ArticlePDF Available

Association of Childhood Trauma Exposure With Adult Psychiatric Disorders and Functional Outcomes

Authors:

Abstract and Figures

Importance Being exposed to trauma is a common childhood experience associated with symptoms and impairments in childhood. Objective To assess the association between cumulative childhood trauma exposure and adult psychiatric and functional outcomes. Design, Setting, and Participants Prospective, population-based cohort study of 1420 participants. A community representative sample of participants was assessed with structured Child and Adolescent Psychiatric Assessment interviews up to 8 times in childhood (ages 9-16 years; 6674 observations; 1993-2000) for lifetime trauma exposure as defined by the Diagnostic and Statistical Manual of Mental Disorders. Participants were followed up 4 times in adulthood (ages 19, 21, 25, and 30 years; 4556 observations of 1336 participants; 1999-2015) with the structured Young Adult Psychiatric Assessment Interview for psychiatric outcomes, functional outcomes, and evidence of a disrupted transition to adulthood. Analysis was completed in 2018. Exposure Participants were assessed with the structured Child and Adolescent Psychiatric Assessment interview (parent and self-report) up to 8 times in childhood for lifetime trauma exposure (ages 9-16 years; 6674 observations; 1993-2000). Main Outcomes and Measures Participants were assessed up to 4 times with the structured Young Adult Psychiatric Assessment interview (self-report) in adulthood (ages 19, 21, 25, and 30 years; 4556 observations of 1336 participants; 1999-2015) for psychiatric outcomes, functional outcomes, and evidence of a disrupted transition to adulthood. Results Among the 1420 study participants, 630 (49.0%) were female and 983 (89.4%) were white. By age 16 years, 30.9% of children (n = 451) were exposed to 1 traumatic event, 22.5% (n = 289) were exposed to 2 such events, and 14.8% (n = 267) were exposed to 3 or more. Cumulative childhood trauma exposure to age 16 years was associated with higher rates of adult psychiatric disorders (odds ratio for any disorder, 1.2; 95% CI, 1.0-1.4) and poorer functional outcomes, including key outcomes that indicate a significantly disrupted transition to adulthood (eg, failure to hold a job and social isolation). Childhood trauma exposure continued to be associated with higher rates of adult psychiatric and functional outcomes after adjusting for a broad range of childhood risk factors, including psychiatric functioning and family adversities and hardships (adjusted odds ratio for any disorder, 1.3; 95% CI, 1.0-1.5). Conclusions and Relevance Cumulative childhood trauma exposure was associated with poor adult outcomes even after accounting for many of the childhood and family factors associated with both trauma exposure and poor adult outcomes. Childhood trauma exposures are common, but often preventable, thus providing a clear target for child-focused public health efforts to ameliorate long-term morbidity.
Original Investigation | Psychiatry
Association of Childhood Trauma Exposure With Adult Psychiatric
Disorders and Functional Outcomes
William E. Copeland, PhD; Lilly Shanahan, PhD; Jennifer Hinesley, PsyD; RobinF. Chan, PhD; Karolina A. Aberg, PhD; John A. Fairbank, PhD;
Edwin J. C. G. van den Oord, PhD; E. Jane Costello,PhD
Abstract
IMPORTANCE Being exposed to trauma is a common childhood experience associated with
symptoms and impairments in childhood.
OBJECTIVE To assess the association between cumulative childhood trauma exposure and adult
psychiatric and functional outcomes.
DESIGN, SETTING, AND PARTICIPANTS Prospective, population-based cohort study of 1420
participants. A community representative sample of participants was assessed with structured Child
and Adolescent Psychiatric Assessment interviews up to 8 times in childhood (ages 9-16 years; 6674
observations; 1993-2000) for lifetime trauma exposure as defined by the Diagnostic and Statistical
Manual of Mental Disorders. Participants were followed up 4 times in adulthood (ages 19, 21, 25, and
30 years; 4556 observations of 1336 participants; 1999-2015) with the structured Young Adult
Psychiatric Assessment Interview for psychiatric outcomes, functional outcomes, and evidence of a
disrupted transition to adulthood. Analysis was completed in 2018.
EXPOSURE Participants were assessed with the structured Child and Adolescent Psychiatric
Assessment interview (parent and self-report) up to 8 times in childhood for lifetime trauma
exposure (ages 9-16 years; 6674 observations; 1993-2000).
MAIN OUTCOMES AND MEASURES Participants were assessed up to 4 times with the structured
Young Adult Psychiatric Assessment interview (self-report) in adulthood (ages 19, 21, 25, and 30
years; 4556 observations of 1336 participants; 1999-2015) for psychiatric outcomes, functional
outcomes, and evidence of a disrupted transition to adulthood.
RESULTS Among the 1420 study participants, 630 (49.0%) were female and 983 (89.4%) were
white. By age 16 years, 30.9% of children (n = 451) were exposed to 1 traumatic event, 22.5%
(n = 289) were exposed to 2 such events, and 14.8% (n = 267) were exposed to 3 or more.
Cumulative childhood trauma exposure to age 16 years was associated with higher rates of adult
psychiatric disorders (odds ratio for any disorder, 1.2; 95% CI, 1.0-1.4) and poorer functional
outcomes, including key outcomes that indicate a significantly disrupted transition to adulthood (eg,
failure to hold a job and social isolation). Childhood trauma exposure continued to be associated with
higher rates of adult psychiatric and functional outcomes after adjusting for a broad range of
childhood risk factors, including psychiatric functioning and family adversities and hardships
(adjusted odds ratio for any disorder, 1.3; 95% CI, 1.0-1.5).
CONCLUSIONS AND RELEVANCE Cumulative childhood trauma exposure was associated with
poor adult outcomes even after accounting for many of the childhood and family factors associated
(continued)
Key Points
Question Are adult psychiatric and
functional outcomes associated with
cumulative childhood trauma exposure?
Findings In this cohort study,
cumulative childhood trauma was
associated with higher rates of adult
psychiatric disorders and poorer
functional outcomes even after
adjusting for a broad range of other
childhood risk factors for these
outcomes, including psychiatric
functioning and family adversities and
hardships.
Meaning Cumulative childhood trauma
exposure is associated with negative
outcomes in health and functioning in
adulthood.
+Invited Commentary
+Supplemental content
Author affiliations and article information are
listed at the end of this article.
Open Access. This is an open access article distributed under the terms of the CC-BY License.
JAMA Network Open. 2018;1(7):e184493. doi:10.1001/jamanetworkopen.2018.4493 November 9, 2018 1/11
Downloaded From: on 11/12/2018
Abstract (continued)
with both trauma exposure and poor adult outcomes. Childhood trauma exposures are common, but
often preventable, thus providing a clear target for child-focused public health efforts to ameliorate
long-term morbidity.
JAMA Network Open. 2018;1(7):e184493. doi:10.1001/jamanetworkopen.2018.4493
Introduction
Exposure to traumatic events (as defined by Diagnostic and Statistical Manual of Mental Disorders
[DSM] criterion A for posttraumatic stress disorder)
1
is a common experience of childhood, with more
than 60% of children exposed by age 16 years and more than 30% exposed to multiple events.
2,3
Exposure to traumatic events is associated with posttraumatic stress and other common childhood
emotional and behavioral problems.
2-5
An extensive literature links childhood trauma, particularly
maltreatment, to adult psychopathology and impairment.
6-10
These studies, however, have generally
relied on reports of adults recalling events that occurred decades earlier.
11
Such retrospective recalls
are prone to simple forgetting or recall bias depending on the individual’s current mental health.
11-13
This study uses a prospective community sample followed up repeatedly from childhood to
adulthood to test whether childhood trauma has lasting effects on adult mental health and
multidomain functioning.
Even if there are lasting effects of prospectively assessed trauma, these associations may be
confounded by other child and family factors that commonly cluster with both trauma exposure and
adult outcomes. For example, trauma exposure could merely be exacerbating premorbid emotional
and behavioral symptoms that also affect adult health and functioning.
14-17
Emotional and behavioral
symptoms could be interpreted as indicators of individuals’ vulnerability and may therefore serve as
a more proximal indicator of risk than trauma exposure itself. Similarly, exposure to trauma is often
correlated with a broader cluster of adverse family circumstances, including socioeconomic strain,
familial instability, or family dysfunction.
3,5,18,19
The broader family context, rather than the specific
exposure to trauma, may better predict long-term health and functioning.
The proposed analysis draws on a prospective, longitudinal study that assessed trauma
exposure from children and their parents up to 8 times in childhood from ages 9 to 16 years.
Participants were then followed up 4 times in adulthood from ages 19 to 30 years to study adult
mental health and functional outcomes. Assessments prior to initial trauma exposure allow us to
evaluate the potential confounding of associations between childhood trauma and adult outcomes
by childhood psychiatric status and adversities. Adult outcomes included psychiatric disorders and
important functional domains such as health, risky and/or criminal behavior, financial and
educational status, and social functioning.
Methods
Participants
This report follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE)
reporting guideline for cohort studies.
20
The Great Smoky Mountains Study is a longitudinal,
representative study of children in 11 predominantly rural counties of North Carolina.
