Abstract
The adverse childhood experiences (ACE) study showed that childhood trauma is common in the general population and has enduring effects on adult emotional and physical health. Levels of childhood adversity among individuals with a history of military service have been found to match or exceed those among individuals with no history of military service. Most studies to date have found that ACEs are associated with poorer mental health outcomes among service members and veterans, although the ways in which childhood adversity may contribute to vulnerability or resilience are not fully understood. Further, the prevalence of ACEs specifically among veterans has not been clearly established. We evaluated the prevalence of childhood adversity at a community-based outpatient mental health clinic within the Department of Veterans Affairs (VA) and found that 85.0% of participating veterans reported experiencing at least one category of ACE before the age of 18, while nearly half of veteran participants (46.0%) reported experiencing four or more categories. We discuss the implications of a high burden of childhood adversity for neurobiological development and psychological functioning among veterans, and for mental health treatment within the VA. Further, we describe the development of a trauma-informed program which utilizes a phase-based, modular approach to better address the psychological sequelae of childhood adversity, and foster resilience and posttraumatic growth. Several case examples are discussed, along with recommendations for future research.
Similar content being viewed by others
References
Afifi, T. O., Taillieu, T., Zamorski, M. A., Turner, S., Cheung, K., & Sareen, J. (2016). Association of child abuse exposure with suicidal ideation, suicide plans, and suicide attempts in military personnel and the general population in Canada. JAMA Psychiatry, 73, 229–238. https://doi.org/10.1001/jamapsychiatry.2015.2732.
Anda, R. F., Felitti, V. J., Bremner, J. D., Walker, J. D., Whitfield, C., Perry, B. D., et al. (2006). The enduring effects of abuse and related adverse experiences in childhood: A convergence of evidence from neurobiology and epidemiology. European Archives of Psychiatry and Clinical Neuroscience, 256, 174–186. https://doi.org/10.1007/s00406-005-0624-4.
Arnsten, A. F. T., Raskind, M. A., Taylor, F. B., & Connor, D. F. (2015). The effects of stress exposure on prefrontal cortex: Translating basic research into successful treatments for post-traumatic stress disorder. Neurobiology of Stress, 1, 89–99. https://doi.org/10.1016/j/ynstr.2014.10.002.
Bandoli, G., Campbell-Sills, L., Kessler, R. C., Heeringa, S. G., Nock, M. K., Rosellini, A. J., et al. (2017). Childhood adversity, adult stress, and the risk of major depression or generalized anxiety disorder in US soldiers: A test of the stress sensitization hypothesis. Psychological Medicine, 47, 2379–2392. https://doi.org/10.1017/S0033291717001064.
Banihashemi, L., Wallace, M. L., Sheu, L. K., Lee, M. C., Gianaros, P. J., MacKenzie, R. P., et al. (2017). Childhood maltreatment moderates the effect of combat exposure on cingulum structural integrity. Developmental Psychopathology, 29, 1735–1747. https://doi.org/10.1017/S0954579417001365.
Blosnich, J. R., & Bossarte, R. M. (2016). Childhood abuse and military experience-important information to better serve those who have served. JAMA Psychiatry, 73, 195–196. https://doi.org/10.1001/jamapsychiatry.2015.2736.
Blosnich, J. R., Dichter, M. E., Cerulli, C., Batten, S. V., & Bossarte, R. M. (2014). Disparities in adverse childhood experiences among individuals with a history of military service. JAMA Psychiatry, 71, 1041–1048. https://doi.org/10.1001/jamapsychiatry.2014.724.
Brown, G. R., McBride, L., Bauer, M. S., & Williford, W. O. (2005). Impact of childhood abuse on the course of bipolar disorder: A replication study in US veterans. Journal of Affective Disorders, 89, 57–67. https://doi.org/10.1016/j.jad.2005.06.012.
