Transgenerational consequences of PTSD: risk factors for the mental health of children whose mothers have been exposed to the Rwandan genocide
© Roth et al.; licensee BioMed Central Ltd. 2014
Received: 3 October 2013
Accepted: 25 March 2014
Published: 1 April 2014
Understanding how parental Posttraumatic Stress Disorder (PTSD) may or may not affect the development and mental health in the offspring is particularly important in conflict regions, where trauma-related illness is endemic. In Rwanda, organised atrocities and the genocide against the Tutsi of 1994 have left a significant fraction of the population with chronic PTSD. The aim of the present investigation was to establish whether PTSD in mothers is associated with symptoms of depression, anxiety, and aggressive and antisocial behaviour in their children.
A community sample of 125 Rwandan mothers who experienced the genocide of 1994 and their 12-year-old children were interviewed. Using a structured interview, symptoms of maternal PTSD and children’s depression, anxiety, and aggressive and antisocial behaviour were assessed by trained and on-site supervised local B.A. psychologists. The interview also included a detailed checklist of event types related to family violence.
In showing that a maternal PTSD was not associated with child’s psychopathology, the results contradict the assumption of straight “trans-generational trauma transmission”. Instead, a child’s exposure to maternal family violence posed a significant risk factor for a negative mental health outcome. Furthermore, it was not maternal PTSD-symptoms but mother’s exposure to family violence during her own childhood that was associated with the magnitude of adversities that a child experiences at home.
Contrary to a simple model of a trans-generational transmission of trauma, neither maternal PTSD nor maternal traumatic experiences were directly associated with symptoms of anxiety, depression, or antisocial and aggressive behaviour in the children. Instead, the present results suggest a relationship between parental child rearing practices and children’s mental health. Furthermore, the study details the “cycle of violence”, showing a significant link between maternal violence against a child and its mother’s experience of childhood maltreatment.
An association between parental exposure to traumatic stress and children’s psychological mental health has been suggested by studies that examined families of veterans. Children of fathers suffering from PTSD showed significantly greater internalized and externalized behavioural problems [1, 2], somatic complaints  and higher scores of depression [3, 4] and anxiety  compared to children of veterans who did not present with a mental disorder. An increased level of behavioural disorders, anxiety and depressive symptoms, as well as posttraumatic stress were also confirmed in offspring of tortured refugee parents suffering from PTSD compared to children with non-traumatized parents [6, 7]. Although children whose mothers and fathers both had PTSD show significantly higher scores of psychopathology such as anxiety and depression, the mother’s anxiety was identified as the most frequent and important predictor of children’s mental health status .
While systematic studies assessing the association of children’s mental health status and parental traumatization are rare, a number of examinations focused on changes and impairments in the family system that stem from parental PTSD and trauma exposure. Several studies have found general impairments of child rearing capacities, such as inadequate emotional reaction , impaired parent–child relationship [9, 10], disrupted communication styles  or physical punishment [12–15]. Physical punishment was often explained by hyperarousal symptoms or substance abuse in the parents  and was associated with combat experiences in veteran fathers and behavioural problems in the offspring . Similar to the dose effect for vulnerability to PTSD [18, 19], a dose effect for the consequences of family violence was found: children who experienced more maltreatment in childhood demonstrated more severe behavioural problems and higher rates of delinquency [20, 21].
The possibility of trans-generational consequences of parental PTSD arises specifically in populations with a high prevalence of PTSD. Rwanda represents a nation with a history of numerous massacres, most devastating the genocide from 1994, killing 10% of Rwanda’s almost 8 million inhabitants, mostly Tutsi and oppositional Hutu . Consequently, even more than a decade after this massive violent event, the prevalence of PTSD has remained exceptionally high in Rwanda [23–26]. Additionally, the Rwandan population has to cope with experiences of massive bereavement and extensive social disruption . Furthermore, Rwandans still remain in a state of hyper-vigilance and trepidation, worrying that genocidal hostilities between the two ethnic groups might occur again . We suppose that existing parental psychopathology resulting from past traumatic experiences and current worries about reoccurrence of the slaughters have a substantial psychological impact on the mental health of the offspring generation. Therefore, the examination of trans-generational consequences of parental PTSD in Rwanda may help to better understand the long-term impact of parental PTSD for children’s mental health, and to detect individual, familial and social needs in order to support a psychological healing process in Rwandan society.
From April to May 2008 we conducted a community-based survey in Rwanda in order to examine trans-generational consequences of PTSD in mothers who experienced the genocide in 1994 and their 12-year-old children who were born two years after the genocide.
The recruitment took place in three different public schools in Butare in southern Rwanda. In order to achieve a wide range of socio-economic status in the examined families, recruitment took place at two rural, and one urban schools. These schools were chosen according to logistical aspects. Participants were recruited according to the following criteria: (1) children were 12 years old, (2) children lived together with the biological mother, and (3) the mothers had lived in Rwanda during the time of the genocide in 1994. We have focused on biological mothers in order to exclude additional confounding variables, which may derive from the experienced stress in the children with the change of the most important caretaker. Approval for the survey was obtained from the National Institute of Statistics of Rwanda and the Ethical Review Board of the University of Konstanz, Germany.
