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The lasting effects of childhood trauma
Evidence-based interventions
can help address PTSD, other
symptoms in adulthood
hildhood trauma, which is also called adverse child-
hood experiences (ACEs), can have lasting detrimen-
Ctal effects on individuals as they grow and mature
into adulthood. ACEs may occur in children age ≤18 years if
they experience abuse or neglect, violence, or other traumatic
losses. More than 60% of people experience at least 1 ACE,
and 1 in 6 individuals reported that they had experienced ≥4
1
ACEs. Subsequent additional ACEs have a cumulative dete-
riorating impact on the brain. This predisposes individuals to
mental health disorders, substance use disorders, and other
psychosocial problems. The efficacy of current therapeutic
approaches provides only partial symptom resolution. For
OLGA_Z/GETTY IMAGESsuch individuals, the illness load and health care costs typi-
1,2
cally remain high across the lifespan.
Shikha Verma, MD, FAPA In this article, we discuss types of ACEs, protective factors
Medical Director, Northern California and risk factors that influence the development of posttrau-
Evolve Treatment Centers matic stress disorder (PTSD) in individuals who experience
Danville, California ACEs, how ACEs can negatively impact mental health in
Assistant Professor
Department of Psychiatry and Behavioral Health adulthood, and approaches to prevent or treat PTSD and
Rosalind Franklin University of Medicine and Science other symptoms.
North Chicago, Illinois
Ruchita Agrawal, MD, FAPA
Associate Chief Medical Officer, Adult Services Types of trauma and correlation with PTSD
Seven Counties Services
Louisville, Kentucky ACEs can be indexed as neglect or emotional, physical, or sex-
ual abuse. Physical and sexual abuse strongly correlate with
3
an increased risk of PTSD. Although neglect and emotional
abuse do not directly predict the development of PTSD, these
Disclosures
The authors report no financial relationships with any companies whose products are mentioned
Current Psychiatry in this article, or with manufacturers of competing products.
18 March 2021 doi: 10.12788/cp.0101
experiences foretell high rates of lifelong Table 1
trauma exposure and are indirectly related to PTSD: Protective factors
late PTSD symptoms.4,5 ACEs can impede an and risk factors
individual’s cognitive, social, and emotional MDedge.com/psychiatry
development, diminish quality of life, and Protective factors
6 Being male (more men than women are
lead to an early death. The lifetime preva-
7 exposed to trauma, but PTSD is twice as
lence of PTSD is 6.1% to 9.2%. Compared common in women)
with men, women are 4 times more likely to A strong relationship with family and peers
7
develop PTSD following a traumatic event.
The development of PTSD is influenced Resilience and hope
by the nature, duration, and degree of Limited genetic predisposition to psychiatric
trauma, and age at the time of exposure illness
to trauma. Children who survive complex Risk factors
trauma (≥2 types of trauma) have a higher Severity and duration of trauma
likelihood of developing PTSD.8 Prolonged Age at trauma
trauma exposure has a more substantial Type and number of traumatic experiences
negative impact than a one-time occurrence. Clinical Point
However, it is an erroneous oversimplifica- Severity of initial response to trauma
tion to assume that each type of ACE has an General childhood adversity ACEs can impede
6 Reported childhood abuse cognitive, social,
equally traumatic effect.
Gender and emotional
Factors that protect against PTSD Low socioeconomic status development,
Low education diminish quality of
Factors that can protect against developing First-degree relative with a history of life, and lead to an
7
PTSD are listed in Table 1. Two of these are depression, other psychiatric illness, or early death
resilience and hope. substance use
Resilience is defined as an individual’s Single, divorced, widowed, or socially
9
strength to cope with difficulties in life. withdrawn
Resilience has internal psychological char- Inadequate family and peer support
acteristics and external factors that aid in PTSD: posttraumatic stress disorder
protecting against childhood adversities.10,11 Source: Reference 7
The Brief Resilience Scale is a self-assess-
ment that measures innate abilities to cope,
including optimism, self-efficacy, patience,
12,13
faith, and humor. External factors associ- PTSD. Some of these factors are outlined in
7
ated with resilience are family, friends, and Table 1.
