MILITARY MEDICINE, 177, 9:1034, 2012

Prevalence of Childhood Trauma Among U.S. Army Soldiers With Suicidal Behavior
Rossybelle Perales, MPH; M. Shayne Gallaway, PhD; Kelly L. Forys-Donahue, PhD; Anita Spiess, MPH; Amy M. Millikan, MD
ABSTRACT In 2009, suicide was reported to be the third leading cause of death among U.S. Army persontiel. The increase of suicides iti the Army indicates the need for additional research to better understand the problem. Research in civilian populations found that experiencing childhood trauma increases the risk for various negative health outcomes, including suicide and suicide attempts, during adulthood. To date, there has been very little focus on pre-existing mental health before joining the service because of a lack of existing data. Participants were active duty Army Soldiers who attempted or completed suicide as identified by the Department of Defense Suicide Event Report. Among Soldiers exhibiting suicidal behavior, analyses were completed to identify significant associations with specific types of childhood trauma experienced before joining the Army. The prevalence of childhood trauma in this population was 43.3% among the suicide cases and 64.7% among the attempt cases. The most common types of childhood trauma among Soldiers were family problems and abuse. The need for further research among military populations is clear given the high prevalence of childhood trauma found among these Soldiers with suicidal behavior and the lack of complete data for this population.

BACKGROUND
In 2009, suicide was reported to be the third leading cause of death among U.S. Army personnel, whereas it was the 11th leading cause of death in the nation.' In the United States, 10.8 per 100,000 people committed suicide in 2008, whereas lifetime prevalence of prior suicide attempt ranges from 1.9 to 8.7% in the general population.^ The rate of suicide attempt among psychiatric patients at the time of first hospitalization has been reported as 8.5%.'' The rate of suicide has increased in the Army from 11 per 100,000 in 2003 to 25 per 100,000 in 2009 (Army GI). Given that suicide is a preventable death, combined with the continued rise in number of suicides in the U.S. Army in recent years, there is a strong need for additional research to better understand the problem. Research in civilian populations has found that experiencing childhood trauma increases the risk for various negative health outcomes, including suicide and suicide attempts, during adulthood.'*"'" Likewise, two large national epidemiologic studies found strong associations between childhood sexual abuse and lifetime suicidal behavior."'^ Clinical studies found women with childhood trauma were more vulnerable to suicidal behavior compared to women who bad not experienced childhood trauma.'^'''* The prevalence of childhood trauma among civilian populations has been reported in previous studies; however, reported rates vary depending on the populations sampled and the methodology used to measure trauma.^"'^"'^ In 1990, a national survey found that 27% of women and 16% of men reported a history of childhood sexual abuse.'^ In a sample of

Army Institute of Public Health, 5188 Blackhawk Road, Aberdeen Proving Ground, MD 2101. This work was presented at the APHA 139th Annual Meeting and Exposition October 29 to November 2, 2011 Washington, DC.

people surveyed in a primary care setting, at least one type of abuse (physical, sexual, or emotional) was reported by nearly half the patients.'^ The Adverse Childhood Experiences Study reported, among people who had attempted suicide, the prevalence of specific adverse childhood experiences including emotional abuse (14.3%), physical abuse (7.8 %), sexual abuse (9.1%), substance abuse in household (7.0%), mental illness in family (9.6%), parental separation/ divorce (6.6%), and family member in jail (10.8%).^ This study also reported a 2- to 5-fold increase in risk of suicide attempts among people experiencing any adverse childhood experience.^ The prevalence of childhood abuse in a military population has not been studied extensively; however, in 1996, a study of 1,365 U.S. Army Soldiers found that 49% of females and 15% of males reported a history of childhood sexual abuse, whereas 48% of female Soldiers and 50% of male Soldiers met criteria for physical abuse." Later in 2008, a Department of Defense (DoD) survey reported that 35% of active duty service members experienced some form of abuse during childhood.^" The link between experiencing childhood trauma and adverse behavioral health outcomes as an adult has biological,^' cognitive,^^ and psychological bases.^^'^'* Studies have consistently found that children who are sexually abused report more social and psychological problems later in life.'^'^^"^^ Childhood abuse and neglect were found to be risk factors for suicidal behavior particularly in populations with post-traumatic stress disorder (PTSD).^ In veterans, a history of childhood abuse was associated with combatrelated PTSD.^' Studies have found that childhood trauma increases the risk of developing psychotic symptoms in adulthood.^"^^ The early onsets of some mental disorders, such as major depression and panic disorder, have also been found to be highly correlated with childhood trauma.^ To date, there

