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The Neurocognitive and Psychosocial Impacts of Violence and Trauma

Proceedings of a Workshop—in Brief

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Washington (DC): National Academies Press (US); .

April 2018

Childhood experiences, both positive and negative, can affect an individual's health and opportunities as an adult and have far-reaching effects on future violence victimization and perpetration (Widom and Maxfield, 2001). To better understand the impact of violence and trauma on neurocognitive functions and psychosocial well-being, the Forum on Global Violence Prevention convened a 2-day workshop July 31– August 1, 2017. The workshop approached childhood experiences, violence, and trauma from a broad range of perspectives and participants heard from survivors of trauma, researchers, and practitioners. The presentations on the first day took a systems-based approach, with speakers and participants exploring the ways in which the growing science around adverse childhood experiences could be moved from evidence into practice through the integration of trauma-informed approaches across those systems most likely to interact with children. The presentations on the second day explored new perspectives across the lifespan, with speakers addressing mental health outcomes, the impact of violence on the aging brain, best practices in building resilient individuals and communities, the effects on first responders, and trauma experienced in the line of duty. Both the talks from invited speakers and the workshop discussions drew on a broad variety of disciplines and perspectives, including public health, behavioral sciences, medicine, education, human rights, policy, and legal sectors.

INTRODUCTION TO THE WORKSHOP

Sheldon Greenberg of Johns Hopkins University highlighted the workshop's overarching message of the multiple ways that trauma can affect individuals as well as the opportunities to prevent, intervene in, and respond to trauma exposure in meaningful ways to reduce the negative outcomes of such exposure.

THE LIVED EXPERIENCE OF TRAUMA

Adam Swanson of the Education Development Center spoke of using his lived experience and content expertise to advocate on behalf of others. Swanson stressed that his own history of abuse, victimization, rape, and trauma is an all too common experience. He said that according to the Centers for Disease Control and Prevention (CDC), lesbian, gay, and bisexual youth are four times more likely to attempt suicide than their heterosexual peers (CDC, 2011), and further, for lesbian, gay, and bisexual individuals in the United States, two-thirds experienced some form of discrimination, verbal harassment, or rejection by family or friends, with 30 percent being physically threatened or attacked (Pew Research Center, 2013). Swanson spoke of how, at age 24, in therapy and on medication yet crying and shaking and unable to see family or friends as a resource, he turned to the campus mental health center to seek help. Yet, rather than receiving services, he said, the police were called, and they responded with mockery and threats as they drove him to the psychiatric hospital. Swanson noted that discrimination, be it overt or subtle, when combined with ill-informed responses to trauma, can lead to mistrust of the very systems designed to provide protection, leaving people unsure of where to go for help. Individuals, family members, and violence prevention practitioners all have the responsibility to do something and to really listen with compassion, Swanson said. He stressed that knowledge and the science exist to help individuals move from grief to action, hurt to hope, and data to practice, without labels and without judgment, and to change lives. Swanson closed by inviting participants to engage in the discussions of problems and solutions that can help people survive and thrive.

CONTEXT OF THE PROBLEM: THE PUBLIC HEALTH AND BRAIN DEVELOPMENT OVERVIEW

During this panel session, moderated by Arturo Cervantes of Mexico's Anáhuac University, speakers addressed the scope and nature of exposure to trauma and violence in childhood from public health, brain development, and child development perspectives.

The Public Health Context of Exposure to Trauma and Violence

According to Melissa Merrick from the Division of Violence Prevention at CDC, early adverse childhood experiences (ACEs), are an urgent public health problem, with 1 billion children experiencing violence annually and about one in seven children having experienced child abuse and neglect in the previous year, which is probably underreported. She described the first ACEs study, which was convened in the late 1990s through a collaboration between CDC and Kaiser Permanente, with a sample of 17,000 adults who were asked to retrospectively report experiences prior to age 18 in three categories: abuse (physical, emotional, sexual), neglect (physical, emotional), and family challenges (mental illness, divorce, mother treated violently, substance abuse, incarcerated relative). While the original sample contained mostly white adults, all of them with insurance coverage, Merrick said that 39 states and the District of Columbia now include ACES information in their Behavioral Risk Factor Surveillance System (BRFSS), which is carried out by telephone surveys that ask participants to self-report health behaviors, conditions, and the use of preventive services. She described how the current findings, representing 70,000 persons, remain similar over time; for example, lasting effects on health (i.e., obesity, diabetes, pulmonary disease, broken bones), behaviors (smoking, alcoholism, drug use), and life potential (graduation rates, academic achievements, lost time from work) did not experience significant changes over time. She said that increases in ACES scores were found to be directly related to negative impacts on physical and mental health. It is also important, Merrick stressed, to recognize the complexities of experiences and to realize, for instance, that an adverse incident may under some circumstances become a protective factor (such as leaving an abusive family environment). She said that CDC has developed technical packages that present strategies to prevent child abuse and neglect, ranging from changing social norms and economic strengthening, to interventions designed to reduce risks and harms. She added that violence prevention is strategic and requires developing new partnerships and working across sectors.

