Intergenerational effects of war trauma among Palestinian families mediated via psychological maltreatment

Neurological Care of Refugees and Other Forcibly Displaced Persons

There are more than 100 million forcibly displaced persons (FDPs) in the world today, including a high number of people who experience neurologic symptoms and presentations. This review summarizes the conceptual frameworks for understanding neurological health risks and conditions across the migration journey (premigration, migration journey, and postmigration) and life span, including special attention to pediatric FDPs. The interaction with psychiatric illness is discussed, as well as the available published data on neurologic presentations in FDPs in the medical literature. A social determinant of health lens is used to provide ways in which forcible displacement can influence brain health and neurological outcomes. Priorities and future needs for the neurological care of refugees and other FDPs are suggested.

Does Hope Reverberate Between Generations?

Intergenerational transmission refers to the transmission of stories, traits, abilities, ideas, behaviors, and various outcomes from parents to their children. To date, there has been little research on the intergenerational transmission of positive behavior, traits, and actions. To determine whether hope may be transmitted from one generation to the next, a qualitative study was performed, using narrative inquiry and thematic analysis. Over 4 months, four mothers of children with mental illness were engaged in repeated conversations about stories of hope related to their past and how they envisioned hope in their children. Findings indicated that hope could be transmitted to the next generation, either explicitly (verbally) or implicitly (i.e., expressed through actions involving one's children). We conclude that also positive patterns may be transmitted both explicitly and implicitly from one generation to the next. Transmitting hope between generations played a significant role in the mothers' experiences of hope.

How Maternal Trauma Exposure Contributed to Children's Depressive Symptoms following the Wenchuan Earthquake: A Multiple Mediation Model Study

Although well-established literature has indicated the burden of mental health among victims after the Wenchuan earthquake, no research has focused on the mental health of mothers and their children who experienced the earthquake and were pregnant during or shortly after it. This study investigates the relationship between maternal trauma exposure (TE) and children's depressive symptoms after the Wenchuan earthquake and explores the risk and protective factors underlying this relationship. A sample of 547 mother-child dyads, in which the mother experienced the Wenchuan earthquake, was used to assess maternal depressive symptoms, maternal TE, children's depressive symptoms, children's perceived impact of the earthquake and maternal posttraumatic growth (PTG). The results showed that maternal TE had two significant one-step indirect associations with children's depressive symptoms (through children's perceived impact of the earthquake and maternal PTG) and one two-step indirect association with children's depressive symptoms (through maternal depressive symptoms via children's perceived impact of the earthquake). The results indicated that maternal depressive symptoms, children's perceived impact of the earthquake and maternal PTG mediated the association between maternal TE and children's depressive symptoms. These findings highlight the importance of mothers in supporting the mental health of these children. Maternal depressive symptoms and PTG, two posttraumatic outcomes, played positive and negative roles in the intergenerational transmission of trauma. Thus, post-disaster interventions should reduce the maternal transmission of trauma-related information and improve maternal PTG to support children's mental health.

Evaluating the Role of Maternal and Paternal Trauma Exposure, Emotional Security, and Mental Health in Predicting Psychological Adjustment among Palestinian Adolescents

Previous research has established a strong relationship between family system functioning and child adjustment outcomes. However, within the context of Gaza, an evaluation of both maternal and paternal factors associated with adolescent psychological adjustment has not yet been thoroughly evaluated. The current study examines how maternal and paternal trauma exposure, emotional security, and mental health are related to parent-reported scores of adolescent psychological adjustment, while controlling for adolescent trauma exposure and security in the family. The sample included N = 68 family units living in the Gaza Strip, with two parents and one adolescent surveyed within each unit (adolescent Mage = 14.03 years). The regression model examining maternal factors was significant overall (F = 7.44, R2 = 42.70%, p < 0.001), with increased maternal depression associated with greater adolescent adjustment difficulties (β = 0.31, p = 0.011) and greater maternal emotional security in the family associated with fewer adolescent adjustment difficulties (β = −0.36, p = 0.004). The regression model examining paternal factors was also significant (F = 4.57, R2 = 31.00%, p < 0.001), with increased paternal trauma exposure associated with greater adolescent adjustment difficulties (β = 0.32, p = 0.012). Understanding family-level factors associated with adolescent adjustment is an important step in conceptualizing the mental health needs of conflict-affected youth within the context of Gaza and more broadly.

Building Resilience Against ViolencE (BRAVE): protocol of a parenting intervention for mothers and fathers with post-traumatic stress disorder in Pakistan

BACKGROUND

Prevalence of post-traumatic stress disorder (PTSD) is high in Pakistan both due to natural disasters and ongoing conflicts. Offspring of trauma survivors are at increased risk for mental and physical illnesses. Parental PTSD has been linked to troubled parent-child relationships, behaviour problems, trauma symptoms, and depression in children. This study aims to explore the acceptability, feasibility and indications of the effectiveness of group learning through play plus trauma-focused cognitive behaviour therapy (LTP Plus TF-CBT) for parents experiencing PTSD.

METHODS/DESIGN

This is a two-arm pilot cluster randomised controlled trial (RCT). We aim to recruit 300 parents with a diagnosis of PTSD. The screening will be done using the Impact of Event Scale-Revised. Diagnosis of PTSD will be confirmed using the Clinician-Administered PTSD Scale-5 (CAPS-5). Union Councils from Peshawar and Karachi will be randomised into either group LTP Plus TF CBT arm or treatment as usual (TAU). The intervention includes 12 sessions of LTP Plus TF-CBT delivered weekly in the first 2 months and then fortnightly in a group setting by trained psychologists. The groups will be co-facilitated by the community health workers (CHWs). Parents will be assessed at baseline and 4th month (end of the intervention), using the Patient Health Questionnaire (PHQ-9), Generalised Anxiety Disorder (GAD-7) Scale, Client Service Receipt Inventory (CSRI), and Ages and Stages Questionnaire (ASQ-3).

DISCUSSION

This trial would help build an understanding of the acceptability, feasibility and indications of the effectiveness of a low-cost parenting intervention.

