However, while the evidence surrounding the long-term effects of foster care placement on child outcomes is mixed, some of this evidence points to the negative effects that placement instability has on child development. As such, there are many who advocate for more emphasis on intervention and family preservation.

Incarceration

There is substantial evidence in the literature that parental incarceration is associated with various negative outcomes for children. Children of incarcerated parents are more likely to exhibit conduct disorders and other delinquent behavior than their peers. For adolescent males in particular, parental incarceration has been shown to be associated with an increase in theft and marijuana use. Teachers report observing more negative, disruptive behaviors in the classroom among children whose parents are incarcerated and fewer positive, pro-social behaviors. There is also evidence that adolescent boys are more likely to drop out of high school, particularly when the mother is the incarcerated parent and the incarceration begins during the child's early adolescence. In addition, a 12-year longitudinal study found that Chicago Public School children who had at least one incarcerated parent had standardized test scores that were, on average, lower than students whose parents were not incarcerated.

Methods

A review of the literature was performed using PsychINFO, PubMed, and the Cochrane database of controlled trials to identify randomized controlled trials of interventions that have been directed at either parents with a substance abuse problem (this includes both drugs and alcohol) and/or children with at least one parent with a substance abuse problem. Search terms included "parents", "mother", "father", "child", "infant", "prenatal", "substance abuse", "substance dependence", "addiction", "substance use", "drug abuse", "drug dependence", "drug use", "alcohol use", "alcohol abuse", "alcohol dependence", "treatment", and "intervention". Search terms were used in combination as well as with the limits "randomized controlled trial", "randomized", or "randomly assigned". Review articles were also obtained and the references scanned for further randomized controlled trials. Studies were included in this review if all of the following criteria were met: 1) all of the study participants were parents who had a substance abuse problem (includes alcohol) and/or children under the age of 18 who had at least one parent who had a substance abuse problem; 2) study participants were randomly assigned to a treatment group; 3) the duration of the participant follow-up was at least 6 months after the completion of the intervention; 4) the study was published in English; 5) participants who dropped out of the program were not excluded in the analyses; and 6) the intervention was effective in improving at least one child outcome during the postintervention follow-up period.

In order to facilitate our summary and comparison of studies, effect sizes were reported for the programs identified in this review where possible. If the effects sizes were reported in the article, we used the effect sizes that were calculated by the authors. Otherwise, we calculated the effect size as Cohen's d if there was enough data to do so. While we are reporting different effect size estimators (ie, r, d, and odds ratio [OR]) in this review, effect sizes will be evaluated according to the classification proposed by Cohen: small (0.20-0.49), medium (0.50-0.79), and large (≥0.80).

Results

In total, 288 articles were retrieved and coded for eligibility. Only four studies met all of the criteria for inclusion in this review. These studies were randomized controlled trials of interventions that targeted families where at least one parent had a substance abuse problem. The interventions were designed to not only reduce drug and alcohol use but also to improve overall family functioning by addressing and overcoming problems in the relationship of the parents as well as providing parenting skills training. All of the studies included in this review are listed in Table 1 and discussed in more detail below.

Parents under pressure

Dawe and Harnett conducted a randomized controlled trial of the Parents under Pressure (PUP) intervention in Australia. PUP is a home-based treatment intervention that is delivered on a weekly basis over a period of 3-4 months. During the weekly sessions, parents are taught skills to help them with child management and how to build solid relationships with their children and with their partners. Participants in the program are also taught how to gain greater control over their emotional state and reduce the likelihood that they will relapse to drug or alcohol use. Additional case management was also provided to the PUP participants on an as-needed basis. A total of 64 families were randomized into either the PUP group, the brief intervention group, or the standard treatment group. The participants in the PUP group received the PUP intervention described above. Participants assigned to the brief intervention group received two sessions of parent training delivered by therapists in the clinic. Participants assigned to the standard treatment group received the regular treatment that was provided by the methadone clinic. Findings from the randomized controlled trial found that families assigned to the PUP program had a significantly greater improvement in family functioning and a significantly decreased likelihood of child abuse compared to families assigned to receive either the brief intervention or the standard methadone treatment. Additionally, the children of PUP participants had significantly greater reductions in problem behaviors over time as measured by the Strengths and Difficulties Questionnaire, which includes the subscales of emotional symptoms, conduct problems, hyperactivity, peer problems, and pro-social behavior.

Focus on families

Behavioral couples therapy

The findings revealed that the children of the BCT participants had significantly better psychosocial functioning scores than the children of PACT and IBT participants throughout the 6- and 12-month postintervention follow-up period. Among the substance-abusing couples in the sample, small effect sizes were found for BCT couples at both the 6-month follow-up ( d=0.38) and 12-month follow-up ( d=0.42) when compared to IBT couples. Likewise, small effect sizes were found for the BCT drug-abusing couples at the 6-month follow-up ( d=0.32) and the 12-month follow-up ( d=0.30) when compared to the PACT drug-abusing couples. Among the alcohol-abusing couples in the sample, small effect sizes were also found for the BCT couples at both the 6-month follow-up ( d=0.46) and the 12-month follow-up ( d=0.26) when compared to the IBT couples. A medium effect was found for the BCT alcohol-abusing couples at the 6-month follow-up ( d=0.50) when compared to PACT couples. However, this effect size was not sustained at the 12-month follow-up, where a small effect size was observed for the BCT alcohol-abusing couples ( d=0.37) when compared to the PACT couples.

Parent skills with behavioral couples therapy

Lam et al conducted a study to assess whether adding a parenting component to BCT would enhance the positive child outcomes found in the previous evaluation of BCT discussed above. In this study, 30 men entering outpatient treatment were randomly assigned to one of three treatment groups: IBT, standard BCT, and Parent Skills with Behavioral Couples Therapy (PSBCT). Similar to the previous study, the men in this study had to be either married for at least 1 year or living with a significant other for at least 2 years. They also had to have at least one child living in their household. Participants assigned to the BCT treatment group received 12 standard BCT sessions, which included both partners. Participants assigned to the PSBCT group attended eight sessions of the standard BCT treatment and four parenting skills training sessions with their significant others. Participants assigned to the IBT group received 12 individual-based coping skills sessions without their partner present. With regard to child outcomes, the Child Behavior Checklist (CBCL) was used to assess problem behavior, the Children's Depression Inventory (CDI) was used to assess depression, and the Revised Children's Manifest Anxiety Scale (RCMAS) was used to assess anxiety.

