Traumatic Childhood Experiences and Posttraumatic Stress Disorder Among Veterans in Substance Use Disorder Treatment

Abstract

Posttraumatic stress disorder (PTSD) dramatically increases the risk of both substance use disorder (SUD) and suicide in veterans. Military-related trauma, however, may not be the only or most significant trauma experienced by veterans. Trauma exposure is high among those joining the military. This study sought to identify the prevalence of five types of childhood trauma (emotional, physical, and sexual abuse and emotional and physical neglect) and three adult trauma symptom clusters (intrusive thoughts, avoidance, and hyperarousal) among veterans seeking SUD treatment and to clarify the associations between types of trauma and specific symptom clusters. Veterans at three Veterans Affairs (VA) SUD treatment facilities in the Midwest completed surveys at treatment entry (n₁ = 195) and at 6-month follow-up (n₂ = 138). Measures included the Childhood Trauma Questionnaire-Short Form and the PTSD Checklist, either a military or a civilian version, depending on whether the most traumatic event occurred in or out of the military. The prevalence of childhood trauma was high, ranging from 40.5% experiencing physical abuse down to 22.8% experiencing sexual abuse. At baseline, 60.2% of the military trauma group met criteria for PTSD, compared with 33.9% of the civilian trauma group, a significant difference, χ²(1, N = 195) = 14.46, p < .01. Childhood emotional and physical abuse were moderately associated with intrusion and hyperarousal in the military trauma group, but in the civilian trauma group a broader spectrum of childhood traumas were associated with a broader array of symptom clusters, including avoidance. At follow-up, symptoms improved and were less associated with childhood trauma. These findings illuminate the persistence of effects of childhood trauma and recommend more targeted PTSD treatments.

Keywords

trauma adverse childhood experiences posttraumatic stress disorder substance use disorder veteran

Although the majority of adults in the United States have experienced trauma, only a small minority of them ever develop posttraumatic stress disorder (PTSD; Breslau, 2009). Gender is a well-known and significant risk factor, with women being more than twice as likely as men to report past-year and lifetime PTSD (McLean et al., 2011). Veteran status, however, also is associated with dramatically higher rates of PTSD. The rate of lifetime PTSD for female veterans is 13.4%, which contrasts with a female civilian rate of 8.0%, comparable to the 7.7% rate for male veterans (Lehavot et al., 2018). By contrast, male civilians’ rate of lifetime PTSD is 3.4%, or a quarter the rate for female veterans and less than half the rate for male veterans (Lehavot et al., 2018).

Understanding the type and timing of events that cause posttraumatic stress is important in developing effective treatment plans. Combat exposure is among the strongest predictors of PTSD (Boscarino, 1995), but for veterans combat exposure may not be the first or even the most traumatic event in their lives. The majority of U.S. Marine recruits report one or more personal traumas prior to enlistment (Wolfe et al., 2005), and 46% of active duty personnel report childhood physical abuse (Seifert et al., 2011). Veterans report more adverse childhood experiences (ACEs) than civilians do (Katon et al., 2015). An analysis of 60,598 responses to the 2010 Behavioral Risk Factor Surveillance System revealed that men with a military history in the all-volunteer era were significantly more likely to have experienced all 11 ACEs than men without a military history (Blosnich et al., 2014). Female veterans of this era reported significantly higher experience with four of the 11 ACEs. Thus, trauma exposure is high among members of the armed forces before they are exposed to service-related traumas.

In military and veteran samples, moreover, childhood adversity is associated with adult psychopathology (McLafferty et al., 2019) and multiple types of ACEs significantly increase the likelihood of post-deployment PTSD (LeardMann et al., 2010), even beyond the contributions of combat (Cabrera et al., 2007). Not only is childhood trauma associated with greater PTSD prevalence, it is also associated with greater PTSD severity in veterans, even when combat exposure is low (Owens et al., 2009).

How do veterans cope with PTSD? Research has linked PTSD with the veteran suicide crisis (Jakupcak et al., 2009), but has paid less attention to substance use disorder (SUD) among veterans. Past-year SUD prevalence (excluding tobacco) among all veterans is 17.1%, which compares to 15.5% for nonveterans (Boden & Hoggatt, 2018). Lifetime nontobacco SUD prevalence for veterans is 38.7%, compared with 30.8% for nonveterans (Boden & Hoggatt, 2018).

Veterans with PTSD, however, are at much higher risk for SUD (Smith et al., 2016). Among veterans of Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF), a diagnosis of PTSD increases the probability of a comorbid SUD three- to fourfold (Seal et al., 2011). The relationship between stress and SUD is likely bidirectional. Evidence suggests that those with PTSD self-medicate using alcohol and drugs (Haller & Chassin, 2014), with drug dependence being associated with greater social and psychiatric impairments than alcohol dependence among those with PTSD (Simpson et al., 2019). Also, the use of substances increases the likelihood of chronic stress and traumatic experiences which trigger biological stress responses (Brady & Sinha, 2005).

As with PTSD, early trauma can dramatically influence later SUD. The ACE study found a dose–response effect such that, “persons who had experienced four or more categories of childhood exposure, compared with those who had experienced none, had 4- to 12-fold increased health risks for alcoholism, drug abuse, depression, and suicide attempt” (Felitti et al., 1998, p. 245). In short, today’s veterans are more likely than nonveterans to have experienced a range of childhood traumas, more likely to develop PTSD, and more likely to have a current SUD.

More clarity is needed regarding associations between traumatic events and PTSD in veterans with SUD. A study of OEF/OIF-era veterans that sought to link specific childhood traumas to adult PTSD found that physical assault and accidents or disasters in childhood were consistent predictors of PTSD symptoms, but that childhood experiences of medical trauma or unexpected death consistently predicted more severe PTSD symptoms (Dedert et al., 2009). The study provided strong evidence that combat exposure is a significant predictor of PTSD, but so is trauma experienced prior to military service, including childhood trauma. Although the study examined associations between particular childhood traumas and PTSD and other comorbid conditions, it did not examine variations in PTSD symptomology and only 6% of the sample met criteria for SUD (Dedert et al., 2009).

This study seeks to extend previous research by examining PTSD symptom clusters in veterans with SUD and determining whether the clusters are more or less likely to manifest among those with military-related trauma or with various types of childhood trauma. Any significant associations could lead to more specific and sensitive screening and could aid in the development of more focused treatments for PTSD and its symptoms. This study relies on a secondary analysis of data from veterans seeking treatment for SUD. As noted above, SUD is associated with both ACEs and PTSD, but those characteristics are not universal in this population. Therefore, this study can help clarify the prevalence of ACEs and their association with specific PTSD symptom clusters in a population at elevated risk for both.

