Addressing psychiatric and psychosocial issues related to children and adolescents
The purpose of the current article is to discuss the relationship between adverse childhood experiences (ACEs) and the mental health of military service members. Since 2001, with the onset of the Global War on Terror, American Veterans have experienced disproportionate burdens of mental illness and suicide. Milliken, Auchterlonie, and Hoge (2007) reviewed post-deployment mental health records immediately upon service members’ (N = 88,235) return from Iraq and then 3 to 6 months later. Upon return, mental health problems seemed low (17%); however, when measures were reassessed 3 to 6 months after post deployment, 25% of service members screened positive for mental health concerns (Milliken et al., 2007).
Although combat exposure and suicidal ideation are linked (Bush et al., 2013), approximately one half of all suicides of Active Duty service members have occurred among those who never deployed (Luxton et al., 2012). Seeking additional risk factors for suicide has resulted in studies demonstrating that Veterans have greater odds of all ACEs, which is a strong predictor of adult morbidity and mortality (Blosnich, Dichter, Cerulli, Batten, & Bossarte, 2014).
What Are Adverse Childhood Experiences?
In the late 1990s, Felitti et al. (1998) described the first report of the ACE Study (access http://www.acestudy.org), which enrolled 17,000 participants (who are still currently followed) via the Kaiser Permanente Health Plan. Later, Kaiser Permanente and the Centers for Disease Control and Prevention (CDC) joined forces, making the ACE Study the largest of its kind to analyze relationships between categories of childhood adversities and health outcomes. Subsequently, the relationship between adversity and childhood was sustained and continues to be supported by recent findings (Van Niel, Pachter, Wade, Felitti, & Stein, 2014).
The ACE scale (access http://www.acestudy.org/yahoo_site_admin/assets/docs/ACE_Calculator-English.127143712.pdf), which quantifies the cumulative exposure of adversities, is scored from 0 to 10, with a positive response in an individual category contributing 1 point. The categories include: (a) recurrent physical abuse; (b) recurrent emotional abuse; (c) contact sexual abuse; (d) a household member who abuses alcohol and/or drugs; (e) an incarcerated household member; (f) a household member who is chronically depressed, mentally ill, institutionalized, or suicidal; (g) a mother who is treated violently; (h) one or no parents; and (i) emotional or physical neglect.
In the original report, Felitti et al. (1998
) offered a number of important conclusions, stating:
[Individuals who experienced four or more categories of ACEs] had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt; a 2- to 4-fold increase in smoking, poor self-rated health, > or = 50 sexual intercourse partners, and sexually transmitted disease; and 1.4- to 1.6-fold increase in physical inactivity and severe obesity. (p. 245)
The results demonstrated a dose-response relationship between ACEs and adult health-risk behaviors, the presence of adult diseases, and poor adult health status; these conclusions have been upheld for decades (Dong et al., 2004; Dube et al., 2001; Van Neil et al., 2014).
Adversity in Childhood and U.S. Veterans
Although there is great awareness of how combat-related experiences can contribute to poorer mental health of Veterans, there is also an interest in how pre-military experiences (e.g., adversity in childhood) and the number of previous deployments play a role in post-deployment mental health. In other words, the cumulative effects of combat and other traumatic stressors occurring prior to military service should be assessed to understand the mental health of Veterans.
Several studies on service members have shown an association between ACEs and later psychiatric symptoms of posttraumatic stress disorder (PTSD). Cabrera, Hoge, Bliese, Castro, and Messer (2007) were the first to identify that ACEs are a significant predictor of psychiatric symptoms beyond the expected contribution of combat exposure. Cabrera et al. (2007) examined the association between ACEs and the presence of depressive or PTSD symptoms among two groups of male soldiers (i.e., those who had and had not deployed). Analyses assessed whether those with childhood adversity were affected differently by combat exposure. Results demonstrated that soldiers with two or more categories of ACEs had significantly higher rates of depression and PTSD.