21
Three cohorts
of children, aged 9, 11, and 13 years, were recruited from a pool of some 12000 children using a 2-stage
sampling design, resulting in 1420 participants (49% female
21
). First, potential participants were
randomly selected from the population using a household equal probability design. Next, participants
were screened for risk of psychopathology, and participants screening high were oversampled in
addition to a random sample of the rest. In addition, American Indian participants were oversampled
to constitute 25% of the sample. Sampling weights were applied to adjust for differential probability of
JAMA Network Open | Psychiatry Childhood Trauma Exposure and Adult Psychiatric Disorders and Functional Outcomes
JAMA Network Open. 2018;1(7):e184493. doi:10.1001/jamanetworkopen.2018.4493 November 9, 2018 2/11
Downloaded From: on 11/12/2018
selection and to allow results to generalize to the broader population of children from which the sample
was drawn. Additional details are available in the eFigure in the Supplement and previous studies.
21-23
Annual assessments were completed on the 1420 children until age 16 years (6674
observations of 1420 individuals; 1993-2000) and then again at ages 19, 21, 25, and 30 years (4556
observations of 1336 participants; 1999-2015) for a total of 11230 assessments. Interviews were
completed separately by a parent figure and the participant until age 16 years, and by the participant
only thereafter. Before all interviews, parent and child signed informed consent or assent forms. The
study protocol and consent forms for each assessment were approved by the Duke University
Medical Center institutional review board and participants received payment for their time.
Childhood Variables
Childhood predictors of adult outcomes included the following constructs: (1) DSM-based traumatic
events, (2) psychiatric and substance disorders, and (3) adversities and hardships. All constructs
were assessed using the structured Child and Adolescent Psychiatric Assessment (CAPA).
24,25
Cumulative childhood lifetime exposure to DSM-based traumatic events was assessed using the
Life Events and Posttraumatic Stress sections of the CAPA. Details about the construction and
psychometric properties of these sections are described elsewhere.
26
The parent or child was
queried about lifetime occurrence of each event and the timing of its occurrence. The Life Events
section covered events that meet the DSM posttraumatic stress disorder criterion A, which stipulates
that the event must involve “exposure to actual or threatened death, serious injury, or sexual
violence.
1,27
The terms trauma and traumatic events are used to describe these events in reporting
our results. eTable 1 in the Supplement includes a list of all events assessed and their frequencies in
childhood. Exposure to lifetime traumatic events was aggregated into a cumulative childhood trauma
exposure variable that coded 0, 1, 2, or 3 or more traumas. Traumatic events were categorized as
violent trauma (including violent death of loved one, physical abuse, experiencing physical violence,
war or terrorism, or captivity), sexual trauma (rape or sexual abuse), witnessing a trauma that caused
or had the potential to cause death or severe injury, learning about a traumatic event occurring to a
loved one, and other traumas (diagnosis with serious illness, serious unintentional injury, natural
disaster, fire, or exposure to a noxious agent).
Childhood Psychiatric Disorders and Other Adversities and Hardships
For psychiatric symptoms, the CAPA focuses on the 3 months immediately preceding the interview
to minimize recall bias. Scoring programs written in SAS statistical software (SAS Institute Inc)
combine information about the date of onset, duration, and intensity of each symptom to create DSM
diagnoses. Test-retest reliability and validity of the CAPA diagnoses are similar to other psychiatric
interviews.
24,25
Psychiatric disorders assessed included anxiety disorders, mood disorders, conduct
disorder, oppositional defiant disorder, attention-deficit/hyperactivity disorder, and substance use
disorders. The following categories of family hardships or childhood adversities were assessed at
each observation: (1) low socioeconomic status; (2) unstable family structure (eg, single-parent
family, divorce, presence of stepparent); (3) family dysfunction, including inadequate parental
supervision; domestic violence; parental overinvolvement; maternal depression; marital relationship
characterized by apathy, indifference, or high conflict; and high conflict between parent and child;
and (4) being bullied by peers. A full description of these variables is available in a previous
publication,
28
in the eAppendix in the Supplement, and in online codebooks at http://devepi.mc.
duke.edu/, which also report basic prevalence data.
Adult Variables
All outcomes except where noted (eg, official criminal records) were assessed using the Young Adult
Psychiatric Assessment (YAPA),
29
an upward extension of the CAPA interview administered to the
participants. The assessment of adult psychiatric disorders resembled that of childhood disorders,
but with only self- (and not parent) reports. Disorders included any DSM anxiety disorder, depressive
JAMA Network Open | Psychiatry Childhood Trauma Exposure and Adult Psychiatric Disorders and Functional Outcomes
JAMA Network Open. 2018;1(7):e184493. doi:10.1001/jamanetworkopen.2018.4493 November 9, 2018 3/11
Downloaded From: on 11/12/2018
disorder, nicotine use disorder, alcohol use disorder, and cannabis use disorder. Psychosis and bipolar
disorder were not included in analyses owing to very low prevalence (<1%) in the community. The
participant was positive for diagnosis if criteria were met at any adult observation. Standardized
scales were derived to provide a broad profile of adult functioning across 4 domains: health, risky
and/or illegal behaviors, wealth (financial and/or educational), and social function. These scales were
summed from dichotomous indictors in each domain (eg, college completion for wealth, smoking
status for health). In some cases the indicators were positive if reported at any point in adulthood; in
other cases (eg, educational attainment) the last observation was used to determine status.
Standardized scores were obtained by subtracting the individual score from the group mean and
dividing the resultant score by the standard deviation. A full description of all indicators used to
construct these scales is available in the eAppendix in the Supplement.
Statistical Analysis
The analytic approach must account for the 2-stage sample design. Each participant was assigned a
sampling weight inversely proportional to his or her probability of selection. Next, all models used the
generalized estimating equations option within SAS PROC GENMOD to derive robust variance
(sandwich-type) estimates to adjust standard errors for the stratified design. Such weighted logistic
(for binary outcomes such as psychiatric status), Poisson (for count variables such as number of
derailments), and linear (for continuous variables such as the zscores for the adult function scales)
regression models were used to look at differences in adult outcomes by childhood trauma status.
Adjusted models account for potential confounding from childhood psychiatric problems and
adversities. Consistent with common conventions, all percentages provided in the results are
weighted and sample sizes are unweighted. Findings are considered statistically significant at 2-sided
P< .05.
Missing Data
Across all assessments, 83% of possible interviews were completed. All 1420 participants were
interviewed at least once in childhood (ages 9-16 years); 1260 participants (88.7%) had 3 or more
childhood observations. Of the total sample, 1336 (94.0%) were followed up at least once in
adulthood at ages 19, 21, 25, or 30 years. Experiencing a childhood trauma was not associated with
lower levels of participation in adulthood, suggesting no differential dropout.
Results
Cumulative Childhood Lifetime Trauma Exposure
Among the 1420 study participants, 630 (49.0%) were female and 983 (89.4%) were white. As
previously reported,
2
exposure to a DSM extreme stressor was common: 30.9% of children (451)
were exposed to 1 traumatic event, 22.5% (289) were exposed to 2, and 14.8% (267) were exposed
to 3 or more such events. Overall prevalence of trauma exposure did not differ by sex (although some
individual traumatic events were more common in boys than girls and vice versa) or race/ethnicity.
The most commonly reported events were witnessing a traumatic event (24.1%), life-threatening
unintentional injuries (22.7%), and learning about an extreme stressor that occurred to a loved one
(21.9%). When analyses were limited to the subset of participants with 3 or more childhood
observations (1260 participants), the overall cumulative lifetime prevalence of exposure to traumatic
events by age 16 years was at 70.5%, suggesting little evidence of downward bias due to attrition in
childhood. Table 1 shows the prevalence and associations between cumulative lifetime childhood
trauma groups and childhood psychiatric problems and other adversities and hardships. Cumulative
trauma was associated with almost every type of childhood emotional and behavioral disorder and
every type of childhood adversity and hardship (ie, low socioeconomic status, familial instability,
family dysfunction, and being bullied by peers). eTable 2 in the Supplement shows similar
associations for individual trauma categories.
JAMA Network Open | Psychiatry Childhood Trauma Exposure and Adult Psychiatric Disorders and Functional Outcomes
JAMA Network Open. 2018;1(7):e184493. doi:10.1001/jamanetworkopen.2018.4493 November 9,2018 4/11
Downloaded From: on 11/12/2018
Associations With Adult Outcomes
Of the total sample, 1336 (94.0%) were followed up at least once in adulthood at ages 19, 21, 25, or
30 years. Table 2 shows the association of cumulative lifetime trauma exposure during childhood
and adult psychiatric outcomes. In models adjusted for sex and race/ethnicity only, childhood trauma
status was associated with adult psychiatric status. All models were rerun adjusting for childhood
psychiatric history (eg, anxiety, depressive, behavioral, and substance disorders) and childhood
adversities and hardships (eg, low socioeconomic status, family instability, family dysfunction, and
being bullied by peers) at the initial childhood assessment. Childhood trauma continued to predict
any adult disorder and any adult anxiety disorder after adjusting for childhood covariates.
A similar pattern of results was identified for health, risky and/or criminal behavior, financial and
educational functioning, and social functioning scales (Table 3 and Figure). Childhood trauma was
associated with all outcomes in models adjusted for sex and race/ethnicity and also models adjusting
for childhood psychiatric problems and hardships and adversities.
