Primary Prevention of Trauma-Related Problems Before Trauma

colorRisk of lifetime exposure to a potentially traumatic event (PTE) increases exponentially across the lifespan until non-exposed individuals are rare.1 Although a minority of individuals in the general population develop trauma-related emotional and behavioral problems,2 this is not true of multiply traumatized or poly-victimized individuals.3-5 These experiences can start to accumulate very early in life with potential to disrupt normal development of stress-related biological systems and trigger the emergence of pervasive emotional and behavioral problems.6-8 Many of these children find their way into the child welfare and juvenile justice systems, where psychopathology, including posttraumatic stress disorder (PTSD), alcohol and drug abuse, delinquency and justice involvement, and suicidal behavior, is exponentially more prevalent in comparison to the general population9-14 In addition, these children are less likely to possess key protective personal and social resources associated with buffering the negative consequences of extreme stress exposure.13 They also face high risk of re-victimization – and in many cases, multiple re-victimizations.15 From a public health perspective, what can we do to curb this trajectory of cumulative trauma and emergent psychopathology? Although important progress has been made in the development of evidence-based treatment interventions and some progress has been made in the area of secondary prevention of trauma-related problems, missing is a primary prevention effort to foster adaptive responses before trauma exposure occurs (or re-occurs).  A preventative model that reduces risk factors and bolsters protective resources prior to exposure could have substantial impact in reducing cumulative risk. To do this, we need to have a better understanding of risk and protective factors that can be modified. Research has supported the notion that although trauma exposure results in a loss of resources, individuals with greater social and personal resources at the time of the traumatic event are better able to utilize their remaining resources to compensate for resources lost.16 Resilient individuals seem to effectively manage the intense cognitive and emotional demands put forth by extreme stressors. This may involve recruitment and development of new, or realization and reinforcement of existing resources.17 In fact, individuals who experience a significant life stressor and resource loss, but then are proactive in establishing a strong reserve of resources may partially inoculate themselves against other major stressors.18-20 In contrast, individuals who lack sufficient resources are vulnerable to additional loss, deleterious consequences, and what Hobfoll describes as a loss spiral, multiple losses that accelerate the loss of resources and impending detriment. If resource gain or optimization is facilitated prior to potential trauma exposure, then potential victims may be better equipped to cope with trauma exposure and compensate for the loss. Before a primary prevention intervention can be developed, however, it is necessary to identify pre-trauma risk and protective factors that are malleable and therefore capable of being deliberately modified in the context of an intervention. A small but developing literature of prospective studies that examine individuals before and after exposure to potential trauma has identified pre-trauma predictors of better outcomes following potential trauma exposure.21 Among these protective factors are some that appear to be dynamic and thus potentially modifiable within a preventive frame. Examples include social support,18,20,22-28 including the parent-child relationship, protective cognitions, 23,29 self-efficacy, 20,30 social competence, 23,30 and self-regulation strategies. 31 To date, the field has not maximized this information to inform a public health approach towards fostering individuals’ adaptive responses to subsequent potential trauma exposure. What do you think about primary prevention of trauma-related problems before trauma exposure? Where should this intervention take place? What challenges do you anticipate? Join the discussion here, on Facebook, Twitter, or LinkedIn.


References Cited: 1.      Breslau N, Kessler RC, Chilcoat HD, Schultz LR, Davis GC, Andreski P. Trauma and posttraumatic stress disorder in the community: the 1996 Detroit Area Survey of Trauma. Archives of general psychiatry. 1998;55(7):626. 2.         Kilpatrick DG, Ruggiero KJ, Acierno R, Saunders BE, Resnick HS, Best CL. Violence and risk of PTSD, major depression, substance abuse/dependence, and comorbidity: Results from the National Survey of Adolescents. Journal of Consulting and Clinical Psychology. 2003;71(4):692-700. 3.         Anda RF, Felitti VJ, Bremner JD, et al. 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. 2006;256(3):174-186. 4.         Dube SR, Anda RF, Felitti VJ, Edwards VJ, Williamson DF. Exposure to abuse, neglect, and household dysfunction among adults who witnessed intimate partner violence as children: Implications for health and social services. Violence and Victims. // 2002;17(1):3-17. 