5
Childhood Trauma

With the long maturation process in humans comes a prolonged period of vulnerability to developmental trauma. Events occurring during development can have profound and lasting impact on functioning and the brain. For the unwanted outcome of suicide, there appear to be at least two pathways through which developmental events can change risk. First, a large body of research describes the impact of developmental events, including childhood trauma, on the occurrence and severity of the mental and substance abuse disorders that increase suicide risk. Secondly, childhood trauma has emerged as a strong and independent risk factor for suicidal behavior in adolescents and adults (Browne and Finkelhor, 1986; Paolucci et al., 2001; Santa Mina and Gallop, 1998). Therefore, understanding childhood trauma and its psychobiological effects has the potential to illuminate the pathway of causation from early trauma to later suicide. With this understanding comes a lengthy, often years-long, opportunity for targeted intervention, both to prevent childhood trauma from taking place and to minimize its impact if it has occurred. Currently, delivery of appropriate intervention and prevention is hampered by numerous obstacles. These include problems in the responsible educational, legal and medical systems, the stigma of mental illness, and limited knowledge among the public about the importance of early emotional development. For additional discussion, see the Surgeon General’s Conference Report on Children’s Mental Health (PHS, 2000).

This chapter describes major advances in understanding the relationships between childhood trauma and suicidality. The chapter focuses on



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Reducing Suicide: A National Imperative 5 Childhood Trauma With the long maturation process in humans comes a prolonged period of vulnerability to developmental trauma. Events occurring during development can have profound and lasting impact on functioning and the brain. For the unwanted outcome of suicide, there appear to be at least two pathways through which developmental events can change risk. First, a large body of research describes the impact of developmental events, including childhood trauma, on the occurrence and severity of the mental and substance abuse disorders that increase suicide risk. Secondly, childhood trauma has emerged as a strong and independent risk factor for suicidal behavior in adolescents and adults (Browne and Finkelhor, 1986; Paolucci et al., 2001; Santa Mina and Gallop, 1998). Therefore, understanding childhood trauma and its psychobiological effects has the potential to illuminate the pathway of causation from early trauma to later suicide. With this understanding comes a lengthy, often years-long, opportunity for targeted intervention, both to prevent childhood trauma from taking place and to minimize its impact if it has occurred. Currently, delivery of appropriate intervention and prevention is hampered by numerous obstacles. These include problems in the responsible educational, legal and medical systems, the stigma of mental illness, and limited knowledge among the public about the importance of early emotional development. For additional discussion, see the Surgeon General’s Conference Report on Children’s Mental Health (PHS, 2000). This chapter describes major advances in understanding the relationships between childhood trauma and suicidality. The chapter focuses on

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Reducing Suicide: A National Imperative recent population-based studies that redress long-standing methodological limitations that have hitherto cast doubt on the veracity of early trauma as a causative factor in suicidality (for review, see Wagner, 1997). It also describes the biological, cognitive, behavioral, and emotional responses to trauma that may lead to psychopathology and later suicidality. These responses occur against the backdrop of development, which is marked by dramatic changes and emergent functions. Trauma during childhood can disrupt psychological and biological development, as manifested by developmental delays or enduring changes in the anatomy and physiology of the brain (Cicchetti and Toth, 1995; De Bellis, 2001; Glaser, 2000; Heim and Nemeroff, 2001). The impact of trauma on the brain’s stress response systems can make children more vulnerable to later stressful events and to the onset of psychopathology. Childhood trauma can also cause earlier onset of psychopathology and suicidality and lead to a cascade of other life events, each of which increase the risk for suicidality. The relatively new field of developmental traumatology attempts to integrate knowledge from disparate fields of developmental psychopathology, developmental neuroscience, and stress and trauma research (De Bellis, 2001). Developmental traumatology benefits from a solid base of biological, behavioral, and psychological research on the effects of trauma. The integration of many disciplines, involving both human and animal evidence, holds enormous potential for tracing the developmental pathways culminating in mental illness or suicidal behavior. This chapter begins with the range of childhood traumas and their prevalence. It then presents the evidence for childhood trauma as a risk factor for later suicidality. Childhood sexual abuse emerges as such a strong risk factor that the next section covers its quantitative contribution to the extent of suicide nationwide. From there, the chapter deals with the more immediate effects of childhood trauma on children’s biological, psychological, and social functioning. It then covers the relationship between trauma and psychopathology. Finally, the chapter covers possible pathways from childhood trauma to suicidality and how they can be interrupted through prevention and treatment. SCOPE AND DEFINITIONS This chapter covers many types of childhood traumas. The list in Table 5-1 includes the more extreme forms of trauma that have traditionally been grouped together under the term “maltreatment”: physical abuse, sexual abuse,1 neglect, and psychological maltreatment (NRC, 1   Unless specified further, child sexual abuse refers to a range of behaviors from genital touching and fondling to penetration.

