Opinion
EDITORIAL
Childhood Abuse and Military Experience—Important Information to Better Serve Those Who Have Served John R. Blosnich, PhD, MPH; Robert M. Bossarte, PhD
Afifi et al1 corroborate results from a recent US study showing higher prevalence of childhood abuse among persons with a history of military service compared with persons who did not serve in the military. 2 More importantly, Afifi and colleagues show how childRelated article hood abuse was differentially associated with suicidal risk among military and nonmilitary samples, and they explore childhood abuse in the context of deployment-related traumatic experiences among military personnel. These important findings have repercussions, from epidemiology through intervention and implementation efforts, for how scientists, health care professionals, and systems tackle the issue of understanding health outcomes, including suicide risk, among individuals who have served in the military. The finding of a greater prevalence of childhood abuse among servicemembers supports a hypothesis that, for some individuals, enlistment in the military may offer an opportunity to escape childhood adversity. However, this hypothesis is admittedly difficult to test because individuals either may not choose to disclose such reasons, or, even if enlistment is to escape, they likely have concomitant positive reasons for enlisting (eg, altruism, patriotism). The escape hypothesis has been criticized as promoting a “damaging stereotype” about military personnel. Are there alternative reasons for patterns of elevated self-reported childhood abuse emerging among military samples? Are persons with military service more honest on surveys than civilians, and thus more prone to disclose childhood abuse? Or, as Ivany and Hoge3 suggested, could broadly defining samples by “ever served in military” or surveying current active duty personnel unfairly increase prevalence of childhood abuse because these samples include people who either may have been dishonorably discharged or may not finish their service terms (presuming said people are more likely to be survivors of childhood abuse)? The many possible explanations notwithstanding, the fact remains that current and former military personnel report high prevalence of potentially traumatic early life abuse, and scientists and systems must take heed of this. From a scientific standpoint, research on mental health (eg, posttraumatic stress disorder) and suicide risk among active duty personnel4 and veterans5 tends to focus on military-incurred traumas. However, an absolute focus on service-related exposures does not provide a complete picture. The complete picture of any individual contains pixels from the past; some colors fade, others wax and wane, and some burn for a lifetime. jamapsychiatry.com
Childhood abuse has clear and consistent ramifications on adult health,6 which is why the results found by Afifi et al are so compelling. Specifically, that (1) deployment-related events were not significantly associated with recent suicidal ideation after controlling for childhood abuse, and (2) the effect sizes of childhood abuse had a greater magnitude of association than deployment-related events with recent suicidal ideation and suicide planning. Although unable to assess temporality, deployment-related events most likely occurred after childhood abuse and, thus, are the more recent exposures. Yet, it was childhood abuse that showed the stronger and more consistent associations with suicidal ideation and planning. Consequently, it makes one wonder if some soldiers had been on a battlefield long before they ever enlisted in the military. Epidemiologic studies need to gather relevant information, such as histories of childhood abuse, that can better inform us as to which individuals may have potent risk factors for poor health in general and suicide risk in particular. From a systems perspective, the Institute of Medicine encourages health care systems to gather data about social determinants of health, such as exposure to violence, in electronic health records.7 However, there are at least 3 types of questions that need to be examined in collecting information from health care consumers about distal and proximal exposure to violence. First, messaging to consumers that such information is pertinent to their health and will be handled just as sensitively as any other piece of personal health information. Second, the modality by which such information would be gathered. Once consumers recognize why a health care system would collect information about exposure to violence, such as childhood abuse, how is that information best collected from those willing to offer it (ie, self-administered questionnaire, clinical interview)? Additionally, which inventory of exposure to violence should be implemented? Third, the meaningfulness of this information must be made clear to health care professionals. This may include training about how this information bears on clinical care, fostering interview skills and referral pathways, developing specific programs to offer to survivors, and exploring potential interface across systems (ie, social services, law enforcement) to construct the architecture for a more complete patient medical home. Lastly, and on a hopeful note, Afifi et al point to the finding that, despite Canadian military personnel having greater prevalence of childhood abuse than the Canadian general population, the association of childhood abuse with suicidality was weaker for military personnel than for the Canadian general population.1 This suggests that, rather than cast a negative valu(Reprinted) JAMA Psychiatry Published online January 27, 2016
Copyright 2016 American Medical Association. All rights reserved.
