The long-term medical consequences of childhood trauma
By Stephanie J. Dallam, RN, MS, FNP
Dallam, S. J. (2001). The long-term medical consequences of childhood trauma. In K. Franey, R. Geffner, & R. Falconer (Eds.), The cost of child maltreatment: Who pays? We all do. (pp. 1-14). San Diego, CA: FVSAI Publications . All rights reserved .
Introduction
Despite the millions of children impacted by abuse or neglect and the well-documented associations between childhood maltreatment and a host of neuropsychiatric conditions (e.g., posttraumatic stress disorder, dissociative disorders, mood disorders, conduct disorders), until recently there has been a relative lack of systematic research on the physiological after-effects of childhood maltreatment. As a result, few people are aware that childhood maltreatment is a powerful risk factor for health problems in adulthood. The present chapter will (1) summarize the effects of maltreatment on the neuroendocrine system; (2) provide an overview of the association between childhood maltreatment and adult health; and (3) examine the potential economic impact of childhood maltreatment on health care utilization.
Physiological Effects of Maltreatment
T'he Neuroendocrine System
The nervous and endocrine system engage in a back and forth dance through which they control the body’s physiology by continuously increasing or decreasing the activity of various neurotransmitters and hormones. The brain orchestrates this dance with the goal of maintaining a state of homeostasis or equilibrium. Stressful events disrupt the dance, upsetting its delicate balance. The brain responds by activating the sympathetic nervous system and the hypothalamic-pituitary-adrenal (HPA) axis, and releasing endogenous opioids. Stimulation of the sympathetic nervous system results in the release of catecholamines into the blood, while the HPA axis induces the release of glucocorticoids (primarily cortisol). Both catecholamines and cortisol have been found to be chronically elevated in abused children (De Bellis, Baum, et al., 1999; Putnam & Trickett, 1997)
Catecholamines
Opioids
When fighting or physically fleeing is not feasible, the child may use a “freeze” or surrender response (dissociation) in which the child detaches from the events and withdraws inwardly (Perry, 2000). Evidence suggests that alterations of the endogenous opiate system and dopaminergic systems are involved in the dissociative response (Perry et al., 1995; Bohus et al. 1999). Most children experience a combination of hyperarousal and dissociation during stressful events. When confronted with a traumatic event, the child will feel threatened and the arousal systems will activate. With increased threat, the child moves along the arousal continuum. At some point along this continuum, the body releases endogenous opioids and the dissociative response is activated. This results in a marked decrease in arousal, decreased awareness of pain, and a decreased heart rate and blood pressure despite increases in circulating epinephrine (see Perry et al., 1995). Overall, females and younger children are more likely to dissociate and while older children and males are more likely to display a classic “fight or flight” response.
Cortisol
During acute stress situations cortisol enhances survival by depressing the body’s reaction to injury. With regards to emotional behavior, experimental increases in cortisol have been shown to initially increase alertness, activity levels, and feelings of well-being; while prolonged elevations stimulate withdrawal, dysphoria, and feelings of “tiredness” (Plihal, Krug, Pietrowsky, Fehm, & Bom, 1996). Chronic secretion of cortisol can also depress the immune system. One of the primary organs of the immune system, the thymus gland, has been found to be significantly smaller in abused and/or neglected children when compared to those of nonabused children. The size of maltreated children’s thymus glands is correlated with the severity and length of maltreatment (Fukunaga et al., 1992).
Use Dependent Changes
When the trauma has ended, feedback mechanisms are activated to counteract the stress hormones and return the heart rate, blood pressure and other physiological adaptations to normal. However, if the stress is severe and chronic, compensatory mechanisms can become over-activated and incapable of restoring the previous state of equilibrium. The physiological system is then forced to re-organize its basal patterns of equilibrium. Research by Dr. Bruce Perry, Professor of Child Psychiatry at the Baylor College of Medicine in Houston, Texas, has shown that chronically traumatized children will often, at baseline, be in a state of low-level fear which is reflected in their body’s physiology (e.g., increase heart rate, muscle tone, rate of respiration). According to Perry, the longer the activation of the stress-response systems (i.e., the more intense and prolonged the traumatic event), the more likely there will be a “use-dependent” change in these neural systems (for a review see Perry et al., 1995). The predominant adaptive style of the child in the acute traumatic situation will determine which post-traumatic symptoms will develop — hyperarousal or dissociative (Perry, 2000).