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Reducing Suicide: A National Imperative TABLE 5-1 Types of Childhood Trauma Physical abuse by adults or peers Sexual abuse by adults or peers Neglect Psychological maltreatment Witnessing violence, especially against the mother Family members with substance use, mental disorders, suicidality Family members who have been incarcerated Loss or separation from parentsa Childhood socio-economic disadvantagea aNot covered by Felitti et al., 1998, but found significant other studies of suicide attempts or completion (Cheng et al., 2000; Fergusson et al., 2000b). 1993). The list also includes other types of trauma, such as witnessing family violence, parental loss, or other serious family adversities. In keeping with the epidemiological literature, childhood traumas do not include “stressful life events,” which are generally defined as the breakdown of a close relationship, interpersonal conflict with parents or friends, school-or work-related difficulties, and legal or disciplinary crises. Sexual and physical abuse have the strongest relationship to suicidality, but there are several reasons for this chapter’s broad focus on many types of childhood trauma. (1) They are similar in violating the child’s home environment as a safe haven and in compromising parents’ roles as physical and emotional care takers (Margolin and Gordis, 2000). (2) Children are often exposed to more than one type of trauma (Felitti et al., 1998; McGee et al., 1995). For example, one-third to one-half of neglected children witness domestic violence (De Bellis, 2001), and child neglect frequently occurs in association with maternal depression (Glaser, 2000). Furthermore, about one-third of abused adults report both physical and sexual abuse as children (McCauley et al., 1997). (3) Despite the range of trauma types, there are finite ways for biological stress systems to respond, and finite categories of mental disorders associated with trauma (anxiety, mood, and personality disorders, see later section) (De Bellis, 2001). (4) Recent epidemiological research indicates that the adverse, long-term health impact of trauma may be cumulative, irrespective of trauma category. The greater the number of past traumas, the greater the health problems (Felitti et al., 1998; see later section).

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Reducing Suicide: A National Imperative FIGURE 5-1 Types of Child Maltreatment. Source: US DHHS, 2001a. Prevalence of Childhood Trauma National surveillance of child maltreatment is conducted annually through the National Child Abuse and Neglect Data System (NCANDS).2 In 1999, an estimated 826,000 children in the U.S. were maltreated (US DHHS, 2001a). The majority of victims (58.4 percent) suffered neglect, 21 percent suffered physical abuse, and 11 percent suffered sexual abuse (Figure 5-1). The remainder were victimized by other types of maltreatment including medical neglect, abandonment, threats of harm, and congenital drug addiction. The overall child victimization rate for 1999 was 11.8 per 1,000, with only small gender differences.3 Trends can be established by comparing this figure to annual figures dating back to 1990, when national surveillance began. The rate in 1990—at 13.4 per 1000— climbed by 1993 to a peak of 15.3 per 1000, and then gradually declined to 1999 (Figure 5-2). These rates are based on official records of children who come to the attention of child protective services. Rates of physical and sexual abuse are much higher when measured in surveys of parents or victims. Surveys of parents find self-reported rates of child physical abuse that are 5–11 times higher than rates from official records (reviewed in Margolin and Gordis, 2000). In terms of cumulative prevalence, two recent community-based surveys of large 2   The national data collection and analysis is a consequence of the Child Abuse Prevention and Treatment Act of 1988. 3   The rate was 12.2 per 1000 female and 10.8 per 1000 male children (US DHHS, 2001a).

