Childhood adversity linked to early puberty, premature brain development and mental illness
Penn study details effects of poverty and trauma on youth brain and behavior
May 31, 2019
Science Daily/University of Pennsylvania School of Medicine
Growing up in poverty and experiencing traumatic events like a bad accident or sexual assault can impact brain development and behavior in children and young adults. Low socioeconomic status (L-SES) and the experience of traumatic stressful events (TSEs) were linked to accelerated puberty and brain maturation, abnormal brain development, and greater mental health disorders, such as depression, anxiety, and psychosis, according to a new study published this week in JAMA Psychiatry. The research was conducted by a team from Perelman School of Medicine at the University of Pennsylvania and Children's Hospital of Philadelphia (CHOP) through the Lifespan Brain Institute (LiBI).
"The findings underscore the need to pay attention to the environment in which the child grows. Poverty and trauma have strong associations with behavior and brain development, and the effects are much more pervasive than previously believed," said the study's lead author Raquel E. Gur, MD, PhD, a professor of Psychiatry, Neurology, and Radiology at the Perelman School of Medicine at the University of Pennsylvania, and director of the Lifespan Brain Institute.
Parents and educators are split into opposing camps with regard to the question of how childhood adversity affects development into mature, healthy adulthood. Views differ from "spare the rod and spoil the child" to concerns that any stressful condition such as bullying will have a harmful and lasting effects. Psychologists and social scientists have documented lasting effects of growing up in poverty on cognitive functioning, and clinicians observed effects of childhood trauma on several disorders, though mostly in the context of post-traumatic stress disorders (PTSD). There are also anecdotal observations, supported by some research, that adversity accelerates maturation -- children become young adults faster, physically and mentally. Neuroscientists, who are aware of the complexity of changes that the brain must undergo as it transitions from childhood to young adulthood, suspected, and more recently documented that childhood adversity affects important measures of brain structure and function. But this study was the first to compare the effects of poverty (L-SES) to those who experienced TSEs in the same sample set.
The researchers analyzed data from the Philadelphia Neurodevelopmental Cohort, which included 9,498 participants aged 8 to 21 years for the study. The racially and economically diverse cohort includes data on SES, TSEs, neurocognitive performance, and in a subsample, multimodal neuroimaging taken via MRI.
The researchers found specific associations of SES and TSE with psychiatric symptoms, cognitive performance, and several brain structure abnormalities.
The findings revealed that poverty was associated with small elevation in severity of psychiatric symptoms, including mood/anxiety, phobias, externalizing behavior (oppositional-defiant, conduct disorder, ADHD), and psychosis, as compared to individuals who did not experience poverty. The magnitude of the effects of TSEs on psychiatric symptom severity was unexpectedly large. TSEs were mostly associated with PTSD, but here the authors found that even a single TSE was associated with a moderate increase in severity for all psychiatric symptoms analyzed, and two or more TSEs showed large effect sizes, especially in mood/anxiety and in psychosis. Additionally, these effects were larger in females than in males.
With neurocognitive functioning, the case was reversed; poverty was found to be associated with moderate to large cognitive deficits, especially in executive functioning -- abstraction and mental flexibility, attention, working memory -- and in complex reasoning. TSEs were found to have very subtle effects, with individuals who experienced two or more TSEs showing a mild deficit in complex cognition, but demonstrating slightly better memory performance.
Both poverty and TSEs were associated with abnormalities across measures of brain anatomy, physiology, and connectivity. Poverty associations were widespread, whereas TSEs were associated with more focused differences in the limbic and fronto-parietal regions of the brain, which processes emotions, memory, executive functions and complex reasoning.
The researchers also found evidence that adversity is associated with earlier onset of puberty. Both poverty and experiencing TSEs are associated with the child physically maturing at an earlier age. The researchers also found the same effects on the brain, with findings revealing that a higher proportion of children who experienced adversity had characteristics of adult brains. This affects development, as the careful layering of the structural and functional connectivity in the brain requires time, and early maturity could prevent the necessary honing of skills.
"Altogether our study shows no evidence to support the 'spare the rod' approach, to the contrary we have seen unexpectedly strong effects of TSEs on psychiatric symptoms and of poverty on neurocognitive functioning, and both are associated with brain abnormalities," Gur said. "The study suggests that it makes sense for parents and anyone involved in raising a child to try and shield or protect the child from exposure to adversity. And for those dealing with children who were already exposed to adversity -- as is sadly the case today with refugees around the world -- expect an increase in symptoms and consider cognitive remediation, a type of rehabilitation treatment which aims to improve attention, memory, and other cognitive functions."
