Childhood trauma, including abuse and neglect, is probably our nation’s single most important public health challenge that has the potential to be largely resolved by appropriate prevention and intervention. Each year over 3,000,000 children are children are reported to authorities for abuse and/or neglect in the United States of which about one million are substantiated. May thousands more undergo traumatic medical and surgical procedures, and are victims of accidents and of community violence. However, most trauma begins at home: the vast majority of people (about 80%) responsible for child maltreatment are children’s own parents.
Inquiry into developmental milestones and family medical history is routine in medical and psychiatric examinations. In contrast, social taboos prevent obtaining information about childhood trauma, neglect and other exposures to violence. Research has shown that traumatic childhood experiences are not only extremely common; they also have a profound impact on many different areas of functioning. For example, children exposed to alcoholic parents or domestic violence rarely have secure childhoods; their symptomatology tends to be pervasive and multifaceted, and is likely to include depression, various medical illnesses, as well as a variety of impulsive and self -destructive behaviors. Approaching each of these problems piecemeal, rather than as expressions of a vast system of internal disorganization runs the risk of losing sight of the forest in favor of one tree.
Photo by Tung Minh
The traumatic stress field has adopted the term “Complex trauma” to describe the experience of multiple and/or chronic and prolonged, developmentally adverse traumatic events, most often of an interpersonal nature (e.g., sexual or physical abuse, war, community violence) and early-life onset. These exposures often occur within the child’s caregiving system and include physical, emotional, and educational neglect and child maltreatment beginning in early childhood.
In the Adverse Childhood Experiences (ACE) study by Kaiser Permanente and the Center for Disease Control, 17,337 adult HMO members responded to a questionnaire about adverse childhood experiences, including childhood abuse, neglect and family dysfunction. 11.0% reported having been emotionally abused as a child, 30.1% reported physical abuse, 19.9% sexual abuse, 23.5% reported being exposed to family alcohol, 18.8% to mental illness, 12.5% witnessed their mothers being battered and 4.9% reported family drug abuse.
The ACE study showed that adverse childhood experiences are vastly more common than recognized or acknowledged and that they have a powerful relation to adult health a half-century later. The study unequivocally confirmed earlier investigations that found a highly significant relationship between adverse childhood experiences and depression, suicide attempts, alcoholism, drug abuse, sexual promiscuity, domestic violence, cigarette smoking, obesity, physical inactivity, and sexually transmitted diseases. In addition, the more adverse childhood experiences reported, the more likely a person was to develop heart disease, cancer, stroke, diabetes, skeletal fractures, and liver disease.
In contrast, chronic maltreatment or inevitable repeated traumatization, such as occurs in children who are exposed to repeated medical or surgical procedures, have a pervasive effect on the development of mind and brain. Chronic trauma interferes with neurobiological development and the capacity to integrate sensory, emotional and cognitive information into a cohesive whole. Developmental trauma sets the stage for unfocused responses to subsequent stress leading to dramatic increases in the use of medical, correctional, social and mental health services. People with childhood histories of trauma, abuse and neglect make up almost our entire criminal justice population: physical abuse and neglect are associated with a very high rates of arrest for violent offenses. In one prospective study of victims of abuse and neglect, almost half were arrested for non-traffic related offenses by age 32. Seventy-five percent of perpetrators of child sexual abuse report to have themselves been sexually abused during childhood. These data suggest that most interpersonal trauma on children is perpetuated by victims who grow up to become perpetrators and/or repeat victims of violence. This tendency to repeat represents an integral aspect of the cycle of violence in our society.