The findings show that the children of the PSBCT participants showed greater improvements in problem behavior, depression, and anxiety throughout the 12-month follow-up period than the children of the parents assigned to the other two groups. The children of BCT participants also showed improvements in all of the outcomes immediately after the intervention but the effects for depression and anxiety were not sustained throughout the postintervention follow-up period. Problem behaviors as rated by the mothers and fathers separately using the CBCL showed small effect sizes for PSBCT children at both the 6-month and 12-month follow-up periods when compared to IBT and BCT children. The effect sizes ranged from 0.20-0.27 for all pairwise comparisons. With regard to depression, small effect sizes were observed for PSBCT children at the 6-month follow-up ( r=0.46) and the 12-month follow-up ( r=0.44) when compared to IBT children. Small effect sizes for a reduction in depression were also observed for PSBCT children at the 6-month follow-up ( r=0.25) and the 12-month follow-up ( r=0.26) when compared to BCT children. When looking at reductions in anxiety, a small effect size was observed for PSBCT children at the 6-month follow-up ( r=0.43) and the 12-month follow-up ( r=0.41) when compared to IBT children. Likewise, a small effect size for a reduction in anxiety was observed for PSBCT children at the 6-month follow-up ( r=0.21) and the 12-month follow-up ( r=0.24) when compared to BCT children.

Recommendations for future areas of research

Despite the large literature that examines the impact of parental substance abuse on children, the findings for this review showed that the interventions that have been developed to address this problem would not qualify as an evidence-based program as set forth by the Blueprints registry. The Blueprints registry was created in 1996 at the University of Colorado to identify programs that promote healthy development among youth. To be considered a model program by the Blueprints registry, programs have to demonstrate effectiveness via empirically based research using an experimental design. Additionally, effects must be sustained for at least 12 months after the intervention has ended, and the findings must be successfully replicated. In order to ensure that we had some interventions that could be included in this review, we reduced the postintervention follow-up period from 12 months to 6 months and did not require that the findings had to be replicated.

Consistent with findings from other reviews, very few studies utilized an experimental design and/or did not assess child outcomes. Overall, only four studies met all of the eligibility criteria for this review. Two of the studies that were reviewed for this paper met all of the eligibility criteria with the exception of the last criteria (ie, intervention had to have a significant impact on at least one child outcome) and thus were excluded from this review. However, it should be noted that one of the studies that did not meet this last criteria was a 1-year follow-up of the FOF intervention that was briefly described above. The main child outcome that was assessed in this particular study was drug use during the previous follow-up period. The authors did not find a significant difference with regard to drug use between the FOF children and the comparison group children and hypothesized that the reason for this may be because of the large number of very young children (younger than 13 years old) in the sample who tend to be less likely to engage in drug use than older children. The findings from the later follow-up study that was included in this review provide some evidence that this intervention may have had a sleeper effect on the drug use outcomes as the findings from the 12-15-year follow-up showed that the FOF male children had a significant reduction in the risk of developing a substance use disorder. This highlights the importance of incorporating longer-term follow-up periods in studies so that it is possible to assess the impact an intervention may have on various child outcomes over different developmental periods, especially when the findings from the previous studies indicate that there are trends favoring the intervention group.

Another finding from this review showed that all of the studies that met the eligibility criteria for this paper were evaluations of family-based interventions that focused on outcomes for children between the ages of 2 and 16 years. However, addressing the negative impact of prenatal drug exposure on child outcomes is one area that has yet to be fully explored. While there have been numerous interventions designed to reduce prenatal drug exposure and the negative impact this has on birth outcomes, the long-term effects that these interventions may have on the developmental outcomes of the exposed infant in later stages in life have not been assessed. Specifically, the studies that addressed this issue did not meet the eligibility criteria because they did not have a postintervention follow-up assessment point of at least 6 months or greater. Additionally, the outcome of interest was limited mainly to birth outcomes, which were assessed relatively close to the conclusion of the intervention.

Nurse-Family Partnership (NFP) is one intervention that may be effective in reducing the negative effects of prenatal substance abuse on children over their life course. This intervention did not meet the eligibility requirement of this review because it was targeted toward low-income mothers, so it was possible that many of the mothers who received the intervention did not abuse drugs. Nevertheless, this particular program was identified by the Blueprints registry of evidence-based programs as a model program. The NFP program provides weekly visitations by nurses to high-risk first-time mothers. Visitations start during the prenatal period and last through the first 2 years of the child's life, with the aim of promoting positive health-related behaviors and effective parenting practices. The findings from randomized controlled trials of this intervention have found that compared to the children of women who did not receive the intervention, children whose mothers did receive the intervention were less likely to report using cigarettes, alcohol, and marijuana, and were less likely to report having internalizing disorders such as anxiety and depression at 12 years of age. When assessing the effect of the program on female girls at the age of 19 years, those whose mothers participated in the NFP program were less likely to have been arrested and convicted than girls whose mothers did not participate in the program. Findings from a recent systematic review suggests that home-visiting programs such as NFP are most effective in improving child outcomes when the intervention is initiated prenatally.

Finally, more randomized controlled trials of interventions that target children of substance-abusing parents directly are needed in order to examine what is effective in building resilience in these children long after the intervention has ended. The majority of interventions that have targeted the children directly were delivered in a school setting. However, the evaluations of these school-based interventions did not meet the eligibility criteria because they did not include a long-term postintervention follow-up and/or they were universal-based interventions that did not directly target children of substance-abusing parents. There is some evidence that mentoring programs may be able to provide a stabilizing influence for children who experience constant disruptions in their family life. The Big Brothers Big Sisters of America (BBBSA) is such a mentoring program that has been identified by the Blueprints registry as a promising intervention for at-risk children. This particular program matches adult volunteer mentors with at-risk children. Mentors and their matched children meet with each other for at least 3-5 hours a week. A case manager identifies goals that the mentor/mentee should seek to address throughout their time spent together such as learning new skills, improving academic performance, and general hygiene. In an experimental study of the BBBSA program, Grossman and Tierney found that youth randomly assigned to the BBBSA program were significantly less likely to use drugs, engage in truancy, and hit someone than the control group, who were put on the waiting list for the BBBSA for 18 months.