Cabrera, O. A., Hoge, C. W., Bliese, P. D., Castro, C. A., & Messer, S. C. (2007). Childhood adversity and combat as predictors of depression and post-traumatic stress in deployed troops. American Journal of Preventive Medicine, 33, 77–82. https://doi.org/10.1016/j.amepre.2007.03.019.
Carroll, T. D., Currier, J. M., McCormick, W. H., & Drescher, K. D. (2017). Adverse childhood experiences and risk for suicidal behavior in male Iraq and Afghanistan veterans seeking PTSD treatment. Psychological Trauma: Theory, Research, Practice, and Policy. https://doi.org/10.1037/tra0000250. (Advance online publication, Jan 12).
Centers for Disease Control and Prevention, Kaiser Permanente. (2016). The ACE Study Survey Data [Unpublished Data]. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/violenceprevention/acestudy/about.html.
Clancy, C. P., Graybeal, A., Tompson, W. P., Badgett, K. S., Feldman, M. E., Calhoun, P. S., et al. (2006). Lifetime trauma exposure in veterans with military-related posttraumatic stress disorder: Association with current symptomology. Journal of Clinical Psychiatry, 67, 1346–1353.
Cloitre, M. (2015). The “one size fits all” approach to trauma treatment: Should we be satisfied? European Journal of Psychotraumatology, 6, 27344. https://doi.org/10.3402/ejpt.v6.27344.
Cloitre, M., Courtois, C. A., Charuvastra, A., Carapezza, R., Stolbach, B. C., & Green, B. L. (2011). Treatment of complex PTSD: Results of the ISTSS expert clinician survey on best practices. Journal of Traumatic Stress, 24, 615–627. https://doi.org/10.1002/jts.20697.
Cloitre, M., Stovall-McClough, K. C., Nooner, K., Zorbas, P., Cherry, S., Jackson, C. L., et al. (2010). Treatment for PTSD related to childhood abuse: A randomized controlled trial. American Journal of Psychiatry, 167, 915–924. https://doi.org/10.1176/appi.ajp.2010.09081247.
Dedert, E. A., Green, K. T., Calhoun, P. S., Yoash-Gantz, R., Taber, K. H., Mumford, M. M., et al. (2009). Association of trauma exposure with psychiatric morbidity in military veterans who have served since September 11, 2001. Journal of Psychiatric Research, 43, 830–836. https://doi.org/10.1016/j.jpsychires.2009.01.004.
Ehlert, U. (2013). Enduring psychobiological effects of childhood adversity. Psychoneuroendocrinology, 38, 1850–1857. https://doi.org/10.1016/j.psyneuen.2013.06.007.
Engel, C. C., Jr., Engel, A. L., Campbell, S. J., McFall, M. E., Russo, J., & Katon, W. (1993). Posttraumatic stress disorder symptoms and precombat sexual and physical abuse in Desert Storm veterans. Journal of Nervous and Mental Disease, 181, 683–688.
Felitti, V. J., Anda, R. F., Nordenberg, M. D., Williamson, M. S., Spitz, A. M., Edwards, V., et al. (1998). Relationship of childhood abuse to many of the leading causes of death in adults: The adverse childhood experiences (ACE) study. American Journal of Preventive Medicine, 14(4), 245–258.
Fritch, A. M., Mishkind, M., Reger, M. A., & Gahm, G. A. (2010). The impact of childhood abuse and combat-related trauma on postdeployment adjustment. Journal of Traumatic Stress, 23, 248–254. https://doi.org/10.1002/jts.20520.
Gahm, G. A., Lucenko, B. A., Retzlaff, P., & Fukuda, S. (2007). Relative impact of adverse events and screened symptoms of posttraumatic stress disorder and depression among active duty soldiers seeking mental health care. Journal of Clinical Psychology, 63, 199–211. https://doi.org/10.1002/jclp.20330.
Gaska, K. A., & Kimerling, R. (2018). Patterns of adverse experiences and health outcomes among women veterans. American Journal of Preventive Medicine, 55, 803–811. https://doi.org/10.1016/j.amepre.2018.06.029.
