OBJECTIVES
INTRODUCTION
Marta is a 23-year-old woman who brings her healthy 3-year-old child in for a check-up with her new family practice provider. She presented to her prior provider’s office with severe headaches many times and has had an extensive workup. Today, she appears depressed and overwhelmed and says she cannot concentrate due to the headaches. When her new provider asks compassionately why Marta thinks she has headaches, Marta wonders if it could be that her father used to slam her head against the table if she did not know the answers to questions. Upon further questioning, Marta’s provider learns that Marta’s mother died when she was a baby. She was the youngest of six children in a poor family in Mexico. Her father was particularly abusive to her. When she was 16 she was taken to an older man’s house and told that she was now married to him. She fled across the Mexico–US border. She does not want to talk about the journey across the border. Marta reveals to her new provider that she is worried that she does not know how to be a good mother.
Trauma is a leading cause of morbidity and mortality worldwide. Traumatic experiences refer to everything from being in a car accident to witnessing terrible events, being abused, or living through a natural disaster or a war. Traumatic events are more disruptive and likely to overwhelm a person’s ability to adapt than the normal stresses and vicissitudes of life. Trauma’s risks also multiply: being exposed to one traumatic event increases both individual and community risks for future traumatic events. The impacts of trauma are dependent on individual and community vulnerabilities, resources, and protective factors. Trauma, especially in childhood, causes health disparities. It is a root cause of adult disease and high-risk behaviors. Trauma also disproportionately affects the most vulnerable people and populations. Trauma prevention and treatment are evolving and improving. Addressing trauma in the health-care setting holds the potential to more effectively improve health, decrease suffering, and promote the achievement of health equity.
DEFINITION OF TRAUMA AND TYPES OF TRAUMATIC EVENTS
Defining trauma is challenging. The term “trauma” is often used interchangeably and inconsistently to refer to events and to the outcomes of the events. Defining an event as traumatic depends on the totality of circumstances. Each person may respond to a similar event differently based upon the circumstances surrounding the event and the interplay between genetic, epigenetic, biological, psychological, environmental, family, community, societal, historical, and other factors. Thus, most experts now understand that trauma is a process that involves the interaction between an event or series of events and the individual and community’s vulnerability, protective and resiliency factors. If an event or series of events overwhelms the person or community’s capacity to adapt in a positive manner and instead lead them to suffer adverse consequences, then the event is considered traumatic.
In discussing trauma the terms individual trauma and complex trauma are often used. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines individual trauma (http://www.samhsa.gov/nctic/about):
Individual trauma: “Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being.”
Complex trauma or complex psychological trauma, on the other hand, is defined as “resulting from exposure to severe stressors that (1) are repetitive or prolonged, (2) involve harm or abandonment by caregivers or other ostensibly responsible adults, and (3) occur at developmentally vulnerable times in the victims’ life, such as early childhood: …”1 but, can also occur later in life.
Trauma may happen to individuals and to entire communities or cultural groups. A traumatic event may be a one-time occurrence. Much more often, it is a series of traumatic events or prolonged exposure to traumatic circumstances. Events or experiences that are traumatic for human beings include catastrophic environmental events (both natural and human influenced); various types of accidents; large-scale violence (e.g., war, genocide, torture, human trafficking, terrorism, and forced migration); “structural violence” that involves systematic oppression or discrimination (e.g., racism, homophobia, and transphobia); interpersonal violence, family violence, childhood or adult sexual assault, abuse and neglect (see Chapter 35); and life events that reduce trust or a sense of safety and security such as the death of loved ones, divorce of one’s parents, major illness, or other life upheavals. This chapter focuses mainly on traumatic events that involve some type of individual interpersonal violence, abuse, or neglect. Nevertheless, to understand, treat, and prevent interpersonal violence, consideration of the broader societal context is necessary.