Conclusion

While parental substance abuse may contribute to physical and mental health and behavioral problems in children, findings from the studies included in this review suggest that these problems can be mitigated by improving the functioning of the family. Specifically, findings from randomized controlled trials of programs that target substance-abusing parents suggest that interventions that target parenting practices in addition to substance abuse show the most promise for improving family functioning, and subsequently, the health and well-being of children. However, these findings should be treated as very preliminary due to the limited number of studies that were found to meet all of the eligibility criteria in this review. Thus, a substantial amount of research is still needed before we can truly identify effective interventions for children affected by parental substance abuse. Furthermore, since the lives of children of substance-abusing parents are often marked by instability, it is also important to find ways to build resilience within the children in order to help mitigate the negative impact that parental substance abuse and its related consequences have on their lives. While mentoring programs such as BBBSA show great promise in helping children successfully cope with the negative impacts on their lives and development, further research using experimental designs is needed to identify and assess other successful interventions that can provide additional help to these children.

Acknowledgments

We would like to thank William Burdon for providing substantive suggestions for improvement, and Kris Langabeer for editorial review. We would also like to thank Priyanka Mehta for assistance with the literature search.

Disclosure

The authors report no conflicts of interest in this work.

References

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Improving the outcomes of children affected by parental substance abus | SAR

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Improving the outcomes of children affected by parental substance abuse: a review of randomized controlled trials Stacy Calhoun,1,2 Emma Conner,2 Melodi Miller,3 Nena Messina1 1UCLA Integrated Substance Abuse Programs, Los Angeles, CA, USA; 2Department of Criminology, Law and Society, University of California, Irvine, CA, USA; 3Social Solutions International, Inc., Silver Spring, MD, USA Abstract: Substance abuse is a major public health concern that impacts not just the user but also the user's family.

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This video explores how children experience and cope with the challenges of living in households affected by parental substance abuse. It offers insights into emotional, social, and developmental consequences and discusses strategies for support.

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Families In Recovery: How Children are Impacted by Parental Substance Use

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This video highlights the wide-ranging effects of parental substance use, focusing on behavioral, emotional, and cognitive impacts on children. It emphasizes the importance of intervention and community support for affected families.

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Presented by Dr. Diana Coffa, this University of California TV program delves into the medical and developmental ramifications of parental substance abuse. It includes research-based information and discusses how healthcare professionals can address the issue.

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UCTV, University of California Television - https://www.uctv.tv

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VIDEO: The Impact of Parental Substance Use on Pediatric Development

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Diana Coffa, MD, Family and Community Medicine, UCSF

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This is a series of child-friendly animated videos teaching children about safe and unsafe touches, secrets, and how to seek help. Designed for K-6 students, it offers actionable steps to prevent abuse through relatable scenarios.

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Is Anybody Out There? Is Anybody Out There? is a short film produced by Barbara Sinatra Children's Center Foundation in collaboration with Wonder Media that explores the importance of a trusted adult and the courage it takes for a teenager to tell their story.

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This animated video discusses the intersection of child abuse, foster care, and trafficking, aiming to raise public awareness of these linked issues. It emphasizes how abuse contributes to vulnerabilities such as trafficking.

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References

1. Fortson, B. L., Klevens, J., Merrick, M. T., Gilbert, L. K., & Alexander, S. P. (2016). Child Abuse and Neglect Prevention Resource for Action: A Compilation of the Best Available Evidence. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Note: The title of this document was changed in July 2023 to align with other Prevention Resources being developed by CDC's Injury Center. The document was previously cited as "Preventing Child Abuse and Neglect: A Technical Package for Policy, Norm, and Programmatic Activities".

2. Leeb RT, Paulozzi L, Melanson C, Simon T, Arias I. Child Maltreatment Surveillance: Uniform Definitions for Public Health and Recommended Data Elements, Version 1.0. Atlanta (GA): Centers for Disease Control and Prevention, National Center for Injury Prevention and Control; 2008.

3. Finkelhor D, Turner HA, Shattuck A, Hamby SL. Prevalence of Childhood Exposure to Violence, Crime, and Abuse: Results from the National Survey of Children's Exposure to Violence. JAMA Pediatr. 2015;169(8):746-754. doi:10.1001/jamapediatrics.2015.0676

4. U.S. Department of Health & Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children's Bureau. (2023). Child Maltreatment 2021. Available from https://www.acf.hhs.gov/cb/data-research/child-maltreatment.

5. Klika JB, Rosenzweig J, Merrick M. Economic burden of known cases of child maltreatment from 2018 in each state. Child and adolescent social work journal. 2020 Jun;37(3):227-34.

6. Centers for Disease Control and Prevention.(2022). Health and Economic Costs of Chronic Diseases. Available from https://www.cdc.gov/chronic-disease/data-research/facts-stats/.

7. Shonkoff J, Garner A, & Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, and Section on Developmental and Behavioral Pediatrics. (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232-e246.

8. Preventing Multiple Forms of Violence: A Strategic Vision for Connecting the Dots. (2016). Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention.

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This page defines child abuse and neglect, presents the latest data, and describes associated outcom

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This center offers research-based guidance and programs focused on reducing injury and violence, including child abuse prevention.

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Navigating Child Abuse Prevention Resources and Interventions | Children’s Safety Network

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This article touches on The Period of PURPLE Crying program which educates parents and caregivers on the characteristics of normal infant crying and strategies to soothe and cope, aiming to prevent shaken baby syndrome (a form of pediatric abusive head trauma). The acronym PURPLE highlights crying patterns like peaks, resistance to soothing, and long durations, typically occurring in the evening. Implemented in hospitals, the program includes educational materials and one-on-one sessions with trained healthcare professionals. Research shows it effectively increases awareness and reduces risks, though sharing of information among caregivers remains limited. Broad implementation could significantly mitigate infant abuse fatalities.

