Childhood trauma

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The term childhood trauma (also childhood stress factors , early childhood stress experiences , adverse childhood experiences for short: ACE ) are summarized as follows: child abuse , sexual abuse of children , severe neglect , war experiences (see also war child ), separation / divorce of parents and other family members / social stressors. A trauma is a serious mental injury.

In Germany, the incidence of severe trauma events is between about 1 and 11% of the population. Childhood trauma can have dramatic and long-term consequences for the health of those affected, especially if there is a corresponding vulnerability (vulnerability, diathesis ). There is a dose-effect relationship: the more serious and long-lasting the trauma events are, the earlier they occur and the more events and stresses there are overall, the higher the likelihood of physical and / or mental illnesses, both in children and in children in adulthood. On the other hand, the far greater proportion of those affected will not develop any illnesses in the long term, if there is no vulnerability, if protective factors ( resilience ) are available or if the traumas are less severe.

The development from childhood traumas to illnesses in adulthood occurs mainly in two ways: on the one hand, the vulnerability of those affected increases to future stressful events, and on the other hand, those affected show increased health risk behaviors, for example smoking or alcohol abuse. The results on the frequency are epidemiologically confirmed by large studies . They suggest prevention measures in early childhood, for example through the use of family midwives .

Prevalence

Figures on the prevalence (frequency) of childhood traumas are available in Germany in the form of police crime statistics and child and youth welfare statistics (see article Child abuse ). A considerable number of unreported cases can be assumed. In the case of population samples, the problem of undetected cases is significantly less. In a representative German population sample from April 2010, 2504 adults were asked retrospectively about childhood traumas up to the age of 18 (mean age 50.6 years, range 14 to 90 years). For five specified forms of abuse and neglect, the respondents gave the frequency and severity in four levels (lifetime prevalence).

Form of abuse easy to extreme% difficult / extreme%
emotional abuse 14.9 1.6
physical abuse 12.0 2.7
sexual abuse 12.5 1.9
emotional neglect 49.3 6.5
physical neglect 48.4 10.8

Tab. 1 Frequency of childhood traumas depending on the degree of severity (middle column all degrees of severity, right column only degree of severity severe / extreme); multiple choices possible

The different forms of abuse and neglect occur with different frequencies. 1.9% of the respondents had been exposed to severe sexual abuse, 10.8% to severe physical neglect. If abuse and neglect of all degrees of severity are taken into account (i.e. with a broad definition), the incidence is higher, for example sexual abuse at 12.5%. Neglect was three to five times more common than abuse. Many respondents had experienced several forms of abuse and neglect (accumulation, accumulation). 3.3% of the respondents were exposed to two forms of severe abuse or neglect, and 2.3% of the respondents to three to five forms.

In an earlier representative survey of the German-speaking population between the ages of 16 and 59, 74.5% of the almost 3,300 respondents reported at least one punishment event before the age of 16 (for example, “My parents knocked me off”). 10.6% of the respondents reported at least one event of physical abuse (for example, “My parents beat me up”). 8.6% of women and 2.8% of men had experienced at least one event of sexual abuse with physical contact before the age of 16. Of these, 3.3% of women and 0.9% of men had been subjected to sexual abuse with penetration. "The greater part of physical contact incidents [consist] of sexual contact without penetration".

The enormous scale of the problem becomes clear in the following model calculation: With a population of around 80 million in Germany and under the hypothetical assumption that the prevalence of childhood trauma is the same in the entire population, a prevalence of 1% would affect an estimated 800,000 people ; at 10% it would be 8 million people.

Ten categories of childhood stress experiences under the age of 18 were retrospectively surveyed in a US population sample of over 17,000 people; In addition to the childhood traumas mentioned above, five situations of familial dysfunction were surveyed (The Adverse Childhood Experiences [ACE] Study; mean age 56 years, range 19 to 92 years).

Childhood Stress Category Prevalence%
emotional abuse 10.6
physical abuse 28.3
sexual abuse (physical contact) 20.7
emotional neglect 14.8
physical neglect 9.9
Violence against mother 12.7
Substance abuse by household member 26.9
psych. Illness of household member 19.4
Separation / divorce of parents 23.3
Household member imprisoned 4.7

Tab. 2 Frequencies of stressful childhood experiences ACE; multiple choices possible

28.3% of the respondents had experienced physical abuse, 26.9% had experienced that at least one member of the household engaged in substance abuse (alcohol or drug abuse). When it comes to sexual abuse, there is a considerable difference between women and men (female 24.7%; male 16.0%). Based on seven stress categories (see Table 2 without emotional and physical neglect and without separation / divorce), only half (49.5%) of the respondents did not suffer any childhood trauma; 24.9% have one trauma and 25.6% have suffered two or more traumas. The accumulation of childhood traumas is very common with a quarter.