PREVALENCE OF TRAUMA
Exposure to some form of trauma is exceedingly common. Traumatic deaths represent a small fraction of the total burden of trauma. Globally, more than 5 million people die annually of injuries. These traumatic deaths represent 9% of all deaths worldwide and exceed the deaths from HIV/AIDS, malaria, and tuberculosis combined.2 In 2011 in the United States, injuries, including all causes of unintentional and violence-related injuries combined, accounted for 51.3% of all deaths among persons 1–44 years of age (more deaths than noncommunicable diseases and infectious diseases combined).3 In 2012, homicide was the third leading cause of death for 15- to 34-year-olds and the fourth leading cause of death for 1- to 14-year-olds in the United States.4 Almost 90% of a national random sample of US residents (who had Internet access) has experienced exposure to a very serious traumatic event (meeting DSM-5 criterion A).5 Exposure to physical or sexual assault over the lifespan for adults in this sample was 53.1% (see Chapter 35).
In one of the largest, most comprehensive studies of the effects of childhood trauma on adulthood disease, the “Adverse Childhood Experiences” (or “ACE Study”), the high prevalence of trauma occurring during childhood has been highlighted.6 In this study, 17,337 adults enrolled in care in Kaiser Permanente’s Health Appraisal Clinic in San Diego completed questionnaires about 10 categories of traumatic events (called “adverse childhood events” or “ACE’s”), including childhood emotional, sexual, and physical abuse; neglect; and familial dysfunction (i.e., witnessing of parental domestic violence, separation, or divorce; or mental illness, substance use or incarceration in a household member). Each category of adverse events is scored as either present or absent and given one point. In this predominantly white, middle-class population, 63.9% of the participants had experienced at least one ACE category and 12.5% had experienced four or more ACE categories. Having one ACE markedly increases the risk of having more than one ACE. Twenty-five percent of the women and 16% of the men reported childhood sexual abuse, a traumatic event rarely identified in the health-care setting.
While adverse childhood experiences are quite common in all communities and the overall ACE score does not vary widely by race/ethnicity, they are more common in communities plagued with adversity such as poverty, low educational attainment, and low employment.7,8 The ACE study also does not measure adversity that exists outside of the family and household, such as community violence or structural violence. The burden of overall trauma in urban underserved communities is thought to approach that of conflict-ridden developing countries.9 The Institute for Safe Families in Philadelphia has developed an “Urban ACE score” that includes measures of witnessed community violence, adverse neighborhood experiences, bullying, and discrimination.10 The World Health Organization has developed and is validating an “ACE International Questionnaire” that includes additional questions related to forced marriage, peer violence, exposure to community violence, and war and collective violence (link: )
The prevalence of trauma in certain disease states is startling high. Increasingly, these diseases are seen as symptoms of the larger epidemic of trauma. For example, among women living with HIV, the rate of intimate partner violence (IPV) is 55%, which is even higher than the rates among national samples of women (36%). The rates of childhood sexual abuse and physical abuse are 39% and 42%, respectively, more than twice the national rates of 16.2% and 22.9%. Lifetime sexual abuse among women living with HIV is 61%, more than five times the national rate (12%).11
RISK FACTORS FOR TRAUMA
David lives with his mother in a neighborhood plagued by community violence, drug dealing, and chronic neglect by city government. David’s father was arrested for domestic violence against his mother when he was 5 years old. As a young child, an uncle who lived with his family sexually abused him. David never told anyone. He attends an overcrowded, under-resourced, and underperforming school where he is frequently bullied and does very poorly in school. His mother, who works multiple jobs, spends hours commuting to work. She is never able to be home to care for David until very late in the evening. At the age of 16, David drops out of school, joins a gang for protection, and is shot in the leg in gang-related violence.
Abuse and violence have been characterized as occurring within the context of an ecological model that takes into account individual, family, community, societal, and macrosocial factors (see Figure 35-1).12 In this model, all forms of interpersonal violence are interrelated and there are common risk and protective factors that create conditions in which violence takes root or is prevented.13 Any characteristic that is associated with diminished real or perceived power and status in society may be a risk factor for increased exposure to many traumatic events and experiences (Box 36-1).