Introduction to the Special Issue: Disproportionate trauma, stress, and adversities as a pathway to health disparities among disenfranchised groups globally

Globally, individuals and communities that are marginalized based on their identities are at heightened risk for exposure to traumatic stress and socioeconomic hardship. Marginalization and disproportionate risk for many types of adversities correspond with disparities in physical health, mental health, and overall well-being. Together, the 12 empirical studies, one systematic review, and commentary in this special issue of the Journal of Traumatic Stress highlight the impact of discrimination and disproportionate adversity among groups marginalized based on race, ethnicity, nativity, caste, gender identity, sexual orientation, economic status, and medical status. Although most studies in this issue focus on the United States, the articles that focus on disparities and risk factors in India, El Salvador, Uganda, and Burundi provides a multicontinent global perspective. The global perspective, including the impact of the global pandemic, invites further examination of how disproportionate exposure to traumatic stress and adversity are associated with inequitable burden and health disparities worldwide. This special issue further highlights the developmental and multigenerational burden of systemic marginalization by including studies of children, young adults, adults, and parent-child dyads. Pathways for change and intervention are illustrated through a liberatory consciousness perspective, with one study utilizing liberatory media skills (e.g., positive media images and messages) to mitigate the adverse effects of trauma exposure on at-risk young adults of color. Worldwide, research on the effects of trauma, stress, and adversities must examine contextual factors (e.g., economic hardship), marginalization (e.g., discrimination, identity factors), and the differential impact on health among individuals and communities.

Psychopathology mediates between maltreatment and memory functioning in Burundian refugee youth

BACKGROUND

The detrimental impact of child maltreatment on children and adolescents' academic achievement and later socioeconomic wellbeing is well known. However, it is still unclear (1) whether maltreatment is actually linked to youth's long- and short-term memory deficits and (2) whether potential impairments are due to maltreatment per se or related psychopathology.

OBJECTIVE

Based on the Attentional Control Theory, we investigated a mediational model in which maltreatment would be related to psychopathology (internalizing symptoms, posttraumatic stress symptoms, posttraumatic cognitions), which would in turn be related to impaired memory functioning.

PARTICIPANTS AND SETTING

We drew on a sample of 155 Burundian refugee youth (aged 11 to 15) currently living in refugee camps in Tanzania and at high risk of experiencing ongoing maltreatment by parents.

METHODS

Youth reported on their experiences of maltreatment and psychopathology in structured clinical interviews and completed visuospatial memory tasks involving a short-term and a working memory component (Corsi Block Tapping Test) and delayed recall from long-term memory (Rey-Osterrieth Complex Figure).

RESULTS

Structural equation modeling showed that psychopathology mediated the association between increased maltreatment and reduced working memory capacity (β = -0.07, p = .02), with a trend towards mediation for short-term memory (β = -0.05, p = .06). Higher levels of maltreatment, but not psychopathology, were directly linked to long-term memory deficits (β = -0.20, p = .02).

CONCLUSIONS

Preventive efforts targeting maltreatment and interventions focusing on related psychopathology are needed to counter memory deficits and their potential negative implications for academic and socioeconomic outcomes.

Intergenerational effects of maternal post-traumatic stress disorder on offspring epigenetic patterns and cortisol levels

Aim: To investigate the association between maternal post-traumatic stress disorder (PTSD) during pregnancy and offspring DNA methylation and cortisol levels. Materials & methods: Blood genome-wide DNA methylation and cortisol was measured in the youngest child of 117 women who experienced sexual violence/torture during the Kosovo war. Results: Seventy-two percent of women had PTSD symptoms during pregnancy. Their children had higher cortisol levels and differential methylation at candidate genes (NR3C1, HTR3A and BNDF). No methylation differences reached epigenome-wide corrected significance levels. Conclusion: Identifying the biological processes whereby the negative effects of trauma are passed across generations and defining groups at high risk is a key step to breaking the intergenerational transmission of the effects of mental disorders.

A call for greater conceptual clarity in the field of mental health and psychosocial support in humanitarian settings

AIMS

When the Interagency Standing Committee (IASC) adopted the composite term mental health and psychosocial support (MHPSS) and published its guidelines for MHPSS in emergency settings in 2007, it aimed to build consensus and strengthen coordination among relevant humanitarian actors. The term MHPSS offered an inclusive tent by welcoming the different terminologies, explanatory models and intervention methods of diverse actors across several humanitarian sectors (e.g., health, protection, education, nutrition). Since its introduction, the term has become well-established within the global humanitarian system. However, it has also been critiqued for papering over substantive differences in the intervention priorities and conceptual frameworks that inform the wide range of interventions described as MHPSS. Our aims are to clarify those conceptual frameworks, to argue for their essential complementarity and to illustrate the perils of failing to adequately consider the causal models and theories of change that underlie our interventions.

METHODS

We describe the historical backdrop against which the term MHPSS and the IASC guidelines were developed, as well as their impact on improving relations and coordination among different aid sectors. We consider the conceptual fuzziness in the field of MHPSS and the lack of clear articulation of the different conceptual frameworks that guide interventions. We describe the explanatory models and intervention approaches of two primary frameworks within MHPSS, which we label clinical and social-environmental. Using the examples of intimate partner violence and compromised parenting in humanitarian settings, we illustrate the complementarity of these two frameworks, as well as the challenges that can arise when either framework is inappropriately applied.

RESULTS

Clinical interventions prioritise the role of intrapersonal variables, biological and/or psychological, as mediators of change in the treatment of distress. Social-environmental interventions emphasise the role of social determinants of distress and target factors in the social and material environments in order to lower distress and increase resilience in the face of adversity. Both approaches play a critical role in humanitarian settings; however, the rationale for adopting one or the other approach is commonly insufficiently articulated and should be based on a thorough assessment of causal processes at multiple levels of the social ecology.

CONCLUSIONS

Greater attention to the 'why' of our intervention choices and more explicit articulation of the causal models and theories of change that underlie those decisions (i.e., the 'how'), may strengthen intervention effects and minimise the risk of applying the inappropriate framework and actions to a particular problem.

Prevalence and correlates of depression among rural and urban Rwandan mothers and their daughters 26 years after the 1994 genocide against the Tutsi

BACKGROUND

In the past 26 years since the genocide against the Tutsi, mental illness continues to be the greatest challenges facing the Rwandan population. In the context of the 1994 genocide against Tutsi, there are three different survival status within Rwandan women. Those who were targeted by the genocide referred to as 'survivors', those who were in the country during the genocide but were not targeted referred to as 'non-targeted', and those who were outside the country referred to as '1959 returnees'. All these groups experienced the traumatic events differently. The literature shows that traumatic stress exposure is associated with depression.

OBJECTIVES

To demonstrate differences in trauma exposure in a sample of mothers and daughters according to their genocide survival status. To examine differences in depression prevalence between these three groups of mothers and daughters as a function of their genocide survival status and place of residence. To examine the relationship between major depression, survival status, place of residence, and trauma exposure in sample of mothers and daughters, including the relationship between mothers' depression and daughters' depression.

METHODS

A sample of 309 dyads of mothers and daughters was recruited. Data were collected using the Mini International Neuropsychiatric Interview, Life Events Questionnaire and the Social Demographics Questionnaire. Data were analysed using descriptive statistics, chi-square test, logistic regression, and one-way ANOVA.

