Longitudinal Effects of Childhood Trauma

This post is to not only provide educational content on the longitudinal effects of childhood trauma, but to also showcase how a Master's level research paper should be conducted & presented. I hope you enjoy this post as much as I appreciated the time and energy put into writing it...

Key Words

Biomarker - An attribute that is objectively measured and evaluated as an indicator of normal biologic processes, pathologic processes, or biological responses to a therapeutic intervention.

Clinician – Represents either a scientist conducting research or describes the role of a health-care worker that directly helps with the process of curing patients that suffer from either a medically-related condition or a mental-health related issue. Examples: Physician, nurse, therapist, dentist, social worker.

Complex Post-Traumatic Stress Disorder - When a person has experienced trauma on an ongoing basis, or one prolonged event.

Counselor (therapist) – A person licensed to provide individual or group psychotherapy and clinically trained to treat psychiatric disorder listed in the DSM-5 through talk-therapy.

Epidemiological – The study of the distribution (frequency, pattern) and determinants (causes, risk factors) of health-related states and events (not just diseases) in specified populations (neighborhood, school, city, state, country, global).The method used to find the causes of health outcomes and diseases in populations.

Epigenetics - the study of heritable changes in gene expression (active versus inactive genes) that do not involve changes to the underlying DNA sequence - a change in phenotype without a change in genotype - which in turn affects how cells read the genes.

FMRI – Measures blood flow through the brain, telling doctors more about the activities of neurons and show which brain regions are most active.

Neurobiology - a branch of the life sciences that deals with the anatomy, physiology, and pathology of the nervous system

Pathology - Describes conditions typically observed during a disease state. Describes the abnormal or undesired condition. The study of the structural and functional changes produced by them

Pathophysiology - The study of the disordered physiological processes that cause, result from, or are otherwise associated with a disease or injury. This seeks to explain the functional changes that are occurring within an individual due to a disease or pathologic state.

Post-Traumatic Stress Disorder - An anxiety disorder that develops following frightening, stressful, or distressing life events. Characterized by intense fear, helplessness, and stress to the point where it affects a person’s normal well-being and ability to function.

Psychopathology - The scientific study of mental disorders, including efforts to understand their genetic, biological, psychological, and social causes; develop classification schemes which can improve treatment planning and treatment outcomes; understand the course of psychiatric illnesses across all stages of development; more fully understand the manifestations of mental disorders; and investigate potentially effective treatments

Reliability - The extent to which the results can be reproduced when the research is repeated under the same conditions. It is assessed by checking the consistency of results across time, across different observers, and across parts of the test itself. A reliable measurement is not always valid: the results might be reproducible, but they’re not necessarily correct.

Trauma – Occurs when a person experiences either an actual or threatened death, endures a serious injury, or is a victim of sexual violence (American Psychiatric Association, 2013).

Validity - The extent to which the results really measure what they are supposed to measure. It is assessed by checking how well the results correspond to established theories and other measures of the same concept. A valid measurement is generally reliable: if a test produces accurate results, they should be reproducible.

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Longitudinal Effects of Childhood Trauma

Introduction

The National Institutes of Health (NIH) believes trauma affects more than two thirds of American children; and estimate that one third experience multiple, often chronic, traumas such as child maltreatment (child sexual, physical, or emotional abuse; child neglect; or domestic violence). Yet widespread efforts to identify and effectively treat the potentially serious and long-term negative impacts of these experiences lag far behind. Research connecting the longitudinal effects of childhood trauma to the later development of adult pathology expands across multiple professional disciplines. Simply exploring the elements of psychopathology, pathophysiology, neuropathology, neurobiology, biochemistry, and epigenetics will provide mental-health practitioners with at best, broad clinical interpretations. This poses the question of how exactly negative health outcomes are linked to childhood adversities. A more complete understanding of these issues is likely to lead to a better understanding of the relationship between childhood adversities and disease burden. Therefore, in order to develop an integrative understanding of the relationship between trauma and the later onset of pathology, clinicians can obtain scholarly journals published by different professional organizations and around the globe. Once a relationship can be established, outlining how the research can implicate and inform a counselor’s work can be presented.

