Substance dependence leads to persistent negative consequences and to the loss of human potential. These consequences often include chronic health problems, disturbed family environments, adverse economic effects, and premature death. According to the Centers for Disease Control and Prevention (CDC), 21.2 million people in the United States met the criteria for a substance-related disorder in 2018. Overdose deaths have tripled in less than two decades, with over 70,000 overdose deaths per year in 2019, 70% of which were from opioids such as morphine and fentanyl.
Substance-related disorders comprise 10 classes of drugs: alcohol; Caffeine; Cannabis; Hallucinogens; Inhalants; Opioids; Hypnotics, sedatives, and anxiolytics; Stimulants; Tobacco; and other / unknown substances. Exposure to childhood trauma increases the risk of addiction in all classifications as well as adverse factors such as physical health and socio-economic challenges. The ACE (Adverse Childhood Experiences) study, originally conducted by Kaiser Permanente and the CDC from 1995 to 1997, identified categories of trauma that can occur before the age of 18. These include physical abuse and neglect, emotional abuse and neglect, sexual abuse, and household dysfunction – e.g. B. violent treatment of the mother, abuse of household substances, imprisonment of the parents, mental illness of the parents and divorce.
These factors form the 10 components of the ACEs score, with studies showing a higher probability of substance-related disorders with increasing exposure to ACEs. According to the American Society of Addiction Medicine (ASAM), addiction has biological, psychological, social, and spiritual manifestations. Given the harmful nature of the addictive etiology, professional counselors need to be aware of the vulnerability to addiction for those affected by childhood trauma. The intersection of ACEs and addiction has consistently negative effects over the entire lifespan.
The National Institutes of Health (NIH) claim that traumatic events can act as triggers for substance abuse. NIH reported that 38% of high school graduates admitted using an illegal substance in 2019, with marijuana being the most commonly used substance. Amazingly, 11.8% of eighth graders said they had used marijuana. In addition, 11.7% of high school graduates reported consuming nicotine on a daily basis, and more than half reported having consumed alcohol in the previous year.
Exposure to ACEs can lead to toxic stress and a myriad of negative consequences, often including lifelong adverse effects on physical and mental health. The high rate of people living with trauma from ACEs is astounding – 61% of people have endured at least one ACE, and nearly 25% of people report three or more ACEs. There appears to be a specific susceptibility to addiction in people who have experienced four or more ACEs. The higher the ACE, the greater the negative health effects. More than half of adolescents living with mental health problems also have diagnosable substance-related disorders, which underscores the comorbidity of the problem.
Consequences of ACEs can include addiction, limited access to education, and susceptibility to sexual exploitation and trafficking. Tobacco and prescription drug use is higher among people with ACEs, and illicit drug use more than doubles for each positive ACE category. Other lifelong instability factors that have been shown to correlate with ACEs include high risk sexual behavior, early pregnancy, suicide attempts, insomnia, poor dental health, and several physical health problems. Both children and adults with existing mental health problems are more likely to abuse substances.
According to the US General Surgeon, approximately 10% of children live with mental health problems that rise to a clinical level, with major depressive disorder being a leading cause of disability in children worldwide. Research supports the strong link between childhood adversity and the resulting development of addiction. More than two thirds of children will experience a traumatic event before the age of 16. In the current pandemic, many children are in violent or otherwise unsafe homes. Worryingly, domestic violence incidents increased by 30% in 2020, exposing countless teenagers to at least one of the ACEs factors.
Treatment requirement
Reports of increased clinical anxiety and depression in the general population suggest that stress related to the COVID-19 pandemic affects everyone. Adolescence is already a critical developmental phase for the initial onset of mental health and substance-related disorders, making this population group more vulnerable. ACEs are a clear and persistent risk factor: childhood trauma survivors are 15 times more likely to attempt suicide, four times more likely to attempt an alcohol-related disorder, and 2.5 times more likely to attempt cigarettes. For childhood trauma survivors, physical and emotional problems often manifest in adolescence and follow through into adulthood.
According to the Agency for Substance Abuse and Mental Health (SAMHSA), 21.6 million people aged 12 and over required treatment for substance use in the US in 2019, while only about 2.6 million people (or just over 12%) got a treatment there. These are blatant treatment needs that cross demographics. Fentanyl, which can be fatal, is sold on the "street" in various forms, perpetuating the opioid crisis in our country. Tens of thousands of overdose deaths occur each year, with nearly 11 million people reporting inappropriate opioid use. People with an ACE greater than 6 were over 1000 times more likely to use injection medication.
