The word “trauma” is used to describe experiences or situations that are emotionally painful and distressing, and that overwhelm people’s ability to cope, leaving them powerless. Trauma has sometimes been defined in reference to circumstances that are outside the realm of normal human experience. Unfortunately, this definition doesn’t always hold true. For some groups of people, trauma can occur frequently and become part of the common human experience.
“Traumatic events are extraordinary, not because they occur rarely, but rather because they overwhelm the ordinary human adaptations to life.” — Judith Herman, Trauma and Recovery
In addition to terrifying events such as violence and assault, we suggest that relatively more subtle and insidious forms of trauma—such as discrimination, racism, oppression, and poverty—are pervasive and, when experienced chronically, have a cumulative impact that can be fundamentally life-altering.
Particular forms of trauma, such as intentional violence and/or witnessing violence, sustained discrimination, poverty, and ensuing chaotic life conditions are directly related to chronic fear and anxiety, with serious long-term effects on health and other life outcomes.
“Trauma theory” is a relatively recent concept that emerged in the health care environment during the 1970s, mostly in connection with studies of Vietnam veterans and other survivor groups (Holocaust survivors, abused women and children, disaster survivors, refugees, victims of sexual assault) (see http://sanctuaryweb.com). “Post-traumatic stress disorder” was added as a new category in the American Psychiatric Association official manual of mental disorders in 1980.
Trauma theory represents a fundamental shift in thinking from the idea that those who have experienced psychological trauma are either “sick” or deficient in moral character to the reframe that they are “injured” and in need of healing.
The Effects of Trauma
We now have a wide body of research indicating that the brains of children who are exposed to chronic trauma and stress and wired differently than children whose experiences have been more secure. When experiencing stress or threat, the brain’s “fight or flight” response is activated through increased production of the powerful hormone cortisol. While cortisol production can be protective in emergencies, in situations of chronic stress its level is toxic and can damage or kill neurons in critical regions of the brain. Especially damaging is the experience of stressors that occur in an unpredictable fashion (e.g., community violence, domestic violence). In extreme cases, this chronic exposure to trauma causes a state of hyperarousal or disassociation. Hyperarousal is characterized by an elevated heart rate, slightly elevated body temperature, and constant anxiety. Disassociation involves an internalized response in which the child shuts down, detaches, or “freezes” as a maladaptive way of managing overwhelming emotions and/or situations. The younger the child is, the more likely he/she will respond with disassociation. Children are more susceptible to post-traumatic stress because in most situations they are helpless and incapable of either “fight or flight.” A state of learned helplessness can pervade children’s development as they learn, through the repeated experience of overwhelming stress, to abandon the notion that they can impact the course of their lives in a positive way. When trauma or neglect happens early in life and is left untreated, the injuries sustained reverberate to all ensuing developmental stages.
During adolescence, the brain goes through a critical period of pruning and reorganizing that may be characterized by the phrase “use it or lost it.” Functions that are being used and stimulated regularly are strengthened and “hard-wired” and functions that are not used and stimulated are pruned away.
This massive remodeling occurs in the cortex, the highest functioning part of the brain that is needed for good judgment, planning, and other essential functions of adulthood. The frustrating and often baffling behavior of teens can be better understood in the context of what’s going on in the adolescent brain. Asking teens to manage more than one task at a time can overwhelm them, as they are just developing the brain functions needed to prioritize issues, sort through problems, and set goals for the future. Because the cortex is under construction, teens use more primitive parts of the brain (limbic) to manage their emotions, thus they are more likely to react versus think and to operate from their gut response versus reasoning. They are more likely to misinterpret body language and are generally more vulnerable to stress at this time. They also require more sleep because of the work their brain is doing to facilitate all of this growth and change.
While this brain reconstruction is going on, adolescents are also experiencing puberty. They are developing sexually before their brain is mature, and thus are most vulnerable to making poor choices about sex and relationships. Chemical changes in the brain make adolescents more prone to risky behaviors, such as alcohol and drug use. Compounding these risk factors is the normal adolescent need and drive to identify, belong to and fit in with a peer group and to separate from their parents as they transition to adulthood.
Effects into adulthood
The relationship between traumatic childhood experiences and physical and emotional health outcomes in adult life is at the core of the landmark Adverse Childhood Experiences (ACE) Study (www.acestudy.org), a collaborative effort of the Centers for Disease Control and Prevention and the Kaiser Health Plan’s Department of Preventative Medicine in San Diego, CA. The ACE Study involves the cooperation of over 17,000 middle aged (average age was 57), middle class Americans who agreed to help researchers study the following nine categories of childhood abuse and household dysfunction:
- Recurrent physical abuse
- Recurrent emotional abuse
- Contact sexual abuse
- An alcohol and/or drug abuser in the household
- An incarcerated household member
- A household member who is chronically depressed, mentally ill, institutionalized, or suicidal
- Mother is treated violently
- One or no parents
- Emotional or physical neglect
Each participant received an ACE score in the range of 0-9 reflecting the number of the above experiences he/she can claim (e.g., a score of 3 indicates that that participant experienced 3 of the above ACEs).
The study claims two major findings. The first of these is that ACEs are much more common than anticipated or recognized, even in the middle class population that participated in the study, all of whom received health care via a large HMO. It is troublesome to ponder what the prevalence of ACEs might be among young African American and Latino males, many of whom live with chronic stress and do not have a regular source of healthcare.
The second major finding is that ACEs have a powerful correlation to health outcomes later in life. As the ACE score increases, so does the risk of an array of social and health problems such as: social, emotional and cognitive impairment; adoption of health-risk behaviors; disease, disability and social problems; and early death. ACEs have a strong influence on adolescent health, teen pregnancy, smoking, substance abuse, sexual behavior, the risk of revictimization, performance in the work force, and the stability of relationships, among other health determinants. The higher the ACE score, the greater the risk of heart disease, lung disease, liver disease, suicide, HIV and STDs, and other risks for the leading causes of death.
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