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Opinion Editorial
ation on military enlistment to escape childhood adversity as a stereotype, an objective hypothesis may be that military enlistment among survivors of childhood abuse is a sign of resilience, ie, having the wherewithal to break away from a tumultuous environment. A complementary hypothesis may be that the structure, training, and fellowship of the military facilitates resiliency among some survivors of childhood abuse. The literature about posttraumatic growth (ie, from trauma or adversity can come positive growth—a sort of “rising from the ashes” phenomenon)8 may provide a particularly compelling framework around which to test these hypotheses and exARTICLE INFORMATION Author Affiliations: Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, US Department of Veterans Affairs, Pittsburgh, Pennsylvania (Blosnich); Department of Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania (Blosnich); Office of Public Health, US Department of Veterans Affairs, Washington, DC (Bossarte); Department of Psychiatry, University of Rochester, Rochester, New York (Bossarte); Department of Public Health Sciences, University of Rochester, Rochester, New York (Bossarte). Corresponding Author: John R. Blosnich, PhD, MPH, Center for Health Equity Research and Promotion, Department of Veterans Affairs, VA Pittsburgh Healthcare System, University Drive C (151C-U), Bldg 30, Pittsburgh, PA 15240-1001 ([email protected]). Published Online: January 27, 2016. doi:10.1001/jamapsychiatry.2015.2736. Conflict of Interest Disclosures: None reported. Disclaimer: The opinions expressed in this work are those of the authors and do not necessarily
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plore the complicated relationships between childhood abuse, resiliency, military-specific trauma, and adulthood health. There are several steps that scientists, health care professionals, and systems can take to better serve the individuals who have bravely served their countries, including an honest reckoning with the growing evidence base showing a disproportionately high burden of childhood abuse among military personnel, a genuine and continuous effort to diminish the stigma of disclosing childhood abuse, and allocation of resources for epidemiologic efforts and treatment modalities to address issues of childhood abuse among military personnel.
represent those of the University of Pittsburgh, the Department of Veterans Affairs, or the US government. REFERENCES 1. Afifi TO, Taillieu T, Zamorski MA, Turner S, Cheung K, Sareen J. Association of child abuse exposure with suicidal ideation, suicide plans, and suicide attempts in military personnel and the general population in Canada [published online January 27, 2016]. JAMA Psychiatry. doi:10.1001 /jamapsychiatry.2015.2732. 2. Blosnich JR, Dichter ME, Cerulli C, Batten SV, Bossarte RM. Disparities in adverse childhood experiences among individuals with a history of military service. JAMA Psychiatry. 2014;71(9):10411048. 3. Ivany CG, Hoge CW. Adverse childhood experiences and military service. JAMA Psychiatry. 2015;72(3):296.
5. Bryan CJ, Griffith JH, Pace BT, et al. Combat exposure and risk for suicidal thoughts and behaviors among military personnel and veterans: a systematic review and meta-analysis [published online April 8, 2015]. Suicide Life Threat Behav. doi:10.1111/sltb.12163. 6. Norman RE, Byambaa M, De R, Butchart A, Scott J, Vos T. The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis. PLoS Med. 2012;9(11):e1001349. 7. Institute of Medicine. Capturing Social and Behavioral Domains in Electronic Health Records: Phase 1. Washington, DC: Institute of Medicine; 2014. 8. Sheikh AI. Posttraumatic growth in trauma survivors: implications for practice. Couns Psychol Q. 2008;21(1):85-97. doi:10.1080 /09515070801896186.
4. LeardMann CA, Powell TM, Smith TC, et al. Risk factors associated with suicide in current and former US military personnel. JAMA. 2013;310(5): 496-506.