This study seeks to answer four specific research questions. The first two questions address the prevalence of childhood trauma and (adult) PTSD symptoms among veterans entering SUD treatment:

Research Question 1 (RQ1): What types of childhood trauma are most prevalent?

Research Question 2 (RQ2): What types of PTSD symptom clusters are most prevalent?

The third and fourth research questions seek to identify associations between specific childhood traumas and specific PTSD symptom clusters and to determine which PTSD symptom clusters improve following SUD treatment:

Research Question 3 (RQ3): Are particular types of childhood trauma associated with particular types of adult PTSD symptom clusters at SUD treatment entry or following SUD treatment?

Research Question 4 (RQ4): Which PTSD symptom clusters are most improved following SUD treatment?

Method

Participants and Procedure

This research study analyzed data collected from participants enrolled in a study of a brief intervention to increase participation in mutual-help groups. The research design and conduct of the study were approved and monitored by the Institutional Review Board of the VA Nebraska-Western Iowa Health Care System (VA NWIHCS). Eligible participants were veterans, age 19 or more, entering one of three intensive SUD treatment programs in the VA NWIHCS (Lincoln, Grand Island, and Omaha, NE sites). Although PTSD diagnoses and treatment were not admission criteria for the SUD treatment program or the study, Veterans Affairs (VA) clinicians continued or initiated PTSD treatment as needed, using psychotherapy (cognitive processing therapy or prolonged exposure) and antidepressants, anxiolytics, or agents to treat insomnia and hyperarousal. At baseline (n₁ = 195), the age of respondents ranged from 25 to 82, with a mean of 46.86 years (SD = 12.25). The sample was predominantly male (91%) and White (77%) or African American (18%), and only 27% were married. Those participants who were contacted and who completed the PTSD Checklist (PCL) at 6-month follow-up comprised 71% of the original sample (n₂ = 138).

At study entry, clinical staff assigned participants to an addiction therapist, half of whom were trained to deliver an intervention more focused than usual care in facilitating 12-step participation. We have described the three-step intervention’s components in detail elsewhere (Young et al., 2018), but they consist primarily of providing information on the effectiveness of 12-step participation, enlisting interpersonal support from a current 12-step member and the participant’s family, and following up repeatedly to address barriers to participation. Those assigned to receive the intervention did not differ significantly from those who received usual care (i.e., encouragement to use 12-step groups) on substance use and 12-step participation outcomes. Therefore, this study does not differentiate them. At entry, participants completed the 28-item Childhood Trauma Questionnaire-Short Form (CTQ-SF) and either the PTSD Checklist-Civilian (PCL-C) or PTSD Checklist-Military (PCL-M) version, as determined by self-report of the participant’s most traumatic experience. At 6-month follow-up, patients again completed the PCL measures.

Measures

The 28-item CTQ-SF measures childhood exposure to trauma in five domains: emotional abuse, physical abuse, sexual abuse, emotional neglect, and physical neglect (Bernstein et al., 2003; Bernstein & Fink, 1998). We excluded the three-item minimization/denial subscale from this analysis, leaving 25 items for the analysis. Likert-type response items range from “never true” (1) to “very often true” (5). Subscale scores can thus range from 5 to 25. The CTQ-SF has demonstrated sufficient psychometric properties in both clinical (Bernstein et al., 1997; Fink et al., 1995) and community (Forde et al., 2012; Scher et al., 2001) samples. For interpretive purposes, we classified participants as having traumatic childhood experiences in the five CTQ-SF domains if their subscore in that domain was at or above the “moderate to severe” classification for that domain. Following previous research (Bernstein & Fink, 1998; Nelson-Gardell & Harris, 2003), the thresholds for moderate to severe childhood trauma measured by the CTQ-SF were at or above 8 for sexual abuse, 10 for both physical abuse and physical neglect, 13 for emotional abuse, and 15 for emotional neglect.

At baseline, participants responded to the question, “Did the most traumatic thing that ever happened to you occur while you were in the military?” Their response determined whether they completed, at both baseline and follow-up, the PCL-C or PCL-M, both of which ask nearly identical questions about past-month experience of 17 symptoms associated with PTSD, based on the criteria established in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV). Response options range from “not at all” (1) to “extremely” (5), with total scores potentially ranging from 17 to 85. The total score comprised three subscale scores, for which the ranges vary: intrusion (5–25), avoidance (7–35), and hyperarousal (5–25). We report data for total PCL and subscale scores, combining the military and civilian versions, as well as reporting them separately. For interpretive purposes, we use a total score at or above 50 to indicate the likely presence of PTSD (Weathers et al., 1991). Both the PCL-M (Bliese et al., 2008; Keen et al., 2008; Weathers et al., 1993; Wilkins et al., 2011) and the PCL-C (Blanchard et al., 1996; Ruggiero et al., 2003) have demonstrated psychometric rigor.

Data Analysis

The measures displayed adequate internal reliability as measured by Cronbach’s alpha. CTQ-SF subscale reliabilities were calculated for emotional abuse (α = .90), physical abuse (α = .86), sexual abuse (α = .96), emotional neglect (α = .91), and physical neglect (α = .82). PCL Cronbach’s alpha reliability scores were adequate for all three subscales (i.e., .80 or higher) on both the baseline and follow-up administrations of both the PCL-M and the PCL-C.

We calculated and reported summary data on CTQ-SF and PCL scores to address the first two research questions regarding prevalence. We answered the third research question by calculating Pearson correlation coefficients and using a one-tailed test of association between the five CTQ-SF subscales and the PCL measures and subscales. We addressed the fourth research question using two-tailed, paired-samples t tests to identify significant changes between baseline and follow-up scores on the PCL. We conducted all data analyses using SPSS and a significance level of p < .05.

Results

Table 1 reports the ranges, means, and standard deviations of CTQ-SF and PCL scores. Mean CTQ-SF subscale scores were in the low to moderate range for all types of trauma. The first research question asked about the prevalence of various childhood traumas. Applying thresholds to identify those experiencing at least moderate childhood trauma in the various domains indicated that 40.5% experienced physical abuse, 36.9% experienced emotional abuse, 27.2% experienced emotional neglect, 23.1% experienced physical neglect, and 22.8% experienced sexual abuse.