11,13
community support.
Hope can help in surmounting ACEs. The
Adult Hope Scale has been used in many Pathophysiology of PTSD
studies to assess this construct in individuals Multiple brain regions, pathways, and
13
who have survived trauma. Some studies neurotransmitters are involved in the
have found decreased hope in individuals development of PTSD. Neuroimaging has
who sustained early trauma and were diag- identified volume and activity changes of
nosed with PTSD in adulthood.14 A study the hippocampus, prefrontal cortex, and
examining children exposed to domestic vio- amygdala in patients with early trauma
lence found that children who showed high and PTSD. Some researchers have sug- Discuss this article at
hope, endurance, and curiosity were better gested a gross reduction in locus coeruleus www.facebook.com/
15 MDedgePsychiatry
able to cope with adversities. neuronal volume in war veterans with a
likely diagnosis of PTSD compared with
controls.16,17 In other studies, chronic stress
PTSD risk factors exposure has been found to cause neuro-
Many individual and societal risk factors nal cell death and affect neuronal plasticity Current Psychiatry
18 Vol. 20, No. 3
can influence the likelihood of developing in the limbic area of the brain. 19
continued on page 24
continued from page 19
Table 2
DSM-5 criteria for posttraumatic stress disorder
Trauma exposure
Trauma Actual or threatened violent death, serious injury or accident, or sexual violence
A. Exposure Via any of the following:
1. Directly exposed to trauma
Lasting effects of 2. Eyewitness (in person) to others directly exposed to trauma
3. Learning of direct exposure to trauma of a close family member or close friend
childhood trauma 4. Repeated or extreme exposure to aversive details of traumatic event (eg, trauma
workers viewing human remains or repeatedly exposed to details of child abuse),
in person or via work-related electronic media
Symptom groups B to E (symptoms beginning or worsening after the traumatic event)
B. Intrusion ≥1 intrusion symptoms:
1. Recurrent, involuntary, distressing trauma memories
2. Recurrent, distressing trauma-related dreams
3. Dissociative reactions/flashbacks related to trauma
4. Intense or prolonged psychological distress to trauma reminders
Clinical Point 5. Marked physiological reactions to trauma reminders
C. Avoidance ≥1 avoidance symptoms:
More than 30% 1. Avoidance of or efforts to avoid distressing internal trauma reminders (memories,
thoughts, feelings)
of individuals 2. Avoidance of or efforts to avoid distressing external trauma reminders (people,
who experience places, activities)
D. Negative ≥2 negative cognition/mood symptoms:
adverse childhood cognition 1. Amnesia for important parts of trauma exposure
experiences and mood 2. Persistent, exaggerated negative beliefs about self, others, or the world
3. Persistent, distorted trauma-related cognitions leading to inappropriate blame
develop PTSD of self/others
4. Persistent negative emotional state (eg, fear, horror, anger, guilt, shame)
5. Loss of interest or participation in significant activities
6. Feelings of detachment or estrangement from others
7. Persistent loss of positive emotions (eg, happiness, satisfaction, love)
E. Hyperarousal ≥2 marked alterations in trauma-related arousal and reactivity:
1. Irritability and angry outbursts with little/no provocation (eg, verbal/physical
aggression toward people/objects)
2. Reckless or self-destructive behavior
3. Hypervigilance
4. Exaggerated startle
5. Concentration problems
6. Sleep disturbance (eg, difficulty falling or staying asleep, restless sleep)
Additional criteria
F. Duration >1 month
G. Distress/ Clinically significant distress; social/occupational/other important functioning
impairment impairment
H. Not Independent of physiological effects of a substance (eg, medication, alcohol) or
attributable another medical condition
to another
disorder
PTSD: posttraumatic stress disorder
Source: Reference 20
Diagnosing PTSD Clinician-Administered PTSD Scale for
21
More than 30% of individuals who expe- DSM-5, which is a 30-item structured
19
rience ACEs develop PTSD. The DSM-5 interview that can be administered in 45
diagnostic criteria for PTSD are outlined to 60 minutes; the PTSD Symptom Scale
20
in Table 2. Several instruments are used Self-Report Version, which is a 17-item,
Current Psychiatry to determine the diagnosis and assess Likert scale, self-report questionnaire;
24 March 2021 the severity of PTSD. These include the and the Structured Clinical Interview:
PTSD Module, which is a semi-structured self-reliance and competence and decreases
interview that can take up to several hours the generalization of anxiety to innocu-
21
to administer. ous triggers. PE typically consists of 9 to
Other disorders. In addition to PTSD, 12 sessions. PE alone or in combination MDedge.com/psychiatry
individuals with ACEs are at high risk with cognitive restructuring is successful
for other mental health issues throughout in treating patients with PTSD, but cog-
their lifetime. Individuals with ACE often nitive restructuring has limited utility in
25,27
experience depressive symptoms (approxi- young children.