Early Experience and Brain Development

Charles Zeanah, Jr. of Tulane University told the audience that brain development begins in the fourth prenatal week and continues into middle adulthood and that structural brain development (how people become who they are) is dependent on biological inheritance (genes) and individual experiences. Using a stack of blocks as a visual, he explained that the foundation is important and that basic information circuits are wired first, with the higher circuits building on lower circuits and leading to skills. Experiences are incorporated into the structure of the brain through experience-expectant development and experience-dependent development. Experience-expectant development, he explained, refers to expected experiences, such as when complex auditory information facilitates the development of language processing or the availability of a caregiver facilitates the development of attachments. Experience-dependent development is unique to each person, Zeanah said, and the active formation of new synaptic connections (across the lifespan) is based on one's interactions with the environment (e.g., remembering events, acquiring vocabulary, quality of attachment). Zeanah stressed that adverse experiences will have a negative impact on brain development and that threats, abuse, and violence lead to an excessive activation of fear circuitry and stress response systems, which will then compromise normal brain development. He also said that the plasticity of the brain decreases over time, so early intervention is key for trauma-impacted individuals. He stressed that there are critical periods during brain development that are affected by both good and bad experiences and that affecting the brain during these sensitive periods makes recovery more difficult to the point that some impacts during critical periods may be irreversible. Noting that building a healthy brain requires a primary caregiver relationship, he suggested that caregiver relationships are the most important context for child development.

Violence and the Developing Teen Brain

The brain, said Jay Giedd of the University of California, San Diego, adapts to the environment and grows by becoming more interconnected and more specialized (such as in areas of decision making). He highlighted a National Institutes of Health (NIH)-sponsored, 23-year longitudinal study exploring the development of the brain, including the mechanisms of and influences on that development, through both health and illness. The study uses combined brain imaging, genetics, and psychological/behavioral assessments. Giedd noted that focusing on teens provides an opportunity to look at the downstream effects of earlier trauma, which can be one-time acute trauma, chronic (e.g., recurring) abuse, and complex trauma or abuse. Giedd clarified that the relationship between violence and brain development depends on various factors, and there is evidence that the effects vary according to the type of trauma, individual, environment, and stage of development. As the brain matures by becoming more interconnected, he added, the plasticity of brain maturation confers both vulnerability and opportunity. For example, 75 percent of mental illnesses occur by age 20, Giedd said, noting that the teen brain is different than the brain of a child or an adult. He described the Adolescent Brain Cognitive Development (ABCD) study, a 10-year longitudinal study of 12,000 9- and 10-year-olds across 22 sites, which expanded its measurements to include the use of sensors designed to monitor heart function and behavior, environmental toxins, and social media activity. He added that humans have no known biological limitations to making change, as the brain is very adaptable during adolescence and even changeable until an individual reaches 25–30 years of age and that this window in particular provides an opportunity for positive change.

TRAUMA-INFORMED GAPS IN THE SYSTEMS THAT IMPACT CHILDREN

The panel used a systems-based approach to highlight the science of ACEs and trauma exposure from practice perspectives within the education, juvenile justice, and health care systems and settings, and spoke about how to incorporate trauma-informed approaches and knowledge into practices and programs.