Table 1.

Summary Data for Childhood Trauma Questionnaire-Short Form (CTQ-SF) and PTSD Checklist (PCL).

Variable	N	Min.	Max.	M	SD
Childhood Trauma Questionnaire
Emotional abuse	195	5	25	11.28	5.67
Physical abuse	195	5	25	9.89	4.69
Sexual abuse	195	5	25	7.26	4.78
Emotional neglect	195	5	25	11.17	5.01
Physical neglect	195	5	21	7.76	3.64
PTSD Checklist: Baseline
Combined: Total	195	17	85	46.66	18.02
Combined: Intrusion	195	5	25	13.55	6.27
Combined: Avoidance^a	194	7	35	18.86	7.93
Combined: Hyperarousal	195	5	25	14.26	5.73
Military: Total	71	17	85	52.80	17.94
Military: Intrusion	71	5	25	15.48	6.45
Military: Avoidance^a	71	7	35	21.24	7.48
Military: Hyperarousal	71	5	25	16.08	5.69
Civilian: Total	124	17	84	43.14	17.17
Civilian: Intrusion	124	5	25	12.44	5.91
Civilian: Avoidance^a	123	7	35	17.48	7.88
Civilian: Hyperarousal	124	5	25	13.21	5.50
PTSD Checklist: Follow-up
Combined: Total	138	17	83	36.16	18.60
Combined: Intrusion	138	5	25	10.11	5.72
Combined: Avoidance^a	138	7	35	14.71	8.10
Combined: Hyperarousal	138	5	25	11.34	6.00
Military: Total	46	17	78	43.11	17.97
Military: Intrusion	46	5	25	12.65	5.49
Military: Avoidance^a	46	7	34	17.04	7.87
Military: Hyperarousal	46	5	23	13.41	5.93
Civilian: Total	92	17	83	32.68	18.02
Civilian: Intrusion	92	5	25	8.84	5.42
Civilian: Avoidance^a	92	7	35	13.54	8.00
Civilian: Hyperarousal	92	5	25	10.30	5.79

Note. PTSD = posttraumatic stress disorder.

The PCL’s avoidance subscale included seven questions, whereas the intrusion and hyperarousal subscales included only five questions.

The prevalence of specific PTSD symptom clusters was the focus of RQ2. At baseline, the overall mean PCL score (military- and civilian-related trauma combined) was 46.66 (SD = 18.02), slightly below the 50-point threshold for a PTSD diagnosis. Only 36.4% of these SUD treatment–seeking veterans indicated at baseline that their most traumatic experience was in the military. Yet, this subgroup, called the military trauma group, had a mean PCL score (M = 52.80, SD = 17.94) significantly higher than the civilian trauma group, M = 43.14, SD = 17.17, t(194) = 3.72, p < .01. Furthermore, the 62.0% of the military trauma group meeting the 50-point threshold for PTSD was significantly higher than the 33.9% of the civilian trauma group meeting that threshold, χ²(1, N = 195) = 14.46, p < .01.

The levels of PTSD symptom clusters cannot directly compare because PCL’s avoidance subscale scores (reported in Table 1) rely on seven questions versus five for the other two subscales. When we standardized the avoidance subscale to the range of 5 to 25, the intensities of the baseline subscale scores were similar, with a mean of 13.55 (SD = 6.27) for intrusive thoughts, a mean of 13.47 (SD = 5.66) for avoidance, and a mean of 14.56 (SD = 5.73) for hyperarousal. But reflecting their higher overall baseline PCL scores, the military trauma group scored significantly higher than the civilian trauma group on each symptom subscale: intrusive thoughts, t(193) = 3.34, p < .01; avoidance, t(192) = 3.26, p < .01; and hyperarousal, t(193) = 3.47, p < .01.

The third research question sought to determine whether particular forms of childhood trauma are associated with particular PTSD symptom clusters at baseline and post-treatment. Table 2 shows the Pearson correlations between the CTQ-SF categories and PTSD symptom clusters at baseline. Significant small to medium correlations resulted for all the childhood trauma categories and combined trauma subscale scores, with the exception of emotional neglect, which showed no association with the combined intrusion PCL subscale. In general, the three types of childhood abuse were more closely associated with all three PTSD symptom clusters than the two types of childhood neglect were. Some different patterns emerged in the military trauma and civilian trauma groups. The military trauma group had fewer and weaker childhood trauma–symptom cluster associations than the civilian trauma group. This finding is unsurprising given that the civilian trauma group specified that their greatest trauma did not occur in the military although it may not necessarily have happened in childhood either. For the military trauma group, the three types of childhood abuse were associated most consistently with intrusive thoughts, somewhat less with hyperarousal, and very little with avoidance.

Table 2.

Correlations Between Childhood Trauma Questionnaire-Short Form (CTQ-SF) and Baseline PTSD Checklist (PCL).

Baseline PCL	CTQ-SF
Baseline PCL	Emotional Abuse	Physical Abuse	Sexual Abuse	Emotional Neglect	Physical Neglect
Combined: Total (N = 195)	.32**	.28**	.32**	.17**	.21**
Combined: Intrusion	.25**	.27**	.31**	.11	.18**
Combined: Avoidance	.33**	.28**	.30**	.22**	.21**
Combined: Hyperarousal	.28**	.22**	.27**	.13*	.19**
Military: Total (N = 71)	.29**	.22*	.24*	.17	.14
Military: Intrusion	.31**	.25*	.27*	.19	.18
Military: Avoidance	.22*	.20	.17	.11	.06
Military: Hyperarousal	.27*	.16	.22*	.18	.16
Civilian: Total (N = 124)	.34**	.35**	.43**	.20*	.29**
Civilian: Intrusion	.20*	.30**	.38**	.07	.22**
Civilian: Avoidance	.40**	.34**	.41**	.31**	.31**
Civilian: Hyperarousal	.28**	.28**	.35**	.11	.24**

Note. PTSD = posttraumatic stress disorder.

p < .05. **p < .01. (One-tailed Pearson correlation tests).

The civilian trauma group, on the other hand, reported significant associations for nearly all possible combinations. In contrast to the military trauma group, the civilian trauma group had much stronger associations between childhood trauma and avoidance, particularly childhood emotional abuse (r = .40) and childhood sexual abuse (r = .41). Childhood neglect was not associated with baseline PTSD symptom clusters among the military trauma group, but for the civilian trauma group emotional neglect was associated with avoidance (r = .31) and physical neglect was associated with all three PTSD symptom clusters.