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Reducing Suicide: A National Imperative FIGURE 5-2 Victimization Rates, 1990–1999. Source: US DHHS, 2001a. samples of adult primary care patients found 22–32 percent of them to report ever experiencing physical or sexual abuse during childhood or adolescence (Felitti et al., 1998; McCauley et al., 1997). While neither study asked subjects about the identity of the perpetrator (e.g., parent, other adult, peer), another study of high school girls (grades 9–12) explicitly asked about victimization by dating partners. In this population-based survey, about 20 percent of girls reported having ever been physically and/or sexually abused by a dating partner (Silverman et al., 2001). Traumas arising within the household are also common: about 26 percent of adults reported having grown up in a household4 with substance abuse, 19 percent with mental illness, 12.5 percent with violence against their mother, and 3.4 percent with a household member being incarcerated (Felitti et al., 1998). According to official crime statistics,5 about 30 per 1000 children (ages 12–17) report being victims of serious violent crimes of rape, robbery, and 4   The household adversity could have affected a parent or other adult (Felitti et al., 1998). 5   The National Crime Victimization Survey.

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Reducing Suicide: A National Imperative aggravated assault in 1996—a rate that is almost two times higher than the adult rate (Snyder and Sickmund, 1999). Victimization rates are highest for American Indians and roughly equivalent for Whites and African Americans. Most of these crimes are perpetrated by friends and acquaintances rather than by relatives (11 percent of the total). Bearing witness to community violence is very common in inner city neighborhoods, with estimates of one-third or more of children and adolescents being exposed (for review, see Margolin and Gordis, 2000). Altogether, these disparate statistics on the prevalence of various forms of trauma indicate that, by adulthood, past traumatic exposure is widespread. In one large study, about 52 percent of adults report having ever been exposed to at least one type of childhood trauma covered in this chapter (Felitti et al., 1998). Methodological Issues The study of childhood trauma is beset by methodological limitations (NRC, 1993). These limitations have implications for efforts to understand the relationship between early childhood trauma and later suicidal behavior. The first area of limitation concerns estimates of the incidence and prevalence of childhood trauma. There are two general sources of information about the magnitude of the problem and the relationship of child trauma to other health outcomes: official records; and self-report by victims/survivors and/or their caregivers and parents. Official report statistics are compiled annually from mandated reporters, most commonly social service, education, law enforcement, and medical personnel as well as non-mandated categories of persons including neighbors, kin, and friends. Official statistics cover several types of reportable trauma: neglect, physical and sexual abuse, psychological maltreatment, medical neglect, and miscellaneous types of abuse. Official records are thought to underreport and underestimate the magnitude of child maltreatment because generally only the more severe and “substantiated”6 cases are reported to local and state authorities, which in turn report their findings to the federal government. Some states include cases that are “indicated,” or those cases about which there is a high level of suspicion but insufficient evidence for adjudication by child protection professionals. The other source of information about the magnitude of child maltreatment—self-reports by victims/survivors—is essential because of underestimation by official records. In a large national sample of more than 6   Substantiated cases are those determined by the child protection agency to be valid based on state law or on policy.