Chronic substance abuse, a clear risk factor for those exposed to trauma, leads to premature death in alarmingly high numbers. Adolescents with experience of depressive episodes are more likely to use cross-category substances. At the same time, 60% of US adolescents with depression are not receiving psychological treatment. Treating the physical and psychological effects of substance use alone is estimated to cost Americans more than half a trillion dollars a year. The CDC has developed a resource at cdc.gov/violenceprevention/pdf/preventingACES.pdf that highlights the research support available for evidence-based prevention of ACEs. These strategies focus on systemic community-based information and training. There is also an emphasis on physical health, positive behavior, and supportive environments.
Considerations for treatment
Certain populations are more susceptible to substance-related disorders due to environmental and genetic factors. This arises from the neurobiological basis of the addiction etiology for the effects of toxic stress. Individuals born in households exposed to ACEs are more prone to addiction, including process addiction that focuses on gambling, internet gaming, sex, shopping, work, social media, etc. Using trauma-informed interventions as early as possible can mitigate harmful effects and provide protective measures against substance-related and other mental and physical health problems. The CDC offers training for those who would like to learn more about the prevention of ACES (see vetoviolence.cdc.gov/apps/aces-training/#/#top).
All clients should be screened for trauma and history of addiction. The coexistence of mental health problems and substance abuse calls for treatment that addresses these challenges. Trauma increases the already high comorbidity (over 50%) between the diagnosis of mental health and substance use. Prevention and early intervention services can examine the frequency, severity, and duration of both the trauma experience and the addiction. The conceptualization of substance use disorders occurring in a continuum (as described in the fifth edition of the Diagnostic and Statistical Manual for Mental Disorders) underscores the importance of prevention and early intervention.
According to the CDC, research shows a tendency towards self-medication with substances to escape or numb negative thoughts and feelings. This suggests that escaping emotional pain triggers the onset of addiction. Women, adolescents and people from marginalized populations are most susceptible to these effects, although anyone can experience childhood trauma and struggle with the resulting addiction .
Physicians should develop individual treatment plans and strong referral systems. Genetic and environmental factors work together. Hence, we need to understand these interactive effects. Long-term support and the provision of physical and dental health services can be important for those exposed to ACES, especially given the likelihood of comorbidity in a diagnosis of physical health. Increased unemployment rates and job dissatisfaction represent an additional need for treatment.
Relational challenges
The difficulty of building healthy relationships over the entire lifespan is a hallmark of survival from adversity in childhood. Counselors should therefore include strategies to strengthen the family and community. Holistic and family advisory services are an advantage. This includes the provision of psychoeducational and parenting education to incorporate general life skills, mindfulness and grounding techniques, positive coping strategies, and career counseling services. Trauma-focused cognitive behavioral therapy (TF-CBT) and multisystem therapy have shown both short- and long-term benefits in these clients. This can be combined with addiction treatments such as drug therapy for alcohol or opioid use disorders. The combination of psychoeducation and supportive, trauma-related and empirically based treatments for substance abuse can cover the broad needs of this population. All treatment modalities and providers should integrate trauma-informed care.
Early identification and intervention remains important in order to minimize risks and break harmful family patterns. Removing barriers to treatment includes tackling stigma and improving education for families and communities. Larger prevention programs, including early intervention and post-prevention services, are indicated. Developing individual treatment strategies that incorporate trauma-informed interventions is also critical.
Professional counselors are hired to advocate for clients and communities. Screenings in hospitals, clinics, and public health facilities can help identify those at risk of substance abuse, especially those with a history of trauma, and link them to treatment services. Psychoeducation in schools and community facilities can also improve outreach and access to care. Education courses for parents and training in life skills are further examples of additional benefits. Incarcerated populations are particularly affected, with some studies suggesting a history of trauma for almost the entire population of female inmates. Professional counselors working in these environments should be aware of risk factors and assessment protocols that are culturally literate and encompass multiple demographics.
Effective treatments for those affected by trauma and addiction may include desensitization and reprocessing of eye movements, motivational therapy, TF-CBT, dialectical behavior therapy, assertive community treatment, and family behavior therapy. Psychotropic drugs and mental health care may be indicated to fully address these complex issues. Some medications can benefit multiple problems (e.g., bupropion for both depression and nicotine addiction). Case management and professional support are important ancillary services for many customers. Community vouchers can be issued for transportation and access to health care and enable potential employment opportunities.
Although thorough and comprehensive treatment can be expensive, it pales in comparison to the economic costs associated with addiction and premature death. With annual addiction and premature death estimates of up to $ 740 billion, there is a need for legislation to fund prevention and early intervention services for those affected by trauma exposure and addiction. With adequate access to treatment and support, many people suffering from the effects of childhood trauma and addiction can experience positive and lasting improvements. The cycle of transmission of trauma between generations can be interrupted, resulting in positive ripple effects for future generations. Individuals can thrive and build healthy families despite their negative experiences.