Trauma-Informed Approached in the Education System

Dana Charles-McCoy of Harvard University's Graduate School of Education identified schools as one of few systems where all children are served and said they thereby offer an opportunity to either mitigate or enhance the effects of violence. Speaking of how to optimize trauma-exposed children's outcomes, she focused on the importance of three things: skill building, taking a holistic approach, and early implementation. She began by discussing how skill building reduces adversity and provides support, which in turn helps children to acquire social-emotional skills; in particular, she cited evidence that the provision of early social-emotional supports (e.g., learning to respect peers and adults and follow directions) has been shown to produce valuable results later in life when the individuals are adults. These results include increased academic achievement, stronger mental and physical health, reduced violence, and increased earnings. Charles-McCoy also reported that social-emotional skills are far more predictive of adult success than IQ and that they must be intentionally taught. A holistic approach, she explained, views violence as affecting children directly and indirectly; direct exposure (witnessing, direct victimization) tends to have effects that are acute and intense, she said, while the effects of indirect exposure tend to be longer lasting and pervasive. To address this, she emphasized, educational systems need to serve as leaders in defining social norms and identifying expectations in behaviors. They also need to include direct support to affected children (i.e., mental health and counseling services) and extend this support to individuals and systems that support children, such as wrap-around services for children and families and services for teachers and staff. She also stressed that early implementation is key, as the preschool age period is an important “window of opportunity” to build social-emotional skills, and early childhood interventions have been shown to be highly cost-effective. Charles-McCoy also highlighted various good practices, including teaching children problem-solving strategies, positive self-regulation, and conflict resolution.

Trauma and the Juvenile Justice System from a Lived Experience Perspective

Hernan Carvente of the Vera Institute of Justice spoke from the perspective of the lived experience, including within the juvenile justice system. Born in Mexico, he witnessed his mother being physically beaten by both his father and grandfather, and he said that his perception of safety was altered by age 5. After he moved with his family to the United States at age 8, he said, his parents' daily fear of deportation meant he could not seek help, as doing so would put his parents at risk. Carvente spoke openly of being incarcerated at age 15 for attempted murder, which he connected to the traumatic environment of the daily violence in the community and of witnessing people being shot or stabbed as well as to participation in gang fights. Today, Carvente said, there are 54,000 incarcerated youth in the United States, and, as with his experience, many of them are living with internalized trauma, having been failed by every system (e.g., schools, family, community). He added that the juvenile justice system strips opportunity and decision making from young people both within the system and in the community, and he said that this group needs to have a voice. He also stressed the need to support community-based workers and the professionals doing this work (including law enforcement, teachers, and those working in the juvenile justice system) and to create a system that understands the value of the human experience and of each person. Carvente spoke of the importance of investing in community alternatives, such as supports that help young people and communities to heal and connect to peers, family, and mentorship.

Trauma-Informed Approaches Within the Health Care System

Trauma significantly impairs quality of life, resulting in increased risk of suicide, poorer overall physical health, and large economic costs to society, according to Terri deRoon-Cassini of the Medical College of Wisconsin. Her approach views trauma as a disease that has biomedical, psychological, and social-environmental impacts, she said, citing evidence that compares injuries due to violence with other types of injuries. The violence-induced injuries are associated with greater inflammation and higher sympathetic nervous system activation, worse posttraumatic stress disorder (PTSD) and depression outcomes, and poorer social-environmental outcomes, such as lower socioeconomic status, higher exposure to community violence, and lower rates of returning to work. Research has shown, she said, that assaultive (violent) trauma results in higher levels of PTSD severity at baseline, which increases significantly in 6 months, and that exposure to pre-injury stress and trauma increases the likelihood of developing PTSD. Saying that the lived experience matters, she described research showing that childhood trauma history significantly predicts different biologic pathways to PTSD. It is important to take a holistic approach, she added, as injury severity is both related to a person's perception of the likelihood of his or life ending and a strong contributing factor to poorer physical and mental health (deRoon-Cassini et al., 2010). She highlighted the MAPIT Approach (Multi-tier Approach to Psychological Intervention after Traumatic Injury), a multidisciplinary approach to physical, psychological, and social-environmental interventions, including outpatient services. deRoon-Cassini also stressed the importance of looking at the socio-ecological factors (i.e., discrimination, exposure to community violence) that lead to differences in biological vulnerability that can in turn lead to negative health outcomes after trauma.