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Reducing Suicide: A National Imperative 2000 adolescents, more than 80 percent of abuse victims did not report the abuse to anyone (Edgardh and Ormstad, 2000). All self-reporting is vulnerable to bias, with particular concern for reports elicited years after events. Some studies have suggested that recall of childhood abuse varies with psychological adjustment (e.g., Falsetti and Resnick, 2000), while others have not found an association (Fergusson et al., 2000a; Robins et al., 1985). Examining this issue in a population-based, longitudinal, prospective study with repeated measures of child abuse self-reports, Fergusson and colleagues (2000a) discovered about a 50 percent rate of forgetting and/or not reporting documented abuse during assessments. They found that lack of recall did not vary with psychiatric diagnosis or suicidality. Other available data on reporting bias of childhood abuse also consistently indicates that abuse is significantly under-reported, with, depending on measures used, 40–60 percent lack of recall for documented cases of maltreatment (Fergusson et al., 2000a; Widom and Shepard, 1996; Widom, 1997; Williams, 1994). The reasons are complex, including forgetting (usually if the victim was less than 5 years old), stigma and embarrassment, relationship to the perpetrator, nature of the abusive or traumatic incident, and sensitivity of the survey or interview measures (see for example Kessler, 2000; Williams, 1994). Another concern about self-reports, particularly with sexual abuse, regards repression of memories as a means of self-protection, with later recovery in adulthood. Repression could lead to either false positive or false negative reporting, but the evidence for repression appears to be controversial (Berliner and Williams, 1994; Loftus et al., 1998). There are no data to indicate what percentage of “recovered memories” are inaccurate, but data indicate 47–95 percent of recovered memories of non-bizarre child abuse are confirmed, and only 1–3 percent of bizarre abuse memories are confirmed (Bowman, 1996a; Bowman, 1996b). A recent study demonstrated that 74 percent of both always recalled and recovered memories could be confirmed from a legal point of view (Dahlenberg, 1996). The aforementioned analysis of longitudinal data by Fergusson’s team (Fergusson et al., 2000a) further suggests that forgetting and later recall of childhood abuse represents a common phenomenon not associated with psychopathology, though they could not distinguish between active repression and simple forgetting. These investigators caution that recall bias obscures true prevalence rates of child maltreatment, though it does not, it appears, significantly alter estimates of relative risk of child abuse for subsequent psychological disorders. A second limitation in the current research on childhood abuse is the use of inconsistent and imprecise definitions of maltreatment (NRC, 1993). Definitions may vary among mandated reporters, both within and across agencies, localities, and states, thereby affecting official reporting statis-

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Reducing Suicide: A National Imperative tics in unknown directions. Definitions also vary across research studies, making comparability problematic. Studies attempting to link child maltreatment and suicide, then, might misestimate the relationship based on the definition of child maltreatment employed. The third limitation is instrumentation. Previous reports by the National Research Council have commented on the lack of reliability and validity testing of self-report instruments (NRC, 1993). However, recently published studies have begun to address this problem (e.g., Bremner et al., 2000; Straus et al., 1998). A fourth limitation is that child maltreatment questions are often excluded from larger studies and epidemiological surveys of children, representing significant missed opportunities. The reasons for the exclusion is that identifying victims triggers responsibility to report potentially illegal activity and to provide them with care and treatment (NRC, 1993). Ethical dilemmas and mandated reporting laws have thus constrained research seeking to question children directly about maltreatment (Black and Ponirakis, 2000; King and Churchill, 2000; Knight et al., 2000; NRC, 1993). Most studies have therefore relied on convenience and clinical samples of adults that restrict the generalizability of the results, making recent nationally representative (e.g., Molnar et al., 2001a) and population-based child samples (e.g., Fergusson et al., 2000b) critical. Finally, the bulk of research on child maltreatment’s role in suicidality employs cross-sectional, retrospective designs generally incapable of establishing variables as causative (see Wagner, 1997) Researchers are therefore increasingly using pathway analyses and controlling for possible confounding variables (e.g., Brent et al., in press; Fergusson et al., 2000b; Yang and Clum, 2000). All of these methodological limitations must be kept in mind in attempts to link childhood trauma to health outcomes, including suicidality. CHILDHOOD TRAUMA AS A RISK FACTOR FOR SUICIDALITY Childhood trauma, especially child sexual abuse, has been identified as a strong risk factor for suicidality. A large body of national and international evidence supports the relationship, including many recent studies from the United States, Sweden, New Zealand, and Australia. An earlier review of about 20 studies, published between 1988 and 1998, assessed the evidence for physical or sexual abuse in relation to suicide attempts (Santa Mina and Gallop, 1998). The review concluded that, despite methodological limitations, there was robust evidence linking childhood sexual and physical abuse and suicidal behavior. The odds ratios from these studies ranged from 1.3 to 25, indicating that adults with