Table 3 reports the associations between CTQ-SF categories and PTSD symptom clusters at 6-month follow-up. Similar to the baseline pattern, childhood abuse was more persistently associated with PTSD symptom clusters than was childhood neglect. Of note, eight of the 12 childhood physical neglect correlations were significant at baseline, but none of them remained significant at follow-up. The military trauma group showed persistent, significant associations between intrusive thoughts and childhood emotional and physical abuse. Furthermore, physical abuse actually became significantly associated with hyperarousal, an association which was nonsignificant at baseline. The baseline sexual abuse associations with intrusion and hyperarousal and the baseline avoidance association with emotional abuse became nonsignificant at follow-up.

Table 3.

Correlations Between Childhood Trauma Questionnaire-Short Form (CTQ-SF) and Follow-Up PTSD Checklist (PCL).

Follow-Up PCL	CTQ-SF
Follow-Up PCL	Emotional Abuse	Physical Abuse	Sexual Abuse	Emotional Neglect	Physical Neglect
Combined: Total (N = 138)	.26**	.18*	.22**	.17*	.08
Combined: Intrusion	.24**	.20**	.19*	.12	.06
Combined: Avoidance	.23**	.13	.22**	.20*	.06
Combined: Hyperarousal	.26**	.21**	.20*	.15*	.11
Military: Total (N = 46)	.23	.24	.18	.19	.19
Military: Intrusion	.25*	.28*	.14	.14	.18
Military: Avoidance	.12	.14	.18	.16	.12
Military: Hyperarousal	.32*	.28*	.19	.23	.24
Civilian: Total (N = 92)	.24*	.12	.26**	.16	.03
Civilian: Intrusion	.20*	.11	.25**	.11	.01
Civilian: Avoidance	.26**	.09	.26**	.22*	.03
Civilian: Hyperarousal	.20*	.13	.22*	.10	.06

Note. PTSD = posttraumatic stress disorder.

p < .05. **p < .01. (One-tailed Pearson correlation tests).

In the civilian trauma group, baseline CTQ-SF scores significantly correlated with PCL scores on 18 of the 20 tests, but only nine were significant at follow-up. The strongest correlations remained between childhood sexual abuse and all three of the PCL subscales. Whereas childhood physical abuse correlated with follow-up PTSD symptom clusters in the military trauma group, it showed no such associations in the civilian trauma group. In this group, childhood emotional abuse showed consistent correlations with a range of symptom clusters at follow-up, most strongly with avoidance (r = .26).

Abatement of PTSD symptoms at 6-month follow-up was the focus of RQ4. Table 1 indicates a reduction in all PCL scores and subscale scores. At 6-month follow-up, only 24.6% of participants met the PTSD threshold (vs. 44.1% at baseline), although the military trauma group’s 37.0% remained significantly higher than the civilian trauma group’s 18.5%, χ²(1, N = 138) = 5.64, p < .05. Table 4 shows the results of paired-samples t tests for participants who had both baseline and follow-up scores. The sample reported significant improvements in overall scores and all subscale scores among both military trauma and civilian trauma groups.

Table 4.

Paired-Samples t Tests of Baseline and Follow-Up PTSD Checklist (PCL) Scores.

Variable	N	Baseline M (SD)	Follow-Up M (SD)	Mean Difference	t
Combined: Total	138	45.91 (18.27)	36.16 (18.60)	9.75	7.03**
Combined: Intrusion	138	13.32 (6.08)	10.11 (5.72)	3.21	6.82**
Combined: Avoidance	138	18.51 (8.04)	14.71 (8.10)	3.80	6.06**
Combined: Hyperarousal	138	14.08 (5.85)	11.34 (6.00)	2.74	6.03**
Military: Total	46	52.28 (18.21)	43.11 (17.97)	9.17	4.74**
Military: Intrusion	46	15.61 (5.91)	12.65 (5.49)	2.96	4.51**
Military: Avoidance	46	21.11 (7.60)	17.04 (7.87)	4.07	4.65**
Military: Hyperarousal	46	15.57 (6.13)	13.41 (5.93)	2.15	3.02**
Civilian: Total	88	42.58 (17.37)	32.50 (17.70)	10.08	5.24**
Civilian: Intrusion	88	12.16 (5.82)	8.69 (5.25)	3.47	5.35**
Civilian: Avoidance	88	17.22 (7.95)	13.58 (7.98)	3.64	4.18**
Civilian: Hyperarousal	88	13.20 (5.54)	10.23 (5.67)	2.98	4.97**

Note. Four participants answered the following question differently at follow-up than they did at baseline: “Did the most traumatic thing that ever happened to you occur while you were in the military?” Their answers could not be included in the “Military” and “Civilian” analyses because they completed different versions of the PCL, although they were included in the “Combined” analysis which did not distinguish the versions. PTSD = posttraumatic stress disorder.

p < .01. (Two-tailed paired-samples t tests)

The small number of women in the study precluded stratifying by sex. Instead, we reanalyzed the data for RQ3 and RQ4 excluding female veterans. As expected with a smaller sample, many results dropped slightly, so we focused on results that dropped from a 99% to a nonsignificant confidence level with women being removed. At baseline, this removal reduced the correlation between emotional abuse and the baseline PCL-M score from r = .29 to r = .18 and between emotional abuse and the baseline PCL-M intrusion subscale from r = .31 to r = .17. This suggests that female veterans exposed to childhood emotional abuse are more susceptible to military-related trauma symptom clusters, particularly intrusive thoughts. At follow-up, such reductions appeared only in some of the combined PCL scores’ correlations with only the three abuse subscales. No clear pattern emerged regarding symptom clusters, but the correlation between childhood sexual abuse and combined PCL scores dropped from r = .22 to r = .09, suggesting that female veterans exposed to childhood sexual abuse are more susceptible to PTSD. Excluding women from the analysis of symptom cluster improvement did not significantly change the results.

Discussion

This study sought to identify the prevalence of various categories of childhood trauma and adult traumatic stress symptom clusters among a sample of veterans seeking SUD treatment and then to determine whether specific forms of childhood trauma are associated with particular types of adult trauma symptom clusters. The findings shed light on the long-term consequences of different types of ACEs as they relate to adult traumatic stress symptom clusters.