Trauma

The American Psychiatric Association (2013) indicates that psychological trauma manifests when a person experiences either an actual or threatened death, endures a serious injury, or is a victim of sexual violence in at least one of the following four ways: (a) directly encounters a threatening event; (b) physically witnesses an intrusive event occurring to others; (c) learns that a close family member or friend experienced a troublesome event; or (d) repetitively experiences aversive details across a series of particular events. It is important to highlight that an actual or threatened death must occur in a violent or accidental manner; and excludes any exposure through social media, television, movies or pictures, unless it is work-related.

Adverse Childhood Events (ACE)

In 1990, Dr. Felitti presented his landmark ACE study showing research that links events of childhood adversity and health outcomes. This would be the first study of its kind to introduce the longitudinal effects of childhood trauma. The ACE study strongly established a dose-response relationship, which is an important step towards demonstrating causality. Through his research efforts, Dr. Felitti (2009) found that a person with a higher ACE score would become more likely to later develop a cluster of diseases. Clinicians would become inspired to study just how trauma over activates the body’s stress response; and many curious how it leads to a person’s physical, emotional, and psychological dysfunction.

ACE: Anatomy & Physiology

Dr. Alan Guttmacher, head of the National Institute of Child Health and Human Development, notions when adverse childhood experiences occur, the body has a series of stress responses. Areas of the brain, such as the amygdala, prefrontal cortex, hypothalamic-pituitary-adrenal (HPA) axis, sympatho-adrenomedullary (SAM) axis, noradrenergic nucleus in the locus coeruleus, and hippocampus all rapidly react to the potentially threatening stimuli. Research indicates that when a child is overly exposed to a stressor, it can reduce the size of their hippocampus by up to 4x its healthy developed state. MRI studies have indicated that when children are chronically traumatized, their risk for dramatically enlarging their amygdalae skyrockets. Research has shown that trauma can trigger chronic inflammation throughout the body, alter how hormones functions for decades, and can alter how DNA is replicated and how our body reads it. Other research using other brain-imaging tests have shown how trauma stunts a child’s skeletal maturity. This indicates that when a child experiences trauma at a young age, the child may continue to age in years but will show the muscular age and growth consistent of their age when the trauma occurred. Overall, the consequences of toxic stress are neurologic, hormonal, immunologic, compromise the health of telomeres, effect epigenetic markets and transgenerational genetics.

Trauma’s Longitudinal Effects on Psychopathology & Pathophysiology

Corso et al. (2008) includes research suggesting that childhood adversities have an independent effect on disease burden, apart from their effect on mental and general medical disorders. These findings are in line with other research showing that childhood adversities are associated with health outcomes in adulthood. Our study adds to this by showing that childhood adversities have a strong impact on disease burden, through increasing the risk of mental and general medical disorders, but also by an effect which is independent from these disorders.

Venigalla H, Mekala HM, Hassan M, et al. (2017) strongly assert that adverse trauma negatively impacts a child’s short-and-long term mental well-being, biological systems, and its structures. They leverage the work of others’ longitudinal research, qualitative-and-quantitative studies, and meta-analyses to support why adverse childhood events increase a child’s risk of later developing a psychopathological disorder(s); such as various mood disorder(s), anxiety disorder(s), alcohol problems, eating disorder(s), and psychotic symptoms. Their own research has revealed childhood adversity being significantly associated with children becoming more susceptible to later experiencing suicidal ideations and suicide attempts. Furthermore, their research findings indicate that childhood trauma can increase a child’s risk for later developing concurrent mental disorder(s), and include the risk of having severe interpersonal difficulties, weight problems, and early retirement due to developing a disability.

Gilbert et al. (2015) illustrate a small sample size of research believes adverse childhood events may be associated with increasing ones risk of later developing a pathophysiological disorder(s); such as various auto-immune diseases, cancer, Alzheimer’s, sexually transmitted infections, including HIV, delayed cognitive development, chronic obstructive pulmonary disease, ischemic heart disease, liver disease, reproductive health problems, migraines, peptic ulcers, arthritis, coronary heart disease, and diabetes. In addition, there is a growing body of research that believes early childhood trauma cause damage to the nervous, endocrine, circulatory, musculoskeletal, reproductive, respiratory, and immune systems. That being said, despite research findings, clinicians do not have enough evidence to support all the correlations.