Green, J. G., McLaughlin, K. A., Berglund, P. A., Gruber, M. J., Sampson, N. A., Zaslavsky, A. M., et al. (2010). Childhood adversities and adult psychiatric disorders in the National Comorbidity Survey Replication I. Archives of General Psychiatry, 67, 113–123. https://doi.org/10.1001/archgenpsychiatry.2009.186.
Herzog, J. I., & Schmal, C. (2018). Adverse childhood experiences and the consequences on neurobiological, psychosocial, and somatic conditions across the lifespan. Frontiers in Psychiatry, 9, 1–8. https://doi.org/10.3389/fpsyt.2018.0420.
Iversen, A. C., Fear, N. T., Simonoff, E., Hull, L., Horn, O., Greenberg, N., et al. (2007). Influence of childhood adversity on health among male UK military personnel. British Journal of Psychiatry, 191, 506–511. https://doi.org/10.1192/bjp.bp.107.039818.
Jennings, P. A., Aldwin, C. M., Levenson, M. R., Spiro, A., & Mroczek, D. K. (2006). Combat exposure, perceived benefits of military service, and wisdom later in life. Research on Aging, 28, 115–134. https://doi.org/10.1177/0164027505281549.
Jobes, D. A. (2012). The Collaborative Assessment and Management of Suicidality (CAMS): An evolving evidence-based clinical approach to suicidal risk. Suicide and Life-Threatening Behavior, 42, 640–653. https://doi.org/10.1111/j.1943-278X.2012.00119.x.
Katon, J. G., Lehavot, K., Simpson, T. L., Williams, E. C., Barnett, S. B., Grossbard, J. R., et al. (2015). Adverse childhood experiences, military service, and adult health. American Journal of Preventive Medicine, 49, 573–582. https://doi.org/10.1016/j.amepre.2015.3.020.
Kehle-Forbes, S. M., Meis, L., Spoont, M. R., & Polusny, M. A. (2016). Treatment initiation and dropout from prolonged exposure and cognitive processing therapy in a VA outpatient clinic. Psychological Trauma: Theory, Research, Practice and Policy, 8, 107–114. https://doi.org/10.1037/tra0000065.
Kendall-Tackett, K. (2002). The health effects of childhood abuse: Four pathways by which abuse can influence health. Child Abuse and Neglect, 6(7), 715–730. https://doi.org/10.1016/S0145-2134(02)00343-5.
Kuo, J. R., Kaloupek, D. G., & Woodward, S. H. (2012). Amygdala volume in combat-exposed veterans with and without posttraumatic stress disorder. Archives of General Psychiatry, 69, 1080–1086. https://doi.org/10.1001/archgenpsychiatry.2012.73.
Landes, S. J., Garovoy, N. D., & Burkman, K. M. (2013). Treating complex trauma among veterans: Three stage-based treatment models. Journal of Clinical Psychology, 69, 523–533. https://doi.org/10.1002/jclp.21988.
Lapp, K. G., Bosworth, H. B., Strauss, J. L., Stechuchak, K. M., Horner, R. D., Calhoun, P. S., et al. (2005). Lifetime sexual and physical victimization among male veterans with combat-related post-traumatic stress disorder. Military Medicine, 170, 787–790. https://doi.org/10.7205/milmed.170.9.787.
LeardMann, C. A., Smith, B., & Ryan, M. A. K. (2010). Do adverse childhood experiences increase the risk of postdeployment posttraumatic stress disorder in US Marines? VMC Public Health, 10, 437–444. https://doi.org/10.1186/1471-2458-10437.
Lee, J. E. C., Phinney, B., Watkins, K., & Zamorski, M. A. (2016). Psychosocial pathways linking adverse childhood experiences to mental health in recently deployed Canadian military service members. Journal of Traumatic Stress, 29, 124–131. https://doi.org/10.1002/jts.22085.
