Adverse Childhood Experiences and Traumatic Stress Disorders

Adverse childhood experiences (ACEs) refer to a broad range of events that can reflect physical or psychological threats to safety, as well as deprivation of basic needs, essential resources, or caregiving necessary for children to thrive and attain healthy development. ACEs can constitute potentially traumatic experiences or nontraumatic adversities with the potential to exacerbate trauma-related impairment or compromise trauma recovery and resilience. This chapter explores ACEs in the context of trauma and trauma-related impairment across the life span. It covers research employing variable- and person-centered analytic strategies for quantifying cumulative and unique constellations of ACEs that probabilistically co-occur, contemporaneously or across development, to influence risk and resilience. Studies examining intergenerational patterns and biological correlates are introduced and progress toward delineating causal risk mechanisms discussed. In addition, several existing tools and methods for assessing ACEs in young and school-age children, adolescents, and adults are summarized. Clinical and public health implications of ACE screening in healthcare, schools, and other settings are considered, as is the clinical application of research on ACEs in trauma-specific prevention and treatment. The chapter concludes with a focus on future research priorities.

Pharmacotherapy for PTSD

Psychotropic medications offer some benefit in treatment of posttraumatic stress disorder (PTSD) symptoms. This chapter reviews classes of medications used as monotherapy and augmentation agents and evidence for their use. Antidepressant medications, particularly selective serotonin reuptake inhibitors, have the greatest body of evidence to support their use in treatment of PTSD, but the benefit they offer is modest, and they are ineffective in some populations. This chapter also reviews novel pharmacologic approaches to treatment of PTSD still under investigation. Beyond sleep, studies to date have not identified strategies to target specific symptom clusters in PTSD. Such studies may help tailor future treatment to symptoms that are either particularly disabling or refractory to other medications of psychosocial intervention. “Repurposing” studies of older agents originally approved for other illnesses may prove effective for specific symptoms or symptom clusters of PTSD.

Prevention and Early Intervention Programs for Older Adults

Age appears to be a consistent protective factor against developing posttraumatic stress disorder (PTSD) subsequent to trauma exposure, followed by social support and proper screening and intervention. However, factors associated with the aging process may complicate identification and treatment of PTSD in older persons, although interventions have been developed in recent years that may help mediate the impact of trauma and stress. This chapter reviews the current risk and protective factors associated with development and treatment of PTSD and comorbidities in older adults, describes research on secondary prevention and early intervention programs for older adults exposed to potentially traumatic events, provides an introduction to a screening/prevention instrument, and presents recommendations for adaptation of extant early traumatic stress treatment programs to meet the needs of older adults.

Prevention and Early Intervention Programs for Children and Adolescents

This chapter provides an overview of basic concepts that lie in the pathway from traumatic stress to a broad range of clinical and life-trajectory outcomes, including characterization of the nature and role of a variety of mediating and moderating factors. Such intervening factors fall within categories of child intrinsic and child extrinsic features. The individual/family and community types of early interventions for children and adolescents after trauma are reviewed. Although many early interventions hold promise, a good deal more methodologically sound research is required to support their use across a variety of contexts. Increased knowledge of mediating and moderating factors on the outcome of trauma can inform development of improved evidence-based screening, clinical assessment, early and intermediate interventions, trauma-informed services for traumatized children and their families across stages of recovery, and public policy.

Traumatic Stress Disorders in Children and Adolescents

Youth’s exposure to natural disasters, acts of violence, motor vehicle accidents, and other injuries, interpersonal violence, and life-threatening medical illnesses often leads to significant psychological distress. Although most youth are resilient, a significant minority experience symptoms of acute stress disorder (ASD), posttraumatic stress disorder (PTSD), or other psychological difficulties that interfere with their adjustment and functioning. This chapter provides a framework for understanding ASD and PTSD in children and adolescents. The chapter first reviews the most well-studied types of traumatic events and describes key components of trauma exposure. This is followed by a review of ASD and PTSD, with particular attention to diagnostic issues and major changes in the conceptualization of these diagnoses. Then, after reviewing the prevalence and course of PTSD across different types of traumatic events, the chapter addresses important developmental issues, issues of comorbidity, and key risk factors that play a role in the development or maintenance of trauma-focused diagnoses in youth. The chapter concludes with key issues for future research that will enhance our understanding of ASD and PTSD in youth.