Moderation by Sex, Race/Ethnicity, Age at First Exposure
Interaction analyses tested whether the effects of childhood trauma differed by sex, race/ethnicity,
and age at first exposure. There was little evidence that associations between childhood trauma and
adult outcomes differed by either sex or race/ethnicity for adult psychiatric status or functional
outcomes. With respect to age at first trauma exposure, the prospective design allowed us to split
trauma exposure as having first occurred in childhood (12 years) or adolescence (13 years). Age at
Table 1. Prevalence of Cumulative Childhood Trauma and Unadjusted Association With Childhood Psychiatric
Problems and Adversities and Hardships
a
Psychiatric Problem, Adversity,
or Hardship
Participants, No. (%)
Odds Ratio
(95% CI)
0 Exposures
(n = 413)
1 Exposure
(n = 451)
2 Exposures
(n = 289)
≥3 Exposures
(n = 267)
Psychiatric problems
Any 100 (14.5) 156 (26.6) 120 (33.9) 154 (46.1) 1.5 (1.3-1.8)
b
Any anxiety disorder 27 (4.2) 56 (10.8) 47 (15.1) 64 (16.9) 1.4 (1.2-1.7)
b
Any depressive disorder 19 (3.3) 36 (7.6) 30 (6.6) 55 (19.7) 1.7 (1.3-2.1)
b
Attention-deficit/hyperactivity
disorder
15 (2.3) 23 (3.7) 19 (3.8) 21 (4.1) 1.2 (0.9-1.5)
Oppositional defiant disorder 36 (5.7) 66 (8.8) 49 (9.7) 87 (21.4) 1.5 (1.2-1.8)
b
Conduct disorder 36 (3.9) 48 (5.6) 46 (11.0) 73 (21.3) 1.8 (1.4-2.2)
b
Substance use disorder 21 (4.9) 27 (5.4) 19 (6.8) 41 (11.8) 1.3 (1.0-1.7)
b
Adversities and hardships
Low family socioeconomic status 147 (28.1) 209 (31.4) 134 (36.5) 159 (49.4) 1.3 (1.1-1.5)
b
Family instability 85 (16.1) 155 (25.7) 104 (29.2) 126 (47.8) 1.5 (1.3-1.8)
b
Family dysfunction 95 (20.5) 124 (19.3) 124 (39.1) 133 (41.7) 1.5 (1.2-1.7)
b
Bullied by peers 89 (14.7) 122 (25.5) 98 (35.5) 112 (36.8) 1.4 (1.2-1.6)
b
a
All percentages are weighted and sample sizes are
unweighted. Cumulative trauma exposure is treated
as a continuous variable. All models adjusted for sex
and race/ethnicity.
b
P< .05.
Table 2. Prevalenceof Cumulative Childhood Trauma and Association With Adult Psychiatric Problems
a
Psychiatric Problem
Participants, No. (%) Adjusted Odds Ratio (95% CI)
0 Exposures 1 Exposure 2 Exposures ≥3 Exposures
Sex and Race/
Ethnicity
Sex, Race/Ethnicity,
Psychiatric Disorders,
and Adversities
Any disorder 100 (37.6) 156 (49.5) 120 (47.1) 154 (54.1) 1.2 (1.0-1.4)
b
1.3 (1.0-1.5)
b
Any anxiety disorder 27 (12.9) 56 (18.3) 47 (14.6) 64 (26.5) 1.3 (1.0-1.5)
b
1.3 (1.0-1.7)
b
Any depressive disorder 19 (8.2) 36 (11.1) 30 (6.9) 55 (17.8) 1.3 (1.0-1.6)
b
1.2 (1.0-1.6)
Any substance disorder 36 (27.1) 66 (36.8) 49 (35.7) 87 (35.9) 1.1 (1.0-1.3) 1.2 (1.0-1. 4)
a
All percentages are weighted and sample sizes are unweighted. Cumulative trauma
exposure is treated as a continuous variable. Psychiatric diagnoses include childhood
depression, anxiety, attention-deficit/hyperactivity disorder, conduct disorder,
oppositional defiant disorder, and substance disorder. Childhood adversities include
low socioeconomic status, familial instability, family dysfunction, and being bullied
by peers.
b
P< .05.
JAMA Network Open | Psychiatry Childhood Trauma Exposure and Adult Psychiatric Disorders and Functional Outcomes
JAMA Network Open. 2018;1(7):e184493. doi:10.1001/jamanetworkopen.2018.4493 November 9, 2018 5/11
Downloaded From: on 11/12/2018
first trauma did not significantly moderate associations between childhood trauma and adult
psychiatric history or functional outcomes except for health functioning, for which childhood trauma
better predicted poor adult health than trauma in adolescence (β = 0.13; 95% CI, 0.05-0.22).
Sensitivity Analyses
Follow-up analyses were conducted to retest findings with changes to variable definition or model
specification. Many studies on childhood trauma have focused on exposure to a single trauma rather
than cumulative exposure. Models for a core set of outcomes (ie, any disorder, health, and financial
and educational functioning) were rerun to test how alternative definitions of trauma exposure
would affect these long-term associations (Table 4). These definitions included dichotomous
variables for any trauma exposure, exposure to 2 or more events, exposure to 3 or more events, or
exposure to an event that was associated with childhood posttraumatic stress disorder symptoms.
All alternative definitions were significantly associated with at least 1 outcome and the variable of any
trauma exposure was associated with all outcomes. Next, we tested associations between specific
types of trauma (ie, violent, sexual, witness trauma, learning about trauma, or other traumas) and
adult outcomes (eTables 3 and 4 in the Supplement). Each trauma category was significantly
associated with at least 1 adverse adult outcome; witnessing trauma was associated with multiple
psychiatric and functional outcomes.
Maltreatment is a distinct form of childhood trauma that is often intrafamilial and chronic and
has demonstrated lasting effects on adult functioning when prospectively assessed.
30,31
Observed
associations of cumulative trauma could be driven by this particularly virulent exposure. All core
outcomes continued to be significantly associated with cumulative trauma status when
Table 3. Associations BetweenChildhood Trauma Groups and Adult Functional Outcome Scales
a
Functional Outcome
Adjusted β (95% CI)
Sex and Race/Ethnicity
Sex, Race/Ethnicity, Psychiatric
Diagnoses, and Adversities
Health 0.20 (0.13-0.27)
b
0.24 (0.17-0.31)
b
Risky and/or criminal behavior 0.10 (0.03-0.16)
b
0.12 (0.05-0.19)
b
Financial and educational 0.19 (0.12-0.25)
b
0.16 (0.09-0.23)
b
Social 0.12 (0.05-0.19)
b
0.11 (0.04-0.18)
b
a
Cumulative trauma exposure is treated as a continuous variable. Psychiatric diagnoses include childhood depression,
anxiety,attention-def icit/hyperactivity disorder, conduct disorder, oppositional defiant disorder,and substance disorder.
Childhood adversities include low socioeconomic status, familial instability, family dysfunction, and being bullied
by peers.
b
P< .05.
Figure. Associations Between Cumulative Childhood Trauma Exposure and Adult Outcomes
–0.6
Health Financial and Educational Social
0.6
0.4
Standardized Units
Functional Outcome
0.2
0
–0.2
–0.4
Criminality
0
No. of events
12 ≥3
Childhood trauma was associated with outcomes for
health, criminality, financial and educational
functioning, and social functioning. Error bars indicate
standard errors.
JAMA Network Open | Psychiatry Childhood Trauma Exposure and Adult Psychiatric Disorders and Functional Outcomes
JAMA Network Open. 2018;1(7):e184493. doi:10.1001/jamanetworkopen.2018.4493 November 9, 2018 6/11
Downloaded From: on 11/12/2018
maltreatment was removed from the cumulative trauma variable and a maltreatment variable was
added to the model (eTable 5 in the Supplement).
Finally, childhood trauma exposure may simply be associated with likelihood of trauma
exposure later in life, which, in turn, may be associated with poor adult outcomes. All models were
retested accounting for adult trauma exposures. Adult trauma exposure was associated with
elevated risk of all adult outcomes (eTable 5 in the Supplement); nevertheless, cumulative childhood
trauma also remained independently associated with adult psychiatric status and functional
outcomes.
Discussion
This study looked prospectively at associations between childhood trauma and adult outcomes. A
few findings are particularly noteworthy. Childhood trauma exposure is a common experience that
affects boys and girls and different racial/ethnic groups at similar rates. Such exposures are
associated with an array of childhood psychiatric problems and other familial hardships and
adversities. Our study suggested that childhood trauma casts a long and wide-ranging shadow,
showing associations with elevated risk for adult psychiatric status, important domains of
functioning (health, risky and/or criminal behavior, financial/educational functioning, and social
functioning). This increased risk persisted when accounting for (1) childhood psychiatric problems,
(2) other family and individual hardships and adversities, and (3) adult exposure to traumatic events.
A large body of studies has linked early adverse experiences, including traumatic events, with
long-term outcomes (notably, the seminal Adverse Childhood Experiences [ACEs] studies).
32,33
The
potential for early trauma to affect behavior and functioning across the lifespan is a tenet of
developmental psychopathology. Although widely accepted, support for this hypothesis has often
rested on studies that assess childhood exposures retrospectively while failing to account for other
childhood factors that commonly co-occur with trauma exposure. Such designs are susceptible to
both recall bias and confounding.