Clinically Detecting Trauma

Venigalla H, Mekala HM, Hassan M, et al. (2017) assert that different methodologies can be used in order to explain and further support the relationship between childhood trauma and being able to predict a person’s health status throughout adulthood. For example, there are several studies that adequately portray how the onset of chronic stress, addiction, or depression at a young age can severely effect a person’s quality of life later on in adulthood. A second way to explain the relationship can be performed by using statistical methods to predict a person’s mortality rate. For instance, the proportional mortality method is a simple way of portraying the burden of a specific disease within a population. Clinicians are also able to calculate how time a person loses in terms of their quality of life, because of year(s) lived with a certain disease. For example, Kruijshaar, Hoeymans, Spijker, Stouthard, & Essink-Bot (2005) estimated that of each year lived with a major depressive disorder, 46% of the quality of life in this year is missed because of the depressive disorder. Despite their being different equations to predict a person’s mortality rate, the calculations have a low validity rate due to the limited research on the overall impact of childhood adversities on disease burden on a population level. Without this data, clinicians are unable to accurately calculate a patient’s mortality rate, which explains why its clinical application has become obsolete in most clinical settings.

ACE Risk Factors

The Centers for Disease Control and Prevention (2015) point out that a child’s risk of being exposed to adverse childhood-related events is influenced by a number of individual, family, and environmental factors, all of which interact to increase or decrease risk over time and within specific contexts. Obvious risk factors include a child’s age and if they have any special needs may increase their vulnerability (e.g., developmental and intellectual disabilities, mental health issues, and chronic physical illnesses). Additional risk factors include the age of the parent(s) or caregiver(s), the number of children in the household, if there is any parental history of abuse, neglect, substance abuse, or mental-health issues, if there is any history of intimate partner or community violence, and concentrated neighborhood disadvantage (e.g., high poverty and residential instability, high unemployment rates). Although risk factors provide information about who is most at risk for being a victim or a perpetrator of child abuse and neglect, they are not direct causes and cannot predict who will be a victim or a perpetrator. Fortson and Mercy have argued that no single factor tells the entire story about how and why adverse childhood experiences occurs, nor outline the exact risk and protective factors.

Epidemiology

Merrick, Fortson, & Mercy (2015) concluded that a child’s risk of being exposed to a trauma-related event varies across several epidemiological factors, such as a person’s race, ethnicity, and family income. The research indicates that younger children are most likely to experience a fatal-related traumatic event while teens are most likely to experience a non-fatal traumatic incident. According to data from child protective services, African American children experience abuse and neglect at rates that are nearly double those for white children. Children living in families with a low socioeconomic status (SES) have rates of child abuse and neglect that are five times higher than those of children living in families with a higher SES. These differences are generally attributed to various community and societal factors, including poverty as well as differences in reporting and investigation. Irrespective of data source, definitions, and measures, the true magnitude of child abuse and neglect is likely underestimated. As a result, these numbers should be considered to be on the lower end of the spectrum. Although risk factors continue to provide practitioners and public officials with information correlating who is most at risk for being a victim of child abuse and neglect, they are not direct causes. Therefore, clinicians are unable to precisely predict who will become a victim. This is can best be explained because correlation does not mean causation.

Biomarkers & Neuroimaging

Venigalla H, Mekala HM, Hassan M, et al. (2017) define a biomarker as an attribute that is “objectively measured and evaluated as an indicator of normal biologic processes, pathologic processes, or biological responses to a therapeutic intervention. A biomarker can be a gene or a group of genes, proteins, or other biomolecules… and can be used to confirm the presence of a specific disease” (472). Psychiatrists aim to use biomarker testing to measure a patient’s biological response before and after any pharmacological interventions are made. In addition, psychiatrist would utilize biomarker testing during a patient’s follow-up appointment in order to assess the overarching pathological process. This kind of strategic approach and systematic process would produce objective data for psychiatrist to use to enhance their ability to make an accurate diagnosis, form a reliable prognosis, and improve the patient’s outcomes.