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Offers practical strategies for parents and caregivers to help children cope with traumatic events, including fostering secure environments and recognizing signs of distress.

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Access a wealth of trauma-informed care resources for families at AAP's website. Explore articles, guides, and tools designed to provide support and understanding to families affected by trauma. Whether you're a parent, caregiver, or advocate, this platform offers valuable information to help navigate the challenges and promote healing in the aftermath of trauma.

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This article explains the essentials of recovery, such as processing past events while living in the present, creating boundaries, and managing triggers through resilience-building. It emphasizes personalizing recovery.

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9 Keys to Successful Recovery from Childhood Trauma

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A psychotherapist shares what successful recovery from childhood trauma does and does not include.

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Focuses on evidence-based therapeutic techniques for helping children heal from trauma, such as Cognitive Behavioral Therapy (CBT), play therapy, and family involvement.

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Child Mind Institute | Transforming Children’s Lives.

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The Child Mind Institute is an independent nonprofit dedicated to transforming the lives of children struggling with mental health and learning disorders.

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The APA Healing from Trauma Guide provides a comprehensive approach to understanding and managing trauma's effects. It covers the psychological and physical impacts of trauma, strategies for emotional regulation, and methods to build resilience. The guide emphasizes the importance of professional support, such as therapy, and self-care practices like mindfulness, exercise, and social connections. Additionally, it highlights the role of community in fostering recovery and healing from traumatic experiences.

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Resources on trauma and healing, including a guide inspired by ‘The Color Purple’

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APA offers comprehensive guidance on coping with traumatic events, depression, anger, anxiety, PTSD, and addiction as well as meaningful pathways to healing, forgiveness, and building resilience.

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This resource explores various therapeutic approaches like psychodynamic, somatic, and attachment-based therapy, focusing on both explicit and implicit memory work. It describes how healing involves reconnecting with one’s body and emotions, restructuring thought patterns, and fostering healthy relationships over time.

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Recovering from childhood trauma: A journey of healing

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Childhood trauma can have lasting effects, but recovery is possible. Learn how therapy aids healing and what to expect in the recovery process.

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This guide highlights the value of trauma-informed practices in recovery, explaining how understanding the impacts of trauma can help individuals rebuild trust, establish safety, and foster resilience. The focus is on holistic healing through emotional, cognitive, and physical support systems.

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The National Child Traumatic Stress Network

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A trauma-informed child and family service system is one in which all parties involved recognize and respond to the impact of traumatic stress.

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A TEDx speaker discusses how childhood trauma alters brain wiring and strategies to foster resilience and healing.

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The effect of trauma on the brain and how it affects behaviors | John Rigg | TEDxAugusta

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Dr. Perry explores how trauma changes brain functions and emphasizes the need for consistent caregiving for healing.

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This video provides an overview of how toxic stress caused by trauma can disrupt brain development and what interventions are effective.

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Center on the Developing Child at Harvard University

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3. Toxic Stress Derails Healthy Development

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This article dives into the neurobiological consequences of early childhood trauma, explaining how repeated stressors alter cortisol levels and impair the brain's ability to handle stress. It also provides insights into preventative measures and resilience-building techniques.

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The neurobiology of childhood trauma and abuse - PubMed

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During the past decade there has been rapid progress in the understanding of the effects of exposure to traumatic life experiences on subsequent psychopathology in children. Trauma exposure affects what children anticipate and focus on and how they organize the way they appraise and process informat …

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This article explores how trauma and PTSD affect brain development in children. It discusses how early traumatic experiences can alter brain regions responsible for emotional regulation, memory, and stress responses. These changes can lead to lasting psychological and behavioral challenges. Early intervention and trauma-informed care are essential for mitigating these effects and helping children recover.

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doi: 10.1007/s11920-017-0825-3.

Affiliation

¹ Department of Psychiatry, University of Wisconsin School of Medicine & Public Health, 6001 Research Park Blvd, Madison, WI, 53719, USA. herringa@wisc.edu.

Free PMC article

Ryan J Herringa . Curr Psychiatry Rep.

Free PMC article

doi: 10.1007/s11920-017-0825-3.

Affiliation

¹ Department of Psychiatry, University of Wisconsin School of Medicine & Public Health, 6001 Research Park Blvd, Madison, WI, 53719, USA. herringa@wisc.edu.

Abstract

Purpose of review: PTSD in youth is common and debilitating. In contrast to adult PTSD, relatively little is known about the neurobiology of pediatric PTSD, nor how neurodevelopment may be altered. This review summarizes recent neuroimaging studies in pediatric PTSD and discusses implications for future study.

Recent findings: Pediatric PTSD is characterized by abnormal structure and function in neural circuitry supporting threat processing and emotion regulation. Furthermore, cross-sectional studies suggest that youth with PTSD have abnormal frontolimbic development compared to typically developing youth. Examples include declining hippocampal volume, increasing amygdala reactivity, and declining amygdala-prefrontal coupling with age. Pediatric PTSD is characterized by both overt and developmental abnormalities in frontolimbic circuitry. Notably, abnormal frontolimbic development may contribute to increasing threat reactivity and weaker emotion regulation as youth age. Longitudinal studies of pediatric PTSD are needed to characterize individual outcomes and determine whether current treatments are capable of restoring healthy neurodevelopment.

Keywords: Adolescents; Children; Neurodevelopment; Neuroimaging; PTSD; Trauma.

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Trauma, PTSD, and the Developing Brain - PubMed

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Pediatric PTSD is characterized by abnormal structure and function in neural circuitry supporting threat processing and emotion regulation. Furthermore, cross-sectional studies suggest that youth with PTSD have abnormal frontolimbic development compared to typically developing youth. Examples includ ...