RESULTS

There is a significant difference in trauma exposure in three survival categories of mothers and daughters. A 23% of mothers and 18.4% of daughters met criteria for major depression, with urban participants twice as likely to meet criteria as participants from rural areas. Depression was associated with trauma exposure and place of residence in mothers' and daughters' samples. Maternal depression was associated with depression in daughters.

CONCLUSIONS

Family support counselling services and research to identify factors of intergenerational depression are needed.

Intergenerational Trauma among Families in El Salvador: an Exploratory Study

Adverse childhood events have been shown to impact individuals through adulthood, particularly the impact on relationships. This study aimed to examine intergenerational trauma exposure among a sample of parents living in a semi-urban Salvadoran community and the relationship between child trauma exposure with maternal perceived discrimination, internal strengths and external support. Survey data was collected from 49 mothers residing in El Salvador. Bivariate analyses and multivariate linear regression analyses were used to examine the relationship between children's exposure to adverse childhood events and parents' exposure to adverse childhood events, while controlling for discrimination. The results of the regression analysis indicate that the maternal number of adverse childhood events and experience of discrimination as an adult explained 52.9% of the variance (R ²  = 0.59, F(6, 43) = 10.18, p < .0001). The number of adverse childhood events was significantly predicted by maternal number of adverse events (B = 0.32, 95% CI = 0.17-0.48, p < .0001) and experience of discrimination as adults (B = 5.79, 95% CI = 3.51-8.07, p < .0001). Results suggest that parent exposure to adverse childhood events and parent experience with discrimination are related to the exposure to adverse childhood events of their children. Further research in this area is warranted to better understand the experiences of parents who have been exposed to childhood trauma and the day-to-day parenting challenges. Greater understanding of the impact of childhood trauma also encourages service providers to explore intergenerational interventions.

The Differential Effects of Insecure Attachment on Post-Traumatic Stress: A Systematic Review of Extant Findings and Explanatory Mechanisms

It is well-documented that insecure attachment poses substantial risks to post-trauma recovery. Although attachment anxiety reliably predicts and is associated with elevated post-traumatic stress symptoms (PTSS), the attachment avoidance-PTSS link has been far less consistent. This suggests both attenuating and enhancing connections between attachment difficulties and post-trauma outcomes. The goal of this study is 2-fold: (a) to review and summarize extant evidence concerning the relation between insecure attachment and PTSS and (b) to review mechanism(s) underlying attachment anxiety and attachment avoidance that may explain the development of PTSS. Following a systematic review of the empirical literature investigating attachment, trauma, and post-trauma reactions, a total of 138 studies were identified and summarized. The review further identifies explanatory mechanisms underlying the association between insecure attachment and PTSS, including stress appraisals, cognitive factors, self-esteem, emotion regulation strategies, social factors, and trauma-specific factors (i.e., type of trauma, extreme stress). Implications for practice, policy, and research are discussed.

Understanding the needs of children returning from formerly ISIS-controlled territories through an emotional security theory lens: Implications for practice

BACKGROUND

Children who spent time in territories formerly controlled by the Islamic State of Iraq and Syria (ISIS) and who are now being reintegrated into their countries of origin have experienced significant trauma and may present with adjustment or mental health problems.

OBJECTIVE

In this paper we describe how Emotional Security Theory (EST; Davies & Cummings, 1994) and its more recent formulation, EST-reformulated (EST-R; Davies & Martin, 2013, 2014), provide a theoretical lens to aid in understanding the ways in which traumatic experiences under ISIS may have an enduring impact on a child's development and well-being.

METHODS & RESULTS

The core assumption of EST is that maintaining safety and security is a central goal for a child growing up in the context of conflict. Children living in conflict zones under ISIS rule may have developed emotional insecurity, which in turn is theorized to lead to developmental cascades across multiple domains of functioning and at times result in clinically significant distress. This theoretical understanding can guide intervention, as it suggests that the foci of intervention must (1) minimize social signals indicative of threat while also (2) reducing behavioral response patterns that limit opportunities for exploration and prosocial affiliation. Trauma Systems Therapy is a multidisciplinary child trauma treatment model that addresses both stressors in the social environment and related emotional dysregulation.

CONCLUSIONS

Challenges and considerations related to implementing such a comprehensive treatment approach in low- and middle-income countries are discussed.

Crossing borders: a systematic review identifying potential mechanisms of intergenerational trauma transmission in asylum-seeking and refugee families

Background: As displacement and forced migration continue to exhibit global growth trends, new and surviving generations of children are being born and spending their formative years in host countries. Refugee children who have not been exposed to traumatic events may still be at risk for adverse developmental and mental health outcomes via intergenerational trauma transmission. Objective: To identify and synthesize potential mechanisms of intergenerational trauma transmission in forcibly displaced families where parents have experienced direct war-related trauma exposure, but children have no history of direct trauma exposure. Methods: PRISMA systematic review guidelines were adhered to. Searches were conducted across seven major databases and included quantitative, qualitative and mixed methods literature from 1945 to 2019. The search resulted in 752 citations and 8 studies (n = 1,684) met review inclusion criteria. Results: Findings suggest that parental trauma exposure and trauma sequelae indirectly affect child well-being via potential mechanisms of insecure attachment; maladaptive parenting styles; diminished parental emotional availability; decreased family functioning; accumulation of family stressors; dysfunctional intra-family communication styles and severity of parental symptomology. Conclusion: Further research is needed to assess independent intergenerational effects and mechanisms of trauma transmission in this population.

Understanding the link between child maltreatment and adolescent future expectations in Northern Uganda: A serial mediation analysis

BACKGROUND

Recent research has identified high levels of child maltreatment and harsh parenting in post-war societies which have had detrimental effects on children's development. Future expectations are an important aspect of adolescents' development particularly in the challenging contexts of post-war societies where social instabilities and violence are prevalent. To date, however, the link between child maltreatment and adolescent future expectations remains understudied.

OBJECTIVE

By applying a socio-ecological perspective, this study aimed to investigate risk (internalizing symptoms) and protective factors (community integration) linking experiences of harsh parenting with adolescents' future expectations.

PARTICIPANTS AND SETTING

Data was collected from N = 199 northern Ugandan adolescents (40.2 % females, M_age = 14.56 years) with structured interviews.

METHODS

Serial mediation analyses were calculated with child maltreatment as the predictor, future expectations as the outcome, and internalizing symptoms as well as community integration as mediating variables.

RESULTS

Results of the mediation model (R² = .22, F(5193) = 10.54, p <  .001, total effect (b = -0.28, p < .005) revealed a direct effect of child maltreatment on future expectations (effect size: -.20, 95 % bootstrap CI = -0.40, -.01) as well as an indirect effect of child maltreatment via internalizing symptoms and community integration on future expectations (effect size of -.07 (95 % bootstrap CI = -0.14, -0.01).