Venigalla H, Mekala HM, Hassan M, et al. (2017) state that despite the past two decades of research centered around biomarkers, clinicians have not been able to identify the etiology of most psychiatric disorders. That being said, the current research literature introduces a set of anatomical and physiological biomarkers that clinicians believe to correlate with the onset of certain psychopathology. For example, Young et al. (2016) theorizes the biomarker “C-reactive protein, Interleukin-6, Tumor necrosis factor- α” influences the onset of clinical depression (474).

Venigalla H, Mekala HM, Hassan M, et al. (2017) indicated that despite any correlations, biomarker testing is not openly available for clinicians to use throughout the diagnostic and intervention process for psychiatric disorders due to its heterogeneous expression. As a result, until research can precisely pinpoint the root cause that explains why a particular psychiatric disorder develops, any clinical application of biomarkers to treat mental-health related disorders will remain in its early stages. To see more examples, refer to “Table-1: Various Studies Proposing Different Biomarkers for Different Psychiatric Diagnoses” on page 16-17 and “Table-2: Various Studies Proposing Genetic and Proteomic Biomarkers for Different Psychiatric Diagnoses” on page 17.

Shonkoff, Boyce, and McEwen (2009) exemplify how the medical community has seen massive technological advances that have allowed clinicians to observe and study the brain like never before. Recent developments in neuroimaging have just began to unravel the existing relationship between psychological trauma and pathophysiology, neurobiology, and psychopathology. Further research is necessary in order to understand how structural brain dysfunction, neuro-hemodynamics, neurobiology, and neurophysiology influence the development of various psychiatric disorders. Such newfound research could guide psychiatrist to establish a reliable set of clinically applicable biomarkers. Until that happens though, clinicians are not able to rely on biomarker testing to predict the longitudinal effects of childhood trauma, nor are they able to better understand how a person’s biological and pathological processes have responded to previous trauma.

Treatment

According to Cohen, Scheid, and Gerson (2014) research study, there are no evidence-based psychopharmacologic treatments available because clinical trials have generally failed to demonstrate its effectiveness in any medication for improving pediatric PTSD (p. 11). Since not all problems respond positively to psychopharmacologic interventions, and for traumatized children in particular, the most effective intervention is evidence-based trauma-focused psychotherapy. When feeling emotionally, behaviorally, or psychologically dysregulated from trauma-induced symptoms, using breathings techniques and incorporating mindfulness exercises can help calm the body’s stress response. When balancing dysregulation pathways by incorporating exercise, maintaining a balanced diet, developing healthy sleep habits, and improving upon interpersonal relationships are all ways to negate the longitudinal effects of adverse childhood trauma. For adults who have not overcome their early-childhood trauma, they can attend therapy/counseling to help improve their quality of life. In order for treatment to be successful, a person must work through intense emotional, mental, and psychological tasks throughout the course of therapy. People may join social support groups, local club, or turn to religion as ways to improve their quality of life.

Counselor’s Future Work

In theory, if the Counsel for Accreditation of Counseling and Related Educational Programs (CACREP) were to adopt a science-based approach throughout their respective graduate curriculums and was to adopt a greater emphasis that acknowledges the longitudinal effects of childhood trauma, then the traditional biopsychosocial approach that counselors are trained to practice, would then drastically shift to a clinical approach that largely embodies one similar to the medical-model. This would significantly effect a counselor’s role and scope of practice within the entire health-care system. For instance, it would foster more leadership-type roles in clinical settings for counselors to earn within the mental-health profession and allow counselors to command greater respect from the general public. Moreover, it may help destigmatize the public’s misconception that attending counseling is scary or that it is ineffective.

If counselors became equipped to incorporate bio-related intervention tactics, it would help guild their clinical practices and could significantly enhance treatment outcomes. Generally, when more efficient and effective interventions are implemented in clinical settings, it will drive down the overall cost for treatment and save people tax dollars. For example, the National Institute on Drug Abuse (2008) reported that the average cost for 1 year of methadone maintenance treatment is approximately $4,700 per patient, whereas 1 year of imprisonment costs approximately $24,000 per person. As one can see, when someone is incarcerated, the costs becomes 5x more than the more efficient, effective treatment route. This historical example adequately depicts how new and improved treatment options could systematically open up doors that allow people to have better access to mental-health services in underserved, rural, poor communities.