Box 36-1. Risk Factors for Trauma
Lack of safe, stable, nurturing relationships
Young age
Female sex for IPV/sexual violence
Male sex for community violence
Minority status (race, ethnicity, religion, sexual orientation, gender identity, other)
Psychiatric illness
Substance use
Disability (physical and mental)
Family history of violence
Homelessness
Poverty
Childhood is a particularly vulnerable time for trauma exposure. The youngest children (ages 0–5) are at the highest risk for exposure to trauma and this trauma may be repetitive and chronic.14 Growing up without the care of a safe, responsive, nurturing caregiver dramatically alters healthy childhood development and sets a child up for a lifetime of future adversity. Parents are at increased risk of abusing or neglecting their children if they do not understand children’s development or needs; have low levels of education and/or poor parenting skills; are unable to be attentive due to substance addiction or severe mental health problems; or have a history of being abused themselves during childhood.14 Exposure to IPV markedly increases the risk of childhood maltreatment. In more than 50% of families with IPV, children are also abused.15 Trauma begets more traumas in an intergenerational cycle. Mothers who were abused as children are more likely to abuse their children, and children who grew up observing IPV are more likely to be in a violent relationship as adults,16 and thus, also have children who are exposed to IPV.17
Social isolation of families and communities puts children at higher risk of being maltreated. In communities that have low “social capital” and are plagued by violence, poverty, housing instability, high density of alcohol sales, and poor social cohesion, the likelihood that children will be abused or neglected is increased (see http://www.cdc.gov/violenceprevention/childmaltreatment/riskprotectivefactors.html).
Gender is highly correlated with the types of trauma that people experience. Violence against women and girls is a worldwide epidemic that includes childhood abuse and sexual exploitation and assault, IPV, rape by nonintimate partner perpetrators and as an instrument of war, “honor killings,” and female genital mutilation. Men (and boys) perpetrate the vast majority of violence against women and girls; their risk of perpetrating violence against women and girls is increased if they have been abused as children themselves. Most often violence against women and girls is perpetrated by intimate partners, family members, and close contacts rather than strangers12 (see Chapter 35). Natural disasters and warfare increase the risk of sexual violence via nonintimate partners/strangers for women worldwide.18
Boys are also at risk of childhood abuse and childhood sexual exploitation.19 Although among young children boys are at risk of violence within the family or by close contacts, adolescent and adult males are predominantly at risk of community and war violence that is perpetrated by other men. Worldwide, three quarters of all homicide victims are boys and men, especially those 15–29 years old. Community violence is a more common cause of homicide than war.2 Yet, homicide represents a very small fraction of the devastating effects of abuse and violence. It is estimated that for every young person killed, there are many more young people who have injuries caused by violence.2
Physical and mental disabilities are both caused by trauma and markedly increase one’s risk of violent victimization and trauma. The risk of child abuse, IPV, sexual violence, elder abuse, and community violence are all increased in people who are vulnerable due to disabilities. Discrimination on the basis of disabilities also leads to a multitude of disadvantages like poverty, homelessness, and lack of access to social and medical services that increase the likelihood of victimization (see Chapter 42).