11
This study builds on this foundational work by adding (1)
prospective, repeated assessment of childhood trauma from multiple informants, (2) measurement
of a broad range of childhood factors associated with trauma exposure, (3) repeated assessments of
adult functioning from age 19 to 30 years, (4) assessment of a broad range of adult functional and
psychiatric outcomes, and (5) careful assessment of traumatic events experienced in adulthood.
Together, these features allow the current study to address limitations in prior work and to more
stringently establish the long shadow of childhood trauma.
How do these findings add to prior knowledge about potential long-term effects of early
trauma? The following conclusions are noteworthy. First, rather than supporting specific effects (eg,
on depression), our findings suggest that childhood trauma has broad effects on adult
functioning—ranging from psychiatric status to financial and educational functioning—and these
could not simply be attributed to preexisting psychiatric vulnerability or other adversities and
Table 4.Associations Be tweenAlternative Trauma Definitions and Adult Outcomes
a
Trauma Definition
Any Diagnosis,
OR (95% CI)
β (95% CI)
Health Financial and Educational
≥1 Events 1.9 (1.2 to 2.9)
b
0.50 (0.31 to 0.68)
b
0.32 (.14 to 0.51)
b
≥2 Events 1.3 (0.9 to 1.9) 0.44 (0.25 to 0.64)
b
0.18 (0.01 to 0.37)
≥3 Events 1.5 (0.9 to 2.5) 0.58 (0.34 to 0.81)
b
0.47 (0.25 to 0.70)
b
Any PTSD symptoms 1.4 (0.8 to 2.5) 0.08 (−0.18 to 0.33) 0.23 (0.06 to 0.52)
Abbreviations: OR, odds ratio; PTSD, posttraumatic stress disorder.
a
All models adjusted for sex, race/ethnicity, psychiatric history (depression, anxiety, attention-deficit/hyperactivity
disorder, conduct disorder, oppositional defiant disorder, and substance disorder), and adversities (low socioeconomic
status, familial instability, family dysfunction, and being bullied by peers).
b
P< .05.
JAMA Network Open | Psychiatry Childhood Trauma Exposure and Adult Psychiatric Disorders and Functional Outcomes
JAMA Network Open. 2018;1(7):e184493. doi:10.1001/jamanetworkopen.2018.4493 November 9, 2018 7/11
Downloaded From: on 11/12/2018
hardships in the child’s developmental context. Previous studies had often focused on a limited
number of traumas, childhood adversities, and adult outcomes, but in this study, we were able to
establish these wide-ranging effects. Second, our findings provide some support for broad
measurement of trauma exposure rather than focusing in on a specific trauma exposure (eg, sexual
trauma).
5,34
There may indeed be some outcome specificity to the effects of individual events,
35,36
but the strongest and most pervasive patterns of associations are established when considering
children’s total trauma history. This is consistent with recent findings on the accumulation model of
trauma.
37
Third, while children from impoverished families or violent communities are more likely to
be exposed to trauma, it is still unclear which subgroups of children are at greatest risk given such
exposure. Efforts to identify moderators of risk (eg, sex, race, or age) have been inconsistent and do
not lend themselves to simple narratives of risk and vulnerability. The findings from this study are
better suited to informing broad-based public policy efforts at reducing trauma exposure and
ameliorating effects of exposure, rather than informing the development of precision medicine
models to influence or predict individual response to treatment.
38
As such, our findings support
initiatives such as North Carolina’s statewide dissemination and implementation of evidence-based
interventions for children with a wide range of exposures to trauma types and with varying traumatic
stress reactions.
39
Fourth, this study supported independent effects of both childhood and adult
trauma exposure on adult functioning. There was limited evidence within our analyses to suggest
that trauma exposure at a certain developmental period was associated with distinct subsequent risk
as has been reported in multiple studies for maltreatment.
40,41
That is, it is by no means clear that
maturation—and the accumulated cognitive and emotional skills that go with it—reduces the effects
of previous trauma exposure.
Limitations
This study has many strengths, but several caveats should be kept in mind. This study is not
representative of the US population. American Indians, an often understudied group, and rural areas
were overrepresented in the communities from which the sample was drawn. Lifetime assessments
of childhood trauma were completed annually through childhood and adolescence, but earlier
experiences may have been subject to recall bias, and some traumatic events could have been
forgotten—another reason to include multiple informants. Furthermore, some adverse adult effects
may not be evident until later in life (eg, onset of chronic diseases). Also, although we tested for
sensitive effects of first trauma exposure, such analyses rely on often unreliable reports of when
participants experienced their first trauma. In addition, a broad test of timing and sensitivity effects
of trauma would involve tests of individual trauma and adversity categories. Finally, additional
unmeasured variables, such as genetic risk and neighborhood environmental factors, may account
for aspects of observed associations.
Conclusions
It is a myth to believe that childhood trauma is a rare experience that only affects few.
2,3
It is similarly
erroneous to believe that the primary pattern of problems in response to such trauma is
characterized by posttraumatic stress symptoms. Rather, childhood trauma exposure is a normative
experience, statistically speaking, that affects the majority of children at some point and
subsequently has the potential to influence many aspects of functioning. This study suggests that
these effects are longstanding—lasting 20 or more years—and independent of other childhood risk
factors that childhood trauma tends to co-occur with. Importantly, participants’ total childhood
trauma history was associated with long-term health and functioning, with each additional trauma
increasing risk for adult outcomes. Together, these findings provide a clear mandate for those
concerned with increasing opportunities, reducing distress, and avoiding morbidity across the
lifespan. Interventions or policies that broadly target this largely preventable cluster of childhood
experiences may have multifaceted effects on health and well-being that persist across the lifespan.
JAMA Network Open | Psychiatry Childhood Trauma Exposure and Adult Psychiatric Disorders and Functional Outcomes
JAMA Network Open. 2018;1(7):e184493. doi:10.1001/jamanetworkopen.2018.4493 November 9, 2018 8/11
Downloaded From: on 11/12/2018
ARTICLE INFORMATION
Accepted for Publication: September 13, 2018.
Published: November 9, 2018. doi:10.1001/jamanetworkopen.2018.4493
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2018 Copeland WE
et al. JAMA Network Open.
Corresponding Author: William E. Copeland, PhD, Vermont Center for Children, Youth and Families, Department
of Psychiatry, University of Vermont, Burlington, VT 05405 (william.copeland@duke.edu).
Author Affiliations: Vermont Center for Children, Youthand Families, Department of Psychiatry, University of
Vermont, Burlington (Copeland); The Jacobs Center for Productive Youth Development, Department of
Psychology, University of Zurich, Zurich, Switzerland (Shanahan); Department of Psychiatry,Virginia
Commonwealth University, Richmond (Hinesley); The Center for Biomarker Research and Precision Medicine,
Virginia Commonwealth University, Richmond (Chan, Aberg, van den Oord); Department of Psychiatry and
Behavioral Sciences, Duke University Medical Center, Durham, North Carolina (Fairbank, Costello).
Author Contributions: Dr Copeland had full access to all of the data in the study and takes responsibility for the
integrity of the data and the accuracy of the data analysis.
Concept and design: Copeland, Shanahan, Aberg, van den Oord, Costello.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Copeland, Shanahan, Hinesley.
Critical revision of the manuscript for important intellectual content: Copeland, Shanahan, Chan, Aberg, Fairbank,
van den Oord, Costello.
Statistical analysis: Copeland, Aberg, van den Oord.
Obtained funding: Shanahan, Aberg, van den Oord, Costello.
Administrative, technical, or material support: Hinesley, Costello.
Supervision: Costello.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was supported by the National Institute of Mental Health (grants MH080230,
MH63970, MH63671,MH48085, MH075766, MH094605, and MH104576), the National Institute on Drug Abuse
(grants DA016977, DA011301, DA036523, and DA023026), the National Institute of Child Health and
Development (grant HD093651), the Brain and Behavior Research Foundation (Early Career Award to Dr
Copeland), and the William T Grant Foundation.
Role of the Funder/Sponsor:The funders had no role in the design and conduc t of the study; collection,
management, analysis, and interpretation of the data; preparation, review, or approvalof the manuscript; and
decision to submit the manuscript for publication.
REFERENCES
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5).
Washington, DC: American Psychiatric Press Inc; 2013.
2. Copeland WE, Keeler G, Angold A, Costello EJ. Traumatic events and posttraumatic stressin childhood. Arch
Gen Psychiatry. 2007;64(5):577-584. doi:10.1001/archpsyc.64.5.577
3. McLaughlin KA , Koenen KC, Hill ED, et al. Trauma exposure and posttraumatic stress disorder in a national
sample of adolescents. J Am Acad Child Adolesc Psychiatry. 2013;52(8):815-830.e14.doi:10.1016/j.jaac.2013.
05.011
4. Arseneault L , Cannon M, FisherHL , PolanczykG, Moff itt TE, Caspi A. Childhood trauma and children’s emerging
psychotic symptoms: a genetically sensitive longitudinal cohort study. Am J Psychiatry. 2011;168(1):65-72. doi:10.