I believe if counselors were to adopt a greater emphasis that acknowledges the longitudinal effects of childhood trauma, it would unify the counseling community by shortening the amount of theoretical orientations that they practice. This is important because other health-care professions argue that the counseling community cannot agree to use just one theory in clinical practice. Although most counselors use cognitive-behavioral therapy (CBT) techniques and strategies, they do so at the expense that insurance companies will generally deny covering treatments that primarily incorporate other theoretical models. This ideological split within the counseling community largely explains why clients may have struggled in the past with finding the right counselor for them or have trouble obtaining mental-health services. Unifying the counseling community could theoretically change these problems.

If counselors were to adopt a greater emphasis that acknowledges the longitudinal effects of childhood trauma, it could shorten the amount of times and extend the length of time that people would attend counseling. That being said, the opposite could occur where it may increase the amount of times and extend the length of time that people would attend counseling. While this can be considered a drawback, it may lead to better treatment outcomes.

Research Methods

In order to successfully complete my independent study, I had to access of a wide array of resources. The interlibrary loan system at Immaculata University played a pivotal role for this study. The platform offered global access to scholarly journals and doctoral dissertations that I otherwise would not have access to as a general visitor of the University. My supervisor, Dr. Martinson, played a significant role during the semester long independent study. Throughout our meetings, he provided a different perspective on clinically relevant content as a way to help me navigate the direction of my research efforts. In addition, he would answer questions with rich insight, would recommend scholarly article that was published in different professional journals, and provided a list of 104 different scholarly publications that may enhance my research findings. Lastly, he would offer guidance in order to help me navigate and facilitate the overall direction of the independent study.

Limitations

Throughout the process of successfully completing my independent study, I encountered a number of limitations that are worth mentioning. Although I was given 15-weeks to complete my study, there are time-related factors that affect the quality-and-amount of content gathered. Had I been provided additional time or a support staff to help me gather research, it is plausible that the quality of content would improve. A second limitation occurred when I was asked to pay in order to access certain publications of research literature. Financial constraints restricted my access to some clinically related publications. By narrowing my research efforts only towards free resources, then I can argue that the overall quality of content I could collect would become limited. A third limitation relates to all of my held or hidden biases’. This complex phenomenon effected what direction I took throughout the research process. This could lead readers to question the reliability of my research findings due to events like information bias or research bias.

Conclusion

There is a large body of research literature that connects the longitudinal effects of childhood trauma to the later development of adult psychopathology and pathophysiology. Clinicians have identified that an association exists between the two, but the amount of participants included in these studies is too small to prove that their findings yield a direct cause-and-effect. Although certain anatomical and physiological biomarkers are directly linked with the onset of certain psychopathology, there is not enough evidence to support anything more than a correlation exists.

As neuroimaging techniques become more affordable and accessible to clinicians, researchers hope to one day unveil the true relationship between psychological trauma and psychopathology, pathophysiology, and neurobiology. As neuroimaging technology continuously develops, neuroscientists would like to use optogenetic on human brains because it would allow them to map the brain’s neural circuitry, ultimately revealing secrets about how the brain processes information and drives human behavior. This breakthrough could allow clinicians to improve treatment outcomes and enhance a patient’s access to effective, affordable care. These improvements may uncover the “how” and “why” trauma causes longitudinal damage.

No matter a person’s geographic location, ethnicity, and socioeconomic background, we all are effected by ACEs in similar ways. Although a child can experience many adverse events or be exposed to severely traumatic incidents, they can forgo to live a happy, healthy life as long as a positive, nurturing support system is in place. The long-term impacts of childhood adversity are not all related to suffering. Adversity can foster perseverance, deepen empathy, strengthen the resolve to protect, and becomes a part of who we are.