In samples of psychiatric and psychosomatic patients, the frequency of childhood traumas is significantly higher. In a retrospective study of 407 adult psychosomatic patients, the three most frequently mentioned childhood stressors were:

  • emotionally bad relationship with parents (67%);
  • chronic family disharmony / with violence (59%);
  • Both parents' professional tension from an early age (43%).

The most serious childhood traumas due to accumulation were:

  • frequently beaten / mistreated (26%);
  • severe sexual abuse (9%).

For these two forms of trauma, the patients reported an average of five additional stress factors.

The most frequently used survey method for childhood trauma is the retrospective survey of adults using questionnaires. This method is to be regarded as valid to the extent that “memories of traumatic events can be recorded in a comparatively valid way with regard to the question of whether an event has occurred or not. [...] Epidemiological studies tend to underestimate the real prevalence. "

Consequences of the trauma experience

Short-term consequences of childhood traumas may include physical injuries as well as acute stress reactions and psychoreactive symptoms, especially acute anxiety symptoms. Furthermore, a post-traumatic stress disorder can develop. With persistent stress, there is an increased cortisol release in the long term . This leads to impairment of brain development and to "biological scars", which can be reflected in a lifelong dysfunction of the stress-processing system in the sense of increased vulnerability to physical and psychosocial stressful situations. Furthermore, it can lead to social, emotional and cognitive impairments.

In the attachment theory founded by John Bowlby , stressful and traumatizing behaviors of parents mean that they are not sensitive to the child . A lack of sensitivity prevents the child from developing a secure attachment. The attachment style acquired in early childhood or an attachment disorder can affect the entire life cycle.

Risk behaviors

The ACE study is based on the assumption that victims of childhood traumas from childhood / adolescence show increased health risk behaviors, for example overeating, which can then lead to increased physical health disorders and / or mental illnesses and a shorter lifespan. The ten selected risk behaviors in adulthood are among the leading causes of morbidity and mortality in the United States . Table 3 shows the probabilities of the risk behavior depending on the ACE value, i.e. i. the number of childhood stress categories in which the respondent had suffered at least one trauma event. The ACE value roughly depicts the accumulation of trauma events.

health risk behaviors ACE = 0% ACE ≥ 4%
currently smokes 6.8 16.5
severe overweight (BMI ≥ 35) 5.4 12.0
Lack of exercise in leisure time 18.4 26.6
≥ 2 weeks depressed mood * 14.2 50.7
ever attempted suicide 1.2 18.3
sees himself as an alcoholic 2.9 16.1
ever used illegal drugs 6.4 28.4
ever injected intravenous drugs 0.3 3.4
Promiscuity (≥ 50 sexual partners) 3.0 6.8
ever sexually transmitted disease 5.6 16.7

Table 3 Probabilities of health risk behaviors depending on the ACE value; * ≥ 2 weeks of depressed mood in the past year

All risk behaviors occurred more frequently in adulthood, the more stress categories the people were exposed to in childhood. For example, 2.9% of the adults with an ACE value = 0 abused alcohol, of those with an ACE value ≥ 4 it was 16.1%. The increase in probabilities was significant in all cases, in some cases dramatically high; with intravenous drug use and suicide attempts it was more than tenfold. With the risk behavior, the persons concerned try to cope with stressful and conflict situations and to regulate their affects down (emotion- oriented coping ), but this often leads to further stressful events. These behaviors may be adaptive for survival in hostile social situations, but dysfunctional for psychosocial adjustment, for example in school and at work.

Physical illness

If a person shows one or more of these risk behaviors, for example alcohol abuse, drug use, smoking and / or obesity, then the risk of physical illness increases. For the following diseases, the probability of occurrence under ACE ≥ 4 is twice as high as under ACE = 0: coronary heart disease (5.6% vs. 3.7%), stroke (4.1% vs. 2.6%), chronic obstructive pulmonary disease (8.7% vs. 2.8%), ever hepatitis / jaundice (10.7% vs. 5.3%). With ACE ≥ 4, the likelihood of cancer, diabetes and ever bone fractures is also increased. Childhood traumas are therefore considered to be the "root causes" of illness and mortality in adulthood.

Of the original participants in the ACE study, 1539 died after an average of just under eight years. The mortality rate was higher, the more childhood stress categories the respondents were exposed to. For people with an ACE value = 0, the mean age at death was 79.1 years, for an ACE value ≥ 6 it was 60.6 years, i.e. the mean life span was shortened by almost 20 years. The five most common leading causes of death, which together explain about 90% of all deaths, were: cardiovascular diseases, malignant neoplasms, nervous and sensory diseases, respiratory diseases and diseases of the digestive system. The assumed relationship between childhood stress and shortened life expectancy was confirmed.