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Prevalence of Childhood Trauma Among U.S. Army Soldiers with Suicidal Behavior

has been very little research on mental health outcomes diagnosed before joining the service because of a lack of data. The purpose of this study was to examine the prevalence of childhood trauma among U.S. Army Soldiers who displayed suicidal behavior from 2005 to 2010 and to determine whether the prevalence of childhood trauma and associated factors differ between Soldiers who attempted suicide and Soldiers who completed suicide.

METHODS The population used for this analysis included only regular active duty Army Soldiers who attempted or completed suicide, as identified by completed Department of Defense Suicide Event Report (DoDSER). The DoDSER is a an electronic surveillance database used to standardize suicide surveillance across the services, including the Air Force, Army, Marine Corps, and Navy (Army Health Promotion in Army Regulation 600-63, HQDA, 2010). The DoDSER is filled out by a behavioral health professional following a confirmed suicide death or attempted suicide resulting in hospitalization.''* All of the suicide attempt cases in our population had intent to die as defined by the DoDSER.^'* There were a total of 2,351 attempt cases and 860 suicide cases between January 1, 2005 and December 31, 2010. The final study population included only regular active duty Army SoldiersActivated Reserve and National Guard Soldiers were excludedto include a total of 2,112 attempt cases and 691 suicide cases during this time period. Data were extracted from the Army Behavioral Health Integrated Data Environment (ABHIDE), a suicide surveillance database maintained by the Behavioral and Social Health Outcomes Program (BSHOP) at the U.S. Army Institute of Public Health (USAIPH). The ABHIDE is a registry of all cases of suicides and suicidal behaviors among U.S. Army Soldiers since 2001, including medical, behavioral, social, and demographic data from a number of Army and DoD data sources. The BSHOP conducts routine public health surveillance analysis for the Department of the Army. A history of childhood tiauma was determined -om reviewing the DoDSERs, specifically, the question that asks the behavioral health professional completing the report to: "Please describe any known childhood or developmental history that may have contributed to the event." When the DoDSER is filled out for a suicide attempt, it is common for the information to be ascertained directly from the patient. However, DoDSERs for suicide cases are often conducted with family and close friends to gather the most complete data. In addition to living sources of information, the complter consults a variety of electronic data sources, including the Soldier's medical record. Using the DoDSER information, a determination was made as to whether the Soldier had experienced childhood trauma (yes, no) or whether there were not sufficient data to make a determination (i.e., missing). After exclusion of 1,281 (60.7%) attempted suicides and 527 (76.3%) suicides

