Written by Zjanya Arwood-Wenke, BS.  Zjanya is a doctoral student in the Department of Psychology at the University of North Carolina – Wilmington and is currently completing her doctoral internship at Chrysalis.

Adverse Childhood Experiences (ACEs) refer to traumatic or potentially traumatic events, ranging from childhood abuse and neglect to family dysfunction (i.e., domestic violence, parental risky substance use, divorce, severe parental mental illness, early parental loss)¹. These experiences are highly prevalent, with about 46 percent of children in the U.S experiencing at least one ACE². This estimate is likely lower than the actual number of children who have experienced ACEs, as ACEs are often under or unreported due to the fact that they typically occur behind closed doors ³.

ACEs are often associated with a myriad of poor behavioral, cognitive, social, and physiological outcomes with a dose-related response; meaning the more ACEs one experiences, the more adverse outcomes there will be⁴. A common deleterious outcome linked to ACEs is substance use, which includes: illicit drug use, prescription/other drug misuse, alcohol misuse, and substance use related disorders⁵. Indeed comorbidity between trauma-related disorders and substance use disorders ranges from 26% to 52%⁹. Several mechanisms for this comorbidity have been identified; some of which include brain related changes that induce neuroendocrine changes and/or morphological changes that may contribute to impulsivity.

In particular research has indicated that trauma and substance use may be the result of a dysregulated stress response system^7,8, which means that our body may be more sensitive to acute stress than it previously would have. For example, one with a dysregulated stress response may have the same physiological response to spilling a cup of coffee as they would losing a job. Overtime this heightened response leaves the body tired, so in an attempt to find balance it will down-regulate the stress response system. This down-regulation has been linked to more fatigue, risk for mood-related disorders, and addiction⁸. With respect to the latter, substances offer an artificial means to re-regulate that stress response system; thus, essentially re-balancing the down-regulated system. Unfortunately, as tolerance develops so to does substance-dependence which can increase risk for experiencing future trauma, cardiac diseases, abnormal brain development, impaired thinking & judgement, etc.

Another way that substance use may develop following trauma is related to alterations in brain development that occur in response to trauma. Specifically research has found changes within the prefrontal cortex (PFC), which is an area of the brain that helps to regulate impulsive behavior. This area of the brain develops well into adulthood, and thus is more sensitive to trauma. These changes in the PFC following trauma have been shown to be related to an increased risk for impulsivity and thus impacts risk for substance use disorders⁹.

Although these brain changes may sound permanent, comorbid trauma-related and substance use disorders are common, manageable, and treatable. The best evidence-based treatment modalities for trauma-related and substance use disorders are Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT)¹⁰. Both treatment modalities are collaborative approaches between client and therapist that aim to alter unhelpful thoughts or behaviors underlying the traumatic event and then teach alternative coping strategies to process trauma and day-to-day stressors.

Sources

1. Felitti, V.J., Anda, R.F., Nordenberg, D., Williamson, D.F., Spitz, A.M., Edwards, V., Koss, M.P., Marks, J.S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American Journal of Preventive Medicine, 14(4), 245-258, doi: 1016/S0749 3797(98)00017-8
2. National Survey of Children’s Health, 2016
3. US Department of Health and Human Services, 2013
4. Bick, J., & Nelson, C. A. (2016). Early Adverse Experiences and the Developing Brain. Neuropsychopharmacology, 41(1), 177–196. http://doi.org/10.1038/npp.2015.252
5. (Dube S.R., Felitti V.J., Dong D.P., Chapman W.G., Giles W.H., Anda R.F. (2002). Childhood abuse, neglect and household dysfunction and the risk of illicit drug use: The Adverse Childhood Experience Study. Pediatrics. 111,564–572
6. Shin, S. H., Miller, D. P., & Teicher, M. H. (2013). Exposure to childhood neglect and physical abuse and developmental trajectories of heavy episodic drinking from early adolescence into young adulthood. Drug and Alcohol Dependence,127(1-3), 31-38. doi:10.1016/j.drugalcdep.2012.06.005
7. Danese, A., & McEwen, B. S. (2012). Adverse childhood experiences, allostasis, allostatic load, and age-related disease. Physiology & Behavior,106(1), 29-39. doi:10.1016/j.physbeh.2011.08.019
8. Koob GF, Schulkin J. Addiction and stress: An allostatic view. Neurosci Biobehav Rev. 2019;106:245-262. doi:10.1016/j.neubiorev.2018.09.008
9. Twardosz, S., & Lutzker, J. R. (2010). Child maltreatment and the developing brain: A review of neuroscience perspectives. Aggression and Violent Behavior, 15(1), 59–68.
10. Dam, D. V., Vedel, E., Ehring, T., & Emmelkamp, P. M. (2012). Psychological treatments for concurrent posttraumatic stress disorder and substance use disorder: A systematic review. Clinical Psychology Review, 32(3), 202-214. doi:10.1016/j.cpr.2012.01.004