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The article from Neuroscience News explains how childhood trauma can cause long-lasting changes in brain development, affecting areas like the hippocampus, amygdala, and prefrontal cortex. These changes impact emotional regulation, memory, and behavior, leading to challenges in coping and learning. Early intervention is crucial for supporting children affected by trauma and helping them recover.

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Researchers shed light on the profound effects of childhood trauma on brain development, uncovering significant disruptions in neural networks critical for self-awareness and problem-solving.

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The SAMHSA article on child trauma reveals that over two-thirds of children experience at least one traumatic event by age 16, such as abuse, violence, or disaster. It highlights the significant impact of trauma, including learning difficulties, increased use of health services, and long-term health problems. Signs of traumatic stress vary by age, with young children showing fear and nightmares, and older children exhibiting anxiety, depression, or substance abuse. Effective recovery involves recognizing trauma triggers, providing emotional reassurance, and seeking professional help. Supportive caregivers and trauma-informed services are crucial for helping children heal and thrive.

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Fast Facts

At least 1 in 7 children have experienced child abuse and/or neglect in the past year, and this is likely an underestimate. In 2019, 1,840 children died of abuse and neglect in the United States.

Each day, more than 1,000 youth are treated in emergency departments for physical assault-related injuries.

In 2019, about 1 in 5 high school students reported being bullied on school property in the last year.

8% of high school students had been in a physical fight on school property one or more times during the 12 months before the survey.

Each day, about 14 youth die from homicide, and more than 1,300 are treated in emergency departments for violence-related injuries.
It's important to recognize the signs of traumatic stress and its short- and long-term impact.
The signs of traumatic stress may be different in each child. Young children may react differently than older children.

Preschool Children

Fear being separated from their parent/caregiver

Cry or scream a lot

Eat poorly or lose weight

Have nightmares

Elementary School Children

Become anxious or fearful

Feel guilt or shame

Have a hard time concentrating

Have difficulty sleeping

Middle and High School Children

Feel depressed or alone

Develop eating disorders or self-harming behaviors

Begin abusing alcohol or drugs

Become involved in risky sexual behavior

The Body's Alarm System

Everyone has an alarm system in their body that is designed to keep them safe from harm. When activated, this tool prepares the body to fight or run away. The alarm can be activated at any perceived sign of trouble and leave kids feeling scared, angry, irritable, or even withdrawn.

Healthy Steps Kids Can Take to Respond to the Alarm

Recognize what activates the alarm and how their body reacts

Decide whether there is real trouble and seek help from a trusted adult

Practice deep breathing and other relaxation methods

Impact of Trauma

The impact of child traumatic stress can last well beyond childhood. In fact, research has shown that child trauma survivors may experience:

Learning problems, including lower grades and more suspensions and expulsions

Increased use of health and mental health services

Increase involvement with the child welfare and juvenile justice systems

Long-term health problems (e.g., diabetes and heart disease)

Trauma is a risk factor for nearly all behavioral health and substance use disorders.
There is hope. Children can and do recover from traumatic events, and you can play an important role in their recovery.
A critical part of children's recovery is having a supportive caregiving system, access to effective treatments, and service systems that are trauma informed.

Get Help Now
SAMHSA Behavioral Health Treatment Services Locator The National Child Traumatic Stress Network: Get Help Now Healthcare Toolbox: Basics of Trauma-Informed Care
Not all children experience child traumatic stress after experiencing a traumatic event. With support, many children are able to recover and thrive.

As a caring adult and/or family member, you play an important role.

Remember To:

Assure the child that he or she is safe.

Explain that he or she is not responsible. Children often blame themselves for events that are completely out of their control.

Be patient. Some children will recover quickly while others recover more slowly. Reassure them that they do not need to feel guilty or bad about any feelings or thoughts.

Seek the help of a trained professional. When needed, a mental health professional trained in evidence-based trauma treatment can help children and families cope and move toward recovery. Ask your pediatrician, family physician, school counselor, or clergy member for a referral.

Visit the following websites for more information:

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Recognize the signs of child traumatic stress and the impact that trauma may have on children. The infographic developed by SAMHSA's National Child Traumatic Stress Initiative (NCSTI) provides information on the prevalence and impact of traumatic events on children, and what actions can be taken to support children who experience traumatic events.

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Severe childhood adversity significantly increases the risk of various lifelong problems, including mental health disorders, physical health issues, and substance abuse. The ACE (Adverse Childhood Experiences) study, involving over 17,000 adults, highlighted a strong correlation between the number of adverse experiences in childhood and increased risks of behaviors and conditions such as heart disease and diabetes. Specifically, individuals with high ACE scores are more likely to develop alcohol dependence and PTSD. Studies show that childhood trauma, particularly abuse, is linked to a higher likelihood of substance use disorders, with early trauma often preceding alcohol dependence. Biological mechanisms, including alterations in stress-response systems and neurotransmitter pathways, may underlie these associations. Treatment approaches that address both trauma and substance abuse simultaneously, such as integrated cognitive-behavioral therapies, show promise in improving outcomes. However, further research is needed to refine and validate these approaches and to explore pharmacological treatments that target co-occurring PTSD and alcohol dependence.

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Kathleen T. Brady, M.D., Ph.D.

Sudie E. Back, Ph.D.

Abstract

Early-childhood trauma is strongly associated with developing mental health problems, including alcohol dependence, later in life. People with early-life trauma may use alcohol to help cope with trauma-related symptoms. This article reviews the prevalence of early-childhood trauma and its robust association with the development of alcohol use disorders and posttraumatic stress disorder. It also examines the potential biological mechanisms by which early adverse experiences can result in long-lasting changes in neurobiology underlying this vulnerability, as well as pharmacological and behavioral interventions. Recent investigations highlight the importance of assessing trauma among patients with alcohol use disorders and the positive benefits associated with the application of integrative psychosocial interventions that target both trauma-related symptoms and alcohol dependence.