INCORPORATING TRAUMA-INFORMED APPROACHES INTO IDENTIFIED SYSTEMS

The next panel, moderated by Valerie Maholmes of NIH, addressed opportunities to incorporate trauma-informed approaches and best practices into institutions and policies and highlighted areas for collaboration across sectors and systems to reduce the negative impacts of trauma exposure and the risk of re-traumatizing already exposed children.

Exploring Potential Opportunities for Adverse Childhood Experiences Prevention in Early Learning and Care Partnerships

David Jacobson of the Education Development Center outlined the challenges to ACEs prevention, such as fragmentation in systems and schools, competing national initiatives, inconsistent quality and age-span gaps in prevention efforts, and a lack of coordination at each stage of development. He said that poverty and family instability adversely affect children and require a multi-faceted response in the early years of life. Jacobson discussed the P-3 Continuum Model, which focuses on children up to age 9 using family engagement and support combined with high-quality teaching, learning, and care to lead to grade 3 academic and social-emotional proficiency. The model includes wraparound programs and services such as enrichment, after school programs, and mental health and physical health. Jacobson also discussed the P-3 Model of the Chicago Child–Parent Centers, where studies found academic gains through high school level, a reduced need for remedial education and special education, lower rates of substance abuse, increased educational attainment and less involvement in the justice system, lower rates of depression, higher income, and a savings of $11 for every dollar invested. Jacobson said success comes from being community based, having increased family engagement and support, strengthening neighborhoods and communities, and engaging in cross-sectoral partnerships. He noted similar findings in the 2015 report from the Cambridge Early Childhood Task Force. He also outlined the report's five recommended goals for addressing achievement and opportunity gaps in order to reduce ACEs (Cambridge Early Childhood Task Force, 2015).

Exploring Potential Opportunities for Trauma-Informed Reform in the Juvenile Justice System

Jane Halladay Goldman of the National Center for Child Traumatic Stress spoke of changing the trajectories of justice-involved youth through trauma-informed, evidenced-based approaches that raise the standard of care and increase access to services for traumatized children, families, and communities. She explained that adolescent development involves the interplay of biological, psychological, and social factors, and she said that the policies of many child-serving systems (schools, child welfare, and juvenile justice) inhibit the needs of the developing adolescent. She explained that connecting trauma and adolescent development calls for an understanding of the impact of trauma reminders, the caregiver's own history of trauma, and how damage to a youth's social contract can affect how that youth interacts with authority figures and systems. For example, trauma reminders can lead to behaviors that seem out of place, but were appropriate—and perhaps even helpful—at the time of the original traumatic event. She described an analysis by the 2013 National Child Traumatic Stress Network of trauma histories among 658 youth (ages 13–18) that had been recently involved in the juvenile justice system. That study found that trauma begins early in life and persists across childhood and adolescence, with more than one-third of youth experiencing multiple exposures each year, with an increased prevalence over time (Dierkhising et al., 2013). Goldman outlined the essential elements of a trauma-informed juvenile justice system, which include trauma-informed policies and procedures, standard of care to include engaged screening of youth for trauma, linguistically and culturally sensitive clinical assessments and interventions, trauma-informed programming and staff education, and the prevention and management of secondary traumatic stress in the workplace to support workforce safety, effectiveness, and resilience. She also noted the importance of cross-system collaboration that includes integrated services with confidential sharing of information across integrated systems.

Bringing Trauma-Informed Care into Primary Care Settings

Larke Huang from the Substance Abuse Mental Health Services Administration (SAMHSA) spoke of SAMHSA's commitment to implement and study trauma-informed approaches throughout health, behavioral health, and related systems. She referred to SAMHSA's guidance, Concept of Trauma and Guidance for a Trauma-Informed Approach, which includes 10 key domains ranging from governance and leadership to cross-sector collaboration, financing, and evaluations (SAMHSA, 2014). She discussed how the guidance has the four Rs of model programs: realize trauma is widespread and recoverable, recognize signs and symptoms, respond appropriately with best practices, and resist retraumatization. She described the principles of a trauma-informed approach as addressing cultural, historical, and gender issues; trustworthiness and transparency; peer support; safety; collaboration and mutuality; and empowerment, voice, and choice. Huang reviewed research done by the Children's Hospital of Philadelphia's Center for Pediatric Traumatic Stress, which is part of the National Child Traumatic Stress Initiative. In that study, 80 percent of children and parents reported acute posttraumatic stress (PTS) reactions in the first month after an acute medical event (injury, cancer, transplant). She stressed the impact of health disparities on trauma-informed care and risk factors for medical trauma, citing as an example a study of children in emergency departments for abdominal pain that found that black children were less likely to receive pain medications and both black and Latino children were more likely to spend more than 6 hours waiting for service (Blackwell et al., 2014). Huang presented some resources available to providers, such as the HealthCare Toolbox, which includes interactive online training and education focused on providers in health and child welfare settings.