Mental illness

Also, mental disorders occur depending on the extent of childhood stress factors statistically more frequently, and that depressive and anxiety disorders , suicidal tendencies , somatoform disorders , eating disorders , addictions , personality disorders and posttraumatic stress disorder . It is assumed that risk behaviors are also involved in the development of the disease.

A high number of patients with borderline personality disorder have suffered trauma in their course of life: experiences of sexual violence around 65%, experiences of physical violence around 60%, neglect around 40%. From a psychotherapeutic perspective, sexual trauma in childhood is seen as one of the most common and strongest influencing factors in the development of borderline personality disorder. According to "many years of clinical experience, violent sexual penetration of the body's boundaries is the most psychologically damaging thing that can be done to a child." which can translate into emotional neglect or abuse.

“Frequent, repeated, prolonged, humiliating physical abuse” is seen as an important factor that can promote the development of antisocial behavior or antisocial personality disorder . People with dissocial personality disorder have "in early childhood as well as in the further course of their lives through some very severe experiences of loss and deficiency (in the sense of abuse, abuse and neglect)."

“In summary, the results of trauma research suggest a significant influence of trauma [in childhood] on the development of later personality disorders . […] However, trauma is not a necessary or even sufficient condition for the development of personality disorders. ”In particular, so-called cluster B personality disorders (narcissistic, borderline and antisocial personality disorders) are more likely to develop after severe traumatic childhood experiences.

According to a psychotherapeutic view, early childhood experiences as well as traumatic and stressful events in childhood significantly influence the development of personality and significantly promote the development of mental illnesses. The risk behaviors mentioned above can be understood as intrapsychic coping mechanisms to ward off unconscious inner conflicts, which can also occur as a "re-enactment of traumatic parent-child constellations" (sometimes also referred to as " repetition compulsion "). The results of the ACE study are also seen as epidemiological confirmation of corresponding psychoanalytic concepts.

Life handicaps

Separation and divorce of the parents as well as the death of one parent are always stressful and decisive events for the children concerned. On their own, however, they have “no relevance for later psychological vulnerability. […] In combination with experiences of violence, however, the divorce of the parents increases the risk “of later mental illnesses considerably. Even if the majority of people affected by childhood traumas do not become manifestly ill, they can later be massively disadvantaged in their social adjustment. People who were abused or neglected as children up to the age of 11 (according to criminal prosecution files) show an overall less favorable life course compared to a case control group about 20 years later: Among other things, their measured intelligence is lower; they are more likely to finish school; their professional level is lower; unemployment is higher; the partnership situation is less favorable (less stable marriages, more often more than one divorce).

Women who were chastened or physically abused in childhood and / or who were sexually abused through physical contact are at a significantly higher risk of suffering physical or sexual violence in their relationship. Parents who were chastened or physically abused in childhood and / or who experience violence in their relationship are at a higher risk of chastising or abusing their children. Suffered childhood trauma lead to a statistically significantly increased risk of renewed traumatising experiences of violence (also referred to as revictimization ) or to passing it on to the next generation.

Protective factors

Only some of the children who have suffered one or more trauma develop risky behaviors and later develop illnesses. The persons with an ACE value ≥ 4 show the individual risk behaviors with probabilities of less than 20–30%; The exception is the depressed mood with 50.7% (Table 3). This means that even severely affected people mostly manage their lives without risky behavior. Likewise, after childhood traumas, the probabilities of physical and mental illness are clearly and unquestionably increased, but are well below 100%.

Childhood traumas have fewer negative effects when the person's vulnerability is low, when the severity and number / duration of the traumatic events are low, and when compensatory protective factors and resources are available. A distinction is made between individual, family and social protection factors (support facilities). The following protective factors have empirically proven to be effective:

  • long-term good relationship with at least one primary caregiver,
  • secure attachment behavior ,
  • Extended family, compensatory parenting relationships,
  • Relief for the mother (especially if a single parent),
  • good substitute environment after a previous mother loss,
  • above-average intelligence ,
  • robust, active and sociable temperament,
  • internal control beliefs ,
  • Self-efficacy ,
  • social support (e.g. through youth groups, school, church),
  • reliable supportive caregiver (s) in adulthood,
  • Lifelong later founding of a family (in the sense of assuming responsibility),
  • Gender (girls are less vulnerable).

The individual protective factors essentially correspond to the concept of resilience (resistance). If protective factors are sufficiently available, a trauma event may be moderated, a child / adolescent can adequately cope with a single trauma, and "normal" development may be possible. The trauma then acts "like a kind of vaccination [...] which can later lead to increased stress resistance". Successful coping increases the resilience of the person concerned.