Fritch, Mishkind, Reger, and Gahm (2010) specifically examined childhood physical abuse and combat-related trauma on post-deployment psychiatric symptoms in an outpatient clinical sample of 1,045 U.S. service members. Combat trauma and childhood physical abuse predicted outcome variables of PTSD, depression, and anxiety in 71% of Active Duty and 29% of represented National Guard or Reserve members. However, no ACE caused by combat exposure interaction was found for any psychiatric symptoms; there was no evidence supporting that the effects of combat exposure on psychiatric status were dependent on a history of childhood physical abuse. Fritch et al. (2010) concluded that clinicians who treat post-deployed service members should not only assess the severity of combat exposure, but also childhood trauma to more fully understand psychiatric outcomes.
More recently, a sample of soldiers from Operation Iraqi Freedom and Operation Enduring Freedom (Afghanistan) were studied to discern implications between childhood trauma and PTSD (Van Voorhees et al., 2012). Van Voorhees et al. (2012) studied 1,301 Veterans and Active Duty soldiers and sought to determine the association of childhood abuse with adult PTSD after accounting for combat exposure. On average, participants reported a moderate degree of combat exposure. Forty percent of the sample reported one or more childhood traumatic events. The researchers concluded that childhood trauma and adult combat exposure contributed independently to adult PTSD symptomatology. Childhood abuse was significantly associated with higher adult PTSD symptom severity.
Finally, Blosnich et al. (2014) studied whether individuals with a history of military service had a higher prevalence of ACEs. Secondary analyses were conducted on data from 60,378 participants who previously completed the ACE survey through the 2010 Behavioral Risk Factor Surveillance System, a large CDC survey-based database of health-related telephone surveys that collected state data regarding U.S. residents and risk behaviors associated with chronic health conditions and use of preventive services (CDC, 2014). History of military service was defined as Active Duty service, including Veteran status and Reserve or National Guard membership. The 9,272 participants with histories of military service had a higher prevalence of ACEs in all categories than those without service histories. In a subanalysis of participants from the all-volunteer era of military service, men had twice the odds of all forms of sexual abuse than women. In addition, men with a history of military service from the all-volunteer era (after 1973), as compared to their nonmilitary counterparts, were twice as likely to experience ACEs in four or more categories, placing them at greater risk for poorer overall health. Few women identified themselves as having served in the military, preventing analyses that mirrored the men.
Psychiatric Nursing Implications
Studies have established the connection between ACEs and poor physical and behavioral health in adulthood. Incorporating an assessment of early childhood trauma will give nurses greater insight into the potential health concerns of their patients. The ACE Study originated in the mid-1990s and revealed that individuals who experienced various types of abuse, neglect, domestic violence, and household dysfunction were more likely to engage in risky health behaviors. Using the standardized ACE questionnaire, researchers found that the effects of ACEs were cumulative, with individuals reporting four or more ACEs being 12 times more likely to attempt suicide (Felitti et al., 1998). The ACE Study is not limited to service members, but the findings are applicable to that population.
Although combat experiences are given a lot of attention, clinicians should avoid neglecting other topics associated with mental health functioning (e.g., early childhood adversity) to fully and accurately assess and treat the mental health of Veterans. Assessment of early childhood adversities, by use of the ACE questionnaire, will give greater insight into the mental and behavioral health needs of Veterans.
In addition to assessing for ACEs, psychiatric nurses should adopt a trauma-informed approach to caring for Veterans. Trauma-informed care involves patient-centered communication, with the psychiatric nurse attending to the therapeutic relationship, focusing on respect for the patient’s values, preferences, and needs. A trauma history is carefully elicited and the clinician listens respectfully, supportively educating the patient regarding the effects of trauma on current health. To fully appreciate the benefits and approaches of trauma-informed care, an overview of best practices authored by an expert panel convened by the Substance Abuse and Mental Health Services Administration (2014), entitled, Trauma-Informed Care in Behavioral Health Services, can be referenced.