Repeated exposure to threatening stimuli also causes sensitization of the nervous system. Sensitization results from a pattern of repetitive neural activation or experience. The nervous system comes to anticipate the trauma, and soon the same neural activation can be elicited by decreasingly intense stimuli. The result is that full-blown hyperarousal or dissociation can be elicited by apparently minor stressors (Perry et al., 1995). The developing brain organizes around this internalization of the fear response resulting in behavior that may be symptomatic of a number of psychiatric conditions. For instance, chronically traumatized children may display signs of post-traumatic stress disorder (PTSD), attention deficit hyperactivity disorder (ADHD), major depression, various dissociative disorders, oppositional-defiant disorder, conduct disorder, separation anxiety or specific phobia (see Perry & Azad, 1999).
Disorders Associated with Dysregulation of the HPA axis
PTSD
Research suggests that dysregulation of the HPA axis and functional alterations in specific cortical and subcortical areas of the brain underlie many of the symptoms of patients with PTSD (Bremner, Narayan, et al., 1999; Bremner, Staib, et al., 1999). Individuals with PTSD show evidence of increased autonomic reactivity (Metzger et al., 1999), and in what appears to be the result of a sensitized feedback mechanism, adults with histories of childhood maltreatment often have lower baseline cortisol levels (Heim, Ehlert, & Hellharnmer, 2000) and a blunted cortisol respond to subsequent stressors. These physiological changes appear to render adult victims of childhood victimization more vulnerable to stress-related disorders and more reactive when confronted with stressors during adulthood.
For instance, women with a history of prior physical or sexual assault have been found to have a significantly attenuated cortisol response to the acute stress of rape compared to women without such a history. Blood samples were drawn from 37 adult female rape victims within 51 hours after they had been raped. Approximately three months later they tested the women for PTSD. Women with a history of previous assault had a lower mean acute cortisol level after the rape and a higher probability of subsequently developing PTSD (Resnick, Yehuda, Pitman, & Foy, 1995). Stressful and traumatic events during childhood have also been found to predispose male and female solders to develop combat related PTSD symptomatology (Bremner, Southwick, Johnson, Yehuda, & Charney, 1993; Engel et al., 1993; Zaidi & Foy, 1994).
Dissociative Disorders
Depression
Stress-related Disorders
Effect of Chronic Maltreatment on Brain Growth and Function
Recent studies of adults indicate that extreme stress during childhood can lead to measurable physical changes in the hippocampus and medial prefrontal cortex, two areas of the brain involved in memory and emotional responses. For example, women reporting childhood abuse have been found to have significantly lower left-sided hippocampal volumes (a region of the brain involved in learning and verbal memory) when compared with matched controls without abuse histories. The degree of decreased hippocampal volume correlates with the severity of dissociative symptoms and PTSD found in the abused women (Stein, Koverola, Hanna, Torchia, & McClarty, 1997). These changes can also lead to ongoing problems with learning and remembering new information. When compared with healthy matched controls, adult survivors of severe childhood physical and sexual abuse have been found to demonstrate significant deficits in verbal short-term recall, which correlates with the severity of the abuse experienced (Bremner et al., 1995).
Health Consequences of Childhood Maltreatment
Subsequent studies have supported Felitti’s findings and demonstrate a strong, linear relationship between childhood maltreatment and indices of adult health. In other words, the greater the severity of maltreatment during childhood, the more health problems reported during adulthood.
Physical Symptoms and Functional Disorders
Although functional disorders are often blamed on psychological illnesses, research indicates that the relationship between the two may actually be mediated by HPA axis dysfunction. For instance, people with somatization have been found to HPA axis dysfunction similar to that found in patients with PTSD (Heim, Ehlert, Hanker, & Hellhammer, 1998). A study of 252 female primary care patients with unexplained symptoms found a strong linear relationship between the severity of sexual abuse and impairment in health-related quality of life, both before and after controlling for the effects of a current psychiatric diagnosis (Dickinson, deGruy, Dickinson, & Candib, 1999).
Health Perceptions and Quality of life
Golding, Cooper and George (1997) examined health perceptions in victims of sexual assault either in childhood or adulthood by combining data on over 10,000 men and women from 7 population surveys. A meta-analysis of the data revealed that a history of sexual assault was associated with poorer subjective health, and this result was consistent regardless of gender, ethnicity, or sample. Controlling depression did not markedly change this result, indicating that depression did not account for or mediate the association. Individuals with histories of multiple assaults reported the worst health.