5.         Edwards VJ, Holden GW, Felitti VJ, Anda RF. Relationship between multiple forms of childhood maltreatment and adult mental health in community respondents: Results from the adverse childhood experiences study. American Journal of Psychiatry. Aug 2003;160(8):1453-1460. 6.         Belsky J, de Haan M. Annual Research Review: Parenting and children’s brain development: the end of the beginning. J Child Psychol Psychiatry. Apr 2011;52(4):409-428. 7.         Chen SH, Wu YC. Changes of PTSD symptoms and school reconstruction: A two-year prospective study of children and adolescents after the Taiwan 921 Earthquake. Natural Hazards. // 2006;37(1-2):225-244. 8.         Grasso D, Ford J, Briggs-Gowan MJ. Early trauma exposure and stress sensitivity in young children. Journal of Pediatric Psychology. In Press. 9.         Kolko DJ, Hurlburt MS, Jinjin Zhang, Barth RP, Leslie LK, Burns BJ. Posttraumatic Stress Symptoms in Children and Adolescents Referred for Child Welfare Investigation. Child Maltreatment. February 1, 2010 2010;15(1):48-63. 10.      McCue Horwitz S, Hurlburt MS, Heneghan A, et al. Mental health problems in young children investigated by u.s. Child welfare agencies. Journal of the American Academy of Child and Adolescent Psychiatry. Jun 2012;51(6):572-581. 11.      Finkelhor D, Ormrod RK, Turner HA. Lifetime assessment of poly-victimization in a national sample of children and youth. Child Abuse & Neglect. 2009;33(7):403-411. 12.      Ford JD, Elhai JD, Connor DF, Frueh BC. Poly-victimization and risk of posttraumatic, depressive, and substance use disorders and involvement in delinquency in a national sample of adolescents. Journal of Adolescent Health. 2010;46(6):545-552. 13.      Grasso D, Saunders B, Williams L, Hanson R, Smith D, Fitzgerald MM. Patterns of Multiple Victimization Among Maltreated Children in Navy Families. Journal of Traumatic Stress. In Press. 14.      Ford JD, Grasso DJ, Hawke J, Chapman JF. Poly-victimization among juvenile justice-involved youths. Child abuse & neglect. Feb 18 2013. 15.      Finkelhor D, Ormrod RK, Turner HA. Re-victimization patterns in a national longitudinal sample of children and youth. Child Abuse & Neglect. 2007;31(5):479-502. 16.      Hobfoll SE. Conservation of Resources: A New Attempt at Conceptualizing Stress. American Psychologist. // 1989;44(3):513-524. 17.      Hobfoll SE. The Ecology of Stress. New York: Hemisphere; 1988. 18.      Hobfoll SE. The influence of culture, community, and the nested-self in the stress process: Advancing Conservation of Resources theory. Applied Psychology: An International Review. 2001;50(3):337-370. 19.      Taylor SE, Stanton AL. Coping resources, coping processes, and mental health. Annual Review of Clinical Psychology. 2007;3:377-401. 20.      Grasso DJ, Cohen LH, Moser JS, Hajcak G, Foa EB, Simons RF. Seeing the silver lining: potential benefits of trauma exposure in college students. Anxiety Stress Coping. Mar 18 2011:1-20. 21.      DiGangi JA, Gomez D, Mendoza L, Jason LA, Keys CB, Koenen KC. Pretrauma risk factors for posttraumatic stress disorder: A systematic review of the literature. Clinical Psychology Review. 2013. 22.      Polusny MA, Erbes CR, Murdoch M, Arbisi PA, Thuras P, Rath MB. Prospective risk factors for new-onset post-traumatic stress disorder in National Guard soldiers deployed to Iraq. Psychological medicine. Apr 2011;41(4):687-698. 23.      Yuan C, Wang Z, Inslicht SS, et al. Protective factors for posttraumatic stress disorder symptoms in a prospective study of police officers. Psychiatry research. Jun 30 2011;188(1):45-50. 24.      Brewin CR, Andrews B, Valentine JD. Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting & Clinical Psychology. 2000;68(5):748-766. 25.      Arnberg FK, Hultman CM, Michel P-O, Lundin T. Social Support Moderates Posttraumatic Stress and General Distress After Disaster. Journal of Traumatic Stress. 2012:n/a-n/a. 26.      Grills-Taquechel AE, Littleton HL, Axsom D. Social support, world assumptions, and exposure as predictors of anxiety and quality of life following a mass trauma. Journal of anxiety disorders. May 2011;25(4):498-506. 27.      Charuvastra A, Cloitre M. Social bonds and posttraumatic stress disorder. Annual Review of Psychology. 2008;59:301-328. 28.      Bonanno GA, Mancini AD. Beyond resilience and PTSD: Mapping the heterogeneity of responses to potential trauma. Psychological Trauma: Theory, Research, Practice, and Policy. 2012;4(1):74-83. 29.      Bryant RA, Guthrie RM. Maladaptive self-appraisals before trauma exposure predict posttraumatic stress disorder. Journal of Consulting and Clinical Psychology. Oct 2007;75(5):812-815. 30.      Lengua LJ, Long AC, Smith KI, Meltzoff AN. Pre-attack symptomatology and temperament as predictors of children’s responses to the September 11 terrorist attacks. J Child Psychol Psychiatry. Jun 2005;46(6):631-645. 31.      Gil S. Coping style in predicting posttraumatic stress disorder among Israeli students. Anxiety, Stress & Coping. 2005;18(4):351-359.