Because various forms of discrimination and structural violence against minority-identified groups and individuals are tolerated and perpetuated in most communities worldwide, minority status in society is a risk factor for being exposed to trauma and multiplicative forms of trauma. For example, LGBTQ individuals are at increased risk of being bullied and are likely at increased risk of sexual assault.20 People who identify as bisexual or lesbian or gay have a 58–66% increased risk of exposure to “ACEs” as compared with heterosexual people.21 Transgender people experience extraordinarily high rates of violent victimization by strangers as well as intimate partners.22
People of minority race/ethnicity are targeted by discrimination resulting in trauma, often by the systems meant to serve them. When measured by household survey, race and ethnicity are not associated with any difference in the rate of child maltreatment.23 Yet, African-American children are reported to child protective service authorities for child maltreatment at a 78% higher prevalence rate than that of white children.24 Racial minorities, targeted by both historical and structural violence, are at dramatically increased risk of community violence. In the United States, between 2007 and 2009, the relative rate difference of homicide for non-Hispanic blacks was at least 650% higher than the rate reported for non-Hispanic whites. Hispanic and American-Indian/Alaskan native people in the United States also had higher homicide rates than non-Hispanic whites.25
The killing of young minority men in the United States by the police is a stark reminder of the traumatic effects of institutionalized racism. Official data are woefully inadequate in reporting exactly how much more often minorities are likely to be killed by police than whites in the United States and estimates vary widely. An analysis of federally collected data by Propublica shows that young black males in recent years were 21 times more likely to be killed by police than their white counterparts (http://www.propublica.org/article/deadly-force-in-black-and-white). The Centers for Disease Control and Prevention (CDC) data likewise reveal racial disparities in rates for both death and injury at the hands of police. According to the CDC, between 1968 and 2011, black people were between two to eight times more likely to die at the hands of law enforcement than whites. (National Violent Death Reporting System: http://wisqars.cdc.gov:8080/nvdrs/nvdrsDisplay.jsp and as reported in Mother Jones, 2014: http://www.motherjones.com/politics/2014/08/police-shootings-ferguson-race-data.) These data reveal a pattern of policing that produces racial disparity and inflicts extensive trauma in minority communities. Black and Latino men are also far more likely to be imprisoned than white men. Generations of minority children suffer the trauma that results from growing up with an incarcerated parent.26
Poverty and societal norms regarding violence also influence the prevalence of violence and trauma in communities. Globally, high rates of income inequality and a society tolerant of violence are associated with high rates of youth violence.27 Living in poverty and, more specifically, in a neighborhood with multiple forms of disadvantage increases one’s risk of exposure to many traumatic experiences including abuse and neglect, hunger, inconsistent housing, family and community violence, parental substance use, severe maternal depression, discrimination, disease, loss of loved ones to premature mortality, and more.13
Trauma and homelessness are inextricably intertwined. Trauma may directly result in homelessness and homelessness increases the risk for subsequent trauma. Family violence and IPV are immediate causes of homelessness when children and adult victims must flee their homes. In a prospective, population-based longitudinal study, both childhood exposure to family adversity and experiences of violent victimization were found to be associated with increased risk of future homelessness.28 In turn, homelessness in both adults and adolescents markedly increases the risk of future violent victimization.29,30
Substance use is also highly correlated with the risk of violence and trauma. Worldwide, alcohol use has been found to increase risk for violent victimization and perpetration through multiple mechanisms including acute and chronic physical and cognitive impairment, increased aggression, the use of alcohol as an excuse to perpetrate violence, and more. Alcohol use increases the risk for violence and is increased by the experience of violence and abuse.31
PROTECTIVE FACTORS AGAINST TRAUMA
David’s best childhood friend, Richard, lives with his mother and grandparents. His father is in jail. His mother works two jobs in order to make enough money to send Richard to a parochial school. When Richard was young, she treasured the 15 minutes she spent reading to Richard before bed. His grandparents picked him up from school and stressed the importance of doing his homework. Richard does well in school and his teachers help him apply to college and for financial aid. Richard dreams of becoming a lawyer to help people like his father, who he thinks was falsely accused of a crime he denies committing.
Protective factors that decrease the likelihood of trauma have not been studied as much as risk factors that increase the likelihood of trauma (Box 36-2). These protective factors also may be examined within the context of an ecological model that takes into account individual, family, community, societal, and macrosocial factors (see Figure 35-1).12 Individual and family factors that protect against childhood maltreatment and violence include individual genetic expression, child IQ, nurturing parenting, parent–child relationship quality, and stable family relationships.32,33 Additional protective factors include parental employment, housing stability, care by other supportive adults, and access to health and social services. Communities that are able to support parents and focus on preventing abuse and violence also protect children from maltreatment.34
Box 36-2. Factors Protective Against Trauma
Supportive family relationships
Secure communities
Financial security
Employment
Stable housing
Higher educational status
IQ
Community engagement
Good health
The single most significant protective factor in preventing both childhood trauma and its adverse outcomes is the presence of a safe, stable, nurturing adult caregiver consistently present in a child’s life.35 In fact, in families in which the mother, who had experienced her own childhood maltreatment, grew up to have safe, stable, nurturing relationships with her intimate partner and her children, the risk of child maltreatment was equivalent to families in which the mother had not been maltreated as a child. Safe, stable, and nurturing relationships can effectively break the intergenerational transmission of abuse.36
Despite trauma and adversity, some children and adults are resilient and able to thrive. Resilience is the capability to surmount adversity. It refers to a “positive, adaptive response despite significant adversity.” The close and responsive attention of a nurturing adult alters childhood development to promote resiliency not only due to the close relationship but also the skills-building and positive experiences that develop through this relationship.35 Some researchers have proposed that resilience be reconsidered as a social-ecological construct in which the community rather than an individual is the source of resilience.37
CONDITIONS RELATED TO TRAUMA
David has chronic pain in his leg from his gunshot wound. He drinks three 48-ounce beers daily and smokes marijuana to “calm down.” He contracts hepatitis C from a tattoo done by a friend and develops diabetes and hypertension by the age of 30. He is unemployed, intermittently homeless, and has just been arrested for physically and sexually assaulting his girlfriend after she got an abortion he didn’t want her to have.