whose DoDSER childhood trauma data were not complete or left blank, the final sample used in the analysis consisted of 995 active duty Soldiers. Because completion of childhood trauma field on the DoDSER was not mandatory, we took a conservative approach and excluded DoDSERs that had been left blank, as a determination could not be made as to whether the behavioral health professional had evidence of no childhood trauma or whether there was a complete lack of evidence. A greater percentage of suicide cases (76.3%) were excluded because of missing data for childhood trauma, compared to attempt cases (60.7%, p < 0.0001). The attempt cases that were excluded from the analysis did not differ significantly by demographic characteristics from those with complete data. Excluded suicide cases had a slightly greater proportion of higher ranking soldiers (p = 0.05) and fewer number of deployments {p < 0.0001). If details were specified, each childhood trauma was further classified by the specific type of trauma experienced to include personal and environmental trauma. Personal trauma was defined as experiencing physical, sexual, or emotional abuse during childhood. Environmental trauma encompassed family problems, family substance abuse or mental health problems, death in the family, suicide in the family, violence, or having a family member in jail. Family mental health problems were defined as having a household family member with a mental illness. Substance abuse in the family was defined as having a household member who abused drugs or alcohol. Family problems were defined as a parental separation/ divorce or family dysfunction, including neglect and adoption. Violence was defined as experiencing or witnessing violence in the home or a violent/traumatic event within the family. Soldiers in whom childhood trauma was noted, but for which the specific type of trauma was unknown, were classified as unspecified. The ABHIDE obtains medical encounter information from the Armed Forces Health Surveillance Center (AFHSC). This data were used to identify behavioral health conditions that preceded suicidal behavior among Soldiers used in this analysis. The Healthcare Effectiveness Data and Information Set (HEDIS) definitions were used as criteria to determine behavioral health conditions (i.e., mood disorder, anxiety disorder, substance abuse, PTSD, adjustment disorder, acute stress, and psychotic disorder). Soldiers were classified as having a specific behavioral health condition if, before when they expressed suicidal behavior as identified by the DODSER information, they had an inpatient medical encounter for the condition, an outpatient medical encounter where the primary diagnosis (i.e., position 1) was for the condition, or at least two different outpatient encounters where the condition was noted in diagnostic positions 2 to 4 within 12 months. Descriptive statistics and prevalence rates were calculated for childhood trauma among Soldiers. Pearson X^ test and Fisher's exact test were used for bivariate analysis. All statistical analyses were conducted using the SAS Version 9.2 software package.

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RESULTS Table I shows the overall composition of the study sample. Soldiers displaying suicidal behavior were predominately white, of lower rank, and more than half had deployed at least once. The prevalence of childhood trauma among the attempt cases was higher (64.7%) when compared with the suicide cases (43.3%; p < 0.0001). Suicide attempt cases with a history of childhood trauma were significantly more likely to be female (29.2%) when compared with attempt cases without a childhood trauma history (17.4%). Although most of attempt cases experiencing childhood trauma were Caucasian (73.1%), Hispanic and "Other" ethnicities were significantly less likely to have a history of childhood trauma (9.7%) when compared with suicide attempt cases with a history of childhood trauma (17.4%). Married attempt cases were significantly less likely to have a history of childhood trauma (39.6%). Suicide cases with a history of childhood trauma were more likely to be female and Caucasian when compared with suicide cases without a childhood trauma history. The specific types of childhood trauma experienced are shown in Table 11. Sixty-four percent of attempt cases experienced childhood trauma compared with 43.3% of suicide cases. Among Soldiers displaying suicidal behavior, the folTABLE 1.

lowing types of childhood trauma were experienced: personal trauma (including physical, sexual, and emotional abuse, 14.1%); environmental trauma (21.9%); and unspecified childhood trauma on the DoDSER (31%). The most prevalent forms of childhood trauma across both groups were abuse and family problems. A history of specific types of childhood trauma (personal, environmental, other) was significantly different between the attempt and suicide cases. In this subset of the population experiencing suicidal ideation with a history of childhood trauma, 25.6% of Soldiers expressing suicidal behavior had legal problems, 42% had a behavioral health issue, and 60% had some type of social issue. Suicide attempt cases with a history of childhood trauma had a significantly higher prevalence of mood and anxiety disorders as compared with suicide attempt cases without a history of childhood trauma (Table III). Overall, suicide cases with a history of childhood trauma had a significantly higher prevalence of behavioral health conditions compared with suicide cases without a history of childhood trauma. More specifically, diagnoses of anxiety, adjustment disorder, and acute stress were more prevalent. Attempt cases experiencing childhood trauma had higher prevalence of several social problems including relationship problems.