The first research question addressed experiences of childhood trauma among veterans. The CTQ-SF scores in the moderate, severe, or extreme ranges indicated that physical (40.5%) and emotional (36.9%) abuse were more common than physical (23.1%) and emotional (27.2%) neglect. Childhood sexual abuse was least common, yet 22.8% of the sample experienced it, or more than one in five. These findings are consistent with the research showing that 40% of OEF/OIF veterans reported at least one childhood abuse event (Van Voorhees et al., 2012).

These data lend support to the idea that many recruits join the military with a history of violence and neglect. Compared with community samples, veterans entering intensive substance use treatment reported higher levels of childhood trauma exposure on each of the five CTQ-SF subscales (Scher et al., 2001). Researchers traditionally approach the problem of traumatic histories among recruits in terms of the potential for attrition (Merrill et al., 2004; Wolfe et al., 2005), but our findings suggest that researchers should also address it as a problem of troop fitness for service and subsequent health care utilization. Our sample consisted of veterans with an SUD and their history of childhood trauma aligns with previous research demonstrating that high-risk drinkers entering the military are more likely than low-risk drinkers to have a history of childhood abuse and to join the military to leave problems behind (Young et al., 2006). Together, these findings suggest that the military could identify and treat childhood trauma that motivates some recruits to engage in unhealthy behavior earlier to enhance troop readiness and minimize the impact on trauma symptoms later.

In answer to the second research question, participants who reported that their most traumatic experience occurred in the military were significantly more likely than the civilian trauma group to report PTSD symptoms, and the majority of the military trauma group met the PTSD threshold. This finding may be expected given that military trauma is likely more recent than civilian trauma (including childhood trauma). The current findings highlight the salience of civilian trauma, especially childhood trauma, among veterans entering SUD treatment. Indeed, 63.6% of participants indicated that their most traumatic experience did not happen in the military. A third (33.9%) were experiencing PTSD-level symptoms at treatment entry. Although those identifying civilian rather than military trauma as their most traumatic experience were less likely to screen positive for PTSD, because of their larger numbers they nearly equaled the military trauma group’s PTSD-positive participants (42 civilian trauma vs. 44 military trauma). Similarities and differences among childhood traumas and military traumas hold implications for symptoms and treatment (Cameron, 1994). Furthermore, the forced-choice nature of the PCL ignores the possibility that veterans may have experienced profound trauma in both their military and civilian lives. It does, however, reveal that civilian trauma may be more common than military trauma and that both types of experiences may contribute to comorbid disorders and result in PTSD.

The third research question identified differential associations between categories of childhood trauma and clusters of PTSD symptoms. The finding that childhood trauma was associated with adult trauma symptoms at baseline among both the military and civilian trauma groups provides evidence supportive of a sensitization effect in which ACEs predispose adults to retraumatization and increase the risk of PTSD from subsequent trauma (Breslau et al., 1999). Overall, associations between childhood trauma and adult trauma symptom clusters were stronger for childhood abuse than for childhood neglect. Physical neglect, however, correlated with all trauma symptom clusters in the civilian trauma group, and with no trauma symptom clusters in the military trauma group. The military trauma group demonstrated associations between abuse (emotional, physical, and sexual) and both intrusive thoughts and hyperarousal. This finding stands in contrast to the civilian trauma group, for which the most consistent associations were between all forms of childhood trauma (including neglect) and avoidance. In short, the military trauma group’s childhood abuse correlated with intrusive thoughts and hyperarousal, but the civilian trauma group’s range of childhood traumas correlated with a range of symptom clusters, but especially with avoidance. Importantly, recent research shows that the duration of childhood sexual abuse is associated with trauma symptom severity and avoidance coping (Batchelder et al., 2018). These findings suggest that clinicians should explore and address potential childhood traumas even among those who identify a military experience as the proximal cause of the PTSD.

At 6-month follow-up, associations between childhood trauma and PTSD symptom clusters weakened overall. Intrusive thoughts and hyperarousal, however, remained significantly associated with childhood emotional and physical abuse in the military trauma group. Among veterans, PTSD’s intrusive thoughts are associated with more alcohol problems (Miller et al., 2019) and hypervigilance is associated independently with both PTSD and military deployment (Kimble et al., 2013). In contrast with the military trauma group, the civilian trauma group showed no significant symptom cluster associations with childhood physical abuse, instead expressing the range of symptoms in association with childhood emotional and sexual abuse. This group exhibited more childhood trauma–symptom cluster associations at follow-up than did the military trauma group, which continued to have more significant trauma scores, although both groups improved. The implication of more weakened associations over time among the military trauma group is that their improvement may better position them to avoid retraumatization, either because they are less likely to have a history of childhood trauma or because they are better able to minimize the association between childhood trauma and their traumatic stress symptoms.

The fourth research question asked about improvement in traumatic stress symptom clusters following SUD treatment, and the results showed a significant and substantial improvement across the board. These findings support research demonstrating the efficacy of SUD treatment to improve PTSD, whether or not treatment integrates a PTSD treatment component (Torchalla et al., 2012). Other research indicates a reciprocal relationship between SUD and PTSD improvement such that an improvement in PTSD symptom clusters, especially hyperarousal, significantly improves the probability of SUD recovery (Back et al., 2006). Of note, the hyperarousal scores of our military trauma group declined less (as a percentage of baseline scores) than the other subscale scores for both groups. This finding agrees with previous research indicating less symptom improvement when hyperarousal was the more pronounced symptom cluster (Schell et al., 2004).

This study’s findings offer practical implications for the treatment of veterans with PTSD, SUD, or both. First, the finding that veterans suffering from PTSD were as likely to identify their most traumatic experience occurring in civilian life as in military life reminds clinicians treating veterans not to assume that recent or combat traumas are the most troubling to the patient. Veterans with comorbid PTSD–SUD may be struggling with experiences from combat, from childhood, from postmilitary life, or from some combinations of these. Second, the type of trauma(s) a patient experienced may predict both PTSD and specific symptoms. In this study, a substantial proportion of SUD treatment–seeking veterans entered the military with histories of childhood abuse or neglect, but PTSD symptom clusters varied by the type of abuse, with childhood sexual abuse particularly being pernicious. Third, treatment is effective. During SUD treatment at VA, PTSD symptoms for both those most traumatized in the military and those most traumatized in civilian life improved. The military trauma veterans, however, started treatment with significantly higher PCL scores and at follow-up their average score (43.11) was nearly as high as the civilian-trauma veterans’ score at baseline (43.14), suggesting that additional PTSD treatment may be useful for veterans with military trauma if retraumatization is to be minimized.