CONCLUSION

Child maltreatment was found to be linked to negative future expectations among Northern Ugandan adolescents, and both internalizing symptoms as well as community integration played mediating roles in the associations. Interventions should take psychopathology and community factors into account.

Supporting Syrian families displaced by armed conflict: A pilot randomized controlled trial of the Caregiver Support Intervention

BACKGROUND

The impact of armed conflict and displacement on children's mental health is strongly mediated by compromised parenting stemming from persistently high caregiver stress. Parenting interventions for refugees emphasize the acquisition of parenting knowledge and skills, while overlooking the deleterious effects of chronic stress on parenting. War Child Holland's Caregiver Support Intervention (CSI) aims to strengthen parenting by lowering stress and improving psychosocial wellbeing among refugee parents, while also increasing knowledge and skill related to positive parenting. The CSI is a nine-session group intervention delivered by non-specialist providers.

OBJECTIVE

We describe the findings of a two-arm pilot randomized controlled trial of the CSI with Syrian refugees in Lebanon. The primary aim was to test the feasibility of our study methodology prior to conducting a definitive RCT.

METHODS

We recruited 78 families (151 parents), who were randomized to the CSI or a waitlist control group. Data were collected at baseline and post-intervention.

RESULTS

Randomization was successful, retention was high (99 %), as was intervention completion (95 % among women, 86 % among men). Implementation fidelity was excellent. Blinding was largely, though not completely effective. The CSI group showed significantly increased parental warmth and responsiveness, decreased harsh parenting, lowered stress and distress, improved psychosocial wellbeing, and improved stress management. CSI parents reported increased child psychosocial wellbeing. Control families showed no significant change on any variable.

CONCLUSIONS

Findings demonstrate the feasibility of our methodology for a definitive RCT, and suggest that the CSI shows promise as a scalable approach to strengthening parenting in refugee communities. Trial registration # ISRCTN33665023.

Protocol for a randomized control trial of the caregiver support intervention with Syrian refugees in Lebanon

Background

There is evidence that chronic stress negatively impacts parenting among refugees and other war-affected communities. Persistent parental stress and distress may lead to unresponsive, anxious, or overly harsh parenting and a corresponding increase in emotional and behavior problems among children. Most parenting interventions emphasize the acquisition of knowledge and skills; however, this overlooks the deleterious effects of chronic stress on parenting. The Caregiver Support Intervention (CSI) aims to strengthen quality of parenting skills by lowering stress and improving psychosocial wellbeing among refugee caregivers of children aged 3–12 years, while also increasing knowledge and skills related to positive parenting. The CSI is a nine-session psychosocial group intervention delivered by non-specialist providers. It is intended for all adult primary caregivers of children in high-adversity communities, rather than specifically targeting caregivers already showing signs of elevated distress.

Methods/design

The primary objective of this study is to assess the effectiveness of the CSI through a parallel group randomized controlled study with Syrian refugee families in North Lebanon. Participants will be primary caregivers of children aged 3–12 years, with one index child per family. Families will be randomized to the CSI or a waitlist control group.

A total of 240 families (480 caregivers) will be recruited into the study. Randomization will be at the family level, and CSI groups will be held separately for women and men. The study will be implemented in two waves. Outcomes for both arms will be assessed at baseline, post-intervention, and at a 3-month follow-up. The primary outcome is quality of parenting skills. Secondary outcomes include parental warmth and sensitivity, harsh parenting, parenting knowledge, and child psychosocial wellbeing. Putative mediators of the CSI on parenting are caregiver stress, distress, psychosocial wellbeing, and stress management.

Discussion

This trial may establish the CSI as an effective intervention for strengthening parenting in families living in settings of high adversity, particularly refugee communities.

Trial registration

International Society for the Registration of Clinical Trials, ISRCTN22321773. Registered on 5 August 2019

Strengthening parenting in conflict-affected communities: development of the Caregiver Support Intervention

BACKGROUND

There is robust evidence that compromised parenting, stemming from persistently high stress, mediates the impact of war and displacement on children's mental health and psychosocial wellbeing. Parenting interventions generally prioritize the acquisition of parenting knowledge and skills, while under-attending to parental stress and distress. This paper describes the development of the Caregiver Support Intervention (CSI), a nine-session group intervention for conflict-affected parents of children aged 3-13, that aims to strengthen parenting both indirectly, by lowering stress and improving psychosocial wellbeing among parents, and directly, by increasing knowledge and skill related to positive parenting.

METHODS

We describe the multi-phase, iterative process by which we developed the CSI, and illustrate the essential role of community input in shaping the intervention and strengthening its cultural fit and perceived usefulness. We used focus group data from participants in successive cycles of implementation, feedback, and revision, as well as quantitative data and expert consultation to develop a culturally and empirically grounded intervention.

RESULTS

This mixed-method, iterative approach to intervention development enabled us to develop a psychosocial intervention for conflict-affected caregivers that is feasible, acceptable, and perceived by participants as useful in addressing their own wellbeing and their parenting. Focus group data support the underlying model in which caregiver wellbeing powerfully influences parenting.

CONCLUSIONS

Programs aimed at strengthening parenting in conflict-affected communities should substantively address caregiver wellbeing. An iterative approach incorporating community feedback can help ensure intervention acceptability and feasibility. We also illustrate the feasibility of involving men in parenting interventions.

Overview of Children and Disasters

Currently, throughout the world, there are nearly 40 million children displaced by natural or man-made disasters. The special needs of children in disasters are often unrecognized, yet children comprise half of disaster victims. The purpose of this review is to provide information on (1) demographics related to children and disasters, both domestic and international; (2) risks for children who experience disasters; (3) programs that help children in disasters; and (4) training programs on the special needs of children in disasters. Children who are displaced by disasters are at risk of acute and long-term medical problems. Disaster experiences can also lead to acute and long-term psychological problems. Ultimately, these have worldwide negative implications for human society, including education, health care, security, and economic and political aspects of daily life. There is a compelling need for more services to help the children who have experienced disasters and for education to train more relief workers about the special needs of children in disasters.

Exposure to family and organized violence and associated mental health in north Korean refugee youth compared to south Korean youth

Background

Studies on populations affected by organized violence have shown elevated levels of family violence against children. This form of violence has been found to contribute to children's psychopathology independently of traumatic experiences related to war, persecution or flight. Little is known, so far, about the exposure to family violence and its relation to mental health in North Korean refugee youth affected by political violence. The aim of this study was to examine the amount of organized and family violence and associated psychopathology in a sample of North Korean refugee youth living in South Korea compared to their South Korean peers.