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Reducing Suicide: A National Imperative a past history of abuse were up to 25 times more likely than adults without a past history to attempt suicide. Child sexual abuse, in particular, was examined in a meta-analysis of 37 studies published between 1981 and 1995 (Paolucci et al., 2001). The total number of subjects was more than 25,000. The unweighted and weighted effect sizes of child sexual abuse on suicide were 0.64 and 0.44,7 confirming a substantial link between child sexual abuse and suicide (defined as suicidal ideation or a suicide attempt). A spate of recent, well-designed studies, including prospective studies, add to this body of evidence (Table 5-2). Virtually all studies found a significant relationship, with odds ratios ranging from about 2 to 10. These odds ratios were derived from prevalences of about 21–34 percent of participants having a past history of abuse or neglect and making a suicide attempt versus about 4–9 percent of participants without a history of abuse or neglect making an attempt (Brown et al., 1999; Fergusson et al., 2000b; Molnar et al., 2001a). The only negative study in Table 5-2 was restricted to physical abuse in children ages 9–17 (Flisher et al., 1997). The difference may be explained by study subjects being younger and by suicide attempts being ascertained only for the previous 6 months. Most other studies record any past suicide attempt. Beyond maltreatment, other childhood adversities have been studied in relation to suicide attempts, but the associations are generally not as strong. Significant associations from large, population-based studies have been found for parental psychopathology (especially depression) or substance use disorders, parental suicide, and family socioeconomic adversity (Fergusson et al., 2000b; Molnar et al., 2001a). Other family factors, while also significantly associated with suicide attempts, were not found by Fergusson and colleagues (2000b) to be independent predictors: parental history of alcoholism/alcohol problems; parental changes due to separation/divorce, death, remarriage and reconciliation; parental history of illicit drug use; and parental history of criminal offending. Nevertheless, these other types of family traumas have a cumulative effect on suicide attempts and independent associations with psychopathology, as explained in later sections. It is important to point out that the studies in Table 5-2 measure suicide attempts as opposed to suicide completion. The psychological autopsy method used for studying suicide victims cannot readily ascertain physical or sexual abuse because family members and friends are generally reluctant to disclose, or lack knowledge of, the abuse. The sole 7   Weighting based on study sample size.

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Reducing Suicide: A National Imperative TABLE 5-2 Child Trauma as a Risk Factor for Attempted Suicide: Recent Large, Controlled Studies Citation No. Subjects Odds Ratio for Suicide Attempts Prospective, Population- or Community-based Studies Silverman et al., 1996 375 Physical abuse Sexual abuse 8a 14.4a Brown et al., 1999 776 Sexual abuse Physical abuse Neglect 5.71b 1.79b 1.42b Fergusson et al., 2000a 1265 Sexual abuse Physical abuse 7.9 5.41 Cross-sectional, Population- or Community-based Studies Molnar et al., 2001a 5877 Ages 15-54 Rape and molestation 3-11 Silverman et al., 2001 2186 Girls Intimate partner violenced 8.6 Dinwiddie et al., 2000 5995 twins Adults Sexual abuse 7.07-7.74 Edgardh and Ormstad, 2000 1943 Age 17 Sexual abuse 4.36-9.28 Flisher et al., 1997 665 Ages 9-17 Physical abuse Not significante Cross-sectional, Community-based Primary Care Felitti et al., 1998 9508 Adults 1-4 or more categories of adverse childhood exposuresd 1.8-12.2 McCauley et al., 1997 1931 Women Physical or sexual abuse 3.7c aFemales only. Findings for physically abused males were non-significant, and males were not assessed for suicide attempts and sexual abuse because too few males were affected. bAfter controlling for other factors. Neglect and physical abuse were not significant, as confidence intervals included 1.0. cCrude prevalence ratio reported by study. d1999 only; Intimate partner violence= physical and/or sexual. Adverse childhood exposures refers to psychological, physical, or sexual abuse; violence against mother; or living with household members who were substance abusers, mentally ill or suicidal, or ever imprisoned. eSuicide attempts in the past 6 months only.