EXPLORING POTENTIAL PREVENTION AND INTERVENTION APPROACHES TO STRENGTHEN RESPONSES TO EXPOSURE TO TRAUMA IN CHILDHOOD

The panel, moderated by Jerry Reed of the Education Development Center, explored practical examples of community-based and social media programming designed to prevent or provide early intervention in cases of exposure to trauma in childhood and to empower youth, caregivers, community members, and those working directly with children.

Using Trauma-Informed Approaches to Redirect At-Risk Youth: Youth Guidance

Phillip Cusic works with the Youth Guidance Program, which focuses on education as an opportunity to help children overcome obstacles and succeed in school and in life. He described the findings of one school-based program, the Becoming a Man (BAM) Project. Based in Chicago public schools, the program reached 4,031 students in 61 schools in the 2016 academic year, all of them male students (grades 7–12) living in economically disadvantaged and high-risk environments. He spoke of how groups of 12 to 15 young men, approximately 67 percent African American and 30 percent Latino, meet weekly with a BAM Counselor during the school day for 2 years and how counselors use check-ins, stories, roleplaying, and group missions to teach social cognitive skills, such as self-awareness, emotional regulation, responsible decision making, and social awareness. Cusic explained that the program helps students connect thoughts, feelings, and actions in order to positively express their emotions, and it includes activities designed to help students deliberately choose responses to challenging situations both within and outside of the BAM circle, with the goal of identifying the difference between intent and impact and learning to take ownership of actions. He highlighted data from two randomized controlled trials conducted by the University of Chicago Crime Lab (Heller et al., 2017). He described the first study, which was conducted during academic year 2009–2010 (with 7th- through 10th-graders), and the second study, conducted over academic years 2013–2015 (with 9th- and 10th-graders), both of which found a statistically significant reduction in violence-related behaviors. He said that Study 1 found a 45 percent decrease in likelihood to commit violent crime during the program year and Study 2 reported a 50 percent decrease; the likelihood of being arrested decreased by 26 percent and 35 percent, respectively, and the likelihood to commit “other” crimes during the program year decreased in Study 1 by 38 percent and in Study 2 by 43 percent. Cusic explained that the program findings also included an increase in social-emotional skills and an increase in school engagement (i.e., reduced dropout rates, higher grades). BAM has scaled lessons learned through developing a training academy and, according to Cusic, has used qualitative data from youth and counselor interviews to design a youth-centered curriculum addressing social norms, agency, and empathy. He described a similar program for women—Working on Womanhood (WOW)—that also provides counseling, workforce development, and after-school programming.

Changing Minds: The Campaign to End Childhood Trauma

Brian O'Connor of Futures Without Violence spoke about the work of the Childhood Trauma Changing Minds Campaign, which is based on the understanding that witnessing traumatic events, such as fighting, shootings, or domestic violence, can affect the physical development of a child's brain and can have lifelong repercussions on health and social issues. He described how the Changing Minds Campaign is targeted to adults in school, health, and community settings and teaches the science of childhood trauma and provides opportunities to engage daily in a child's life to provide support and positive environments. O'Connor stressed that having a supportive, caring adult in a child's life is an important factor in helping a child or youth overcome the effects of childhood trauma. He outlined five actions that can create a difference, which are listening and showing interest in a child's ideas, using affirming language and not put-downs, comforting through calmness and patience, inspiring a child by sharing new ideas, and focusing on building collaborations with the child or youth. He described how the campaign uses online video, a website, social media, web banners, print materials, and direct mail to reach communities. He mentioned toolkits and resources designed to help activate community members and schools to be part of the campaign and he described the Changing Minds Institute, which works with community-driven, multi-disciplinary teams to help develop a strategic plan for enhancing opportunities for healing and wellness in schools and community.