Methods

Sixty-five North Korean refugee youth and 65 South Korean youth were recruited. Trained researchers conducted the survey in group meetings of five to ten participants. Using questionnaires researchers assessed traumatic experiences, family and organized violence, PTSD symptoms, depressive symptoms and other mental health problems.

Results

Higher rates of violence and trauma, and higher levels of mental health problems were found in the North Korean sample compared to the South Korean sample. Linear regression analyses including the various types of trauma as potential predictors showed that the severity of PTSD and depressive symptoms in the North Korean sample were associated with the amount of traumatic events and family violence but not with higher levels of organized violence.

Conclusions

The findings suggest that in a context of organized violence, abusive experiences by family members constitute an important problem that is strongly linked to the psychopathology of adolescents. Our data suggest that psychological treatment and prevention approaches for North Korean refugees should be carefully tailored to fit the specific requirements of this population and address the mental health of the individual as well as potential problems at the family level.

Is silence about trauma harmful for children? Transgenerational communication in Palestinian families

Style of family communication is considered important in the transgenerational transmission of trauma. This study had three aims: first, to identify the contents of family communication about past national trauma; second, to examine how parents' current war trauma is associated with transgenerational communication; and third, to analyze the associations between transgenerational communication and children's mental health, measured as posttraumatic stress disorder (PTSD), depression and psychological distress. The study sample consisted of 170 Palestinian families in Gaza Strip, in which both mothers (n = 170) and fathers (n = 170) participated, each with their 11-13-year-old child. Mothers and fathers responded separately to three questions: 1) what did their own parents tell them about the War of 1948, Nakba?; 2) what did they tell their own children about the Nakba?; and 3) What did they tell their own children about the 1967 Arab-Israeli War and military occupation? Current war trauma, as reported separately by mothers, fathers and their children, refers to the Gaza War 2008/09. Children reported their symptoms of PTSD, depression, and psychological distress. Results revealed seven communication content categories and one category indicating maintaining silence about the traumas. Fathers' high exposure to current war trauma was associated with a higher level of communicating facts, reasons, and meanings regarding the1948 and 1967 wars, and mothers' high exposure to current war trauma was associated with a lower level of maintaining silence. Family communication about facts, reasons, and meanings was significantly associated with children not showing PTSD and marginally with not showing psychological distress, while maintaining silence was not associated with children's mental health.

How Stress Gets Under the Skin: Early Life Adversity and Glucocorticoid Receptor Epigenetic Regulation

Early life adversity is associated with both persistent disruptions in the hypothalamic-pituitary-adrenal (HPA) axis and psychiatric symptoms. Glucocorticoid receptors (GRs), which are encoded by the NR3C1 gene, bind to cortisol and other glucocorticoids to create a negative feedback loop within the HPA axis to regulate the body's neuroendocrine response to stress. Excess methylation of a promoter sequence within NR3C1 that attenuates GR expression, however, has been associated with both early life adversity and psychopathology. As critical regulators within the HPA axis, GRs and their epigenetic regulation may mediate the link between early life adversity and the onset of psychopathology. The present review discusses this work as one mechanism by which stress may get under the skin to disrupt HPA functioning at an epigenetic level and create long-lasting vulnerabilities in the stress regulatory system that subsequently predispose individuals to psychopathology. Spanning prenatal influences to critical periods of early life and adolescence, we detail the impact that early adversity has on GR expression, physiological responses to stress, and their implications for long-term stress management. We next propose a dual transmission hypothesis regarding both genomic and non-genomic mechanisms by which chronic and acute stress propagate through numerous generations. Lastly, we outline several directions for future research, including potential reversibility of methylation patterns and its functional implications, variation in behavior determined solely by NR3C1, and consensus on which specific promoter regions should be studied.

Transmitting trauma: a systematic review of the risk of child abuse perpetrated by parents exposed to traumatic events

OBJECTIVES

To review the empirical evidence of a potential association between parental trauma and parental child abuse.

METHODS

Following PRISMA guidelines, 4645 publications were identified through a systematic search in PubMed, PsycINFO and Cochrane. The final number of publications included was 15.

RESULTS

The prevalence of child abuse was found to be consistently higher in populations exposed to traumatic events (prevalence range 36.0-97.5%) compared with non-exposed groups. Parents exposed to trauma were more likely to abuse their children in all studies, and trauma severity, including a PTSD diagnosis in parents, was associated with perpetration of child abuse in most studies. Such associations appeared to be independent of the type of traumatic event. The findings underscore that trauma does not only affect the individual, but also the family.

CONCLUSIONS

Parental trauma seems to be associated with perpetration of child abuse within the family. Abusive behavior against children could be a potential trauma reaction, which should be considered in preventive strategies aimed at reducing harm in traumatized families.

The Security Scale as a measure of attachment: meta-analytic evidence of validity

This meta-analysis evaluated the psychometric properties of the Security Scale (SS; k = 57 studies), a measure specifically designed to assess attachment in middle childhood, using several criteria: stability over time, associations with other attachment measures, relations with caregiver sensitivity, and associations with theoretically driven outcomes. The SS demonstrated moderate stability and meaningful associations with other attachment measures and caregiver sensitivity. Furthermore, the SS showed significant associations with developmental correlates of attachment: school adaptation, emotional and peer social competence, self-esteem, and behavioral problem. Some effect sizes varied as a function of socioeconomic status (SES; peer social competence and maladjustment) and publication status (emotional competence, peer social competence, and self-esteem). The association between the SS and our constructs of interest were, for the most part, independent of geographical location and child gender or age. Overall, findings suggest that the SS is a robust measure of attachment in middle childhood and early adolescence.

Modeling the effects of war exposure and daily stressors on maternal mental health, parenting, and child psychosocial adjustment: a cross-sectional study with Syrian refugees in Lebanon

BACKGROUND

The psychological effects of war trauma are well-documented, but comparatively little research has focused on the mechanisms underlying intergenerational impacts of war and displacement. Specifically, the effects of armed conflict on family processes such as parenting behavior, and subsequent impacts on child psychosocial outcomes, are less understood.

METHODS

This study tests a conceptual model linking past war trauma and current displacement-related stressors to maternal mental health, parenting behavior, and child psychosocial problems. Cross-sectional data were collected in 2016-2017 from a sample of 291 Syrian refugee mothers in Lebanon. We used structural equation modeling to examine associations between war trauma, daily stressors, mothers' general psychological distress and post-traumatic stress (PTS), negative parenting, and child psychosocial problems.

RESULTS

Exposure to war-related events was directly associated with maternal PTS and general psychological distress, as well as indirectly via daily stressors. Mothers' general psychological distress, but not PTS, was directly associated with negative parenting and child psychosocial difficulties. Negative parenting mediated the association between maternal general psychological distress and child psychosocial problems. Model fit statistics indicate that the measurement and structural models provided a good fit to the data.