"Traumas that happen to young children can have lifelong consequences," said the study's senior author Ruben C. Gur, PhD, a professor of Psychiatry, Radiology, and Neurology, and director of the Brain Behavior Laboratory. "Obviously it would be best if we could ameliorate poverty and prevent traumatic events from occurring. Short of that, the study calls for paying more attention to a child's socioeconomic background and to effects of trauma exposure. Parents and educators should become more aware of the special needs of children who are exposed to either adversity. Additionally, mental health professionals should be particularly on notice that traumatic events are associated not only with PTSD, but with elevations across domains including mood, anxiety, and psychosis."
https://www.sciencedaily.com/releases/2019/05/190531085404.htm
PTSD symptoms improve when patient chooses form of treatment
October 19, 2018
Science Daily/University of Washington
A new study is the first large-scale trial of hundreds of PTSD patients, including veterans and survivors of sexual assault, to measure whether patient preference in the course of treatment impacts the effectiveness of a type of cognitive behavioral therapy and use of selective serotonin reuptake inhibitors, a type of antidepressant often prescribed for PTSD.
The study, led by the University of Washington and Case Western Reserve University, was conducted at outpatient clinics in Seattle and Cleveland. It found that both a medication -- Sertraline, marketed as Zoloft -- and a specific form a therapy known as prolonged exposure were effective in reducing PTSD symptoms during the course of treatment, with improvements maintained at least two years later. But patients who received their choice between the two possible treatments showed greater reduction in symptoms, were more apt to stick to their treatment program and even lost their PTSD diagnosis over time.
The study, published Oct. 19 in the American Journal of Psychiatry, is the first large-scale trial of hundreds of PTSD patients, including veterans and survivors of sexual assault, to measure whether patient preference in the course of treatment impacts the effectiveness of a type of cognitive behavioral therapy and use of selective serotonin reuptake inhibitors, a type of antidepressant often prescribed for PTSD.
"In any form of health care, when receiving a recommendation from a provider, patients may or may not be given a choice of approaches to address their problems," said the study's lead author, Lori Zoellner, a UW professor of psychology and director of the Center for Anxiety & Traumatic Stress. "This research suggests that prolonged exposure and Sertraline are both good, evidence-based options for PTSD treatment -- and that providing information to make an informed choice enhances long-term outcomes."
The 200 subjects in the study, all adults, had been diagnosed with chronic PTSD. At the start of the study, all participants expressed a treatment preference between two options -- medication or 10 weeks of therapy -- at the outset of the trial. The study was doubly randomized, meaning that participants were randomly assigned to a group in which they received their preferred treatment, or to a group in which they were also randomly assigned to one treatment program or the other. All participants were evaluated by clinicians for PTSD symptoms, along with the patients' own reports of feelings and behaviors, before, immediately after, and at three, six, 12 and 24 months later.
In this study, 61 percent of participants expressed a preference for prolonged exposure therapy. This form of counseling is often used to treat PTSD because it encourages patients to talk about what happened to them, learn coping strategies and explore their thoughts and feelings through repeatedly approaching the trauma memory and reminders of the trauma.
Of those participants who received prolonged exposure therapy, nearly 70 percent were determined to be free of their PTSD diagnosis two years after the therapy ended, compared with 55 percent of those who had taken and stayed on Sertraline through the follow-up.
Comparing medication to psychotherapy is rare in a clinical trial because it is time- and labor-intensive, Zoellner explained. In this case, both treatments had positive effects, though therapy demonstrated a slight edge. "When both interventions reduce symptoms, it is often difficult to detect a difference because of patients' varying responses -- some get a lot better, some do not. This study showed both prolonged exposure and Sertraline provide generally large and clinically meaningful effects to reduce PTSD and related symptoms," she said. "Prolonged exposure psychotherapy for PTSD is as good as Sertraline, if not better, for the treatment of PTSD."
When treatment preference is taken into account, results are more dramatic. Of those who wanted and received therapy, 74 percent had lost their PTSD diagnosis two years later; of those who preferred therapy but received medication instead, only 37 percent were PTSD-free after two years.
Whether patients received their choice of treatment appeared to directly affect their commitment: Nearly 75 percent of those who were "matched" with their preferred method completed their full treatment program, while more than half of those who were "mismatched" with a treatment method did not complete that course of treatment.
Though PTSD is commonly associated with combat veterans, more than half the participants in the study were diagnosed with chronic PTSD due to a sexual assault, in either childhood or adulthood. Three-quarters of participants were women.
Not all survivors of sexual assault have PTSD or depression, Zoellner pointed out, but those who do may not know that short-term therapy or a medication can yield significant long-term benefits.
"Sexual assault often has a long-term impact on the trauma survivor, but for many it need not be in the form of chronic psychiatric problems," she said. "Survivors should know good, short options exist and need not suffer in silence."
Cost-effectiveness information from the trial, released in 2014, showed that patient choice in treatment also saved money, in the form of fewer emergency department visits, hospitalizations and other care, as well as indirect savings such as fewer lost work hours.
Overall, the trial indicates the importance of tailoring PTSD treatment to the patient, said study co-author Norah Feeny, a psychology professor at Case Western Reserve University.
"Dr. Zoellner and our team showed that we've got two effective, very different interventions for chronic PTSD and associated difficulties," Feeny said. "Given this, and the fact that getting a treatment you prefer confers significant benefit, we are now able to move toward better personalized treatment for those suffering after trauma. These findings have significant public health impact and should inform practice."
https://www.sciencedaily.com/releases/2018/10/181019131515.htm