Keywords: Alcohol dependence, alcohol use disorders, childhood, childhood trauma, trauma-related symptoms, posttraumatic stress disorder, coping with stress or anxiety, neurobiology, biological mechanisms, treatment, pharmacological intervention, behavioral intervention, integrative psychosocial intervention, adverse child-rearing environment

Children exposed to severe adversity early in life are at increased risk of subsequently developing mental health problems, including alcohol dependence. In general, the onset of trauma precedes the onset of alcohol dependence. Although it is impossible to establish a direct causal relationship, this temporal relationship suggests a robust and positive relationship between exposure to early-life trauma and alcohol-related problems later in life. People with trauma-related symptoms and other negative consequences of early-life trauma may use alcohol to help mitigate such symptoms. People with both a positive history of early childhood trauma and co-occurring alcohol dependence have a more severe clinical profile, as well as worse treatment outcomes when compared with those with either early trauma or alcohol dependence alone. Recent investigations highlight the importance of assessing trauma among patients with alcohol use disorders and the positive benefits associated with the application of integrative psychosocial interventions that target both trauma-related symptoms and alcohol dependence. This article reviews the prevalence of early-childhood trauma and its robust association with the development of alcohol use disorders and posttraumatic stress disorder (PTSD). It also examines the potential biological mechanisms by which early adverse experiences can result in long-lasting changes in neurobiology underlying this vulnerability, as well as pharmacologic and behavioral interventions.

Prevalence

There is little doubt that severe childhood adversity may place an individual at life-long risk for a variety of problems, including those related to mental health, physical health, employment, and legal difficulties ( Putnam 2006). In a study conducted by the Centers for Disease Control and Prevention and Kaiser Permanente (Adverse Childhood Experiences [ACE] study; Felitti et al. 1998), a sample of 17,337 adults recruited from a large health maintenance organization were surveyed concerning a range of adverse events that might occur during childhood (e.g., physical or sexual abuse, incarcerated household member, emotional neglect) and adult risk behaviors, health status, and disease. The investigators found a graded relationship between the number of adverse childhood experiences (i.e., ACE score), risk behaviors during adulthood, and leading causes of morbidity and mortality in the United States, including heart disease, diabetes, liver disease, and emphysema. It is possible that these increased rates of medical conditions are not a direct result of childhood adversity but rather the result of dysfunctional and unhealthy behaviors in which many victims of childhood abuse engage.

A number of studies also report that victims of child maltreatment are more likely to have emotional difficulties and psychiatric disorders. One of the most consistent results across these studies is the finding that childhood maltreatment is associated with an increased risk for alcohol and drug use disorders ( Enoch 2011). In a population-based sample of 1,411 female adult twins, self-reported childhood sexual abuse was positively associated with a number of psychiatric disorders, but the strongest associations were with alcohol and drug dependence ( Kendler et al. 2000). In the ACE study, the risk of alcohol dependence increased 7.2-fold, and illicit drug use increased 4.5-fold for people with four or more ACEs ( Anda et al. 2006). People with a history of childhood abuse or neglect are vulnerable to using alcohol in order to cope with stressful situations, which in turn may lead to excessive alcohol use ( Schuck and Widom 2001). An investigation by Widom and colleagues (2007) demonstrates that the increased risk of excessive alcohol use among victims of childhood abuse or neglect is consistent and stable into middle adulthood (e.g., age 40). Furthermore, research has shown that alcohol-dependent patients with a history of sexual abuse are more likely than nonabused patients to relapse to alcohol use (87.5 vs. 63.3 percent) and to relapse more quickly (median time to first drink = 60 vs. 115 days) in the first year following inpatient treatment for alcohol dependence ( Greenfield et al. 2002).

In addition to alcohol use disorders, childhood adversity is associated with an increased risk of PTSD ( Widom 1999). Data from a number of studies over the last 20 years have emphasized the high co-occurrence of PTSD and alcohol disorders. For example, among 3,768 female twins participating in the longitudinal Missouri Adolescent Female Twin Study (MOAFTS), Sartor and colleagues (2010) found that women exposed to trauma were nearly twice as likely to develop alcohol dependence (hazard ratio 1.85), and women exposed to trauma who also had PTSD were even more likely to develop alcohol dependence (hazard ratio 3.54; significantly higher than women with trauma exposure alone) when compared with women who had not experienced trauma. Studies of samples of individuals seeking treatment for alcohol use disorders also find a high prevalence of reported childhood adversity and PTSD. In a study of men and women in treatment for addictions, 62 percent reported having been victims of childhood physical or sexual abuse ( Grice et al. 1995). A review of studies of individuals seeking treatment for addictions reveals rates of PTSD as high as 50 percent or greater ( Dansky et al. 1994). In the majority of cases, the development of PTSD precedes the development of the substance use disorder.

These high rates of childhood victimization in individuals with PTSD and alcohol and other substance-related problems suggests that there is a link between childhood adversity and the development of these disorders, although it is impossible to establish a direct causal relationship. However, even when studies control for demographic differences, family discord, and parental pathology, the specific relationship between childhood abuse and the development of substance use disorders holds true. Several theoretical connections have been postulated ( Miller et al. 1993). Childhood victimization may lead to low self-esteem and the subsequent use of alcohol to deal with negative cognitions. It also is possible that victims of childhood abuse feel that their experiences make them "different" from other children and lead them to withdraw from healthier social circles toward fringe groups, where alcohol use is more accepted. In any case, given that victims of child abuse are more likely to develop alcohol use disorders as adults, early intervention, prevention, and training for parents are all important in interrupting this cycle of violence and alcohol problems.

Neurobiology

Recognizing the pervasive and detrimental effects of adverse childhood experiences on quality of life and health outcomes has led to the exploration of potential biological mechanisms by which early experiences can produce long-lasting changes. Evidence from both animal and human research suggests that early stressors can lead to neurobiological changes in systems known to be involved in the pathophysiology of depression, anxiety, and substance use disorders ( De Bellis et al. 1999; Heim and Nemeroff 2001). The hypothalamic-pituitary-adrenal (HPA) axis plays a critical role in the stress response and is involved in the pathophysiology of addictive disorders. Early stressors cause long-term increases in the stress response of the hormone cortisol ( Plotsky and Meaney 1993) as well as decreased genetic expression of cortisol receptors and increased expression of corticotropin-releasing factor in the hypothalamus, both of which may contribute to dysregulation of the HPA axis ( Ladd et al. 1996). The noradrenergic system also plays a key role in stress ( Bremner 2003), and early stressors can lead to long-term decreases in α-2 noradrenergic receptors in the locus coeruleus, which may lead to loss of feedback inhibition of noradrenergic activity with associated increases in the noradrenergic stress responses ( Caldji et al. 1998; Sanchez et al. 2001).