1176/appi.ajp.2010.10040567
5. Suliman S, Mkabile SG, Fincham DS, Ahmed R, Stein DJ, Seedat S. Cumulative effect of multiple trauma on
symptoms of posttraumatic stress disorder, anxiety, and depression in adolescents. Compr Psychiatry. 2009;50
(2):121-127. doi:10.1016/j.comppsych.2008.06.006
6. Kessler RC, McLaughlin KA, Green JG, et al. Childhood adversities and adult psychopathology in the WHO World
Mental Health Surveys. Br J Psychiatry. 2010;197(5):378-385. doi:10.1192/bjp.bp.110.080499
7. Scott KM, McLaughlin KA, Smith DA, Ellis PM. Childhood maltreatment and DSM-IV adult mental disorders:
comparison of prospective and retrospective findings. Br J Psychiatry. 2012;200(6):469-475. doi:10.1192/bjp.bp.
111.103267
JAMA Network Open | Psychiatry Childhood Trauma Exposure and Adult Psychiatric Disorders and Functional Outcomes
JAMA Network Open. 2018;1(7):e184493. doi:10.1001/jamanetworkopen.2018.4493 November 9, 2018 9/11
Downloaded From: on 11/12/2018
8. Green JG, McLaughlin KA , Berglund PA, et al. Childhood adversities and adult psychiatric disorders in the
national comorbidity survey replication I: associations with first onset of DSM-IV disorders. Arch Gen Psychiatry.
2010;67(2):113-123. doi:10.1001/archgenpsychiatry.2009.186
9. McLaughlin KA , Conron KJ, Koenen KC, Gilman SE. Childhood adversity, adult stressful life events, and risk of
past-year psychiatric disorder: a test of the stress sensitization hypothesis in a population-based sample of adults.
Psychol Med. 2010;40(10):1647-1658.doi:10.1017/S0033291709992121
10. Carr CP, Martins CMS, Stingel AM, Lemgruber VB, Juruena MF. The role of early life stress in adult psychiatric
disorders: a systematic review according to childhood trauma subtypes. J Nerv Ment Dis. 2013;201(12):1007-1020.
doi:10.1097/NMD.0000000000000049
11. Hardt J, Rutter M. Validity of adult retrospective reports of adverse childhood experiences: review of the
evidence. J Child Psychol Psychiatry. 2004;45(2):260-273. doi:10.1111/j.1469-7610.2004.00218.x
12. Reuben A, Moff itt TE, Caspi A, et al. Lest we forget: comparing retrospective and prospective assessments of
adverse childhood experiences in the prediction of adult health. J Child Psychol Psychiatry. 2016;57(10):1103-1112.
doi:10.1111/jcpp.12621
13. Colman I, Kingsbur y M, GaradY, et al. Consistency in adult reporting of adverse childhood experiences. Psychol
Med. 2016;46(3):543-549. doi:10.1017/S0033291715002032
14. Copeland WE, Wolke D, Shanahan L, Costello EJ. Adult functional outcomes of common childhood psychiatric
problems: a prospective, longitudinal study. JAMA Psychiatry. 2015;72(9):892-899. doi:10.1001/jamapsychiatry.
2015.0730
15. Fergusson DM, Horwood LJ, Ridder EM. Show me the child at seven: the consequences of conduct problems
in childhood for psychosocial functioning in adulthood. J Child Psychol Psychiatry. 2005;46(8):837-849. doi:10.
1111/j.1469-7610.2004.00387.x
16. McLeod GF, Horwood LJ, Fergusson DM. Adolescent depression, adult mental health and psychosocial
outcomes at 30 and 35 years. Psychol Med. 2016;46(7):1401-1412. doi:10.1017/S0033291715002950
17. Kim-Cohen J, Caspi A, Moffitt TE, Harrington H, Milne BJ, Poulton R. Prior juvenile diagnoses in adults with
mental disorder: developmental follow-back of a prospective-longitudinal cohort. Arch Gen Psychiatry. 2003;60
(7):709-717.doi:10.1001/archpsyc.60.7.709
18. Cuffe SP, Addy CL, Garrison CZ, et al. Prevalence of PTSD in a community sample of older adolescents. JAm
Acad Child Adolesc Psychiatry. 1998;37(2):147-154.doi:10.1097/00004583-199802000-00006
19. Koenen KC, Moffitt T, Poulton R, Martin J,Caspi A . Early childhood factors associated with the development of
post-traumatic stress disorder: results from a longitudinal birth cohort. Psychol Med. 2006;37(2):181-192. doi:10.
1017/S0033291706009019
20. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The
Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for
reporting observational studies. Ann Intern Med. 2007;147(8):573-577.doi:10.7326/0003-4819-147-8-
200710160-00010
21. Costello EJ, Mustillo S, Erkanli A, Keeler G, Angold A. Prevalence and development of psychiatric disorders in
childhood and adolescence. Arch Gen Psychiatry. 2003;60(8):837-844. doi:10.1001/archpsyc.60.8.837
22. Costello EJ, Angold A, Burns BJ, et al. The Great Smoky Mountains Study of Youth. goals, design, methods, and
the prevalence of DSM-III-R disorders. Arch Gen Psychiatry. 1996;53(12):1129-1136. doi:10.1001/archpsyc.1996.
01830120067012
23. Copeland WE, Angold A , Shanahan L, Costello EJ. Longitudinal patterns of anxiety from childhood to
adulthood: the Great Smoky Mountains Study. J Am Acad Child Adolesc Psychiatry. 2014;53(1):21-33. doi:10.1016/j.
jaac.2013.09.017
24. Angold A , CostelloEJ. The Child and Adolescent Psychiatric Assessment (CAPA). J Am Acad Child Adolesc
Psychiatry. 2000;39(1):39-48. doi:10.1097/00004583-200001000-00015
25. Angold A, Costello EJ. A test-retest reliability study of child-reported psychiatric symptoms and diagnoses
using the Child and Adolescent Psychiatric Assessment (CAPA-C).P sychol Med. 1995;25(4):755-762. doi:10.1017/
S0033291700034991
26. Costello EJ, Messer SC, Reinherz HZ, Cohen P, Bird HR. The prevalence of serious emotional disturbance:a re-
analysis of community studies. J Child Fam Stud. 1998;7:411-432. doi:10.1023/A:1022901909205
27. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders Fourth Edition
(DSM-IV). Washington, DC: American Psychiatric Press Inc; 1994.
28. Copeland WE, Wolke D, Angold A, Costello EJ. Adult psychiatric outcomes of bullying and being bullied by
peers in childhood and adolescence. JAMA Psychiatry. 2013;70(4):419-426. doi:10.1001/jamapsychiatry.2013.504
JAMA Network Open | Psychiatry Childhood Trauma Exposure and Adult Psychiatric Disorders and Functional Outcomes
JAMA Network Open. 2018;1(7):e184493. doi:10.1001/jamanetworkopen.2018.4493 November 9, 2018 10/11
Downloaded From: on 11/12/2018
29. Angold A, Cox A, Prendergast M, et al. The Young Adult Psychiatric Assessment (YAPA). Durham, NC: Duke
University Medical Center; 1999.
30. Currie J, Widom CS. Long-term consequences of child abuse and neglect on adult economic well-being. Child
Maltreat. 2010;15(2):111-120. doi:10.1177/1077559509355316
31. Hor witz AV, Widom CS, McLaughlin J, White HR. The impact of childhood abuse and neglect on adult mental
health: a prospective study. J Health Soc Behav. 2001;42(2):184-201. doi:10.2307/3090177
32. Brown DW, Anda RF, Tiemeier H, et al. Adverse childhood experiences and the risk of premature mortality. Am
J Prev Med. 2009;37(5):389-396. doi:10.1016/j.amepre.2009.06.021
33. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many
of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) Study. Am J Prev Med. 1998;14
(4):245-258. doi:10.1016/S0749-3797(98)00017-8
34. Turner RJ, Lloyd DA. Lifetime traumas and mental health: the significance of cumulative adversity. J Health Soc
Behav. 1995;36(4):360-376. doi:10.2307/2137325
35. Sheridan MA , PeverillM, Finn AS, McLaughlin KA. Dimensions of childhood adversity have distinct associations
with neural systems underlying executive functioning. Dev Psychopathol. 2017;29(5):1777-1794. doi:10.1017/
S0954579417001390
36. Brown GW, Harris TO, Peto J. Life events and psychiatric disorders, part 2: nature of causal link. Psychol Med.
1973;3(2):159-176. doi:10.1017/S0033291700048492
37. Dunn EC, Soare TW, Raffeld MR, et al. What life course theoretical models best explain the relationship
between exposure to childhood adversity and psychopathology symptoms: recency, accumulation, or sensitive
periods? [published online February 26, 2018]. Psychol Med. doi:10.1017/S0033291718000181
38. Psaty BM, Dekkers OM, Cooper RS. Comparison of 2 treatment models: precision medicine and preventive
medicine. JAMA. 2018;320(8):751-752. doi:10.1001/jama.2018.8377
39. Amaya-Jackson L, Hagele D, Sideris J, et al. Pilot to policy: statewidedissemination and implementation of
evidence-based treatment for traumatized youth. BMC Health Serv Res. 2018;18(1):589. doi:10.1186/s12913-018-
3395-0
40. Kaplow JB, Widom CS. Age of onset of child maltreatment predicts long-term mental health outcomes.
J Abnorm Psychol. 2007;116(1):176-187. doi:10.1037/0021-843X.116.1.176
41. Dunn EC, McLaughlin KA, Slopen N, Rosand J, Smoller JW. Developmental timing of child maltreatment and
symptoms of depression and suicidal ideation in young adulthood: results from the National Longitudinal Study of
Adolescent Health. Depress Anxiety. 2013;30(10):955-964.