IMPACTS OF TRAUMA ACROSS THE LIFE-COURSE AND ACROSS SETTINGS

The next panel, moderated by Kristen Kracke of the U.S. Department of Justice, addressed how trauma exposure affects mental health—in particular how trauma affects individuals across the lifespan as well as entire communities—and it dealt with opportunities to build resilient, trauma-informed communities across the lifespan.

Mental Health Outcomes Across the Life-Course

Research has found that the majority of persons exposed to violence will have no mental health sequelae after the trauma, with 6 out of 10 reporting no noticeable symptoms of depression or anxiety following a violent encounter, said Maria A. Oquendo of the University of Pennsylvania (Friborg et al., 2015). Looking at the mental health sequelae of violence and trauma from a lifespan perspective, she said, the research showed that more than 30 percent of adult psychopathology is directly related to childhood maltreatment, including PTSD, major depressive disorder, anxiety, suicidal behavior, substance abuse, antisocial behaviors, and feelings of worry, loneliness, and low quality of life in later life. On the specific issue of discussing interpersonal violence (IPV), Oquendo said that mental health problems and psychiatric symptoms increased in step with the severity of IPV; she added that a perception that the IPV had ended was found to be a protective factor. Violence or abuse in childhood has a direct and transgenerational impact, she said, with childhood sexual abuse in the parent correlated with an increased likelihood of the children experiencing PTSD, earlier onset of depression, and impulsivity, and maternal violence against a child correlated with the mother's own experience of childhood maltreatment. Focusing on suicidal behavior and violence and trauma, Oquendo presented evidence that childhood sexual abuse is a stronger predictor of suicidal behaviors than childhood physical abuse, that earlier onset of sexual abuse is correlated with increased suicidal intent, and that reported childhood sexual abuse in parents is correlated with suicide attempts in the children. Oquendo proposed creating strategies to strengthen family cohesion and maternal closeness as well as to enhance collective efficacy (e.g., social control in neighborhoods) in order to reduce the risk and incidence of child abuse and trauma.

The Aging Brain and Trauma

Older adults are among the fastest growing population in both the United States and around the world, and, according to Vijeth Iyengar from the Administration for Community Living at the U.S. Department of Health and Human Services, older adults experience trauma in three general areas: physically induced traumas due to falls; historically rooted trauma due to multigenerational trauma experienced by a specific cultural, racial, or ethnic group; and interpersonal induced trauma, such as elder abuse. He noted that as brains age, they experience a decrease in volume and integrity and a decline in functions such as attention, episodic memory, and executive functioning, with verbal memory and real-world knowledge better preserved. A brain exposed to high levels of cortisol, which can happen with abuse, experiences deficits in structure, especially a decline in the hippocampus volume, which has been shown to affect memory performance. Iyengar described several programs funded by the Administration for Community Living: (1) the National Falls Prevention Resource Center oversees public awareness and education for consumers and professionals with the goal of reducing the risk of falls through the use of evidence-based best practices for fall prevention; (2) programs working with aging Holocaust survivors address historical trauma through infusing principles of trauma-informed care into current practice to address the high rates of emotional distress, anxiety disorders, and sleep disturbances experienced by survivors; and (3) the National Indigenous Elder Justice Initiative is a culturally appropriate initiative designed to help professionals working with Native elders better assess and prevent elder abuse. Iyengar discussed gaps in research as well as in government programs and services for older adults and he also spoke of the need for policy and funding support for programs and grantees to translate findings into mainstream aging services.

Impacts of and Responses to Community-Based Trauma

In 2016, seeking funding from SAMHSA for the Resiliency in Communities After Stress and Trauma (ReCAST) program, Andrew Masters and colleagues from the Baltimore City Health Department reached out to experts in behavioral health services and trauma-informed care. However, Masters said, the project proposal was rejected in part due to the fact that although the program would focus on predominantly black communities, ReCAST was not run by individuals with strong community ties. Masters stressed that historical trauma, institutional racism, and community power are critical issues to recognize and acknowledge when working to address trauma. In September 2016 the ReCAST program received a grant from SAMHSA and was designed to build capacity according to three principles: the work will be community led and community driven; the largest program partners commit to hire, work, and build the capacity of local organizations; and grant money would be given directly to local community-run organizations. Masters also spoke of the importance and power of language, and he said that use of the SAMHSA definition of trauma resulted in community members taking leadership to define trauma in a way that is relevant to their community, environment, and daily lived experiences.