Chronic Pain
Health Care Utilization
Serious Illnesses
The researchers also reported a strong graded relationship between the number of categories of childhood exposure and every adult health risk behavior they studied. For instance, a strong relationship was found between the number of adverse childhood experiences and self-reports of cigarette smoking, obesity, physical inactivity, alcoholism, drug abuse, depression, suicide attempts, sexual promiscuity, and sexually transmitted diseases. These findings suggest that the poorer health found in many survivors of childhood maltreatment may be related in large part to participation in high risk behaviors.
Associations have also been found between early sexual abuse and several health conditions in the elderly. Murray B. Stein, MD, of the University of California, San Diego’s Anxiety and Traumatic Stress Disorders Program, and co-author Elizabeth Barrett-Connor (2000), analyzed health data on more than 1,300 elderly white, middle class men and women from a Southern California community. In women, early sexual assault appeared to increase the risk of arthritis and breast cancer, with multiple abuse episodes increasing disease risk by two- to three-fold compared with a single episode. In men, early sexual assault appeared to increase the risk of thyroid disease (“Sexual Abuse May,” 2000).
High-Risk Behaviors
For example, consider the results of the Commonwealth Fund Adolescent Health Survey, which was based on a nationally representative cross-section sample of 3,015 girls in grades 5 through 12. After controlling for demographic characteristics (grade level, ethnicity, family structure, and socioeconomic status) the researchers found that when compared to their nonabused peers, girls who reported experiencing both physical and sexual abuse were over five times more likely to experience depressive symptoms and over three times more likely to report moderate to high life stress. The abused girls were also many times more likely to report that they engaged in regular smoking, regular drinking, illicit drug use, or to give a history of bingeing and purging behavior. In addition, they were almost twice as likely to rate their health status as fair to poor (Diaz, Simatov, & Rickert, 2000).
Cigarette Smoking
Alcohol and Illicit Drug Use
Risky Sexual Behaviors
Other surveys have reported similar findings. For instance, a survey of 3,128 high school girls found that adolescents with a history of sexual abuse were more likely to report having had intercourse by age 15, to have not used birth control at last intercourse, and to have had more than one sexual partner compared to their nonabused peers (Stock, Bell, Boyer, & Connell, 1997). Another study followed 510 girls from birth to adulthood. At age 18, women who reported child sexual abuse, especially those reporting severe abuse involving intercourse, had significantly higher rates of early onset consensual sexual activity, multiple sexual partners, unprotected intercourse, sexually transmitted disease, and sexual assault after the age of 16. A multifactoral causal relationship was noted in which various factors such as family instability, impaired parent child relationships, and childhood sexual abuse resulted in the early onset sexual activity which, in turn, led to heightened risks of other adverse outcomes in adolescence (Fergusson, Horwood, & Lynskey, 1997).
For instance, abused women are more likely than their peers to be treated for venereal disease, pelvic inflammatory disease, and surgical evaluation of pelvic pain (Lechner et al., 1993). Women with a history of childhood sexual abuse also tend to report less efficacy concerning prevention of HIV (Johnsen & Harlow, 1996) – one of the most rapidly increasing causes of death in the United States (McGinnis & Foege, 1993). This potential connection is strengthened by the findings of a study of HIV-seropositive adolescents. Over 50% of the adolescents had a documented history of sexual abuse and 82% had a history of substance use (Pao et al., 2000).
Childhood maltreatment is also an important risk factor of adolescent pregnancy (Adams & East, 1999; Fergusson et al., 1997; Kellogg, Hoffman, & Taylor, 1999). Pregnancy during adolescence is accompanied with its own set of health risks in the form of complications such as preterm delivery, low birth weight, and neonatal mortality (Olausson, Cnattingius, & Haglund, 1999). In addition, infants bom to teenage mothers are themselves at increased risk for being abused and/or neglected, thus perpetuating the cycle of maltreatment into the next generation (de Paul & Domenech, 2000).