Treating Trauma-Related Symptoms in Special Populations

Although there is much research on the treatment of posttraumatic psychological reactions in survivors of civilian trauma, there is much less empirical evidence to drive interventions with survivors of other kinds of trauma, including persecution, torture, and sexual abuse, particularly in other cultural groups. This chapter illustrates some of the factors that should be taken into consideration when treating such populations. The chapter is divided into sections that address key issues relevant to special populations of trauma survivors: type of trauma, current stressors, comorbidity, anger, cultural issues such as culturally specific interpretations of trauma-related symptoms, and bereavement. The implications of these issues for the treatment of refugees and asylum seekers are examined. As this chapter indicates, the treatment of traumatic distress in special populations warrants more research to ensure that the optimal psychological interventions are available to such highly traumatized groups.

Promising Psychological Treatments for Posttraumatic Stress Disorder

Trauma-focused therapies, particularly prolonged exposure and cognitive processing therapy, are recommended as first-line treatments for posttraumatic stress disorder (PTSD). However, a subset of patients refuse, fail to respond, or respond only partially to these interventions. This chapter outlines numerous promising adaptions of and augmentation methods for existing evidence-based PTSD treatments in an effort to improve outcomes for all treatment seekers. These include couple- and family-based adaptions of PTSD treatment, augmenting psychotherapy with pharmacological and neurostimulation interventions, the use of Internet-based and smartphone-based platforms to deliver PTSD treatment, and the use of complementary and integrative medicine approaches to supplement evidence-based psychotherapy. Also reviewed is the evidence for using complementary and integrative medicine approaches to target sleep disturbances. Although many of these approaches are in preliminary stages of development and require further study, they represent important progress in helping clinicians better serve the many needs of individuals with PTSD.

Genetics and Genomics of Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is a complex disorder; a range of molecular features likely contributes to individuals’ increased risk for, or resistance to, developing PTSD when exposed to trauma. The focus here is on studies that investigate molecular factors that may be associated with this disorder. This chapter reviews the existing studies on molecular genetic, epigenetic, and gene expression associations with PTSD. This chapter also reviews novel statistical approaches used with genome-, methylome-, and expression-wide data. Future research in this rapidly evolving area should focus on the combined examination of genetic sequence, epigenetic effects, and gene expression to obtain a more complete picture of the systems biology of PTSD.

Empirically Supported Psychological Treatments: Cognitive Processing Therapy

Cognitive processing therapy (CPT) has been recognized by recent clinical practice guidelines as one of the most effective treatments for posttraumatic stress disorder (PTSD). This chapter provides a brief overview of the CPT session content, the underlying mechanisms of the therapy, a review of the empirically based literature outlining the treatment effectiveness, limitations of the therapy, and areas of future research. In addition, the authors discuss the utility of the various versions of CPT, including CPT+Account, group, individual, and combination. Further, the research supporting the effectiveness of CPT for treating PTSD related to a variety of traumas (e.g., combat, child abuse, and rape) and the significant impact CPT can have in areas of mental health related to PTSD (e.g., anger, guilt, social functioning) are described.

Classification of Acute Stress Disorder

The diagnosis of acute stress disorder (ASD) was originally introduced in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) to identify survivors soon after a trauma who were likely to develop posttraumatic stress disorder (PTSD). However, despite demonstrating acceptable predictive power, subsequent research often failed to display high rates of sensitivity or specificity for ASD predicting PTSD. This led researchers to question the utility of the diagnosis and ultimately led to a revision of the diagnosis in the fifth edition of DSM. The updated ASD diagnosis was intended to primarily promote access to healthcare services following a traumatic event, and symptoms were not selected with the aim of predicting likelihood of one developing PTSD. Ultimately, the DSM-5 ASD criteria align more closely with PTSD symptoms without an emphasis on dissociative symptoms (as was true of the DSM-IV). This chapter summarizes the development of the ASD criteria/diagnosis and evaluates the utility of the reconceptualized diagnosis for both clinicians and researchers.