CONCLUSIONS

Results suggest that the adverse effects of past war trauma and ongoing displacement on refugee mothers' general mental health can increase the risk of negative parenting behavior, and in turn contribute to poorer psychosocial outcomes for children. Interventions should focus on psychosocial and parenting support for war-affected caregivers, as well as address structural challenges that debilitate caregiver and child mental health.

Association of the World War II Finnish Evacuation of Children With Psychiatric Hospitalization in the Next Generation

IMPORTANCE

Although there is evidence that adverse childhood experiences are associated with worse mental health in adulthood, scarce evidence is available regarding an emerging concern that the next generation might also be affected.

OBJECTIVE

To compare the risk of psychiatric hospitalization in cousins whose parents were vs were not exposed to the Finnish evacuation policy that involved a mean 2-year stay with a Swedish foster family.

DESIGN, SETTING, AND PARTICIPANTS

This multigenerational, population-based cohort study of Finnish individuals and their siblings born between January 1, 1933, and December 31, 1944, analyzed the association of evacuee status as a child during World War II in the first generation with the risk of psychiatric hospitalization among offspring in the second generation. Evacuee status during World War II was determined using the Finnish National Archive's registry of participants in the Finnish evacuation. Data on evacuee status were linked to the psychiatric diagnoses in the Finnish Hospital Discharge Register from January 1, 1971, through December 31, 2012, for offspring (n = 93 391) born between January 1, 1950, and December 31, 2010. Sex-specific Cox proportional hazards regression models were used to estimate hazard ratios for risk of psychiatric hospitalization during the follow-up period. Because offspring of evacuees and their nonevacuated siblings are cousins, the Cox proportional hazards regression models included fixed effects to adjust for confounding factors in families. Data analysis was performed from June 15, 2016, to August 26, 2017.

EXPOSURES

Parental participation in the evacuation during World War II (coded 1 for parents who were evacuated and placed in foster care and 0 for those not evacuated).

MAIN OUTCOMES AND MEASURES

Offspring's initial admission to the hospital for a psychiatric disorder, obtained from the Finnish Hospital Discharge Register from January 1, 1971, through December 31, 2012.

RESULTS

Of the 93 391 study persons, 45 955 (49.2%) were women and 47 436 (50.8) were men; mean (SD) age in 2012 among survivors was 45.4 (6.58) years. Female offspring of mothers evacuated to Sweden during childhood had an elevated risk of psychiatric hospitalization (hazard ratio for any type of psychiatric disorder: 2.04 [95% CI, 1.04-4.01]; hazard ratio for mood disorder: 4.68 [95% CI, 1.92-11.42]). There was no excess risk of being hospitalized for a psychiatric disorder among women whose fathers were exposed to the Finnish evacuation policy during World War II or among men whose mothers or fathers were exposed.

CONCLUSIONS AND RELEVANCE

In a prior follow-up study of the Finnish evacuees, girls evacuated to Swedish foster families during World War II were more likely to be hospitalized for a psychiatric disorder-in particular, a mood disorder-in adulthood than their nonevacuated sisters. The present study found that the offspring of these individuals were also at risk for mental health problems that required hospitalization and suggests that early-life adversities, including war-related exposures, may be associated with mental health disorders that persist across generations.

Intergenerational transmission of violence and resilience in conflict-affected Burundi: a qualitative study of why some children thrive despite duress

BACKGROUND

Research suggests that in environments where community conflict and violence are chronic or cyclical, caregiving can impact how children may begin to reproduce violence throughout the various stages of their lives. The aim of this study is to understand how caregiving affects processes of reproducing violence and resilience among children in conflict-affected Burundi.

METHODS

We combined a socio-ecological model of child development with a child-actor perspective. We operationalized the core concepts 'vulnerable household', 'resilience', and 'caregiving' iteratively in culturally relevant ways, and put children's experiences at the center of the inquiry. We carried out a comparative case study among 74 purposively sampled vulnerable households in six collines in three communes in three provinces in the interior of Burundi. Burundian field researchers conducted three consecutive interviews; with the head of the household, the main caregiver, and a child.

RESULTS

Our findings reveal a strong congruence between positive caregiving and resilience among children. Negative caregiving was related to negative social behavior among children. Other resources for resilience appeared to be limited. The overall level of household conditions and embedment in communities attested to a generalized fragile ecological environment.

CONCLUSIONS

In conflict-affected socio-ecological environments, caregiving can impact children's functioning and their role in reproducing violence. Interventions that support caregivers in positive caregiving are promising for breaking cyclical violence.

And I Shot Her: On War, and the Creation of Inequities in the Development of Youths' Moral Capacities

War creates a multifaceted web of inequities that encompass most levels of the ecology of youth development. These include psychosocial inequities bearing on war-exposed youth's limited access to medical and educational services and job-training and employment opportunities, as well as some of the unique psychological sequelae of trauma exposure. In this chapter we put forth a twofold argument. First, we argue that the protracted hardships of war also create enduring psychological inequities that go beyond the well-documented psychosocial needs and psychological trauma, and encompass other aspects of youths' healthy development; these are inequities inasmuch as they represent profound alterations of the developmental pathways available to war-affected youth. Second, we maintain that the psychological sciences must strive to understand such longstanding developmental inequities even if we do not, at this time, have the tools to fully address them.

War trauma and maternal-fetal attachment predicting maternal mental health, infant development, and dyadic interaction in Palestinian families

Optimal maternal-fetal attachment (MFA) is believed to be beneficial for infant well-being and dyadic interaction, but research is scarce in general and among risk populations. Our study involved dyads living in war conditions and examined how traumatic war trauma associates with MFA and which factors mediate that association. It also modeled the role of MFA in predicting newborn health, infant development, mother-infant interaction, and maternal postpartum mental health. Palestinian women from the Gaza Strip (N = 511) participated during their second trimester (T1), and when their infants were 4 (T2) and 12 (T3) months. Mothers reported MFA (interaction with, attributions to, and fantasies about the fetus), social support, and prenatal mental health (post-traumatic stress disorder, depression, and anxiety) at T1, newborn health at T2, and the postpartum mental health, infant's sensorimotor and language development, and mother-infant interaction (emotional availability) at T3. Results revealed, first, that war trauma was not directly associated with MFA but that it was mediated through a low level of social support and high level of maternal prenatal mental health problems. Second, intensive MFA predicted optimal mother-reported infant's sensorimotor and language development and mother-infant emotional availability but not newborn health or maternal postpartum mental health.