In addition to the long-lasting effects of early trauma on the stress response, a number of studies indicate that early trauma has specific effects on the neurotransmitter systems involved in the positive reinforcing effects of alcohol and drugs, particularly the brain pathway for dopamine (i.e., the mesocorticolimbic dopamine system) ( Meaney et al. 2002). Higley and colleagues (1991) found that adult rhesus monkeys raised in peer groups without maternal care showed increased HPA response to stress and increased alcohol consumption during periods of stress ( Higley et al. 1991). In a series of studies, Meaney and colleagues (2002) demonstrated that repeated periods of maternal separation in the early life of rats decreased dopamine transporter expression and increased dopamine responses to stress and behavioral responses to stress, cocaine, and amphetamine. These findings suggest that early-life experiences can affect the development of the mesocorticolimbic dopamine system and lead to a vulnerability to addiction in later life. Thus, in addition to effects on stress reactivity, early-life events might predispose individuals to the development of alcohol use disorders by directly influencing the reinforcing effects of alcohol. Other neurotransmitter systems involved in the pathophysiology of alcohol dependence, such as brain-derived neurotrophic factor (BDNF), serotonin, and γ-aminobutyric acid (GABA) systems also are affected by early-life trauma in ways that may influence vulnerability to the development of alcohol dependence, but the mechanistic connections in these systems are under active investigation and are not as well understood ( Enoch 2011).

Not all children exposed to early-life trauma develop alcohol dependence or other significant pathology, clearly suggesting that resilience and mediating factors play a role ( Enoch 2011). The genetic risk for alcohol and drug dependence involves multiple genes. Emerging evidence suggests that variation in some stress-related genes may determine the risk for psychopathology or resilience in people exposed to early-life trauma. In particular, it seems that there are important variations in the genes encoding the CRF system that can influence the development of alcohol dependence following an early-life trauma in a gene-by-environment interaction. One study of at-risk children found an interaction between a particular genetic variant coding for the CRF receptor (i.e., CRHR1) and sexual trauma in adolescents that predicted an earlier age of onset of drinking and heavy alcohol consumption ( Blomeyer et al. 2008). This finding is supported by animal studies demonstrating that the CRHR1 genotype and expression interact with environmental stress to reinstate alcohol-seeking in rodents ( Hansson et al. 2006), and a functional CRF promoter variant in monkeys conferred increased stress reactivity and was associated with increased alcohol consumption in animals reared under stressful conditions ( Barr et al. 2009). These findings suggest that the interaction of genetic susceptibility and environmental exposure can lead to a pathologically activated CRF system, which increases the risk for the development of alcohol dependence in some people.

Treatment

Both behavioral and pharmacological interventions are important to consider in the treatment of alcohol dependence and trauma/PTSD ( Davis et al. 2006; Weiss and Kueppenbender 2006). To date, most empirical studies of behavioral or pharmacological agents have investigated the treatment of either alcohol dependence or PTSD alone.

Psychosocial Interventions

With regard to psychosocial interventions, cognitive-behavioral therapies (CBTs) are the most widely studied and empirically valid treatments for both PTSD and alcohol use disorders. The CBTs used to treat PTSD fall into three main categories: (1) exposure-based therapies, (2) cognition-focused therapy, and (3) anxiety/stress-management therapy. Exposure-based therapies are considered the gold standard treatment for PTSD ( Institute of Medicine 2008) and involve having patients confront safe, but anxiety-provoking situations (i.e., physical location where childhood abuse occurred), known as in vivo exposure; and the memory of the traumatic experience, known as imaginal exposure ( Foa et al. 2006). With prolonged, repeated in vivo and imaginal exposure, the trauma-related anxiety is extinguished. Cognition-focused therapy includes cognitive therapy, which addresses the meaning that people assign to early-life trauma; and cognitive-processing therapy, which combines a narrative element of exposure therapy with efforts to identify and modify unhelpful cognitions related to the themes of safety, trust, power, esteem, and intimacy ( Resick and Schnicke 1992). Finally, stress inoculation training ( Meichenbaum and Novaco 1985), one of the most widely used and empirically investigated forms of anxiety management therapies, aims to provide a sense of mastery over PTSD symptoms by teaching patients a variety of coping skills. Stress inoculation training also has been incorporated into CBTs for substance use disorders and includes relaxation training, breathing retraining, thought stopping, self-instruction training, assertiveness training, cognitive restructuring, anger management, and problem solving.

Recently, integrative psychosocial interventions have been developed to address both trauma/PTSD and substance use disorders simultaneously ( Back 2010). Clinicians previously believed that trauma interventions were inappropriate until after a patient had been abstinent from alcohol or drugs for a sustained period of time (e.g., 3 months). This model, known as the "sequential" model, posits that continued alcohol use impedes therapeutic efforts to address and process the trauma, and that trauma interventions commenced before sustained abstinence would result in increased risk of relapse. Contrary to these beliefs, however, recent data reported by several different investigators in the United States and Australia show that treatment outcomes of substance dependent patients who engage in integrative CBT interventions typically experience significant improvements in both conditions and that rates of relapse are not increased by the introduction of therapy for trauma ( Brady et al. 2001; Hien et al. 2004; McGovern et al. 2009; Najavits 2002; Triffleman et al. 1999). Proponents of integrative treatments posit that unprocessed trauma-related memories and PTSD symptoms may, at least in part, drive alcohol use. Thus, attending to and treating the trauma-related symptoms early in the process of therapy may improve the chances of long-term recovery from alcohol ( Back et al. 2006; Hien et al. 2010). Although more randomized controlled trials of integrative treatments are needed, the studies to date clearly demonstrate that for the majority of alcohol-dependent patients with trauma/PTSD, the inclusion of trauma interventions confers substantial therapeutic benefits.