Specifically when working with children and adolescents, psychiatric nurses should attune to adversities in childhood. Fortunately, preliminary work has started on a childhood/adolescent version of the ACE scale, expanding the 10-item questionnaire to provide a more comprehensive assessment to determine the burden of adversities. Additional items that may be added once psychometric testing is complete include questions about parental arguing, lack of good friends, having someone close with a severe illness or accident, peer and property victimization, and exposure to community violence. These questions are pertinent to mental health assessment for children. In fact, psychiatric nurses who work with children may find that they need to contact child welfare services because physical and sexual abuse may be disclosed. Uncovering these adversities is essential as they violate the rights of children and cause pain and suffering.
ACEs confer additional risk for the mental health of children, service members, and Veterans, and it is incumbent on psychiatric nurses and other clinicians to understand this higher risk. Helping patients make the connection between trauma histories and presenting problems is vital. In this manner, trauma-related issues should be addressed proactively, focusing on the patient’s strengths and supporting his or her resilience.
- Blosnich, J., Dichter, M., Cerulli, C., Batten, S. & Bossarte, R. (2014). Disparities in adverse childhood experiences among individuals with a history of military service. JAMA Psychiatry, 71, 1041–1048. doi:10.1001/jamapsychiatry.2014.724 [CrossRef]
- Bush, N.E., Reger, M.A., Luxton, D.D., Skopp, N.A., Kinn, J., Smolenski, D. & Gahm, G.A. (2013). Suicides and suicide attempts in the U.S. military, 2008–2010. Suicide and Life-Threatening Behaviors, 43, 262–273. doi:10.1111/sltb.12012 [CrossRef]
- Cabrera, O., Hoge, C., Bliese, P., Castro, C. & Messer, S. (2007). Childhood adversity and combat as predictors of depression and post-traumatic stress in deployed troops. American Journal of Preventive Medicine, 33, 77–82. doi:10.1016/j.amepre.2007.03.019 [CrossRef]
- Centers for Disease Control and Prevention. (2014). Behavioral risk factor surveillance system. Retrieved from http://www.cdc.gov/brfss/about/index.htm
- Dong, M., Anda, R.F., Felitti, V.J., Dube, S.R., Williamson, D.F., Thompson, T.J. & Giles, W.H. (2004). The interrelatedness of multiple forms of childhood abuse, neglect, and household dysfunction. Child Abuse & Neglect, 28, 771–784. doi:10.1016/j.chiabu.2004.01.008 [CrossRef]
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- Fritch, A., Mishkind, M., Reger, M. & Gahm, G. (2010). The impact of childhood abuse and combat-related trauma on postdeployment adjustment. Journal of Traumatic Stress, 23, 248–254. doi:10.1002/jts.20520 [CrossRef]
- Luxton, D.D., Osebach, J.E., Reger, M.A., Smolenski, D.J., Skopp, N.A., Bush, N.E. & Gahm, G.A. (2012). Department of Defense suicide event report: Calendar year 2011 annual report. Retrieved from http://t2health.dcoe.mil/sites/default/files/dodser/DoDSER_2011_Annual_Report.pdf
- Milliken, C., Auchterlonie, L. & Hoge, C. (2007). Longitudinal assessment of mental health problems among active and reserve component soldiers returning from the Iraq War. Journal of the American Medical Association, 298, 2141–2148. doi:10.1001/jama.298.18.2141 [CrossRef]
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- Van Neil, C., Pachter, L.M., Wade, R., Felitti, V. & Stein, M.T. (2014). Adverse events in children: Predictors of adult physical and mental conditions. Journal of Developmental and Behavioral Pediatrics, 35, 549–551. doi:10.1097/DBP.0000000000000102 [CrossRef]
- 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 social support. Child Abuse and Neglect, 36, 423–432. doi:10.1016/j.chiabu.2012.03.004 [CrossRef]