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
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Open Access. This is an open access article distributed under the terms of the CC-BY License.
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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.
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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
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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
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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.
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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 (ⱕ12 years) or adolescence (ⱖ13 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.
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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.
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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.
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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.
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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.
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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
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