SUPPLEMENT.
eFigure. Ascertainment of the Original Great Smoky Mountains Study Sample
eTable 1. Childhood Traumatic Events and Frequencies
eAppendix. Childhood Covariates and Adult Functional Outcomes
eTable 2. Unadjusted Associations Between Specific Childhood Trauma Groups and Childhood Psychiatric
Problems and Other Adversities/Hardships.
eTable 3. Unadjusted Associations Between Specific Cumulative Trauma Groups and Adult Psychiatric Groups and
Functional Outcomes
eTable 4. Associations Between Specific Cumulative Trauma Groups and Adult Psychiatric Groups and Functional
Outcomes Adjusted for Childhood Psychiatric Problems and Adversities/Hardships
eTable 5. Follow-up Analyses Adjusted for Comorbid Maltreatment and Adult Trauma Exposure
JAMA Network Open | Psychiatry Childhood Trauma Exposure and Adult Psychiatric Disorders and Functional Outcomes
JAMA Network Open. 2018;1(7):e184493. doi:10.1001/jamanetworkopen.2018.4493 November 9, 2018 11/11
Downloaded From: on 11/12/2018
... In addition, a prospective, population-based cohort study investigated mental health disorders in adults with cumulative and single childhood trauma experiences. Between all of the investigated mental health disorders, odds for internalizing mental health disorders were among the highest for adults with a cumulative childhood trauma history: 1.7 for depressive disorders and 1.4 for anxiety disorders compared to 1.5 for any mental health disorder (Copeland et al., 2018). Moreover, a longitudinal 25-year study on the association between child maltreatment and internalizing mental health disorders across adulthood revealed a significantly elevated risk for individuals with a CTE history, compared to those with no or low child maltreatment history (Rapsey et al., 2019). ...
... These included separation anxiety, social phobia, specific phobia, dysthymia, and major depression, as well as a significantly higher index score (i.e., total number of internalizing mental health disorders). The high(er) rates of current and lifetime internalizing mental health disorders in the CTE group were expected and corroborate existing literature on comparable, but younger, samples (e.g., Greeson et al., 2011;Nelson et al., 2017;Copeland et al., 2018). Moreover, the high prevalence rates within the CTE group emphasize the importance of not only considering trauma-related disorders in the context of (complex) trauma exposure (e.g., PTSD), but also specifically considering internalizing mental health disorders (e.g., Ford et al., 2010;Kroska et al., 2018;Humphreys et al., 2020). ...
Article
Individuals with complex trauma exposure (CTE) in early life (i.e., childhood/adolescence) are at heightened risk for developing problems in various domains of functioning. As such, CTE has repeatedly been linked to internalizing mental health disorders, such as depression and anxiety, as well as emotion dysregulation across the lifespan. While these correlates of CTE are comparatively well studied up to middle adulthood, they are insufficiently studied in older adulthood. Therefore, this study aimed to (a) compare Swiss older adults with and without a CTE history regarding current and lifetime internalizing mental health disorders and emotion regulation strategies; and (b) to examine the potential mediating role of emotion regulation in the mental health disparities between these groups. A total of N = 257 participants (age = 49–95 years; 46.3% female) were assessed in a retrospective, cross-sectional study, using two face-to-face interviews. The CTE group (n = 161; Mage = 69.66 years, 48.4% female) presented with significantly more current and lifetime internalizing mental health disorders than the non-affected (nCTE) group (n = 96; Mage = 72.49 years, 42.7% female). The CTE group showed significantly higher emotion suppression and lower emotion reappraisal compared to the nCTE group. Mediation analysis revealed that the two emotion regulation strategies were significant mediators between CTE history and internalizing mental health disorders. Findings emphasize the relevance of emotion (dys-)regulation in understanding mental health disparities in older age and deciding about treatment strategies. Research and practice should pay more attention to the needs of this high-risk group of older individuals.
... Finally, it is important to better understand how experiencing stress and adversity during pregnancy and the presence of stress-related psychopathology impacts inflammation through alterations in behavior, such as eating (76) and sleep (77). Another limitation of existing studies characterizing the impacts of stress/trauma and psychopathology on inflammation in pregnancy, especially those on trauma exposure, consist of samples that have experienced relatively few traumatic events over their lifespan, including childhood trauma which confers disproportionate risk for adverse health outcomes in adulthood (78). It is especially important to understand the relationships between stress/trauma exposure and inflammation in pregnancy in order to address health inequities in pregnancy-related adverse health outcomes that may be driven by increased systemic inflammation. ...
Article
Full-text available
Many studies have focused on psychoimmunological mechanisms of risk for stress-related mental health disorders. However, significantly fewer studies have focused on understanding mechanisms of risk for stress-related disorders during pregnancy, a period characterized by dramatic changes in both the innate and adaptive immune systems. The current review summarizes and synthesizes the extant literature on the immune system during pregnancy, as well as the sparse existing evidence highlighting the associations between inflammation and mood, anxiety, and fear-related disorders in pregnancy. In general, pregnant persons demonstrate lower baseline levels of systemic inflammation, but respond strongly when presented with an immune challenge. Stress and trauma exposure may therefore result in strong inflammatory responses in pregnant persons that increases risk for adverse behavioral health outcomes. Overall, the existing literature suggests that stress, trauma exposure, and stress-related psychopathology are associated with higher levels of systemic inflammation in pregnant persons, but highlight the need for further investigation as the existing data are equivocal and vary based on which specific immune markers are impacted. Better understanding of the psychoimmunology of pregnancy is necessary to reduce burden of prenatal mental illness, increase the likelihood of a successful pregnancy, and reduce the intergenerational impacts of prenatal stress-related mental health disorders.
... Psychiatric difficulties associated with ELA are also more severe, persistent, and treatment-resistant than difficulties and disorders not associated with ELA [7]. Thus, ELA is a critical target of public health inititives designed to reduce population disparities in mental health among children and youth [12]. ...
Article
Full-text available
Emerging evidence suggests that partially distinct mechanisms may underlie the association between different dimensions of early life adversity (ELA) and psychopathology in children and adolescents. While there is minimal evidence that different types of ELA are associated with specific psychopathology outcomes, there are partially unique cognitive and socioemotional consequences of specific dimensions of ELA that increase transdiagnostic risk of mental health problems across the internalizing and externalizing spectra. The current review provides an overview of recent findings examining the cognitive (e.g., language, executive function), socioemotional (e.g., attention bias, emotion regulation), and mental health correlates of ELA along the dimensions of threat/harshness, deprivation, and unpredictability. We underscore similarities and differences in the mechanisms connecting different dimensions of ELA to particular mental health outcomes, and identify gaps and future directions that may help to clarify inconsistencies in the literature. This review focuses on childhood and adolescence, periods of exquisite neurobiological change and sensitivity to the environment. The utility of dimensional models of ELA in better understanding the mechanistic pathways towards the expression of psychopathology is discussed, with the review supporting the value of such models in better understanding the developmental sequelae associated with ELA. Integration of dimensional models of ELA with existing models focused on psychiatric classification and biobehavioral mechanisms may advance our understanding of the etiology, phenomenology, and treatment of mental health difficulties in children and youth.
... 11 12 A recent large prospective study found that cumulative childhood trauma exposure increases the risk of developing psychopathology in adulthood as well as poor social functioning. 13 Physical abuse, sexual abuse and physical neglect were significantly associated with reduced scores in working memory, executive function and verbal tasks. 14 As a severe neuropsychiatric disorder, schizophrenia was considered to have significant associations with ACEs. ...
Article
Full-text available
Background: Adverse childhood experiences have a significant impact on different mental disorders. Objective: To compare differences in adverse childhood experiences among those with different mental disorders and their relationships in a cross-disorder manner. Methods: The study included 1513 individuals aged ≥18 years : 339 patients with substance use disorders, 125 patients with schizophrenia, 342 patients with depression, 136 patients with bipolar disorder, 431 patients with obsessive-compulsive disorder (OCD), and 140 healthy controls. The Early Trauma Inventory Self Report-Short Form was used to investigate childhood traumatic experiences, and the Addiction Severity Index, Positive and Negative Syndrome Scale, Hamilton Depression Scale, Young Mania Rating Scale, and Yale-Brown Obsessive-Compulsive Scale were used to assess mental disorder severity. Correlation and multivariate logistic regression were analysed between adverse childhood experiences and clinical features. Results: Levels of adverse childhood experiences were significantly different among different mental disorders. Moreover, 25.8% of patients with substance use disorders reported childhood trauma, which was significantly higher than found in the other four psychiatric disorder groups. Emotional abuse scores were positively correlated with disease severity: the higher the total trauma score, the more severe the mental disorder. Conclusions: Adverse childhood experiences are a common phenomenon in those with mental disorders, and the level of trauma affects mental disorder severity. Emotional abuse is closely related to many mental disorders. The incidence or severity of mental disorders can be reduced in the future by reducing the incidence of adverse childhood experiences or by timely intervention in childhood trauma.