PTSD's Underlying Dimensions in Typhoon Haiyan Survivors: Assessing DSM-5 Symptomatology-Based PTSD Models and Their Relation to Posttraumatic Cognition

The recent changes in posttraumatic stress disorder (PTSD) symptomatology in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) call for a re-examination of PTSD's latent factor structure. The present study assessed six competing models of PTSD based on DSM-5 symptomatology using confirmatory factor analysis in a sample of young adult Filipino survivors of typhoon Haiyan, one of the strongest typhoons in the world ever recorded at the time of its landfall (N = 632). Furthermore, the differential relationships of the factors of the best-fitting model with posttraumatic cognitions were also investigated. Results showed the 7-factor hybrid model of PTSD comprised of intrusion, avoidance, negative affect, anhedonia, externalizing behaviors, anxious arousal, and dysphoric arousal, to be the best fitting model. In addition, the varying degrees of relationship with posttraumatic cognitions support the distinctiveness of each factor. These findings are pertinent in light of the changes in DSM-5 PTSD symptomatology, as well as in understanding the underlying dimensions of PTSD among Asian, particularly Filipino, survivors of a natural disaster.

Perceived Changes in Social Relations after Earthquake Trauma among Eastern Anatolian Women: Associated Factors and Mental Health Consequences

In this study, we examined social relations in women exposed to earthquake trauma in Eastern Anatolia, Turkey. We examined women's perceptions regarding the changes in their social relations within their neighbourhood, within their marriage and with their children; analysed the factors that were associated with these relations; and tested the hypothesis that an improvement in social relations will protect women's mental health from the negative impact of earthquake trauma. Participants consisted of a random selection of 1253 women, who were interviewed regarding their psychosocial needs and mental health status 1 year after earthquake. They reported trauma-related changes in their social relations; their mental health was evaluated using the Post Traumatic Stress Diagnostic Scale and Brief Symptom Inventory. Our study demonstrated severe earthquake trauma was associated with deteriorated social relations, especially neighbourhood and marital relations. Deteriorated marital and child relations were associated with increased levels of psychiatric distress; deteriorated neighbourhood relations were associated with intrusive posttraumatic stress symptoms. Improved neighbourhood relations, but not family relations, were able to protect women's mental health from the negative impact of trauma. The results are discussed regarding their relevance to gender effects and the provision of relation-specific and symptom-specific disaster relief. Copyright © 2014 John Wiley & Sons, Ltd.

Determinants of Children's Mental Health in War-Torn Settings: Translating Research Into Action

Research on the mental health and psychosocial wellbeing of children in conflict-affected settings has undergone a significant paradigm shift in recent years. Earlier studies based on a war exposure model primarily emphasized the effects of direct exposure to armed conflict; this has gradually given way to a broader understanding of the diverse pathways by which organized violence affects children. A robustly supported comprehensive model includes risk factors at multiple points in time (prior war exposure, ongoing daily stressors) and at all levels of the social ecology. In particular, findings suggest that material deprivation and a set of family variables, including harsh parenting, parental distress, and witnessing intimate partner violence, are important mediators of the relationship between armed conflict and children's wellbeing. To date, however, interventions aimed at supporting war-affected children's wellbeing, both preventive and treatment-focused, have focused primarily on direct work with children, while paying only modest attention to ongoing risk factors in their families and broader environments. Possible reasons for the ongoing prioritization of child-focused interventions are considered, and examples are provided of recent evidence-based interventions that have reduced toxic stressors (harsh parenting and the use of violent discipline by teachers) in conflict-affected communities.

Children of the postwar years: A two-generational multilevel risk assessment of child psychopathology in northern Uganda

In postconflict settings risk factors at multiple levels of the social ecology, including community, family, and relationship factors, potentially affect children's mental health. In addition, intergenerational risk factors such as guardians' history of childhood family violence, war exposure, and psychopathology may contribute to children's psychopathological symptoms. In this study, we aimed to identify risk constellations that predict child internalizing and externalizing behavior problems, depression, and posttraumatic stress symptoms in the postconflict setting of northern Uganda. In a cross-sectional epidemiological study, 513 second-grade students and their female guardians were interviewed using standardized clinical questionnaires. A higher exposure to traumatic events, more witnessed or experienced violence within the family, and lower child-reported care from female guardians independently predicted psychopathological symptoms in children. While controlling for intergenerational risk factors in female guardians, serial mediation modeling revealed that the effect of trauma exposure on children's psychopathological symptoms was partially mediated by higher exposure to family violence and lower child-perceived care from female guardians. The mediation appeared to be stronger for children's depression symptoms and internalizing and externalizing behavior problems than for posttraumatic stress symptoms. The current findings support the need for targeted interventions at the individual and family system levels that are matched to children's psychopathological symptoms.

The lasting impact of early-life adversity on individuals and their descendants: potential mechanisms and hope for intervention

The adverse effects of early-life stress are pervasive, with well-established mental and physical health consequences for exposed individuals. The impact of early adverse experiences is also highly persistent, with documented increases in risk for mental illness across the life span that are accompanied by stable alterations in neural function and hormonal responses to stress. Here, we review some of these 'stress phenotypes', with a focus on intermediary factors that may signal risk for long-term mental health outcomes, such as altered development of the fear regulation system. Intriguingly, recent research suggests that such stress phenotypes may persist even beyond the life span of the individuals, with consequences for their offspring and grand-offspring. Phenotypic characteristics may be transmitted to future generations via either the matriline or the patriline, a phenomenon that has been demonstrated in both human and animal studies. In this review, we highlight behavioral and epigenetic factors that may contribute to this multigenerational transmission and discuss the potential of various treatment approaches that may halt the cycle of stress phenotypes.

Germ Cell Origins of Posttraumatic Stress Disorder Risk: The Transgenerational Impact of Parental Stress Experience

Altered stress reactivity is a predominant feature of posttraumatic stress disorder (PTSD) and may reflect disease vulnerability, increasing the probability that an individual will develop PTSD following trauma exposure. Environmental factors, particularly prior stress history, contribute to the developmental programming of the hypothalamic-pituitary-adrenal stress axis. Critically, the consequences of stress experiences are transgenerational, with parental stress exposure impacting stress reactivity and PTSD risk in subsequent generations. Potential molecular mechanisms underlying this transmission have been explored in rodent models that specifically examine the paternal lineage, identifying epigenetic signatures in male germ cells as possible substrates of transgenerational programming. Here, we review the role of these germ cell epigenetic marks, including posttranslational histone modifications, DNA methylation, and populations of small noncoding RNAs, in the development of offspring stress axis sensitivity and disease risk.