One limitation of this study is the sample size, which did not allow for detailed subgroup analyses. The sample roughly represented the broader population of older veterans in the setting’s Midwest region, but therefore also lacked ethnic and gender diversity. Also, participants indicating that a civilian experience was their most traumatic likely included those with few traumatic childhood experiences, and this group completing the PCL-C also included those whose traumatic experiences occurred at some point in adulthood. The most recent version is the PTSD Checklist for DSM-5 (PCL-5), which no longer includes different civilian and military forms, simplifying both the administration and reporting of results (Weathers et al., 2013). It also expands the symptom clusters to include negative alterations of cognitions and mood. Our 70.8% participant follow-up rate was respectable for this transient population, and those who were lost to attrition may have affected the outcome. Specifically, they may not have improved on the traumatic stress measures as much as those who were contacted did. Finally, to screen for the presence of PTSD, we had a research assistant administer the PCL, which is adequate only for preliminary diagnoses. Future studies should use the Clinician-Administered PTSD Scale (CAPS; Weathers et al., 1999). The CAPS is more time-consuming and requires a clinician to administer, but is more accurate than the PCL (Murphy et al., 2017).

Future research should also continue to explore the consequences of repetitive traumatic stress, among both active duty troops and veterans. Larger samples would allow comparisons between those with and without traumatic military experiences (like combat) and those with and without traumatic childhood experiences. Such comparisons would clarify the differences in the development of traumatic stress symptom clusters and coping responses, and may also identify whether the various groups respond differently to standard treatment modalities.

In conclusion, this study provides evidence that many veterans likely continue to suffer the effects of traumatic childhood experiences long after their military service. Clinicians should consider such experiences in the process of understanding the extent of patients’ traumatic experiences in the military in terms of PTSD symptoms and psychological problems comorbid with PTSD. Therefore, clinicians should identify patients’ trauma histories from childhood through adulthood, and their potential implications for treatment planning.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development (RCS 00-001) and the VA Office of Rural Health Midwest Rural Health Resource Center (grant no. N32-FY13Q1-S1-P00642). The views expressed in this article are those of the authors and do not necessarily reflect the views or policy of the Department of Veterans Affairs or the U.S. government.

ORCID iD

Lance Brendan Young

Author Biographies

Lance Brendan Young, PhD, MBA, is an Associate Professor of Communication at Western Illinois University–Quad Cities. His research focuses on multiple aspects of health communication, including the role of social support in addiction and recovery, perceptions and experiences of military sexual trauma, and increasing rural access to health care via telehealth.

Christine Timko, PhD, is a research career scientist at the VA Palo Alto Health Care System and a clinical professor at Stanford’s Department of Psychiatry and Behavioral Sciences. Her research focuses on the quality of care for patients with substance use and/or psychiatric disorders. She is developing and evaluating specialized interventions for substance use disorder patients with co-occurring problems.

R. Dario Pulido, PhD, is a psychologist at the Substance Use Disorder Program/Substance Abuse Residential Rehabilitation Treatment Program (SUDP/SARRTP) in the VA Nebraska-Western Iowa Health Care System in Omaha. His research interests include clinical assessment and dual diagnosis of comorbid conditions.

Kimberly A. Tyler, PhD, is the Willa Cather Professor and Graduate Chair in the Department of Sociology at the University of Nebraska. Her research interests include child abuse, sexual victimization, HIV risk behaviors, social networks, and dating violence and substance use.

Cynthia Beaumont, CCRC, has done clinical research for 17 years. Her research interests include treatment of cigarette smoking–related diseases and substance use disorders in underserved populations.

Kathleen M. Grant, MD, has worked in the substance abuse treatment field since 1983. She is a staff physician at the Omaha VA Medical Center and is associate professor in the Department of Internal Medicine at the University of Nebraska Medical Center. Her research interest is in the treatment of nicotine addiction and of addictions in rural settings and correctional populations.

References

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.).

Back

S. E.

Brady

K. T.

Sonne

S. C.

Verduin

M. L.

(2006). Symptom improvement in co-occurring PTSD and alcohol dependence. The Journal of Nervous and Mental Disease, 194(9), 690–696. https://doi.org/10.1097/01.nmd.0000235794.12794.8a

Batchelder

A. W.

Safren

S. A.

Coleman

J. N.

Boroughs

M. S.

Thiim

Ironson

G. H.

Shipherd

J. C.

O’Cleirigh

(2018). Indirect effects from childhood sexual abuse severity to PTSD: The role of avoidance coping. Journal of Interpersonal Violence. Advance online publication. https://doi.org/10.1177/0886260518801030

Bernstein

D. P.

Ahluvalia

Pogge

Handelsman

(1997). Validity of the Childhood Trauma Questionnaire in an adolescent psychiatric population. Journal of the American Academy of Child and Adolescent Psychiatry, 36(3), 340–348. https://doi.org/10.1097/00004583-199703000-00012

Bernstein

D. P.

Fink

(1998). Childhood Trauma Questionnaire: A retrospective self-report manual. Psychological Corporation.

Bernstein

D. P.

Stein

J. A.

Newcomb

M. D.

Walker

Pogge

Ahluvalia

… Zule

(2003). Development and validation of a brief screening version of the Childhood Trauma Questionnaire. Child Abuse and Neglect, 27(2), 169–190. https://doi.org/10.1016/S0145-2134(02)00541-0

Blanchard

E. B.

Jones-Alexander

Buckley

T. C.

Forneris

C. A.

(1996). Psychometric properties of the PTSD Checklist (PCL). Behaviour Research and Therapy, 34(8), 669–673. https://doi.org/10.1016/0005-7967(96)00033-2

Bliese

P. D.

Wright

K. M.

Adler

A. B.

Cabrera

Castro

C. A.

Hoge

C. W.

(2008). Validating the primary care posttraumatic stress disorder screen and the Posttraumatic Stress Disorder Checklist with soldiers returning from combat. Journal of Consulting and Clinical Psychology, 76(2), 272–281. https://doi.org/10.1037/0022-006X.76.2.272

Blosnich

J. R.

Dichter

M. E.

Cerulli

Batten

S. V.

Bossarte

R. M.

(2014). Disparities in adverse childhood experiences among individuals with a history of military service. JAMA Psychiatry, 71(9), 1041–1048. https://doi.org/10.1001/jamapsychiatry.2014.724

10.