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Table 1: Various Studies Proposing Different Biomarkers for Different Psychiatric Diagnoses

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Table 2: Various Studies Proposing Genetic and Proteomic Biomarkers for Different Psychiatric Diagnoses

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Abstract

This independent study focuses on drawing relevant educational experiences tied to research connected with the longitudinal effects of childhood trauma to the development of adult psychopathology and pathology. This includes focusing on developing an integrative understanding of the connection of past trauma and psychopathology and the implications of these perceptions on a counselor’s work by looking into relevant research. Discussions will address how better understanding of the development of implementing this research into counselor education and clinical practice can inform a counselor’s work. A multitude of scholarly journals and the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) was analyzed in order to complete my research (American Psychiatric Association, 2013; Centers for Disease Control and Prevention, 2015; Cohen, Scheid, and Gerson, 2014; Corso, Edwards, Fang, and Mercy, 2008; Felitti, 2009; Gilbert, Breiding, Merrick, Thompson, Ford, Dhingra, and Parks, 2015; Kruijshaar, Hoeymans, Spijker, Stouthard, and Essink-Bot, 2005; Merrick, Fortson, and Mercy, 2015; National Institute on Drug Abuse, 2008; Shonkoff, Boyce, and McEwen, 2009; Venigalla, Mekala, Hassan M, et al., 2017). The goal was to discover how childhood trauma contributes to the later development of psychopathology and pathophysiology. The clinically relevant knowledge I gained has allowed me to create a literature review that could later represent a future thesis or future research endeavors. That being said, it is important that I highlight the major research limitations encountered. No official funding was implemented in order to discover the outcome of my findings. My conclusion is that childhood trauma can influence the later development of a mental-health disorder or can contribute to the later onset of a physical illness that is associated with a plethora of physiological effects and complications.

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Works Cited

1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

2. Centers for Disease Control and Prevention. (2015). Child maltreatment: Risk and protective factors. National Center for Injury Prevention and Control, Division of Violence Prevention. Retrieved from http://www.cdc.gov/violenceprevention/childmaltreatment/riskprotective factors.html.

3. Cohen, J.A., Scheid, J., Gerson, R. (2014). Transforming Trajectories for Traumatized Children. Journal of the American Academy of Child & Adolescent Psychiatry, 53(1), 9-13.

4. Corso, P.S., Edwards, V.J., Fang, X., Mercy, J.A. (2008). Health-Related Quality of Life Among Adults Who Experienced Maltreatment During Childhood. American Journal of Public Health, 98(6), 1094-1100. doi: 10.2105/AJPH.2007.119826

5. Felitti V. (2009). Adverse childhood experiences and adult health. Academic Pediatrics, 9, 131- 132.

6. Gilbert, L. K., Breiding, M. J., Merrick, M. T., Thompson, W. W., Ford, D. C., Dhingra, S. S., & Parks, S. E. (2015). Childhood adversity and adult chronic disease. An update from ten states and the District of Columbia. American Journal of Preventive Medicine, 48(3), 345-349. Retrieved from: https://doi.org/10.1016/j.amepre.2014.09.006

7. Kruijshaar, M.E., Hoeymans, N., Spijker, J., Stouthard, M.E., Essink-Bot, M.L. (2005), Has the burden of depression been overestimated? Bull World Health Organ, 83(6), 443-448. doi:/S0042-96862005000600012

8. Merrick, M. T., Fortson, B. L., & Mercy, J. A. (2015). The epidemiology of child maltreatment. In P. D. Donnelly & C. L. Ward (Eds.), Oxford textbooks in public health – Violence: A global health priority. Oxford, UK: Oxford University Press.

9. National Institute on Drug Abuse (2008). National Institute of Health. Retrieved from: https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research- based-guide-third-edition/frequently-asked-questions/drug-addiction-treatment-worth-its- cost

10. Shonkoff, J.P., Boyce, W.T., McEwen, B.S. (2009). Neuroscience, Molecular Biology, and the Childhood Roots of Health Disparities: Building a New Framework for Health Promotion and Disease Prevention. JAMA. 301(21), 2252–2259. doi:10.1001/jama.2009.754

11. Venigalla H, Mekala H.M, Hassan M, et al. (2017), An Update on Biomarkers in Psychiatric Disorders - Are we aware, Do we use in our clinical practice? Mental Health in Family Medicine 13, 471-479.