Self Harm and Suicide
According to Dr. Judith Herman (1992), a psychiatrist specializing in treating victims of interpersonal violence, normal regulation of emotional states is disrupted by traumatic experiences that repeatedly evoke terror, rage, and grief. These emotions create a dysphoric state that may subsequently be evoked in response to perceived threats of abandonment and cannot be terminated by ordinary means of self-soothing. Abused children discover at some point that intolerable feelings can be most effectively terminated by a major jolt to the body. The most dramatic method of achieving this result is through the deliberate infliction of injury. In some instances the magnitude of these intolerable feelings can drive the victim to attempt suicide. One study found that high school students with a history of sexual abuse were three times more likely, and those who had been physically abused were five times more likely, to attempt suicide than their peers (Riggs et al., 1990). Another study found that sexually abused boys were 10 times more likely than their peers to report having attempted suicide (Garnefski & Arends, 1998).
The Cost of Childhood Maltreatment
Increasing rates of childhood maltreatment may help explain the increasing rates of depression and suicide found in young people. Suicide is currently the fourth leading cause of death among children between the ages of 10 and 14. A study by the Massachusetts Institute of Technology (MIT) found that depression costs the United States economy over $43 billion a year (Sumner, 1998). Depression is also associated with increased medical costs as somatic complaints lead depressed people to make more visits to health care providers and receive more tests. For instance, a study of over 6,000 primary care patients found that patients diagnosed with depression had significantly higher annual health care costs (including specialty, medical inpatient, pharmacy, laboratory) when compared with other primary care patients. These costs persisted even after the depression was treated (Simon, VonKorff, & Barlow, 1995). In addition, depressed patients with serious medical disorders experience significantly increased morbidity and mortality when compared with controls (Murberg, Bru, Svebak, Tveteras, & Aarsland, 1999).
The total economic impact of PTSD and other anxiety disorders is similar to that of depression. For example, a recent large scale study revealed that anxiety disorders cost the United States economy almost $42 billion a year, with about half of the costs going for nonpsychiatric medical care. Research suggests that individuals with an anxiety disorder are 3 to 5 times more likely to go to a physician, and 6 times more likely to be hospitalized than those without such a disorder (Greenberg et al., 1999).
The costs attributable to childhood maltreatment are also subsumed in the staggering economic burden associated with high-risk behaviors. For example, the combined effects of tobacco, alcohol, and drugs inflict a greater toll on the health and well-being of Americans than any other single preventable factor. For instance, substance abuse is a significant contributor to morbidity, causing approximately 40 million illnesses and injuries each year. Nearly 590,000 deaths — about a quarter of all deaths in the United States — are caused by addictive substances. The total costs attributable to addiction are estimated at greater than $400 billion every year, including health care costs, lost worker productivity, and crime (McGinnis & Foege, 1999). Less quantifiable, but equally important, is the emotional toll that addiction exacts on families and communities. Children of substance-abusing parents are more likely to be maltreated and to, as adults, also become addicted (McGinnis & Foege, 1999).
An indication of the enormous socioeconomic costs associated with child maltreatment are provided by a state-level analysis of the costs associated with child abuse and its consequences performed by Michigan Children’s Trust Fund. Based on information for 1991, the costs of child abuse in Michigan were estimated at 823 million dollars annually. These costs included those associated with low birthweight babies, infant mortality, special education, protective service, foster care, juvenile and adult criminality, and psychological services. (The impact on adult health was not examined by the study because little research in this area was available at the time of the study.) The costs of prevention programs were estimated to be 43 million dollars annually. It was concluded that child abuse prevention yields a 19 to 1 cost advantage for taxpayers (Caldwell, 1992).
A partial quantification of the health care costs attributable to a history of childhood maltreatment has seen been provided by a recent large-scale study of 1,225 randomly selected female members of a HMO. The investigators compared direct health care costs for women who reported childhood maltreatment to women without such a history. Women with histories of childhood maltreatment were found to have significantly higher primary care and outpatient costs and more frequent emergency department visits than nonabused women. Moreover the researchers found a linear relationship between the amount and type of maltreatment experienced and increased costs. Thus patients who reported no childhood maltreatment had the lowest health care costs, women who reported any abuse or neglect had median annual health care costs that were $97 greater, women who reported sexual abuse had health care costs that were $245 greater, and those who reported the most types of maltreatment had the highest costs — an average of $439 more annually. These differences persisted after controlling for demographic and chronic disease variables (Walker, Unutzer, et al., 1999). It should be noted that these figures are conservative, as the investigators did not include the cost of treating chronic medical disease in their analysis. In addition, they did not measure the indirect costs related to childhood maltreatment such as disability or lost work productivity.
Conclusion
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