... These scale was summed from the individual dichotomous indicators. This scale has previously served as a marker of the long-term effects of childhood trauma in several publications [11,12]. ...
Article
Full-text available
Childhood trauma is robustly linked to a broad range of adverse outcomes with consequences persisting far into adulthood. We conducted a prospective longitudinal study to predict psychiatric disorders and other adverse outcomes from trauma-related methylation changes 16.9 years after trauma exposure in childhood. Methylation was assayed using a sequencing-based approach that provides near-complete coverage of all 28 million sites in the blood methylome. Methylation data involved 673 assays from 489 participants aged 13.6 years (SD = 1.9) with outcomes measures collected at age 30.4 (SD = 2.26). For a subset of 303 participants we also generated methylation data in adulthood. Trauma-related methylation risk scores (MRSs) significantly predicted adult depression, externalizing problems, nicotine dependence, alcohol use disorder, serious medical problems, social problems and poverty. The predictive power of the MRSs was higher than that of reported trauma and could not be explained by the reported trauma, correlations with demographic variables, or a continuity of the predicted health problems from childhood to adulthood. Rather than measuring the occurrence of traumatic events, the MRSs seemed to capture the subject-specific impact of trauma. The majority of predictive sites did not remain associated with the outcomes suggesting the signatures of trauma do not become biologically embedded in the blood methylome. Instead, the long-term effects of trauma therefore seemed more consistent with a developmental mechanism where the initial subject-specific impacts of trauma are magnified over time. The MRSs have the potential to be a novel clinical biomarker for the assessment of trauma-related health risks.
Article
Full-text available
Abstract Background This international online survey investigated the experience and impact of emotional blunting in the acute and remission phases of depression from the perspective of patients and healthcare providers (HCPs). This paper presents data on the history and severity of psychological trauma and its potential impact on emotional blunting in major depressive disorder (MDD); differences between patient and HCP perceptions are explored. Methods Patient respondents (n = 752) were adults with a diagnosis of depression who were currently taking antidepressant therapy and reported emotional blunting during the past 6 weeks. HCPs provided details on two eligible patients: one in the acute phase of depression and one in remission from depression (n = 766). Trauma was assessed using questions based on the Childhood Trauma Questionnaire; emotional blunting was assessed using the Oxford Depression Questionnaire (ODQ). Multivariate regression analyses were applied to examine the relationship between trauma and ODQ score. Results A history of any childhood or recent traumatic event was reported by 97% of patients in the self-assessed cohort and for 83% of those in the HCP-assessed cohort (difference, p
Article
Background A central concept of attachment theory is that early experiences with close attachment figures shape the way we interact with and relate to other social partners throughout life. As such, early experiences of childhood maltreatment (CM) have been suggested as a key precursor of adult insecure attachment representations. As CM has been linked to feelings of loneliness in adulthood, this study examines whether insecure attachment could explain the relationship between CM and loneliness. Also, the moderating role of a diagnosis of persistent depressive disorder (PDD) is investigated, a disorder characterized by high levels of CM and loneliness. Method 60 patients with PDD (DSM-5) and 60 gender- and age-matched non-clinical control participants (NC) completed self-report questionnaires measuring attachment, loneliness, and CM. Mediation analyses (PDD as a moderator) were performed. Results PDD patients reported higher levels of CM, attachment anxiety, attachment avoidance, and loneliness than NC. CM was positively associated with loneliness in both groups. Mediation analyses demonstrated that the relationship between CM and loneliness was mediated by avoidant, but not anxious attachment, regardless of a diagnosis of PDD. Limitations Caution when interpreting these results is crucial as the study lacked a clinical control group, relied on self-report measures, and the cross-sectional design limits the ability to draw causal inferences. Conclusions All constructs studied were present to a greater degree in PDD. Above, findings provide initial evidence that avoidant attachment may explain the relationship between CM and loneliness. Potentially, adult avoidant attachment may lead to and maintain feelings of loneliness, regardless of PDD.
Article
Background Polygenic risk scores (PRSs) are indices of genetic liability for illness, but their clinical utility for predicting risk for a specific psychiatric disorder is limited. Genetic overlap among disorders and their effects on allied phenotypes may be a possible explanation, but this has been difficult to quantify given focus on singular disorders and/or allied phenotypes. Methods We constructed PRSs for five psychiatric disorders (schizophrenia (SZ), bipolar disorder (BPD), major depressive disorder (MDD), autism spectrum disorder (ASD), attention-deficit hyperactivity disorder (ADHD)) and three non-psychiatric control traits (height, type 2 diabetes (T2D), irritable bowel disease (IBD)) in the UK Biobank (N=31,616) and quantified associations between PRSs and phenotypes allied with mental illness: behavioral (symptoms, cognition, trauma) and brain (structural MRI and diffusion) measures. We then evaluated the extent of specificity among PRSs and their effects on these allied phenotypes. Results Correlations among psychiatric PRSs replicated previous work, with overlap between SZ and BPD, which was distinct from overlap between ASD and ADHD; overlap between psychiatric and control PRSs was minimal. There was, however, substantial overlap of PRS effects on allied phenotypes among psychiatric disorders and among psychiatric disorders and control traits, where the extent and pattern of overlap was phenotype-specific. Conclusions Results show that genetic distinctions between psychiatric disorders and between psychiatric disorders and control traits exist, but this does not extend to their effects on allied phenotypes. Although overlap can be informative, work is needed to construct PRSs that will function at the level of specificity needed for clinical application.
Chapter
Trauma affects students in areas of social/behavioral skills and academic performance. This observation is supported with research. Researchers noted that traumatic exposure at home, school, or in the community has been associated with social anxiety, depression, suicidal ideation, and oppositional and aggressive behavior. Goodman et al. reported that trauma can have a negative impact on academic functioning, with higher symptoms of traumatic stress predicting poorer reading, math, and science achievement scores among elementary students. Trauma is indeed a social justice issue. Socioeconomic inequality, low educational level, and living in impoverished neighborhoods are major predisposing factors for exposure to a traumatic event. This chapter will provide recommendations on the utilization of trauma-informed care in addressing social justice issues in schools. Strategies to assist varied student groups will be noted in the chapter.
Article
Background The role of psychosocial stressors in psychiatric disorders and executive dysfunction has been reported, separately. The literature has also suggested the involvement of social support and coping strategies in these relationships. However, there is a lack of research conducted to examine the relationships among multiple stressors and neuropsychiatric comorbidities while considering the presence of social support and coping strategies. This study aims to articulate the roles of multiple psychosocial stressors, social support, and coping strategies in the subsequent occurrence of neuropsychiatric comorbidities. Methods Data analyzed were from the 6th data collection of a large-scale, longitudinal population-based cohort from Southwest Montreal in Canada. The cumulative effects of multiple stressors were separately examined by a composite score and latent profile analysis. Multinomial logistic regression models were used to test the relationship between cumulative stressors and neuropsychiatric comorbidities. Results A total of 210 participants were included in the analyses. The LPA identified a 2-class model for psychosocial stressors (low and high) and executive function (executive dysfunction and no executive dysfunction), respectively. There were 11.8% of participants with neuropsychiatric comorbidities. Both the composite stress score (RR = 1.08, 95%CI = 1.01–1.15) and latent stress groups (RR = 3.65, 95%CI = 1.15–11.57) were associated with neuropsychiatric comorbidities after adjusting for social support and coping strategies. The risk of developing neuropsychiatric comorbidities decreased when the level of social support was high (P < 0.05). Conclusions Exposures to multiple stressors increased the risk of subsequent neuropsychiatric comorbidities, but the risk can be modified by a higher level of social support.
Article
Full-text available
Background: A model for statewide dissemination of evidence-based treatment (EBT) for traumatized youth was piloted and taken to scale across North Carolina (NC). This article describes the implementation platform developed, piloted, and evaluated by the NC Child Treatment Program to train agency providers in Trauma-Focused Cognitive Behavioral Therapy using the National Center for Child Traumatic Stress Learning Collaborative (LC) Model on Adoption & Implementation of EBTs. This type of LC incorporates adult learning principles to enhance clinical skills development as part of training and many key implementation science strategies while working with agencies and clinicians to implement and sustain the new practice. Methods: Clinicians (n = 124) from northeastern NC were enrolled in one of two TF-CBT LCs that lasted 12 months each. During the LC clinicians were expected to take at least two clients through TF-CBT treatment with fidelity and outcomes monitoring by trainers who offered consultation by phone and during trainings. Participating clinicians initiated treatment with 281 clients. The relationship of clinician and client characteristics to treatment fidelity and outcomes was examined using hierarchical linear regression. Results: One hundred eleven clinicians completed general training on trauma assessment batteries and TF-CBT. Sixty-five clinicians met all mastery and fidelity requirements to meet roster criteria. One hundred fifty-six (55%) clients had fidelity-monitored assessment and TF-CBT. Child externalizing, internalizing, and post-traumatic stress symptoms, as well as parent distress levels, decreased significantly with treatment fidelity moderating child PTSD outcomes. Since this pilot, 11 additional cohorts of TF-CBT providers have been trained to these roster criteria. Conclusion: Scaling up or outcomes-oriented implementation appears best accomplished when training incorporates: 1) practice-based learning, 2) fidelity coaching, 3) clinical assessment and outcomes-oriented treatment, 4) organizational skill-building to address barriers for agencies, and 5) linking clients to trained clinicians via an online provider roster. Demonstrating clinician performance and client outcomes in this pilot and subsequent cohorts led to legislative support for dissemination of a service array of EBTs by the NC Child Treatment Program.