The project manager of ReCAST, Larry Simmons, hired through a community-led interview and scoring process, added that the success of the project is due to community involvement, including by a coalition of 64 community members, partners, and a board of directors comprised of community members. He said that to build sustainability, the community created B-CIITY (Baltimore City Intergenerational Initiatives for Trauma and Youth), which is a community coalition committed to breaking down silos by reaching out to schools, behavioral health services, housing services, and universities with the goal of unifying the community. He described how B-CIITY will build on the resiliency of the underserved communities and young people, highlighting the assets and resiliency of the underserved communities.

SITUATIONS OF ACUTE AND PROLONGED TRAUMA EXPOSURE OF FIRST RESPONDERS

This portion of the workshop explored trauma in the context of episodes of mass trauma and the ways in which first responders are uniquely affected by trauma in their day-to-day work.

First Responders and the Trauma Experienced in the Line of Duty

Henry Stawinski of Prince George's County (MD) Police Department spoke about the ways that trauma affects police officers. Police officers can experience trauma in multiple ways, including responding to a traumatic event or to a violent crime, which can involve multiple victims and have a residual impact on the officer and community. Stawinski noted that police officers make up a fragmented community in the United States, with no central governing body. Generally speaking, they receive very little mental health training and no trauma training and are judged on an absence of negatives rather than a presence of positives. Stawinski described the Prince George's County Police Department as an agency at the center of research on American policing, which provides an opportunity to learn about the impact of trauma, to learn how to help officers reduce the impact of long-term trauma, and to expand the research on resiliency. He provided details on one program, the Transforming Neighborhoods Initiative, which aims to reduce crime in areas with high crime rates by focusing government resources on the improvement of surrounding social issues, such as education and public health, in those same areas. Using an epidemiology approach, he said, the department is assessing and identifying factors related to high crime rates, addressing and removing those factors, and then focusing on “real-time” factors to reduce the risk of crime. He described how the department also engages the health and social services agencies in identifying those services and resources needed to help reduce violence and increase overall community health and how they work across sectors and services to think comprehensively, build capacity, and marshal resources to achieve better outcomes.

Jacqueline Rafterry, also of the Prince George's County Police Department, then explained that the department has successfully integrated mental health providers into the police department and the police academy—a step that also helps to build the skills and capacity of police to address critical incidents and trauma. She said that the growing opioid crisis is helping society recognize that policing is not the solution, but rather is a catalyst for positive change that will require a multi-disciplinary approach to get better results. She said that one example of this approach is the “one-stop” Family Justice Center, a location that includes police, social services, health services, and legal resources.

THE ROLE OF TRAUMA IN GLOBAL HEALTH

Concerning the importance of clinical care for trauma patients, Megan Reeve Snair, a program officer on the Board on Global Health of the National Academies of Sciences, Engineering, and Medicine, referred to the recently released consensus study report Global Health and the Future Role of the United States (NASEM, 2017). Snair then introduced Juan Puyana, a trauma surgeon, associate professor at the University of Pittsburgh, and member of the committee for the consensus report.

Puyana stressed that the role taken by the United States will continue to shape international policy, which can have a positive effect on the safety of American citizens by improving health and producing more stable societies for the millions of people around the world facing a heavy disease burden. He said that the consensus study report includes four areas of actions: addressing global health security, maintaining a sustained response to the continuous threat of communicable diseases, promoting cardiovascular health and preventing cancer, and saving and improving the lives of women and children. Puyana noted that the report does not specifically mention injury and violence prevention. On the subject of the challenges to including violence prevention as an important part of global health, he spoke of the importance of translating the evidence and terminology in specific ways so as to address children and families and violence prevention, adding the report's 14 recommendations actually do have many areas that include violence prevention (e.g., HIV/AIDS, children and women, building public health capacity). Noting that investments in human capital contribute significantly to economic growth and stability in countries, Puyana spoke of the topics explored by the Forum on Global Violence Prevention as an opportunity to find common language to help engage sponsors in the support of future efforts. He closed by noting that a continued awareness of global issues and active engagement in the international global health arena includes understanding that the health and well-being of other countries affect, both directly and indirectly, the health, safety, and economic security of all Americans.