Demographic and Military Characteristics for U.S. Army Soldiers With Suicidal Behavior From 2005 to 2010
Suicide Attempt n = 831 No Childhood Trauma n % 35.3 82.6 17.4 62.5 31.4 6.1 0.0 66.9 15.0 17.4 0.7 45.4 46.8 7.5 0.3 76.5 19.5 2.7 1.4 29.4 42.7 19.5 8.5 Childhood Trauma n 538 381 157 351 151 35 1 393 93 52 0 256 213 64 5 436 88 10 4 192 213 94 39 % 64.7 70.8 29.2 65.2 28.1 6.5 0.2 73.1 17.3 9.7 0.0 47.6 39.6 11.9 0.9 81.0 16.4 1.9 0.7 35.7 39.6 17.5 7.3 p-Value n 93 90 3 48 33 12 0.61 60 13 20 0.04 43 37 12 1 65 22 2 4 26 34 23 10 46.2 39.8 12.9 1.1 69.9 23.7 2.2 4.3 28.0 36.6 24.7 10.8 31 33 7 0 48 17 5 1 16 33 18 4 43.7 46.5 9.9 0.0 67.6 23.9 7.0 1.4 22.5 46.5 25.4 5.6 64.5 14.0 21.5 57 6 80.3 8.5 11.3 0.08 Completed Suicide n -= 164 No Childhood Trauma % 56.7 96.8 3.2 51.6 35.5 12.9 Childhood Trauma n 71 66 5 36 28 7 % 43.3 93.0 7.0 50.7 39.4 9.9 0.78 p-Value

Total Male Female Age 18-24 25-34 35-60 Missing RaceEthnicity CaucasianAVhite African American Hispanic and Other Missing Marital Status Single Married Other Missing Rank E1-E4 E5-E9 Ol-O3/CadetsAVl-W3 O4-O9AV4-W5 Number of Deployments Never Deployed 1 2 3 or More

293 242 51 183 92 18 0 196 44 51 2 133 137 22 1 224 57 8 4 86 125 57 25

0.002"

0.26

0.05

0.67

0.40

0.38

0.32

0.44

Demographic and military characteristics of the total Army for comparability are as follows: male (87%), Caucasian/white (70%), married (59%), E1-E4 (46%), previously deployed (72%). Data Source: Defense Manpower Data Center, Active Duty (September 2OIO)/CTS deployment file (December 2010).

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Prevalence of Childhood Trauma Among U.S. Army Soldiers with Suicidal Behavior TABLE II. Prevalence of Various Types of Trauma Among U.S. Army Soldiers Reporting Childhood Trauma From 2005 to 2010
Total = 995 n Any Childhood Trauma Any Personal Trauma Abuse Physical, Sexual, or Emotional Any Environmental Trauma Family Problems Substance Abuse (Family) Mental Health Problem (Family) Death in Family Suicide in Family Violence Family Member in Jail Unspecified Trauma People can report more than one type of trauma. 609 141 218 161 49 29 14 10 5 8 308 % 61.2 14.2 21.9 16.2 4.9 2.9 1.4 1.0 0.5 0.8 31.0 n 538 108 169 130 35 24 11 6 3 7 305 Suicide Attempt 7 = 831 % 64.7 13.0 20.3 15.6 4.2 2.9 1.3 0.7 0.4 0.8 36.7 n 71 33 49 31 14 5 3 4 2 1 3 Suicide n = 164 % 43.3 20.1 29.9 18.9 8.5 3.1 1.8 2.4 1.2 0.6 1.8 p-Value <0.0001 0.02 0.007

<0.0001

TABLE III.