Community Impact and Integrated Care
A multi-faceted approach to looking at immediate problems such as addiction is essential for those exposed to ACEs. Managing the trauma and providing family services, social support and preventive measures remain essential. All professional counselors can value trauma-related and integrative care. Here are some simple strategies to tackle this complex problem: listen with empathy, gain training in trauma-related practices, develop a strong support and referral system, and offer specialized services to treat trauma and addiction. Working together, mental health professionals in a variety of disciplines can help childhood trauma survivors manage life in healthy and productive ways.
The global health pandemic has increased the use of distance-based services such as telemental health advice. This modality can provide easier access to services for individuals in rural communities, people with transport problems, and people with other barriers to treatment.
It remains important to emphasize the team approach to addressing the complex problems of childhood trauma, addiction and the resulting consequences for physical and mental health. The ubiquitous nature of this challenge leads to a call to action. Gathering data through in-depth assessment can influence community decision-making and provide program funding. The youth risk behavior monitoring system assesses overarching data available at local, state and national levels. The National Child Health Survey and the National Crime Victimization Survey also collect data that may affect service delivery.
The CDC provides information on promoting a safe environment for children and reducing exposure to ACEs and subsequent addiction and disease. At the micro level, professional counselors can focus on parenting and family skills, mentoring, social emotional learning, professional skills and psychoeducation related to healthy family and interpersonal relationships. At the macro level, professional counselors can promote community connection, relationship management, and positive social norms. The critical importance of trauma-related interventions tailored to individual or family circumstances, as well as community-wide prevention strategies, are needed to address these serious and widespread risk factors. These programs can help children, parents, and families fail to relieve symptoms.
Family-centered addiction treatments can deal with the effects on the generations. The deficits associated with trauma and addiction are compensated for by evidence-based interventions and prevention strategies. Access to programs should be available to all levels of care and can be performed concurrently with the ancillary services. The counseling settings can span the home, school, or office and often involve multiple integrated health professionals. Given the complexity of the challenge, comprehensive care services that include the connection between home and school settings and the larger family system remain essential. The widespread effects of ACEs and their intersection with addiction require coordinated care across all disciplines. This includes effective tracking and coordination of prevention and intervention services in all aspects of service delivery.
Cross-generational trauma transmission patterns represent a vicious circle that professional counselors can break. Prevention programs need to address dysfunctions and adversity in the household, especially given that ACEs indicate earlier onset of substance use. The idea of being numb or seeking solace suggests that adversity in childhood can lead to addiction through attempts to alleviate suffering. Good quality mental health care can address and improve these poorly adapted coping mechanisms. ACEs also correlate with substance use disorders in older adulthood, underscoring the lifelong consequences of exposure to childhood trauma.
Addiction treatment facilities that work together with comprehensive and comprehensive services can offer targeted interventions to cope with individual trauma experiences. Addressing the systemic nature of childhood adversity through family services and community advocacy provides additional resources for clients. Professional counselors are an integral part of the entire treatment team. Customers can and do learn new behavior patterns and positive coping mechanisms that will help them live longer, healthier lives. The benefits of prevention and early intervention should not be underestimated. Treatment alleviates trauma and addiction, and often leads to positive change in individuals and families.
Professional counselors can help community members find resources and addiction treatment centers across the country through the SAMHSA National Helpline: 800-662-HELP (4357). It is imperative to look at childhood trauma survivors struggling with addiction or other poorly adjusted coping mechanisms through a strength-based approach. These struggles do not arise from characterological weakness, but result from the effects of lived trauma experiences. Empathy and care are essential to working successfully with trauma survivors.
Conclusion
Abuse, neglect and dysfunction in the household clearly lead to physical and mental health problems. The risk of addiction, early death, and intergenerational transmission of trauma increases with each adverse exposure in childhood. Consumption of alcohol and other illegal substances is detrimental to mental and physical health in a variety of ways and often overlaps with the trauma experience. Children and young people at risk can and must be protected. Today more than ever, professional consultants play a central role.
In 2020, SAMHSA reported a 900% increase in call volume to its disaster emergency number (800-985-5990). Almost half of the Kaiser Family Foundation respondents said the COVID-19 pandemic is having a negative impact on their overall mental health. The global health pandemic underscores the growing need for treatment for more and more vulnerable people. Experiencing trauma in childhood can hinder the individual in all areas of life. The negative reverberations for families and communities should make this a problem for everyone. Professional counselors have the potential to make positive change for countless individuals, families and communities. Let's make a difference – now and in the future.
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Shannon Karl is Professor in the Department of Counseling at Nova Southeastern University, Licensed Mental Health Advisor (Supervisor) in Florida, active member of the American Counseling Association and past president of the Association for Spiritual, Ethical and Religious Values in the Consultation. Contact her at [email protected] or linkedin.com/in/shannon-karl-phd.
Knowledge sharing articles were developed from sessions presented at American Counseling Association conferences.
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Opinions and statements in articles appearing on CT Online should not be assumed to reflect the opinions of the editors or guidelines of the American Counseling Association.