CLOSING REMARKS

Workshop participants, speakers, forum members, and invited guests convened to review the discussions and presentations and to describe opportunities to take information to their organizations and institutions. Greenberg opened the discussion by stressing that trauma takes a toll across the lifespan and occurs in all communities and that evidence has shown that trauma can be prevented, managed, and overcome. He said that while evidence and successful programs exist, there is more to be done to share information across sectors, and there is a need to move the pendulum from response to a collective approach to prevention.

Rodrigo Guerrero, mayor of Cali, Colombia, called for language that reaches the desired audience, such as connecting with those interested in childhood development or the economic impact of violence on families and communities. Jacquelyn Campbell of Johns Hopkins University reflected on the evidence that links youth trauma and the rates of use of violence later in life, and she said that by labeling youth as, for example, perpetrators or offenders, there is a loss of their humanity and of the impact of their violent experiences as children. She spoke of the programming at the Veterans Health Administration that, in recognizing the impact and interconnection of PTSD and violence, uses terms of “people experiencing violence” and “people using violence” rather than “victims” and “perpetrators.” She also mentioned a randomized controlled trial implemented by Judith Bass of Johns Hopkins University, in which community health workers in the Democratic Republic of the Congo implemented a short intervention for PTSD that could be adopted and tailored in other settings.

Maholmes spoke of the importance of maintaining human resources that require moving beyond the characteristic leaders and noted that the forum could help address the leadership vacuum by working to keep researchers and practitioners in the pipeline. Elizabeth Ward of the Violence Prevention Alliance spoke of the need to look beyond the complexities of an intervention to identify and address the fundamental roots to violence, such as poverty and lack of food or a job. Cervantes spoke of building better networks and of the need to use forum workshop discussions to create communication mechanisms, including social media and using public figures, to expand reach.Image common-1.jpg

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DISCLAIMER:

This Proceedings of a Workshop—in Brief was prepared by Evelyn Tomaszewski as a factual summary of what occurred at the workshop. The statements made are those of the rapporteur or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.

Planning Committee for Workshop on The Neurocognitive and Psychosocial Impacts of Violence and Trauma**

Sheldon F. Greenberg (Chair), Johns Hopkins University; David Jacobson, Education Development Center; Jennifer Kaminski, Centers for Disease Control and Prevention; Kristen Kracke, U.S. Department of Justice; Valerie Maholmes, National Institutes of Health; Gerald Reed, Education Development Center; and Jennifer Tyson, U.S. Department of Justice

Footnotes

**

The National Academies of Sciences, Engineering, and Medicine's planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop—in Brief rests with the institution.

REVIEWERS:

To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Shavon Artis Dickerson, U.S. Department of Health and Human Services, Stephen Hargarten, Medical College of Wisconsin, and Laura Krausa, Catholic Health Initiatives. Lauren Shern, National Academies of Sciences, Engineering, and Medicine, served as the review coordinator.

SPONSORS:

This workshop was partially supported by Administration for Community Living; Anheuser-Busch InBev; Archstone; Avon Foundation; Becton, Dickinson and Company; Catholic Health Initiatives; Felix Foundation; Insituto Nacional para la Evaluación de la Educación; JSI Research & Training Institute, Inc. (USAID); Kaiser Permanente; Leading Age; National Institutes of Health; New Venture Fund Oak Foundation; Robert Wood Johnson Foundation; and the U.S. Department of Labor.

For additional information regarding the workshop, visit nationalacademies.org/hmd/Activities/Global/ViolenceForum/2017-JUL-31.aspx.

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2018. The neurocognitive and psychosocial impacts of violence and trauma: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/25077.

Health and Medicine Division

The National Academies of SCIENCES • ENGINEERING • MEDICINE

The nation turns to the National Academies of Sciences, Engineering, and Medicine for independent, objective advice on issues that affect people's lives worldwide.

www.national-academies.org

Rapporteur: Evelyn Tomaszewski.

Copyright 2018 by the National Academy of Sciences. All rights reserved.
Bookshelf ID: NBK498651PMID: 29718637DOI: 10.17226/25077

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