mately 40%); anxiety (approximately 30%); Cognitive exposure can be individual or
anger; guilt or shame; negative self-cogni- group therapy delivered over 3 months,
tion; interpersonal difficulties; rumination; where negative self-evaluation and trau-
22
and thoughts of self-harm and suicide. matic memories are challenged with the
Epidemiological studies suggest that goal of interrupting maladaptive behav-
27
patients who experience childhood sexual iors and thoughts.
abuse are more likely to develop mood, Stress inoculation training (SIT) provides
anxiety, and substance use disorders psychoeducation, skills training, role-play-
23,24 Clinical Point
in adulthood. ing, deep muscle relaxation, paced breath-
ing, and thought stopping. Emphasis is on Before starting CBT,
coaching skills to alleviate anxiety, fear, ensure that your
Psychotherapeutic treatments and symptoms of depression associated
for PTSD with trauma. In SIT, exposures to trau- patient has the coping
Cognitive-behavioral therapy (CBT) matic memories are indirect (eg, role play), skills to manage
addresses the relationship between an indi- compared with PE, where the exposures distress related to
25
vidual’s thoughts, emotions, and behav- are direct. their ACEs
iors. CBT can be used to treat adults and The American Psychological Association
children with PTSD. Before starting CBT, conditionally recommended several other
assess the patient’s current safety to ensure forms for psychotherapy for treating patients
26
that they have the coping skills to manage with PTSD :
distress related to their ACEs, and address Brief eclectic psychotherapy uses CBT and
25
any coexisting substance use. psychodynamic approaches to target feel-
27
According to the American Psychological ings of guilt and shame in 16 sessions.
Association, several CBT-based psycho- Narrative exposure therapy consists of 4
therapies are recommended for treating to 10 group sessions in which individuals
26
PTSD : provide detailed narration of the events;
Trauma-focused–CBT includes psycho- the focus is on self-respect and personal
27
education, trauma narrative, processing, rights.
exposure, and relaxation skills training. Eye movement desensitization and repro-
It consists of approximately 12 to 16 ses- cessing (EMDR) is a 6- to 12-session, 8-phase
sions and incorporates elements of family treatment that uses principles of accel-
therapy. erated information processing to tar-
Cognitive processing therapy (CPT) get nonverbal expression of trauma
focuses on helping patients develop adap- and dissociative experiences. Patients
tive cognitive domains about the self, the with PTSD are suggested to have dis-
people around them, and the world. CPT rupted rapid eye movements. In EMDR,
therapists assist in information processing patients follow rhythmic movements of
by accessing the traumatic memory and the therapist’s hands or flashed light.
25,27
trying to eliminate emotions tied to it. This is designed to decrease stress asso-
CPT consists of 12 to 16 structured indi- ciated with accessing trauma memories,
vidual, group, or combined sessions. the emotional/physiologic response from
Prolonged exposure (PE) targets fear-related the memories, and negative cognitive dis-
emotions and works on the principles of tortions about self, and to replace negative
habituation to extinguish trauma and fear cognition distortions with positive thoughts Current Psychiatry
25,27 Vol. 20, No. 3
response to the trigger. This increases about self. 25
continued
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