Pharmacological Interventions

There are several general issues to consider when treating co-occurring alcohol dependence and trauma/PTSD. When pharmacological agents are used, treatment should generally follow routine clinical practice for the treatment of PTSD. Regardless, relapse is common, and it is critical to consider the potential toxic interactions that may occur between the prescribed medication and alcohol. Given the high co-occurrence of alcohol and illicit drug use, potential toxic interactions between the prescribed medication and other substances of abuse must also be addressed. The pharmacological agent with the least abuse liability potential should be chosen for this population. Although benzodiazepines are effective in providing immediate relief of anxiety symptoms, they are generally not considered a first-line treatment for patients with alcohol dependence given the abuse potential of benzodiazepines. During the initial phase of treatment, when latency of onset of antidepressants is an issue, benzodiazepines may be considered as adjunctive medication. The amount of benzodiazepines prescribed to the patient should be limited, and the patient should be closely monitored for relapse or nonmedical use of benzodiazepines or other medications.

The use of pharmacological agents to specifically target alcohol dependence and PTSD is underexplored. Most studies to date, however, show promise and suggest that patients with co-occurring alcohol dependence and trauma/PTSD respond well to standard PTSD pharmacotherapies. Sertraline, a serotonin-specific reuptake inhibitor, has been investigated in patients with comorbid alcohol dependence and PTSD. The first study was a small ( n = 9) open-label, 12-week trial, which demonstrated significant pre-post decreases in alcohol use severity (e.g., number of drinking days, number of drinks per day), as well as PTSD symptoms of re-experiencing the trauma, avoidance, and hyperarousal ( Brady et al. 1995). A second study examined the efficacy of 12 weeks of sertraline compared with placebo in 94 patients with alcohol dependence and PTSD ( Brady et al. 2005). The primary outcome analysis indicated no significant effect of sertraline on alcohol-related outcomes and only trend-level findings for the PTSD outcomes. The sertraline-treated group showed statistical trends for greater improvement in the experience of sudden flashbacks of the traumatic event and hyperarousal symptoms (e.g., insomnia, inability to concentrate). Follow-up cluster analyses suggested that individuals with primary PTSD, compared with primary alcohol dependence, derived more benefit from sertraline treatment as evidenced by significantly less severe alcohol use. The results suggested that patients with early-onset alcohol dependence actually had worse alcohol-related outcomes with sertraline treatment compared with placebo ( Brady et al. 2005).

In another study of 254 veterans with alcohol dependence and a variety of co-occurring mood and anxiety disorders ( Petrakis et al. 2005), naltrexone, disulfiram, or a combination of both was added to treatment as usual. A high percentage (42.9 percent) of the study participants had PTSD, although data analysis for specific disorders was not conducted. Alcohol-related outcomes improved significantly in patients treated with either medication alone or with combination therapy, compared with placebo, but there was no added improvement with combination therapy when compared with monotherapy. This study strongly suggests that alcohol-dependent patients with co-occurring PTSD should receive medications targeting alcohol consumption.

There is good rationale for the exploration of a number of other compounds in the treatment of co-occurring PTSD and alcohol dependence. Prazosin blocks a specific α ₁-adrenergic receptor and has shown promise in several well-controlled trials for the treatment of PTSD, particularly in decreasing PTSD-related sleep disturbance and nightmares ( Raskin et al. 2007). In a preliminary study, prazosin decreased alcohol consumption in an alcohol-dependent population ( Simpson et al. 2009). This inexpensive and relatively safe drug warrants investigation in the treatment of co-occurring PTSD and alcohol dependence. In addition, several anticonvulsant agents, such as topirimate, have shown promise in the treatment of alcohol dependence ( Johnson et al. 2003). It is hypothesized that actions on the glutamatergic systems might be responsible for these agents' therapeutic actions. PTSD also has been associated with glutamatergic dysregulation, and anticonvulsant agents have shown promise in small-number, open-label studies in the treatment of PTSD. This is another area in which additional investigation is warranted. More research clearly is needed to help advance the behavioral and pharmacological treatment of co-occurring trauma/PTSD and substance use disorders.

Conclusions

Epidemiologic studies as well as studies in treatment-seeking populations converge to support the finding that early-life trauma is common in people with alcohol dependence. There are a number of potential mechanistic explanations for the connection between early-life trauma and the development of alcohol dependence. These include psychological and developmental issues that are affected by trauma, as well as neurobiological effects of early trauma that can lead to increased vulnerability to the development of alcohol and other substance use disorders. These explanatory hypotheses are not mutually exclusive. There is a growing literature on efficacious psychotherapeutic and pharmacotherapeutic treatments for individuals with co-occurring PTSD and alcohol dependence. Integrative psychosocial interventions combining efficacious interventions from the alcohol and PTSD fields have shown promise. Evidence suggests that agents targeting alcohol consumption (i.e., disulfiram, naltrexone) can be useful in patients with co-occurring PTSD and alcohol dependence, but additional investigation clearly is needed.

Acknowledgments

This work was supported in part by grants K24 DA-00435 (to Kathleen T. Brady) and K23 DA-021228 (to Sudie E. Back) from the National Institute on Drug Abuse.

Footnotes

Financial Disclosures
The authors declare that they have no competing financial interests.

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Articles from Alcohol Research : Current Reviews are provided here courtesy of National Institute on Alcohol Abuse and Alcoholism

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Childhood Trauma, Posttraumatic Stress Disorder, and Alcohol Dependence

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Early-childhood trauma is strongly associated with developing mental health problems, including alcohol dependence, later in life. People with early-life trauma may use alcohol to help cope with trauma-related symptoms. This article reviews the prevalence ...

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How Trauma Affects Kids in School - Child Mind Institute

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Learn how trauma from ongoing neglect, abuse, homelessness or violence causes children to have problems with learning and behavior. How to help these kids.

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Measure posttraumatic stress in children, ages 8 to 16, with the Trauma Symptom Checklist for Children (TSCC). Order from PAR today.

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