Intervention / therapy

The findings suggest preventive measures (secondary prevention) in early childhood. The aim is to intervene with mothers and families in risk situations with the aim of preventing trauma events for the children. Midwives with the additional qualification of family midwives have this task . The focus is on psychosocial and medical advice and care for vulnerable pregnant women and mothers with small children through outreach activities and interdisciplinary cooperation with other institutions and professional groups.

In the acute trauma or stressful situation of a child or adolescent, child protection measures , medical treatment and psychosocial care may be required as part of a crisis intervention . There are special trauma-focused psychotherapy approaches for children / adolescents who are victims of sexual abuse (see article Post-traumatic stress disorder in children and adolescents ).

For adults who were exposed to trauma as a child, psychotherapy may be indicated in the event of later mental illness , which is geared to the respective type of disorder / diagnosis (see above). In these cases, the sick person and the illness can only be understood with adequate consideration of the childhood traumatization.

The parent program Safe - Safe Education for Parents, developed by the child psychiatrist Karl Heinz Brisch , serves to prevent childhood trauma from being passed on to one's own children .

See also

Individual evidence

  1. ^ A b W. Hauser, G. Schmutzer, E. Brähler , H. Glaesmer: Maltreatment in childhood and adolescence: Results from a survey of a representative sample of the German population. In: Dt. Ärzteblatt International. 2011, 108, pp. 287-294.
  2. ↑ a b P. Wetzels : Experiences of violence in childhood. Sexual abuse, physical abuse and its long-term consequences. Nomos, Baden-Baden 1997.
  3. ↑ a b c d e V. J. Felitti, RF Anda, D. Nordenberg, DF Williamson, AM Spitz, V. Edwards, MP Koss, JS Marks: Relationship of Childhood Abuse and Household Dysfunction to Many of the Leading Causes of Death in Adults. The Adverse Childhood Experiences (ACE) Study. In: American Journal of Preventive Medicine. 1998; 14, pp. 245-258.
  4. ^ Centers for Disease Control and Prevention. Prevalence of Individual Adverse Childhood Experiences. www.cdc.gov/ace/prevalence.htm
  5. ↑ a b U. T. Egle, J. Hardt, R. Nickel, B. Kappis, SO Hoffmann: Early stress and long-term consequences for health - Scientific knowledge and research desiderata. In: Z Psychosomatic Medicine & Psychotherapy. 2002, 48, pp. 411-434.
  6. ↑ a b c d L. Goldbeck: Child abuse and child protection. In: F. Petermann (Ed.): Textbook of Clinical Child Psychology. 7th edition. Hogrefe, Göttingen 2013, pp. 661–699.
  7. ↑ a b c d e U. T. Egle, J. Hardt: Health consequences of abuse, mistreatment and neglect in childhood. In: M. Cierpka (Ed.): Early Childhood 0 - 3. Springer, Berlin 2012, pp. 103–114.
  8. ↑ KE Grossmann, K. Grossmann: The Development of Psychological Security in Attachments - Results and Conclusions for Therapy. In: Z Psychosomatic Medicine & Psychotherapy. 2007, 53, pp. 9-28.
  9. ^ DW Brown, RF Anda, H. Tiemeier, VJ Felitti, VJ Edwards, JB Croft, WH Giles: Adverse childhood experiences and the risk of premature mortality. In: American Journal of Preventive Medicine. 2009, 37, pp. 389-396.
  10. ↑ M. Bohus , K. Höschel: Psychopathology and treatment of borderline personality disorder. In: Psychotherapist. 2006, 51, pp. 261-270.
  11. ↑ a b L. Reddemann , U. Sachsse : Trauma-centered psychotherapy for chronic, complex post-traumatic stress disorder with the phenotype of borderline personality disorders. In: O. Kernberg , B. Dulz , U. Sachsse (eds.): Handbook of borderline disorders. Schattauer, Stuttgart 2000, pp. 555-571.
  12. ^ P. Fiedler : Personality disorders. 6th edition. Beltz, Weinheim 2007.
  13. ↑ U. Rauchfleisch : Antisocial Behavior and Delinquency. In: O. Kernberg, B. Dulz, U. Sachsse (eds.): Handbook of borderline disorders. Schattauer, Stuttgart 2000, pp. 381-391.
  14. ↑ S. Barnow: Personality Disorders: Causes and Treatment. Huber / Hogrefe, Bern 2008.
  15. ↑ a b V. J. Felitti, PJ Fink, RE Fishkin, RF Anda: Results of the Adverse Childhood Experiences (ACE) study on childhood trauma and violence. Epidemiological validation of psychoanalytic concepts. In: Trauma & Violence. 2007, 1, pp. 18-32.
  16. ↑ CS Widom: Childhood victimization: Early adversity and Subsequent psychopathology. In: BP Dohrenwend (Ed.): Adversity, stress, and psychopathology. Oxford Univ. Press, New York 1998, pp. 81-95.