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Reducing Suicide: A National Imperative suicide completer study to have included a measure of past abuse found very large odds ratios of 11.7–49.3 for suicide by adolescents (Brent et al., 1999). These odds ratios were derived from prevalences of 30–42 percent of suicides having an abuse history versus about 2.5 percent of matched controls without a history of abuse. Abuse history, obtained as part of a life events inventory, was collected from about half of subjects and all of controls (n=131). Thus, this study of suicide victims confirms studies of suicide attempters on the importance of abuse as a risk factor. Daniel, an 18-year-old college freshman, was the eldest of three children. Throughout his childhood, Daniel was physically beaten by his alcoholic father…. At the age of 13, Daniel chose to live with his divorcing mother while his two siblings stayed with the father…. The family was bitterly divided and his father refused to pay his mother any alimony. [He] earned … an academic scholarship at a local university. In the summer prior to his freshman year, Daniel’s mother was diagnosed as having inoperable stomach cancer and she died one month prior to Daniel’s starting college…. His Thanksgiving visit to his father’s home was a disaster. Daniel returned to school a day early. On the night of his return, Daniel called his father and during an argument on the phone, shot himself in the head with a revolver he had apparently taken from his father’s home. Daniel’s last words to his father prior to the fatal gunshot were “I hate me and I hate you—it’s time for the big payback, Dad….” (Berman & Jobes, Adolescent Suicide: Assessment and Intervention, 1991:40-41). CHILDHOOD SEXUAL ABUSE AND POPULATION ATTRIBUTABLE RISK FOR SUICIDE Child sexual abuse carries the highest risk of a suicide attempt compared with other types of childhood maltreatment (Table 5-2). For example, Brown and colleagues (1999) found that sexual abuse carried higher odds ratios for a suicide attempt than did physical abuse or neglect, after controlling for other contextual factors. Child sexual abuse also carried the highest odds ratio for suicide attempts in a prospective, population-based study in New Zealand (Fergusson et al., 2000b). Sexual abuse also carried an extremely high risk (OR=30.3) for repeated suicide attempts in adolescents (Brown et al., 1999). Based on the strength of childhood sexual abuse as a risk factor, several population-based studies calculated the percentage of suicide attempts that are attributable to child sexual abuse, i.e., the population

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Reducing Suicide: A National Imperative affect brain development, ushering in a failure to self-regulate emotion and behavior, especially upon exposure to other traumas or to stressful life events. This failure to regulate emotion and behavior underlies a range of behavioral outcomes: externalizing behavior, internalizing behavior, as well as cognitive and learning disorders. By early to middle childhood, these problem behaviors can lead to chronic PTSD, depression, attention-deficit disorders, and poor school performance. These can progress to, or be accompanied by, conduct disorder or substance abuse by adolescence and personality disorders by adulthood. These models represent a milestone in attempting to integrate the wide-ranging short-term and long-term effects of childhood trauma. They form an important departure point for integrative neuroscience research to examine biological, psychological, and behavioral measures and their interactions. What makes this line of research even more challenging is that trauma can occur at distinct stages of development. There is likely to be a diversity of pathways from childhood trauma to suicidality, any of which can by determined by (or interrupted by) a host of risk and protective factors prior to, during, or after trauma exposure (Cicchetti et al., 2000; Fergusson et al., 2000b). These risk and protective factors can arise in the individual (e.g., genes, age, gender, temperament), family, school, peer group, or community (US DHHS, 1999). PREVENTION/INTERVENTION In the United States, the health and welfare of children are protected by multiple institutions: schools, the health care system, and the legal system. According to the Surgeon General’s Conference Report on Children’s Mental Health (PHS, 2000), these systems have been largely ineffective at improving the health of our children. The prevalence of serious emotional disturbances is no different in younger versus older children and has failed to change over the last 20 years (PHS, 2000). The Surgeon General’s Report goes on to suggest that integration of these systems, along with home and community care, would enhance timely recognition of children at risk, and therefore enable delivery of databased interventions prior to any further developmental costs (PHS, 2000). Given the impact of child abuse on risk of suicide, such an integration of services would likely have positive repercussions for this important outcome, as well. Family-oriented programs are effective in the prevention of child abuse. A meta-analysis found a weighted effect size of .41, meaning that programs were effective by comparison with control/comparison groups. The greater the level or frequency of intervention, the more successful the program in preventing child abuse (MacLeod and Nelson, 2000). One of

