Using a longitudinal design, Copeland et al1 have repeatedly assessed traumatic experiences in children aged 9 to 16 years and have then linked the exposure data to adult psychiatric disorders, significant health problems, criminal and violent behavior, poverty, drug use, educational failure, and problems in social functioning between the ages of 19 and 30 years. The current study presents high-quality, unequivocal longitudinal data on a large sample, attesting to the profound intertwining of these phenomena. Furthermore, 67.8% of the 1420 followed-up participants had experienced at least 1 such event, 22.5% reported experiencing 2, and 14.8% had experienced 3 or more such events. About 25% of the reported childhood traumas were related to violence (violent death, physical violence, and abuse), 11% to sexual trauma, and another approximately 25% to witnessing a life-threatening event.
For some time, it has been known that trauma during childhood is a major indicator of adult mental disorders,2 serious physical illnesses,3 criminal and/or violent behavior,4 and drug addiction.5 Furthermore, socioeconomic inequality and low educational level,6 as well as living in an impoverished neighborhood,7 are major predisposing factors for exposure to a traumatic event. The cited effect of trauma on the development of mental disorders is also often large. For example, a seminal review on the link between childhood trauma, psychosis, and schizophrenia8 suggests that the chance of developing psychotic features in adulthood after child abuse surpasses, by far, any other causally implied biological factor cited in the literature regarding the development of schizophrenia in adulthood. In addition, dose-related mental health problems were observed; for example, 1 study suggested a 30 times greater chance of developing psychosis in adulthood among those who were the most severely exposed to trauma and a 5 times greater chance for those who were less exposed compared with those who had not.9
Trauma never occurs within a vacuum, but within a social context that will determine not only whether a traumatic injury can be remediated, but, as shown in the study by Copeland et al,1 that sets the probability of exposure. Considering the fact that those who have been exposed to trauma have a higher chance of repeated trauma exposure and potential perpetration, disenfranchised neighborhoods may include a higher than average concentration of potential perpetrators10 and fewer resources to treat those who have been exposed to trauma.
These and other studies show the obvious, namely that exposure to trauma is fostered, and its effects are augmented by social and economic factors that are inherently related to social inequality. Children born into families with low economic means in poor neighborhoods, where good community schooling is lacking, may grow up in an unsafe environment with a high risk of community, family, and sex-related violence, higher divorce rates, unwanted pregnancies, and a stressogenic atmosphere.7 This kind of environment provides many opportunities for exposure to traumatic events, potentially weakening individuals and their families, as well as taking its toll on the wider, already resource impoverished, community. As the results of Copeland et al1 suggest, being exposed to trauma cannot only lead to psychopathology, but can also foster socially deviant careers in the form of criminality and addiction, thereby leading to more interpersonal and community violence, difficulty in holding a badly paid job, and a problem-riddled social life. Growing up with a lack of resources in an impoverished, unsafe, and highly stressogenic environment will increase the likelihood of exposure to trauma, as well as of nontraumatic stresses of all kinds.
The study by Copeland et al,1 shows that trauma begets economic and educational difficulties, mental and social problems, or, in other words, inadequate personal, familial, and community resources. The conclusion is difficult to avoid. It does not need a great leap of faith to recognize a prevailing vicious circle between societal forces such as poverty, lack of education, familial and neighborhood violence, poor mental health, and trauma exposure. Within low-resource contexts, trauma begets trauma, trauma begets poverty, poverty begets poverty, poverty begets trauma, and the cycle goes on.
Although the individual has been the locus of conventional trauma treatment, the presented data suggest the importance of recognizing trauma as a major public health policy issue. If we accept this premise, when treating trauma, one has to consider the social ills that foster trauma.
The history of trauma in the western world in the last 150 years, appertained to the history of movements for social justice. In 1874, the American Society for the Prevention of Cruelty to Animals brought Mary Ellen McCormack’s case of child abuse to the New York State Supreme Court, leading to the creation of the New York Society for the Prevention of Cruelty to Children. The campaign to prevent the injustice of child abuse and to provide help for those abused that followed continues to resonate until today. The demand for social recognition and justice for returning Vietnam soldiers served as the impetus for the modern awareness and study of the effect of trauma and the development of services for war veterans. Today, it is imperative to accept that social justice has to become a public health issue because as the article suggests,1 extreme social contexts and living conditions affect people’s mental state and behavior, and these behaviors and mental resources affect the community. If the ills of our societies, including trauma, are to be tackled seriously, then injustice must be held accountable.
Published: November 9, 2018. doi:10.1001/jamanetworkopen.2018.4488
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2018 Gelkopf M. JAMA Network Open.
Corresponding Author: Marc Gelkopf, PhD, Department of Community Mental Health, University of Haifa, Abba Khousy Ave 199, Haifa 3498838, Israel (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
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Gelkopf M. Social Injustice and the Cycle of Traumatic Childhood Experiences and Multiple Problems in Adulthood. JAMA Netw Open. 2018;1(7):e184488. doi:10.1001/jamanetworkopen.2018.4488
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