Legal, Behavioral Health, and Social Problems on U.S. Army Soldiers With Suicidal Behavior From 2005 to 2010
Suicide Attempt No Childhood Trauma % 39.3 65.9 38.3 17.4 46.3 29.9 13.2 4.5 3.1 95.9 48.8 88.1 19.1 7.5 21.8 Childhood trauma
n

Suicide No Childhood Trauma p-Value 0.64 0.60 0.03 0.0009 0.54 0.22 0.95 0.93 0.11 0.03 0.03 <0.0001 0.07 0.01 <0.0001 36 55 26 5 30 24 9 2 5 89 54 74 20 13 8 % 38.7 59.1 28.0 5.4 32.3 25.8 9.7 2.2 5.4 95.7 58.1 79.6 21.5 14.0 8.6 Childhood Trauma 35 52 22 17 37 22 10 6 3 68 50 58 21 11 33 % 49.3 73.2 31.0 23.9 52.1 31.0 14.1 8.5 4.2 95.8 70.4 81.7 29.6 15.5 46.5 p-Value 0.18 0.06 0.67 0.0005 0.01 0.46 0.38 0.08 0.99 0.98 0.10 0.73 0.24 0.79 <0.0001 % 40.9 67.9 46.2 25.4 48.6 26.0 13.1 4.7 5.6 98.3 56.3 73.6 24.6 13.2 60.4

Legal Problems Behavioral Health Any Behavioral Health Mood Anxiety Adjustment Disorder Substance Abuse PTSD Acute Stress Psychotic Disorders Social Problems Any Social Problem Relationship Problem Military/Work Stress Physical Health Problem Perpetrator of Abuse Victim of Abuse

115 189 110 50 133 86 38 13 9 281 143 258 56 22 64

220 363 247 136 260 139 70 25 30 529 303 396 132 71 325

'

Nine people are missing behavioral health data above.

military/work stress, and being a perpetrator or victim of abuse. Suicide cases that experienced childhood trauma were more likely to be a victim of abuse in adulthood and to have relationship problems. DISCUSSION Findings from this analysis indicate a high prevalence of childhood trauma among Soldiers with suicidal behavior (61.2 %). These findings are not unlike previous research among military populations.'^-^"'^^ The DoD survey of health-related behaviors reported about 42% of service members experience some form of abuse in their lifetime with the majority occurring during childhood (35%).^ Another study measuring childhood trauma among a general population of Soldiers reported a childhood physical abuse history for males (48%)

and females (51%).'^ This study also reported the prevalence of childhood sexual abuse to be lower among male (17%) versus female (51%) Soldiers.'^ A study conducted among female Navy recruits found 57% had experienced some type of childhood abuse.^^ The current study population of Soldiers with suicidal behaviors is a higher risk population, and this could explain part of the differences in prevalence rates. The most common types of childhood trauma experienced were family problems and abuse among both groups, which is consistent with childhood prevalence rates from civilian studies.^ Many studies have found associations between childhood trauma and suicide. Molnar et al" used data from the National Comorbidity Study to show that child rape and molestation were significantly associated with the onset of suicidal behaviors among adult men and women. A replication of the