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Reducing Suicide: A National Imperative the most prominent programs is a home visitation program by nurses targeted to high risk mothers during pregnancy and infancy (almost 25 visits). A 15-year follow-up of a home visitation program with a randomized controlled design found lower incidence of verified reports of childhood abuse and neglect in comparison with families in comparison group (Olds et al., 1997). Since social supports significantly influence the intergenerational cycle of child abuse (Egeland et al., 1988), intervention programs that offer support to high-risk children and their families can be of great benefit in terms of providing protective functions and promoting positive outcomes (Berrueta-Clement, 1984; Consortium for Longitudinal Studies, 1983; Copple et al., 1987; Price et al., 1988). Individuals with a history of child abuse may require alternative approaches to standard treatment. Holmes (1995) found that within a group of adults being treated for depression and anxiety, a history of child abuse was the main determinant of treatment effectiveness. However, while the various psychological treatments were very effective for patients without a history of abuse, they were ineffective for those with a history of abuse. Consequently, Stevenson (1999:92) points out that “the assumption that treatments found to be effective in general are also likely to be of greatest benefit to victims of maltreatment needs to be treated with caution.” Yet the controlled clinical trials conducted thus far have found that cognitive-behavioral therapy for child sexual abuse, in particular, is effective at reducing symptoms of anxiety and depression, both risk factors for suicide, in children. These trials included treatment of non-offending parents (Cohen and Mannarino, 1996; 1998; Deblinger and Heflin, 1996; King et al., 2000). The American Academy of Pediatrics recommends universal screening of adolescents for sexual victimization (AAP, 2001). While there appears to be no formal study of pediatrician practices, it is believed that universal screening is not done as frequently or consistently as it should be (Personal communication, D.W. Kaplan, University of Colorado, October 11, 2001). FINDINGS Childhood traumas are highly prevalent in the population and elevate suicide risk. While childhood abuse increases the risk for development of mental disorders, it also may be a risk factor for suicide independent of psychopathology. Of the many types of childhood trauma, childhood sexual abuse is the strongest and most independent risk factor for suicide attempts, accounting for 9–20 percent of suicide attempts. Exposure to trauma can affect the developing brain with potentially lifelong alterations in the physiological stress response system and

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Reducing Suicide: A National Imperative cognitive development. Childhood trauma also has psychological and behavioral effects, including low self-esteem, poor attachments to caregivers, and substance use, all of which are associated with suicide. The study of childhood trauma and its relationship to suicide offers a powerful opportunity for integrative neuroscience research. Interdisciplinary research that weaves together biological, cognitive, and social effects of trauma has the potential to elucidate the complex pathways from childhood trauma to mental illness and/or suicidality and thereby elucidate multiple possibilities for intervention. Early adversity increases the likelihood of developing mental illnesses associated with suicide risk, such as substance use, posttraumatic stress disorder, and depression. Understanding the precise pathways from childhood trauma to suicidality has been hampered by the paucity of longitudinal, population-based studies and the legal and ethical difficulties of asking children and adolescents about childhood sexual and physical abuse. The field requires longitudinal, inter-sectoral research to reveal post-trauma protective factors and processes and effective means of intervention and prevention across the life span. Including measures of suicidality in follow-up studies of child abuse prevention programs would yield invaluable information for suicide reduction strategies. Early treatment for child abuse survivors and early family-based interventions to reduce child abuse are expected to reduce suicide. Society has a large window of opportunity to treat identified victims of childhood trauma in order to minimize the likelihood of psychopathology and suicidality. The development of biological, social, or cognitive markers to identify children at greatest risk for adverse effects could enhance targeted prevention/intervention efforts. REFERENCES AAP (American Academy of Pediatrics, Committee on Adolescence). 2001. Care of the adolescent sexual assault victim. Pediatrics, 107(6): 1476-1479. Agid O, Shapira B, Zislin J, Ritsner M, Hanin B, Murad H, Troudart T, Bloch M, Heresco-Levy U, Lerer B. 1999. Environment and vulnerability to major psychiatric illness: A case control study of early parental loss in major depression, bipolar disorder and schizophrenia. Molecular Psychiatry, 4(2): 163-172.

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Reducing Suicide: A National Imperative Life is what I want; dutifulness is also what I want. If I cannot have both, I would rather take dutifulness than life. —MENCIUS (VI.A.10)