JAMA Psychiatry Published online January 27, 2016 (Reprinted)
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://archpsyc.jamanetwork.com/ by a GAZI UNIVERSITESI User on 01/28/2016
jamapsychiatry.com
EDITORIAL
Childhood Abuse and Military Experience—Important Information to Better Serve Those Who Have Served John R. Blosnich, PhD, MPH; Robert M. Bossarte, PhD
Afifi et al1 corroborate results from a recent US study showing higher prevalence of childhood abuse among persons with a history of military service compared with persons who did not serve in the military. 2 More importantly, Afifi and colleagues show how childRelated article hood abuse was differentially associated with suicidal risk among military and nonmilitary samples, and they explore childhood abuse in the context of deployment-related traumatic experiences among military personnel. These important findings have repercussions, from epidemiology through intervention and implementation efforts, for how scientists, health care professionals, and systems tackle the issue of understanding health outcomes, including suicide risk, among individuals who have served in the military. The finding of a greater prevalence of childhood abuse among servicemembers supports a hypothesis that, for some individuals, enlistment in the military may offer an opportunity to escape childhood adversity. However, this hypothesis is admittedly difficult to test because individuals either may not choose to disclose such reasons, or, even if enlistment is to escape, they likely have concomitant positive reasons for enlisting (eg, altruism, patriotism). The escape hypothesis has been criticized as promoting a “damaging stereotype” about military personnel. Are there alternative reasons for patterns of elevated self-reported childhood abuse emerging among military samples? Are persons with military service more honest on surveys than civilians, and thus more prone to disclose childhood abuse? Or, as Ivany and Hoge3 suggested, could broadly defining samples by “ever served in military” or surveying current active duty personnel unfairly increase prevalence of childhood abuse because these samples include people who either may have been dishonorably discharged or may not finish their service terms (presuming said people are more likely to be survivors of childhood abuse)? The many possible explanations notwithstanding, the fact remains that current and former military personnel report high prevalence of potentially traumatic early life abuse, and scientists and systems must take heed of this. From a scientific standpoint, research on mental health (eg, posttraumatic stress disorder) and suicide risk among active duty personnel4 and veterans5 tends to focus on military-incurred traumas. However, an absolute focus on service-related exposures does not provide a complete picture. The complete picture of any individual contains pixels from the past; some colors fade, others wax and wane, and some burn for a lifetime. jamapsychiatry.com
Childhood abuse has clear and consistent ramifications on adult health,6 which is why the results found by Afifi et al are so compelling. Specifically, that (1) deployment-related events were not significantly associated with recent suicidal ideation after controlling for childhood abuse, and (2) the effect sizes of childhood abuse had a greater magnitude of association than deployment-related events with recent suicidal ideation and suicide planning. Although unable to assess temporality, deployment-related events most likely occurred after childhood abuse and, thus, are the more recent exposures. Yet, it was childhood abuse that showed the stronger and more consistent associations with suicidal ideation and planning. Consequently, it makes one wonder if some soldiers had been on a battlefield long before they ever enlisted in the military. Epidemiologic studies need to gather relevant information, such as histories of childhood abuse, that can better inform us as to which individuals may have potent risk factors for poor health in general and suicide risk in particular. From a systems perspective, the Institute of Medicine encourages health care systems to gather data about social determinants of health, such as exposure to violence, in electronic health records.7 However, there are at least 3 types of questions that need to be examined in collecting information from health care consumers about distal and proximal exposure to violence. First, messaging to consumers that such information is pertinent to their health and will be handled just as sensitively as any other piece of personal health information. Second, the modality by which such information would be gathered. Once consumers recognize why a health care system would collect information about exposure to violence, such as childhood abuse, how is that information best collected from those willing to offer it (ie, self-administered questionnaire, clinical interview)? Additionally, which inventory of exposure to violence should be implemented? Third, the meaningfulness of this information must be made clear to