Boden

M. T.

Hoggatt

K. J.

(2018). Substance use disorders among veterans in a nationally representative sample: Prevalence and associated functioning and treatment utilization. Journal of Studies on Alcohol and Drugs, 79(6), 853–861. https://doi.org/10.15288/jsad.2018.79.853

11.

Boscarino

J. A.

(1995). Post-traumatic stress and associated disorders among Vietnam veterans: The significance of combat exposure and social support. Journal of Traumatic Stress, 8(2), 317–336. https://doi.org/10.1007/bf02109567

12.

Brady

K. T.

Sinha

(2005). Co-occurring mental and substance use disorders: The neurobiological effects of chronic stress. American Journal of Psychiatry, 162(8), 1483–1493. https://doi.org/10.1176/appi.ajp.162.8.1483

13.

Breslau

(2009). The epidemiology of trauma, PTSD, and other posttrauma disorders. Trauma, Violence, & Abuse, 10(3), 198–210. https://doi.org/10.1177/1524838009334448

14.

Breslau

Chilcoat

H. D.

Kessler

R. C.

Davis

G. C.

(1999). Previous exposure to trauma and PTSD effects of subsequent trauma: Results from the Detroit Area Survey of Trauma. American Journal of Psychiatry, 156(6), 902–907. https://doi.org/10.1176/ajp.156.6.902

15.

Cabrera

O. A.

Hoge

C. W.

Bliese

P. D.

Castro

C. A.

Messer

S. C.

(2007). Childhood adversity and combat as predictors of depression and post-traumatic stress in deployed troops. American Journal of Preventive Medicine, 33(2), 77–82. https://doi.org/10.1016/j.amepre.2007.03.019

16.

Cameron

(1994). Veterans of a secret war: Survivors of childhood sexual trauma compared to Vietnam war veterans with PTSD. Journal of Interpersonal Violence, 9(1), 117–132. https://doi.org/10.1177/088626094009001008

17.

Dedert

E. A.

Green

K. T.

Calhoun

P. S.

Yoash-Gantz

Taber

K. H.

Mumford

M. M.

… Beckham

J. C.

(2009). Association of trauma exposure with psychiatric morbidity in military veterans who have served since September 11, 2001. Journal of Psychiatric Research, 43(9), 830–836. https://doi.org/10.1016/j.jpsychires.2009.01.004

18.

Felitti

V. J.

Anda

R. F.

Nordenberg

Williamson

D. F.

Spitz

A. M.

Edwards

… 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. https://doi.org/10.1016/s0749-3797(98)00017-8

19.

Fink

L. A.

Bernstein

D. P.

Handelsman

Foote

Lovejoy

(1995). Initial reliability and validity of the childhood trauma interview: A new multidimensional measure of childhood interpersonal trauma. American Journal of Psychiatry, 152(9), 1329–1335. https://doi.org/10.1176/ajp.152.9.1329

20.

Forde

D. R.

Baron

S. W.

Scher

C. D.

Stein

M. B.

(2012). Factor structure and reliability of the Childhood Trauma Questionnaire and prevalence estimates of trauma for male and female street youth. Journal of Interpersonal Violence, 27(2), 364–379. https://doi.org/10.1177/0886260511416461

21.

Haller

Chassin

(2014). Risk pathways among traumatic stress, posttraumatic stress disorder symptoms, and alcohol and drug problems: A test of four hypotheses. Psychology of Addictive Behaviors, 28(3), 841–851. https://doi.org/10.1037/a0035878

22.

Jakupcak

Cook

Imel

Fontana

Rosenheck

McFall

(2009). Posttraumatic stress disorder as a risk factor for suicidal ideation in Iraq and Afghanistan war veterans. Journal of Traumatic Stress, 22(4), 303–306. https://doi.org/10.1002/jts.20423

23.

Katon

J. G.

Lehavot

Simpson

T. L.

Williams

E. C.

Barnett

S. B.

Grossbard

J. R.

… Reiber

G. E.

(2015). Adverse childhood experiences, military service, and adult health. American Journal of Preventive Medicine, 49(4), 573–582. https://doi.org/10.1016/j.amepre.2015.03.020

24.

Keen

S. M.

Kutter

C. J.

Niles

B. L.

Krinsley

K. E.

(2008). Psychometric properties of PTSD Checklist in sample of male veterans. Journal of Rehabilitation Research and Development, 45(3), 465–474. https://doi.org/10.1682/JRRD.2007.09.0138

25.

Kimble

M. O.

Fleming

Bennion

K. A.

(2013). Contributors to hypervigilance in a military and civilian sample. Journal of Interpersonal Violence, 28(8), 1672–1692. https://doi.org/10.1177/0886260512468319

26.

LeardMann

C. A.

Smith

Ryan

M. A.

(2010). Do adverse childhood experiences increase the risk of postdeployment posttraumatic stress disorder in US marines? BMC Public Health, 10(1), Article 437. https://doi.org/10.1186/1471-2458-10-437

27.

Lehavot

Katon

J. G.

Chen

J. A.

Fortney

J. C.

Simpson

T. L.

(2018). Post-traumatic stress disorder by gender and veteran status. American Journal of Preventive Medicine, 54(1), e1–e9. https://doi.org/10.1016/j.amepre.2017.09.008

28.

McLafferty

Ross

Waterhouse-Bradley

Armour

(2019). Childhood adversities and psychopathology among military veterans in the US: The mediating role of social networks. Journal of Anxiety Disorders, 65, 47–55. https://doi.org/10.1016/j.janxdis.2019.05.001

29.

McLean

C. P.

Asnaani

Litz

B. T.

Hofmann

S. G.

(2011). Gender differences in anxiety disorders: Prevalence, course of illness, comorbidity and burden of illness. Journal of Psychiatric Research, 45(8), 1027–1035. https://doi.org/10.1016/j.jpsychires.2011.03.006

30.

Merrill

L. L.

Stander

V. A.

Thomsen

C. J.

Crouch

J. L.

Milner

J. S.

(2004). Childhood exposure to family violence and attrition in the navy. Military Medicine, 169(6), 465–469. https://doi.org/10.7205/milmed.169.6.465

31.