Montgomery, A. E., Cutuli, J. J., Evans-Chase, M., Treglia, D., & Culhane, D. P. (2013). Relationship among adverse childhood experiences, history of active military service, and adult outcomes: Homelessness, mental health, and physical health. American Journal of Public Health, 103, S262–S268. https://doi.org/10.2105/AJPH.2013.01474.
Pietrzak, R. H., Goldstein, M. B., Malley, J. C., Rivers, A. J., Johnson, D. C., Morgan, C. A., et al. (2010). Posttraumatic growth in veterans of operations enduring freedom and Iraqi freedom. Journal of Affective Disorders, 126, 230–235. https://doi.org/10.1016/j.jad.2010.03.021.
Porges, S. W. (2003). Social engagement and attachment: A phylogenetic perspective. Annals of the New York Academy of Sciences, 1008, 31–47. https://doi.org/10.1196/annals.1301.004.
Ramos, C., & Leal, I. (2013). Posttraumatic growth in the aftermath of trauma: A literature review about related factors and application contexts. Psychology, Community & Health, 2, 43–54. https://doi.org/10.5964/pch.v2i1.39.
Robinson, R., Davis, J. D., Krueger, M., Gore, K., Freed, M. C., Kuesters, P., et al. (2008). Acceptability of adverse childhood experiences questions for health surveillance in US armed forces. Military Medicine, 173, 853–859. https://doi.org/10.7205/milmed.173.9.853.
Ross, J., Waterhouse-Bradley, B., Contractor, A., & Armour, C. (2018). Typologies of adverse childhood experiences and their relationship to incarceration in US military veterans. Child Abuse and Neglect, 79, 74–84. https://doi.org/10.1016/j.chiabu.2018.01.023.
Sareen, J., Henrikson, C. A., Bolton, S.-L., Afifi, T. O., Stein, M. B., & Asmundson, J. G. (2013). Adverse childhood experiences in relation to mood and anxiety disorders in a population-based sample of active military personnel. Psychological Medicine, 43, 73–84. https://doi.org/10.1017/S003329171200102X.
Scott, J. C., Pietrzak, R. H., Southwick, S. M., Jordan, J., Silliker, N., Brandt, C. A., & Haskell, S.G. (2014). Military sexual trauma interacts with combat exposure to increase risk for posttraumatic stress symptomology in female Iraq and Afghanistan veterans. Journal of Clinical Psychiatry, 75, 637–643. https://doi.org/10.4088/JCP.13m08808.
Seery, M. D., Holman, E. A., & Silver, R. C. (2010). Whatever does not kill us: Cumulative lifetime adversity, vulnerability, and resilience. Journal of Personality and Social Psychology, 99, 1025–1041. https://doi.org/10.1037/a0021344.
Seifert, A. E., Polusny, M. A., & Murdoch, M. (2011). The association between childhood physical and sexual abuse and functioning and psychiatric symptoms in a sample of US Army soldiers. Military Medicine, 176, 176–181.
Spinazzola, J., Hodgdon, H., Liang, L., Ford, J. D., Layne, C. M., Pynoos, R., et al. (2014). Unseen wounds: The contribution of psychological maltreatment to child and adolescent mental health and risk outcomes. Psychological Trauma: Theory, Research, Practice, and Policy, 6(Suppl 1), S18–S28. https://doi.org/10.1037/a0037766.
Springer, K. W., Sheridan, J., Kuo, D., & Carnes, M. (2007). Long-term physical and mental health consequences of childhood physical abuse: Results from a large population-based sample of men and women. Child Abuse and Neglect, 31, 517–530. https://doi.org/10.1016/j.chiabu.2007.01.003.
Steele, M., Germain, A., & Campbell, J. S. (2017). Mediation and moderation of the relationship between combat experiences and post-traumatic stress symptoms in active duty military personnel. Military Medicine, 182, e1632–e1639. https://doi.org/10.7205/milmed-d-16-00169.