Effectiveness of psychosocial intervention enhancing resilience among war-affected children and the moderating role of family factors

The study examines, first, the effectiveness of a psychosocial intervention based on Teaching Recovery Techniques (TRT) to increase resiliency among Palestinian children, exposed to a major trauma of war. Second, it analyses the role of family factors (maternal attachment and family atmosphere) as moderating the intervention impacts on resilience. School classes in Gaza were randomized into intervention (N=242) and control (N=240) groups. The percentage of girls (49.4%) and boys (50.6%) were equal, and the child age was 10-13 years in both groups. Children reported positive indicators of their mental health (prosocial behaviour and psychosocial well-being) at baseline (T1), post-intervention (T2) and at a six-month follow-up (T3). At T1 they accounted their exposure to war trauma. Mothers reported about their willingness to serve as an attachment figure, and the child reported about the family atmosphere. Resilience was conceptualized as a presence of positive indications of mental health despite trauma exposure. Against our hypothesis, the intervention did not increase the level of resilience statistically significantly, nor was the effect of the intervention moderated by maternal attachment responses or family atmosphere.

Site-specific methylation changes in the glucocorticoid receptor exon 1F promoter in relation to life adversity: systematic review of contributing factors

There has been recent interest in epigenetics in psychiatry since it offers a means of understanding how stressful life experiences, in interaction with the genotype, result in epigenetic changes that result in altered gene expression, ultimately affecting the risk for mental disorders. Many studies focused on methylation of the glucocorticoid receptor exon 1F promoter following an initial observation that changes in this region could be modulated by the environment. This review examines all published studies that have attempted to measure methylation in this region using different techniques, several tissue types, populations at different behavioral state and stages of development. Methodological issues have been raised with the aim of attempting to understand methylation quantification and site of action. We propose that it is useful to examine whether methylation at specific sites within the promoter region may be particularly relevant to psychiatric vulnerability to stress-related outcomes.

Influences of maternal and paternal PTSD on epigenetic regulation of the glucocorticoid receptor gene in Holocaust survivor offspring

OBJECTIVE

Differential effects of maternal and paternal posttraumatic stress disorder (PTSD) have been observed in adult offspring of Holocaust survivors in both glucocorticoid receptor sensitivity and vulnerability to psychiatric disorder. The authors examined the relative influences of maternal and paternal PTSD on DNA methylation of the exon 1F promoter of the glucocorticoid receptor (GR-1F) gene (NR3C1) in peripheral blood mononuclear cells and its relationship to glucocorticoid receptor sensitivity in Holocaust offspring.

METHOD

Adult offspring with at least one Holocaust survivor parent (N=80) and demographically similar participants without parental Holocaust exposure or parental PTSD (N=15) completed clinical interviews, self-report measures, and biological procedures. Blood samples were collected for analysis of GR-1F promoter methylation and of cortisol levels in response to low-dose dexamethasone, and two-way analysis of covariance was performed using maternal and paternal PTSD as main effects. Hierarchical clustering analysis was used to permit visualization of maternal compared with paternal PTSD effects on clinical variables and GR-1F promoter methylation.

RESULTS

A significant interaction demonstrated that in the absence of maternal PTSD, offspring with paternal PTSD showed higher GR-1F promoter methylation, whereas offspring with both maternal and paternal PTSD showed lower methylation. Lower GR-1F promoter methylation was significantly associated with greater postdexamethasone cortisol suppression. The clustering analysis revealed that maternal and paternal PTSD effects were differentially associated with clinical indicators and GR-1F promoter methylation.

CONCLUSIONS

This is the first study to demonstrate alterations of GR-1F promoter methylation in relation to parental PTSD and neuroendocrine outcomes. The moderation of paternal PTSD effects by maternal PTSD suggests different mechanisms for the intergenerational transmission of trauma-related vulnerabilities.

Maternal PTSD associates with greater glucocorticoid sensitivity in offspring of Holocaust survivors

Intergenerational effects of trauma have been observed clinically in a wide range of populations, and parental PTSD has been associated with an increased risk for psychopathology in offspring. In studies of Holocaust survivor offspring, parental PTSD, and particularly maternal PTSD, has been associated with increased risk for PTSD, low basal urinary cortisol excretion and enhanced cortisol suppression in response to dexamethasone. Such findings implicate maternally derived glucocorticoid programming in the intergenerational transmission of trauma-related consequences, potentially resulting from in utero influences or early life experiences. This study investigated the relative influence of Holocaust exposure and PTSD in mothers and fathers on glucocorticoid sensitivity in offspring. Eighty Holocaust offspring and 15 offspring of non-exposed Jewish parents completed evaluations and provided blood and urine samples. Glucocorticoid sensitivity was evaluated using the lysozyme suppression test (LST), an in vitro measure of glucocorticoid receptor sensitivity in a peripheral tissue, the dexamethasone suppression test (DST), and 24-h urinary cortisol excretion. Maternal PTSD was associated with greater glucocorticoid sensitivity in offspring across all three measures of glucocorticoid function. An interaction of maternal and paternal PTSD on the DST and 24-h urinary cortisol showed an effect of decreased glucocorticoid sensitivity in offspring with paternal, but not maternal, PTSD. Although indirect, these findings are consistent with the hypothesis that epigenetic programming may be involved in the intergenerational transmission of trauma-related effects on glucocorticoid regulation.

The relationship between organized violence, family violence and mental health: findings from a community-based survey in Muhanga, Southern Rwanda

BACKGROUND

The relationship between organized violence and family violence, and their cumulative effect on mental health in post-conflict regions remains poorly understood.

OBJECTIVE

The aim of the present study was to establish prevalence rates and predictors of family violence in post-conflict Rwanda. And to examine whether higher levels of war-related violence and its socio-economic consequences would result in higher levels of violence within families and whether this would be related to an increase of psychological distress in descendants.

METHOD

One hundred and eighty-eight parent-child pairs from four sectors of the district Muhanga, Southern Province of Rwanda, were randomly selected for participation in the study. Trained local psychologists administered structured diagnostic interviews. A posttraumatic stress disorder (PTSD) diagnosis was established using the PTSD Symptom Scale Interview (PSS-I) and child maltreatment was assessed by means of the Childhood Trauma Questionnaire (CTQ). Additionally, the Hopkins Symptom Checklist (HSCL-25) assessed symptoms of depression and anxiety in descendants.

RESULTS

Prevalence rates of child abuse and neglect among descendants were below 10%. Ordinal regression analyses revealed that the level of child maltreatment in descendants was predicted by female sex, poverty, loss of the mother, exposure to war and genocide as well as parents' level of PTSD and reported child maltreatment. Poor physical health, exposure to war and genocide, parental PTSD symptoms, and reported childhood trauma were significantly associated with depressive and anxious symptoms, while only exposure to war and genocide and poor physical health predicted the level of PTSD.

CONCLUSION

The results indicate that cumulative stress such as exposure to organized violence and family violence in Rwandan descendants poses a risk factor for the development of depressive and anxious symptoms. Besides the support for families to cope with stress, awareness-raising initiatives challenging the current discourse of discipline toward children in schools or at home need to be fostered.