Home > Public Resources > Trauma Blog > 2022 - September Military Matters: Childhood Trauma Among Veterans: Impact and Implications Jacqueline O. Davis-Wright, PhD September 29, 2022 During my psychology internship training last year at a U.S. hospital within the Department of Veterans Affairs (VA), I co-facilitated an ongoing sexual trauma psychotherapy group for female veterans. Before joining this group, I assumed that it would focus on the veterans’ experiences of military sexual trauma (MST). However, I came to learn that group sessions frequently focused on experiences of childhood abuse. Unfortunately, these veterans were far from alone in their experiences. Childhood trauma is a highly prevalent, yet often under-discussed, issue among veterans. Estimates of the prevalence of childhood trauma among veterans range from 26-85% (Katon et al., 2015). In a large, nationally representative sample of U.S. veterans, one in five had experienced childhood physical or sexual abuse (Nichter et al., 2020). Among female veterans, one review found that 27-49% reported childhood sexual abuse and 35% reported childhood physical abuse (Zinzow et al., 2007). It is important to assess for childhood trauma among veterans, given its high prevalence and the many detrimental ways in which such experiences may influence health and coping. Effects of Childhood Trauma In the first known study examining adverse childhood experiences (ACEs) in a military sample, Cabrera and colleagues (2007) found that ACEs predicted symptoms of depression and PTSD, above and beyond the expected contribution of combat exposure. Subsequent studies have supported these findings, evidencing childhood trauma’s influence on depressive symptoms (Youssef et al., 2013), PTSD symptoms (Van Voorhees et al., 2012), and suicidality (Nichter et al., 2020) among veterans, even after controlling for combat exposure. In a study examining the impact of childhood abuse on female veterans’ health, Mercado et al. (2015) found that childhood physical abuse predicted poorer physical health, greater symptoms of depression and PTSD, and more frequent health care utilization, even after adjusting for MST exposure. Interestingly, childhood sexual abuse did not predict these poorer outcomes in Mercado and colleagues’ (2015) study; however, in a larger, non-gender-specific veteran sample, childhood sexual abuse predicted lifetime suicide attempts (Nichter et al., 2020). Furthermore, exposure to multiple traumas, and particularly childhood traumas, appears to have compounding effects on mental health. Cumulative childhood trauma exposure predicts greater symptom complexity (Cloitre et al., 2009), and exposure to multiple types of childhood trauma has been shown to predict greater PTSD symptoms in a sample of U.S. veteran and civilian women (Bosch et al., 2020). Subsequent military trauma may complicate the clinical picture. Nichter and colleagues (2020) found that veterans exposed to both childhood sexual abuse and combat were three times more likely to contemplate suicide. Davis et al. (2022) explored different profiles of ‘polyvictimization’ (having experienced multiple types of trauma) among U.S. veterans using latent class analysis. Four polyvictimization profiles emerged, including a “moderate childhood trauma and combat trauma” profile. All four profiles were associated with increased symptoms of depression and PTSD and risky substance use (Davis et al., 2022). Further research is needed to better understand the impacts of particular types of childhood trauma and the interactions among types of trauma exposure. Nevertheless, the existing literature provides clear cause for concern regarding the impacts of cumulative traumas, particularly childhood and military traumas. Less clear, however, is the influence of these experiences on treatment. Impacts on Treatment The ways in which a veteran’s history of childhood trauma may impact treatment are not clear. In a sample of veterans referred for PTSD treatment, non-completers had higher rates of childhood trauma (Miles & Thompson, 2016). However, Eftekhari et al. (2020) found that veterans who focused on childhood trauma in Prolonged Exposure Therapy were less likely to drop out than those who focused on combat trauma. Regarding symptom reduction, women who have experienced more types of childhood trauma show less improvement following Cognitive Processing Therapy (CPT; Bosch et al., 2020). However, Walter and colleagues (2014) found no difference in treatment outcomes between female veterans with and without childhood sexual abuse histories receiving CPT for MST. Implications for treatment, given the varied and limited findings, are discussed. Implications First, the literature makes clear that providers working with veterans should, at minimum, assess for childhood trauma and integrate this information into their case conceptualization. When working with a veteran with a history of childhood trauma, consult best practices for treating complex trauma. Experts in complex trauma largely agree on a phase-based approach to treatment (Cloitre et al., 2011; Landes et al., 2013) with phases targeting sets of symptoms. First-line interventions might include emotion regulation skills, stress management strategies, trauma memory narration, interpersonal skills, or cognitive restructuring (Cloitre et al., 2011). Mindfulness-based strategies are a common second-line intervention (Cloitre et al., 2011). For veterans who are ready to engage in an evidence-based protocol for PTSD, consider and discuss whether the index trauma is one from childhood. Veterans willing to focus on childhood trauma may be more motivated to complete treatment (Eftekhari et al., 2020). If the veteran’s index trauma is a childhood trauma, this may inform the sequencing of phase-based treatment. Cole and colleagues (2022) studied the effect of time since the index trauma on trauma-related beliefs. Their results showed that more time since the index trauma was