Steenkamp, M. M. (2016). True evidence-based care for posttraumatic stress disorder in military personnel and veterans. JAMA Psychiatry, 73, 431–432. https://doi.org/10.1001/jamapsychiatry.2015.2879.
Steenkamp, M. M., Litz, B. T., Hoge, C. W., & Marmar, C. R. (2015). Psychotherapy for military-related PTSD: A review of randomized clinical trials. Journal of the American Medical Association, 314, 489–500. https://doi.org/10.1001/jama.2015.8370.
Stein, A. L., Tran, G. Q., Lund, L. M., Haji, U., Dashevsky, B. A., & Baker, D. G. (2005). Correlates for posttraumatic stress disorder in Gulf War veterans: A retrospective study of main and moderating effects. Journal of Anxiety Disorders, 19, 861–876. https://doi.org/10.1016/j.janxdis.2004.09.006.
Tedeschi, R. G., & McNally, R. J. (2011). Can we facilitate posttraumatic growth in combat veterans? American Psychologist, 66, 19–24. https://doi.org/10.1037/a0021896.
Teicher, M. H., & Samson, J. A. (2016). Annual research review: Enduring neurobiological effects of childhood abuse and neglect. Journal of Child Psychology and Psychiatry, 57, 241–266. https://doi.org/10.1111/jcpp.12507.
Tsai, J., Mota, N. P., Southwick, S. M., & Pietrzak, R. H. (2016). What doesn’t kill you makes you stronger: A national study of U.S. military veterans. Journal of Affective Disorders, 189, 269–271. https://doi.org/10.1016/j.jad.2015.08.076.
Van Voorhees, E. E., Dedert, E. A., Calhoun, P. S., Brancu, M., Runnals, J., & Beckham, J. C. (2012). Childhood trauma exposure in Iraq and Afghanistan war era veterans: Implications for posttraumatic stress disorder symptoms and adult functional support. Child Abuse and Neglect, 36, 423–432. https://doi.org/10.1016/j.chiabu.2012.03.004.
Woodward, S. H., Kuo, J. R., Schaer, M., Kaloupek, D. G., & Eliez, S. (2013). Early adversity and combat exposure interact to influence anterior cingulate cortex volume in combat veterans. Neuroimage: Clinical, 2, 670–674. https://doi.org/10.1016/j.nicl.2013.04.016.
Wright, M. O., Crawford, E., & Del Castillo, D. (2009). Childhood emotional maltreatment and later psychological distress among college students: The mediating role of maladaptive schemas. Child Abuse and Neglect, 33, 59–68. https://doi.org/10.1016/j.chiabu.2008.12.007.
Yehuda, R., & Hoge, C. W. (2016). The meaning of evidence-based treatments for veterans with posttraumatic stress disorder. JAMA Psychiatry, 73, 433–434. https://doi.org/10.1001/jamapsychiatry.2015.2878.
Youssef, N. A., Green, K. T., Dedert, E. A., Hertzberg, J. S., Calhoun, P. S., Dennis, M. F., et al. (2013). Exploration of the influence of childhood trauma, combat exposure, and the resilience construct on depression and suicidal ideation among US Iraq/Afghanistan era military personnel and veterans. Archives of Suicide Research, 17, 106–122. https://doi.org/10.1080/13811118.2013.776445.
Zaidi, L. Y., & Foy, D. W. (1994). Childhood abuse experiences and combat-related PTSD. Journal of Traumatic Stress, 7, 33–42.
Acknowledgements
We would like to acknowledge Beeta Homaifar, PhD for her thoughtful guidance on this project throughout its implementation and preparation for publication. The views expressed in this presentation are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical Approval
This project was deemed exempt from full review by the local Department of Veterans Affairs Institutional Review Board.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Laird, C.W., Alexander, P. Prevalence of Adverse Childhood Experiences Among Veterans. Clin Soc Work J 47, 384–393 (2019). https://doi.org/10.1007/s10615-019-00703-5
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10615-019-00703-5