health care professionals. This may include training about how this information bears on clinical care, fostering interview skills and referral pathways, developing specific programs to offer to survivors, and exploring potential interface across systems (ie, social services, law enforcement) to construct the architecture for a more complete patient medical home. Lastly, and on a hopeful note, Afifi et al point to the finding that, despite Canadian military personnel having greater prevalence of childhood abuse than the Canadian general population, the association of childhood abuse with suicidality was weaker for military personnel than for the Canadian general population.1 This suggests that, rather than cast a negative valu(Reprinted) JAMA Psychiatry Published online January 27, 2016
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://archpsyc.jamanetwork.com/ by a GAZI UNIVERSITESI User on 01/28/2016
E1
Opinion Editorial
ation on military enlistment to escape childhood adversity as a stereotype, an objective hypothesis may be that military enlistment among survivors of childhood abuse is a sign of resilience, ie, having the wherewithal to break away from a tumultuous environment. A complementary hypothesis may be that the structure, training, and fellowship of the military facilitates resiliency among some survivors of childhood abuse. The literature about posttraumatic growth (ie, from trauma or adversity can come positive growth—a sort of “rising from the ashes” phenomenon)8 may provide a particularly compelling framework around which to test these hypotheses and exARTICLE INFORMATION Author Affiliations: Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, US Department of Veterans Affairs, Pittsburgh, Pennsylvania (Blosnich); Department of Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania (Blosnich); Office of Public Health, US Department of Veterans Affairs, Washington, DC (Bossarte); Department of Psychiatry, University of Rochester, Rochester, New York (Bossarte); Department of Public Health Sciences, University of Rochester, Rochester, New York (Bossarte). Corresponding Author: John R. Blosnich, PhD, MPH, Center for Health Equity Research and Promotion, Department of Veterans Affairs, VA Pittsburgh Healthcare System, University Drive C (151C-U), Bldg 30, Pittsburgh, PA 15240-1001 ([email protected]). Published Online: January 27, 2016. doi:10.1001/jamapsychiatry.2015.2736. Conflict of Interest Disclosures: None reported. Disclaimer: The opinions expressed in this work are those of the authors and do not necessarily
E2
plore the complicated relationships between childhood abuse, resiliency, military-specific trauma, and adulthood health. There are several steps that scientists, health care professionals, and systems can take to better serve the individuals who have bravely served their countries, including an honest reckoning with the growing evidence base showing a disproportionately high burden of childhood abuse among military personnel, a genuine and continuous effort to diminish the stigma of disclosing childhood abuse, and allocation of resources for epidemiologic efforts and treatment modalities to address issues of childhood abuse among military personnel.
represent those of the University of Pittsburgh, the Department of Veterans Affairs, or the US government. REFERENCES 1. Afifi TO, Taillieu T, Zamorski MA, Turner S, Cheung K, Sareen J. Association of child abuse exposure with suicidal ideation, suicide plans, and suicide attempts in military personnel and the general population in Canada [published online January 27, 2016]. JAMA Psychiatry. doi:10.1001 /jamapsychiatry.2015.2732. 2. Blosnich JR, Dichter ME, Cerulli C, Batten SV, Bossarte RM. Disparities in adverse childhood experiences among individuals with a history of military service. JAMA Psychiatry. 2014;71(9):10411048. 3. Ivany CG, Hoge CW. Adverse childhood experiences and military service. JAMA Psychiatry. 2015;72(3):296.
5. Bryan CJ, Griffith JH, Pace BT, et al. Combat exposure and risk for suicidal thoughts and behaviors among military personnel and veterans: a systematic review and meta-analysis [published online April 8, 2015]. Suicide Life Threat Behav. doi:10.1111/sltb.12163. 6. Norman RE, Byambaa M, De R, Butchart A, Scott J, Vos T. The long-term health consequences of child physical abuse, emotional abuse, and neglect: a systematic review and meta-analysis. PLoS Med. 2012;9(11):e1001349. 7. Institute of Medicine. Capturing Social and Behavioral Domains in Electronic Health Records: Phase 1. Washington, DC: Institute of Medicine; 2014. 8. Sheikh AI. Posttraumatic growth in trauma survivors: implications for practice. Couns Psychol Q. 2008;21(1):85-97. doi:10.1080 /09515070801896186.
4. LeardMann CA, Powell TM, Smith TC, et al. Risk factors associated with suicide in current and former US military personnel. JAMA. 2013;310(5): 496-506.
JAMA Psychiatry Published online January 27, 2016 (Reprinted)
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://archpsyc.jamanetwork.com/ by a GAZI UNIVERSITESI User on 01/28/2016
jamapsychiatry.com