Trauma can be devastating (Box 36-3). Physical injuries from traumatic violence are often life altering. Both children and adults may suffer severe traumatic brain injuries due to violence. Children’s brains are particularly vulnerable to physical violence. Babies may suffer blindness, cerebral palsy, severe cognitive impairment, and even death from “shaken baby syndrome.”38 Less visible are the emotional disturbances, psychological scars, and injury to the ability to form and sustain good relationships that result from trauma. Trauma, whether caused by a one-time catastrophic events or chronic, ongoing traumatic events, can shatter one’s sense of safety. Trauma that involves interpersonal abuse and violence especially from a family member or partner represents profound human betrayal and has been found to be particularly devastating.
Box 36-3. Conditions Related to Trauma
Physical injury and homicide
Psychiatric illnesses (anxiety, depression, posttraumatic stress disorder [PTSD], complex PTSD [cPTSD], suicidality)
Chronic illnesses (heart, lung, liver, and other diseases)
Sexually transmitted infections including HIV
Sleep disorders
Unwanted pregnancy and pregnancy at early age
Childhood learning and behavior problems
Substance use
Homelessness
Premature death (due to poor health, homicide, suicide)
Future victimization or perpetration of violence
Although all people who experience trauma are altered by it, children are particularly vulnerable to serious lifelong adverse effects of trauma. In order to develop optimally healthy brains, bodies, and relationships, children need stable, nurturing, consistent, and highly attuned relationships with caregivers. Secure and attuned attachments with caregivers allow children to internalize abilities to self-soothe, develop a positive self-image, learn to relate to others with care and love, and to play and explore in ways that promote healthy brain development. Conversely, the developmental life course of children who have been abused and neglected, often by someone who was supposed to be a trustworthy or caregiving figure, is profoundly disturbed.
Trauma disrupts our optimal health and normal development. The mechanisms through which trauma affects our health are beginning to be elucidated. There is a dynamic, continuous, and interplay between “nature” (our biology) and “nurture” (our environment). Our biology is altered by our experiences, relationships, and other responses to our environment. Positive stress that briefly increases stress hormones but then remits, as when a toddler falls and gets back up or when an adolescent takes a test, is necessary for normal development. Prolonged stress or trauma that overwhelms one’s capacity to weather these experiences and is not relieved by a healthy, caring relationship or one’s capability to self-soothe is called “toxic stress” or “traumatic stress.”
Toxic stress adversely affects our health through autonomic, neuroendocrine, inflammatory, genetic, epigenetic, and behavioral pathways. Cumulative exposure to extreme stress can result in an imbalance in our biological steady state. Persistent activation of stress hormones and other bodily stress-reactive processes can result in pathological biological changes. For example, toxic stress activates the hypothalamic–pituitary–adrenocortical axis and the sympathetic-adrenomedullary system and causes the release of inflammatory mediators.
When toxic stress occurs during the extraordinarily active periods of brain development in childhood and adolescence, it can cause remodeling of the brain’s architecture and body’s biology in ways that have lasting ill effects throughout the lifespan.39,40,41
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