Risk of lifetime exposure to a potentially traumatic event (PTE) increases exponentially across the lifespan until non-exposed individuals are rare.1 Although a minority of individuals in the general population develop trauma-related emotional and behavioral problems,2 this is not true of multiply traumatized or poly-victimized individuals.3-5 These experiences can start to accumulate very early in life with potential to disrupt normal development of stress-related biological systems and trigger the emergence of pervasive emotional and behavioral problems.6-8 Many of these children find their way into the child welfare and juvenile justice systems, where psychopathology, including posttraumatic stress disorder (PTSD), alcohol and drug abuse, delinquency and justice involvement, and suicidal behavior, is exponentially more prevalent in comparison to the general population9-14 In addition, these children are less likely to possess key protective personal and social resources associated with buffering the negative consequences of extreme stress exposure.13 They also face high risk of re-victimization – and in many cases, multiple re-victimizations.15 From a public health perspective, what can we do to curb this trajectory of cumulative trauma and emergent psychopathology? Although important progress has been made in the development of evidence-based treatment interventions and some progress has been made in the area of secondary prevention of trauma-related problems, missing is a primary prevention effort to foster adaptive responses before trauma exposure occurs (or re-occurs). A preventative model that reduces risk factors and bolsters protective resources prior to exposure could have substantial impact in reducing cumulative risk. To do this, we need to have a better understanding of risk and protective factors that can be modified. Research has supported the notion that although trauma exposure results in a loss of resources, individuals with greater social and personal resources at the time of the traumatic event are better able to utilize their remaining resources to compensate for resources lost.16 Resilient individuals seem to effectively manage the intense cognitive and emotional demands put forth by extreme stressors. This may involve recruitment and development of new, or realization and reinforcement of existing resources.17 In fact, individuals who experience a significant life stressor and resource loss, but then are proactive in establishing a strong reserve of resources may partially inoculate themselves against other major stressors.18-20 In contrast, individuals who lack sufficient resources are vulnerable to additional loss, deleterious consequences, and what Hobfoll describes as a loss spiral, multiple losses that accelerate the loss of resources and impending detriment. If resource gain or optimization is facilitated prior to potential trauma exposure, then potential victims may be better equipped to cope with trauma exposure and compensate for the loss. Before a primary prevention intervention can be developed, however, it is necessary to identify pre-trauma risk and protective factors that are malleable and therefore capable of being deliberately modified in the context of an intervention. A small but developing literature of prospective studies that examine individuals before and after exposure to potential trauma has identified pre-trauma predictors of better outcomes following potential trauma exposure.21 Among these protective factors are some that appear to be dynamic and thus potentially modifiable within a preventive frame. Examples include social support,18,20,22-28 including the parent-child relationship, protective cognitions, 23,29 self-efficacy, 20,30 social competence, 23,30 and self-regulation strategies. 31 To date, the field has not maximized this information to inform a public health approach towards fostering individuals’ adaptive responses to subsequent potential trauma exposure. What do you think about primary prevention of trauma-related problems before trauma exposure? Where should this intervention take place? What challenges do you anticipate? Join the discussion here, on Facebook, Twitter, or LinkedIn.
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