associated with less improvement in negative trauma-related beliefs about the world and less early improvement in negative self-beliefs. Although CPT can be an effective treatment for childhood abuse-related PTSD (Chard, 2005), for a veteran with strongly held beliefs rooted in childhood trauma, starting with emotion regulation skills or exposure-based work, for instance, may prove useful. Flexible dosing of sessions is encouraged for veterans with a childhood trauma history (Bosch et al., 2020; Galovski et al., 2012). Within the VA health care system in the U.S., we must also address systemic issues that may impede important work addressing childhood trauma, such as mandates within some clinics that treatment focus on military trauma. Such requirements may not best serve veterans with complex and/or childhood trauma histories. Ultimately, the index trauma and treatment approach chosen should align with the patient’s preferences and treatment goals. Assessing for childhood trauma history, however, is an important part of treatment that may allow us to understand the veteran’s presentation more holistically. About the Author Jacqueline Davis-Wright, PhD, is a clinical psychology postdoctoral fellow in trauma psychology at the West Los Angeles VA Healthcare Center. Broadly, her clinical and scholarly interests include treatment for trauma and related disorders, supervision and training in health service psychology, and improving access to and outcomes of psychology services for marginalized communities. References Bosch, J., Mackintosh, M.-A., Wells, S. Y., Wickramasinghe, I., Glassman, L. H., & Morland, L.A. (2020). PTSD treatment response and quality of life in women with childhood trauma histories. Psychological Trauma: Theory, Research, Practice, and Policy, 12(1), 55–63. Cabrera, O. A., Hoge, C. W., Bliese, P. D., Castro, C. A., & Messer, S. C. (2007). Childhood adversity and combat as predictors of depression and post-traumatic stress in deployed troops. American Journal of Preventive Medicine, 33(2), 77-82. Chard, K. M. (2005). An evaluation of cognitive processing therapy for the treatment of posttraumatic stress disorder related to childhood sexual abuse. Journal of Consulting and Clinical Psychology, 73(5), 965. Cloitre, M., Stolbach, B. C., Herman, J. L., Kolk, B. V. D., Pynoos, R., Wang, J., & Petkova, E. (2009). A developmental approach to complex PTSD: Childhood and adult cumulative trauma as predictors of symptom complexity. Journal of Traumatic Stress, 22(5), 399- 408. Cloitre, M., Courtois, C. A., Charuvastra, A., Carapezza, R., Stolbach, B. C., & Green, B. L. (2011). Treatment of complex PTSD: Results of the ISTSS expert clinician survey on best practices. Journal of Traumatic Stress, 24(6), 615-627. Cole, T. A., Reuman, L., Lee, D. J., Shotwell Tabke, C., Marx, B. P., & Sloan, D. M. (2022). The effect of time since index trauma on trauma-related beliefs. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. Davis, J. P., Lee, D. S., Saba, S., Fitzke, R. E., Ring, C., Castro, C. C., & Pedersen, E. R. (2022). Applying polyvictimization theory to veterans: Associations with substance use and mental health. Psychology of Addictive Behaviors, 36(2), 144-156. Eftekhari, A., Crowley, J. J., Mackintosh, M.-A., & Rosen, C. S. (2020). Predicting treatment dropout among veterans receiving prolonged exposure therapy. Psychological Trauma: Theory, Research, Practice, and Policy, 12(4), 405-412. Galovski, T.E., Blain, L.M., Mott, J.M., Elwood, L., & Houle, T. (2012). Manualized therapy for PTSD: Flexing the structure of cognitive processing therapy. Journal of Consulting and Clinical Psychology, 80, 968-981. Katon, J. G., Lehavot, K., Simpson, T. L., Williams, E. C., Barnett, S. B., Grossbard, J. R., Schure, M.B., Gray, K.E., & Reiber, G. E. (2015). Adverse childhood experiences, military service, and adult health. American Journal of Preventive Medicine, 49(4), 573- 582. Landes, S. J., Garovoy, N. D., & Burkman, K. M. (2013). Treating complex trauma among veterans: Three stage‐based treatment models. Journal of Clinical Psychology, 69(5), 523-533. Mercado, R. C., Wiltsey-Stirman, S., & Iverson, K. M. (2015). Impact of childhood abuse on physical and mental health status and health care utilization among female veterans. Military Medicine, 180(10), 1065-1074. Miles, S. R., & Thompson, K. E. (2016). Childhood trauma and posttraumatic stress disorder in a real-world Veterans Affairs clinic: Examining treatment preferences and dropout. Psychological Trauma: Theory, Research, Practice, and Policy, 8(4), 464- 467. Nichter, B., Hill, M., Norman, S., Haller, M., & Pietrzak, R. H. (2020). Associations of childhood abuse and combat exposure with suicidal ideation and suicide attempt in US military veterans: a nationally representative study. Journal of Affective Disorders, 276, 1102-1108. Van Voorhees, E. E., Dedert, E. A., Calhoun, P. S., Brancu, M., Runnals, J., VA Mid-Atlantic MIRECC Workgroup, & 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 & Neglect, 36(5), 423-432. Walter, K. H., Buckley, A., Simpson, J. M., & Chard, K. M. (2014). Residential PTSD treatment for female veterans with military sexual trauma: does a history of childhood sexual abuse influence outcome?. Journal of Interpersonal Violence, 29(6), 971-986. https://doi.org/10.1177/0886260513506055 Youssef, N. A., Green, K. T., Dedert, E. A., Hertzberg, J. S., Calhoun, P. S., Dennis, VA Mid Atlantic MIRECC Workgroup, & Beckham, J. C. (2013). Exploration of the influence of childhood trauma, combat exposure, and the resilience construct on depression and suicidal ideation among US Iraq/Afghanistan era military personnel and veterans. Archives of Suicide Research, 17(2), 106-122. https://doi.org/10.1080/13811118.2013.776445 Zinzow, H. M., Grubaugh, A. L., Monnier, J., Suffoletta-Maierle, S., & Frueh, B. C. (2007). Trauma among female veterans: A critical review. Trauma, Violence, & Abuse, 8(4), 384-400. https://doi.org/10.1177/1524838007307295