Miller

M. B.

Metrik

Borsari

Jackson

K. M.

(2019). Longitudinal associations between sleep, intrusive thoughts, and alcohol problems among veterans. Alcoholism: Clinical and Experimental Research, 43(11), 2438–2445. https://doi.org/10.1111/acer.14191

32.

Murphy

Ross

Ashwick

Armour

Busuttil

(2017). Exploring optimum cut-off scores to screen for probable posttraumatic stress disorder within a sample of UK treatment-seeking veterans. European Journal of Psychotraumatology, 8(1), Article 1398001. https://doi.org/10.1080/20008198.2017.1398001

33.

Nelson-Gardell

Harris

(2003). Childhood abuse history, secondary traumatic stress, and child welfare workers. Child Welfare, 82(1), 5–26.

34.

Owens

G. P.

Dashevsky

Chard

K. M.

Mohamed

Haji

Heppner

P. S.

Baker

D. G.

(2009). The relationship between childhood trauma, combat exposure, and posttraumatic stress disorder in male veterans. Military Psychology, 21(1), 114–125. https://doi.org/10.1080/08995600802574530

35.

Ruggiero

K. J.

Del Ben

Scotti

J. R.

Rabalais

A. E.

(2003). Psychometric properties of the PTSD Checklist-Civilian Version. Journal of Traumatic Stress, 16(5), 495–502. https://doi.org/10.1023/a:1025714729117

36.

Schell

T. L.

Marshall

G. N.

Jaycox

L. H.

(2004). All symptoms are not created equal: The prominent role of hyperarousal in the natural course of posttraumatic psychological distress. Journal of Abnormal Psychology, 113(2), 189–197. https://doi.org/10.1037/0021-843X.113.2.189

37.

Scher

C. D.

Stein

M. B.

Asmundson

G. J. G.

McCreary

D. R.

Forde

D. R.

(2001). The Childhood Trauma Questionnaire in a community sample: Psychometric properties and normative data. Journal of Traumatic Stress, 14(4), 843–857. https://doi.org/10.1023/A:1013058625719

38.

Seal

K. H.

Cohen

Waldrop

Cohen

B. E.

Maguen

Ren

(2011). Substance use disorders in Iraq and Afghanistan veterans in VA healthcare, 2001–2010: Implications for screening, diagnosis and treatment. Drug and Alcohol Dependence, 116(1–3), 93–101. https://doi.org/10.1016/j.drugalcdep.2010.11.027

39.

Seifert

A. E.

Polusny

M. A.

Murdoch

(2011). The association between childhood physical and sexual abuse and functioning and psychiatric symptoms in a sample of U.S. Army soldiers. Military Medicine, 176(2), 176–181. https://doi.org/10.7205/MILMED-D-10-00038

40.

Simpson

T. L.

Rise

Browne

K. C.

Lehavot

Kaysen

(2019). Clinical presentations, social functioning, and treatment receipt among individuals with comorbid life-time PTSD and alcohol use disorders versus drug use disorders: Findings from NESARC-III. Addiction, 114(6), 983–993. https://doi.org/10.1111/add.14565

41.

Smith

S. M.

Goldstein

R. B.

Grant

B. F.

(2016). The association between post-traumatic stress disorder and lifetime DSM-5 psychiatric disorders among veterans: Data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III). Journal of Psychiatric Research, 82, 16–22. https://doi.org/10.1016/j.jpsychires.2016.06.022

42.

Torchalla

Nosen

Rostam

Allen

(2012). Integrated treatment programs for individuals with concurrent substance use disorders and trauma experiences: A systematic review and meta-analysis. Journal of Substance Abuse Treatment, 42(1), 65–77. https://doi.org/10.1016/j.jsat.2011.09.001

43.

Van Voorhees

E. E.

Dedert

E. A.

Calhoun

P. S.

Brancu

Runnals

Beckham

J. C

. (2012). Childhood trauma exposure in Iraq and Afghanistan war era veterans: Implications for posttraumatic stress disorder symptoms and adult functional social support. Child Abuse and Neglect, 36(5), 423–432. https://doi.org/10.1016/j.chiabu.2012.03.004

44.

Weathers

F. W.

Huska

J. A.

Keane

T. M.

(1991). The PTSD Checklist-Military Version (PCL-M). National Center for PTSD.

45.

Weathers

F. W.

Litz

B. T.

Herman

D. S.

Huska

J. A.

Keane

T. M.

(1993, January). The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility [Paper presentation]. Annual Convention of the International Society for Traumatic Stress Studies, San Antonio, TX, United States.

46.

Weathers

F. W.

Litz

B. T.

Keane

T. M.

Palmieri

P. A.

Marx

B. P.

Schnurr

P. P.

(2013). The PTSD Checklist for DSM-5 (PCL-5)—Extended criterion A [Measurement instrument]. National Center for PTSD. http://www.ptsd.va.gov/

47.

Weathers

F. W.

Ruscio

A. M.

Keane

T. M.

(1999). Psychometric properties of nine scoring rules for the Clinician-Administered Posttraumatic Stress Disorder Scale. Psychological Assessment, 11(2), 124–133. https://doi.org/10.1037/1040-3590.11.2.124

48.

Wilkins

K. C.

Lang

A. J.

Norman

S. B.

(2011). Synthesis of the psychometric properties of the PTSD Checklist (PCL) military, civilian, and specific versions. Depression and Anxiety, 28(7), 596–606. https://doi.org/10.1002/da.20837

49.

Wolfe

Turner

Caulfield

Newton

T. L.

Melia

Martin

Goldstein

(2005). Gender and trauma as predictors of military attrition: A study of Marine Corps recruits. Military Medicine, 170(12), 1037–1043. https://doi.org/10.7205/MILMED.170.12.1037

50.

Young

L. B.

Grant

K. M.

Pulido

R. D.

Simpson

J. L.

Tyler

K. A.

Timko

(2018). Intensive referral of veterans to mutual-help groups: A mixed-methods implementation evaluation. Alcoholism Treatment Quarterly, 36(2), 179-201. https://doi.org/10.1080/07347324.2017.1407224

51.

Young

S. Y. N.

Hansen

C. J.

Gibson

R. L.

Ryan

M. A. K.

(2006). Risky alcohol use, age at onset of drinking, and adverse childhood experiences in young men entering the US Marine Corps. JAMA Pediatrics, 160(12), 1207–1214. https://doi.org/10.1001/archpedi.160.12.1207