Article
Full-text available
Much biomedical research is observational. The reporting of such research is often inadequate, which hampers the assessment of its strengths and weaknesses and of a study's generalisability. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative developed recommendations on what should be included in an accurate and complete report of an observational study. We defined the scope of the recommendations to cover three main study designs: cohort, case-control, and cross-sectional studies. We convened a 2-day workshop in September, 2004, with methodologists, researchers, and journal editors to draft a che-cklist of items. This list was subsequently revised during several meetings of the coordinating group and in e-mail discussions with the larger group of STROBE contributors, taking into account empirical evidence and methodological considerations. The workshop and the subsequent iterative process of consultation and revision resulted in a checklist of 22 items (the STROBE statement) that relate to the title, abstract, introduction, methods, results, and discussion sections of articles. 18 items are common to all three study designs and four are specific for cohort, case-control, or cross-sectional studies. A detailed explanation and elaboration document is published separately and is freely available on the websites of PLoS Medicine, Annals of Internal Medicine, and Epidemiology. We hope that the STROBE statement will contribute to improving the quality of reporting of observational studies.
Article
Full-text available
Background: There is limited information on long-term outcomes of adolescent depression. This study examines the associations between severity of depression in adolescence and a broad array of adult functional outcomes. Method: Data were gathered as part of the Christchurch Health and Development Study, a 35-year longitudinal study of a birth cohort of 1265 children born in Christchurch, New Zealand in 1977. Severity of depression at age 14-16 years was classified into three levels according to DSM symptom criteria for major depression (no depression/sub-threshold symptoms/major depression). This classification was related to adult functional outcomes assessed at ages 30 and 35 years using a generalized estimating equation modeling approach. Outcome measures spanned domains of mental disorder, education/economic circumstances, family circumstances and partner relationships. Results: There were modest but statistically significant bivariate associations between adolescent depression severity and most outcomes. After covariate adjustment there remained weak but significant (p < 0.05) associations with rates of major depression, anxiety disorder, illicit substance abuse/dependence, any mental health problem and intimate partner violence (IPV) victimization. Estimates of attributable risk for these outcomes ranged from 3.8% to 7.8%. For two outcomes there were significant (p < 0.006) gender interactions such that depression severity was significantly related to increased rates of unplanned pregnancy and IPV victimization for females but not for males. Conclusions: The findings reinforce the importance of the individual/family context in which adolescent depression occurs. When contextual factors and probable maturational effects are taken into account the direct effects of adolescent depression on functioning in mature adulthood appear to be very modest.
Article
Full-text available
Background: Many studies have used retrospective reports to assess the long-term consequences of early life stress. However, current individual characteristics and experiences may bias the recall of these reports. In particular, depressed mood may increase the likelihood of recall of negative experiences. The aim of the study was to assess whether specific factors are associated with consistency in the reporting of childhood adverse experiences. Method: The sample comprised 7466 adults from Canada's National Population Health Survey who had reported on seven childhood adverse experiences in 1994/1995 and 2006/2007. Logistic regression was used to explore differences between those who consistently reported adverse experiences and those whose reports were inconsistent. Results: Among those retrospectively reporting on childhood traumatic experiences in 1994/1995 and 2006/2007, 39% were inconsistent in their reports of these experiences. The development of depression, increasing levels of psychological distress, as well as increasing work and chronic stress were associated with an increasing likelihood of reporting a childhood adverse experience in 2006/2007 that had not been previously reported. Increases in mastery were associated with reduced likelihood of new reporting of a childhood adverse experience in 2006/2007. The development of depression and increases in chronic stress and psychological distress were also associated with reduced likelihood of 'forgetting' a previously reported event. Conclusions: Concurrent mental health factors may influence the reporting of traumatic childhood experiences. Studies that use retrospective reporting to estimate associations between childhood adversity and adult outcomes associated with mental health may be biased.
Article
In an effort to improve the risk-benefit profile of therapies in clinical care, precision medicine seeks to identify and make use of factors, often genetic variants or biomarkers, that influence or predict the response to treatment. The Precision Medicine Initiative defines precision medicine as “an emerging approach for disease treatment and prevention that takes into account individual variability in genes, environment, and lifestyle for each person.”¹ Across the United States, departments, institutes, and centers have created new groups focused on this approach. Precision medicine has acquired strong vested interests, including industry and academic medical centers with committed researchers, spin-off companies, and occasionally, some enthusiastic clinicians. A favored theory can be a powerful force.
Article
Background Although childhood adversity is a potent determinant of psychopathology, relatively little is known about how the characteristics of adversity exposure, including its developmental timing or duration, influence subsequent mental health outcomes. This study compared three models from life course theory (recency, accumulation, sensitive period) to determine which one(s) best explained this relationship. Methods Prospective data came from the Avon Longitudinal Study of Parents and Children ( n = 7476). Four adversities commonly linked to psychopathology (caregiver physical/emotional abuse; sexual/physical abuse; financial stress; parent legal problems) were measured repeatedly from birth to age 8. Using a statistical modeling approach grounded in least angle regression, we determined the theoretical model(s) explaining the most variability ( r² ) in psychopathology symptoms measured at age 8 using the Strengths and Difficulties Questionnaire and evaluated the magnitude of each association. Results Recency was the best fitting theoretical model for the effect of physical/sexual abuse (girls r² = 2.35%; boys r² = 1.68%). Both recency (girls r² = 1.55%) and accumulation (boys r² = 1.71%) were the best fitting models for caregiver physical/emotional abuse. Sensitive period models were chosen alone (parent legal problems in boys r² = 0.29%) and with accumulation (financial stress in girls r² = 3.08%) more rarely. Substantial effect sizes were observed (standardized mean differences = 0.22–1.18). Conclusions Child psychopathology symptoms are primarily explained by recency and accumulation models. Evidence for sensitive periods did not emerge strongly in these data. These findings underscore the need to measure the characteristics of adversity, which can aid in understanding disease mechanisms and determining how best to reduce the consequences of exposure to adversity.
Article
Childhood adversity is associated with increased risk for psychopathology. Neurodevelopmental pathways underlying this risk remain poorly understood. A recent conceptual model posits that childhood adversity can be deconstructed into at least two underlying dimensions, deprivation and threat, that are associated with distinct neurocognitive consequences. This model argues that deprivation (i.e., a lack of cognitive stimulation and learning opportunities) is associated with poor executive function (EF), whereas threat is not. We examine this hypothesis in two studies measuring EF at multiple levels: performance on EF tasks, neural recruitment during EF, and problems with EF in daily life. In Study 1, deprivation (low parental education and child neglect) was associated with greater parent-reported problems with EF in adolescents ( N = 169; 13–17 years) after adjustment for levels of threat (community violence and abuse), which were unrelated to EF. In Study 2, low parental education was associated with poor working memory (WM) performance and inefficient neural recruitment in the parietal and prefrontal cortex during high WM load among adolescents ( N = 51, 13–20 years) after adjusting for abuse, which was unrelated to WM task performance and neural recruitment during WM. These findings constitute strong preliminary evidence for a novel model of the neurodevelopmental consequences of childhood adversity.
Article
Background: Adverse childhood experiences (ACEs; e.g. abuse, neglect, and parental loss) have been associated with increased risk for later-life disease and dysfunction using adults' retrospective self-reports of ACEs. Research should test whether associations between ACEs and health outcomes are the same for prospective and retrospective ACE measures. Methods: We estimated agreement between ACEs prospectively recorded throughout childhood (by Study staff at Study member ages 3, 5, 7, 9, 11, 13, and 15) and retrospectively recalled in adulthood (by Study members when they reached age 38), in the population-representative Dunedin cohort (N = 1,037). We related both retrospective and prospective ACE measures to physical, mental, cognitive, and social health at midlife measured through both objective (e.g. biomarkers and neuropsychological tests) and subjective (e.g. self-reported) means. Results: Dunedin and U.S. Centers for Disease Control ACE distributions were similar. Retrospective and prospective measures of adversity showed moderate agreement (r = .47, p < .001; weighted Kappa = .31, 95% CI: .27-.35). Both associated with all midlife outcomes. As compared to prospective ACEs, retrospective ACEs showed stronger associations with life outcomes that were subjectively assessed, and weaker associations with life outcomes that were objectively assessed. Recalled ACEs and poor subjective outcomes were correlated regardless of whether prospectively recorded ACEs were evident. Individuals who recalled more ACEs than had been prospectively recorded were more neurotic than average, and individuals who recalled fewer ACEs than recorded were more agreeable. Conclusions: Prospective ACE records confirm associations between childhood adversity and negative life outcomes found previously using retrospective ACE reports. However, more agreeable and neurotic dispositions may, respectively, bias retrospective ACE measures toward underestimating the impact of adversity on objectively measured life outcomes and overestimating the impact of adversity on self-reported outcomes. Associations between personality factors and the propensity to recall adversity were extremely modest and warrant further investigation. Risk predictions based on retrospective ACE reports should utilize objective outcome measures. Where objective outcome measurements are difficult to obtain, correction factors may be warranted.