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National Comorbidity Survey reported that childhood trauma exposures account for 50% of suicide attempts.^^ Roy''^ showed substance-dependent patients who had attempted suicide had significantly higher childhood trauma compared with patients who had never attempted suicide. Previous studies have also identified that childhood trauma is associated with negative behavioral health outcomes other than suicide.''^"^' In the current study, a higher prevalence of mood and anxiety disorders was found among the suicide attempt cases with childhood trauma. Among suicide cases that experienced childhood trauma, there was a higher prevalence of having any behavioral health condition, particularly anxiety, adjustment disorder, and acute stress. Mental disorders account for part of the association between childhood trauma and suicidal behavior; however, findings from Enns et a P ' suggest that childhood trauma is also an independent risk factor for suicidal behavior. Because trauma has a physiological effect on the body'*'^"'*^ and given that children experience stress as more traumatic,** the diathesis stress model, which explains behavior as a result of a combined biological vulnerability and stress from life experiences, could also help to explain the association between childhood trauma and suicide.''^ The experience of childhood trauma could be a predisposing factor, and when an individual with a history of trauma encounters stress as an adult, he or she is more likely to develop a mental health disorder or to engage in suicidal behavior.^'''^'''^ Findings among a sample of Brazilian patients suggested that patients with mood disorders had higher rates of childhood physical abuse compared with patients without such a diagnosis.'" Hall et al'*" showed women experiencing abuse were almost 4.5 times more likely to report high depressive symptoms, compared with women who were not sexually abused in childhood. In a recent study''* of 5,673 health maintenance organization patients, no evidence was found that gender moderates the risk for depression, indicating that men and women with a history of childhood trauma are equally likely to suffer from it in adulthood. Social problems were found to be particularly higher among the Soldiers with a history of childhood trauma who attempted suicide in the current study. Several studies have found adults who have been sexually abused as children report more psychological and social problems than nonabused groups.^^^* Patients with a history of physical and sexual abuse have been shown to have impaired social functioning and an increased number of comorbid diagnoses.''^ Childhood trauma can interfere with the ability to form secure bonds with others, which can inhibit the ability for self-regulation and interpersonal relatedness.'*^ This weakness negatively impacts relationships throughout life, which, in tum, negatively affects social skills and social support. This lack can lead to isolation, stress, and coping problems, which could culminate in behavioral health issues to include suicidal events.^ Without strong social skills, individuals are less likely to have strong social support networks and, therefore, likely to have fewer resources for coping. A physiological response caused by

childhood trauma coupled with a lack of coping skills or a reliance on avoidant coping strategies^" can make stressful events seem devastating; resultihg.ih a host of negative behavioral health states including anxiety,^' depression,^' and substance abuse.^^ Being a victim of abuse in adulthood was also significantly higher among the Soldiers with a history of childhood trauma for both the attempt and suicide cases. This concurs with findings from Merrill et al^^ who found rape significantly more likely among female Navy recruits who had experienced childhood abuse. This study is not without limitations, and therefore the results presented must be interpreted with caution. There are some inherent limitations of using DoDSER data for research because the true purpose is as a surveillance database. The data did not allow us to examine the progression from suicidal ideation to suicidal attempt or death by suicide. The data used were available only for cases of suicide attempt and suicide death and not for a control group of Soldiers without suicidal behavior; thus, we were unable to conduct statistical tests for association between childhood trauma and suicidal behavior. The true rate of childhood trauma among Soldiers who have displayed suicidal behavior is difficult to estimate given the limited amount of data ascertained and the incompleteness of the data provided on existing measures. However, demographically, the attempt and suicide cases excluded because of missing data were fairly similar to those who were included. Suicide cases had a greater proportion of missing childhood trauma data, which could have some unknown impact on the true estimate of childhood trauma. Missing data could be partially attributable to the manner in which historical data are ascertained for suicide cases (i.e., interviews with family and friends), leading to the possibility of underreporting of childhood trauma. Memory studies among survivors of sexual abuse found that as many as 38% are unable to recall the abuse when interviewed in adulthood.^^'^"* However, estimates ofthe prevalence of childhood trauma in this high-risk population of Soldiers displaying suicidal behavior were roughly comparable to estimates found in a previous study of Soldiers." The need for further research among military populations is clear given the high prevalence of childhood trauma found among these Soldiers with suicidal behavior and the lack of complete data for this population. Routine collection of data on childhood trauma is almost minimal, with the exception of the information ascertained after suicidal events, and even still it is recommended steps be taken to ensure these fields are filled out completely on the DoDSER. Unspecified trauma was highly prevalent (36.7%) among the attempt cases. This finding supports the need to standardize response categories for the childhood trauma question on the DoDSER to facilitate more accurate and reliable data collection of this important information. Additional studies are needed within broader military populations to include service members with

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and without behavioralhealth and suicidal issues. This type of study would allow us.to further eJucidate the true magnitude of association betvi^etl childhood trauma and negative behavioral health outcomes, incding suicidal behavior. This research is especially important given the increasingly high rates of suicidal behaviors among U.S. Army Soldiers and the need to identify factors that place service members at higher risk and interventions to prevent future suicidal behavior.

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