A convenient sample of 125 women and their 12-year old children (41 boys and 84 girls) were interviewed. The mothers were on average 42 years old (range = 24 – 59), 52% (n = 65) were married, 36% (n = 45) were widows, 10% (n = 13) divorced or separated, and 3 mothers (2%) were single. The children reported having on average 3 to 4 siblings (mean = 3.87; range = 0 – 10; SD = 2.04) and attended the second (9%, n = 11), third (31%, n = 28), forth (40%, n = 50) and fifth grade (20%, n = 25). The majority of the households owned a house/hut (81%, n = 101), 72% (n = 90) possessed a vegetable garden and 8% (n = 10) grew crops in order to sell them. A global index of the household’s economical status was created in order to test its association with children’s psychopathology. The index was calculated by adding up the z-standardized scores of family possession, such as furniture (table, beds, carpets), books, cooking pots, bikes, motorbikes, television, radio, property (house, garden), farm animals, children’s possession (number of toys and cloths), as well as the family’s average monthly income and the number of meals per day of mothers and children. This indicator ranged from -15 to 27.
The children were selected by the directors and teachers of the schools according to the inclusion criteria. The teachers first informed the children to ask their mother to come to the school on the following day, where they were informed about the investigation by the interviewers. After the mothers have agreed to take part in the study, the interviewers accompanied them to their home, where the interview took place. None of the mothers refused to participate in the study. At home in a confidential setting a more detailed explanation of the study was given. If the mother still agreed to participate, she signed a written informed consent for herself and for her child. Each mother was interviewed at her home and subsequently the child was investigated at the school. Six of the originally-recruited 131 mother-child pairs were excluded since the interviewed caregiver turned out not to be the biological mother of the child. The interviews were conducted by a group of six Rwandan B.A.-level psychologists recruited from the National University of Rwanda in Butare. The interviewers had been previously trained by colleagues from the University of Konstanz in conducting interviews in order to assess PTSD, depression, anxiety and suicidal tendencies . The interviewers attended an additional training for this study. The training lasted eight days and included theoretical sessions on the purpose of the study, concepts of trauma, the questionnaires, and role-plays conducting the survey. The project coordinator closely supervised the interviewers during the whole period of data collection.
All instruments were available in their original English version. A professional translator created a Kinyarwanda language version of all questionnaires. The translated version was back-translated and discussed with the local interviewers in the training and corrected where necessary. All diagnostic instruments were administered as clinical interviews.
Assessment of traumatic experiences and PTSD in mothers
An extensive list of 25 items adapted to the Rwandan genocide was used to assess traumatic experiences and included items such as “Have you seen dead or mutilated bodies?” or “Were you forced to hide under dead bodies?” . The Posttraumatic Symptom Scale – Interview Version (PSS-I)  was chosen to assess symptoms of PTSD in the mothers. The severity of a symptom is rated on the basis of its frequency, intensity/severity, or both. The diagnosis for PTSD was created regarding the DSM-IV criteria. The procedure has been validated in East African settings [32, 33] and both instruments have been used by our team in the Rwandan context previously. Symptoms of trauma can be observed in any culture . The debate about a nosological entity of PTSD in various cultures is not relevant in this context. “PTSD” in this case simply refers to a set of symptoms that obviously can be observed in any culture.
Assessment of depression, anxiety, antisocial and aggressive behaviour in children
With the help of a subscale of the Hopkins Symptom Checklist (HSCL) [32, 35], children‘s anxiety symptoms occurring during the last seven days were assessed. Symptom intensity was rated on a scale from 0 (“not at all”) to 3 (“extreme”). Symptoms of depression were acquired with the 10-item short version of the Children’s Depression Inventory (CDI-S), an instrument appropriate for children aged 7 to 17 years . Each item is composed in three different questions, which represent the different intensity of a symptom and scores from 0 to 2. For example: (0) “I am sad once in a while”; (1) “I am sad many times” and (2) “I am sad all the times”. The summed score of the items ranges from 0 to 20, with a higher score representing greater depressive symptoms. Clinical relevant symptom scores of anxiety and depression were identified according to cut-off recommendations [36, 37].
Conduct Disorder (CD) and Oppositional Deviant Disorder (ODD) were assessed with the help of the Sections P and Q of the M.I.N.I. Kid . In order to apply the instrument adequately in the Rwandan context, the cut-off for normal – not normal for every item was discussed in the training with the local interviewers. Additionally, a short version of the aggression scale by Buss and Perry  was used to assess aggressive behaviour in the children. It contains 16 items, with subscales for physical and verbal aggression, anger and hostility. Answers range from 0 (“I don’t agree”) to 4 (“I totally agree”), with a higher score representing higher aggressive behaviour and attitude, with a maximum sum score of 64.
A score of children’s psychopathology was generated by adding up the standardized (z-transformed) symptom sum scores for anxiety, depression, aggression, ODD, and CD. The score ranged from -5.7 to 9.8 (0 ± SD 3.33).
Assessment of family violence in mothers and children
The Checklist of Family Violence (CFV)  was used to assess experiences of family violence in mothers and children. The 36 item checklist defines familial violence as exposure to neglect, physical, emotional or sexual violence as well as witnessing violence between other family members. Additional items at the end of the checklist asked about the identification of the perpetrators of the violence (multiple possible answers), and the interviewee’s subjective psychological experience upon experiencing the violence, e.g., “Did you feel helpless?” The participant could answer the questions with “yes” or “no”. In this study we asked the child to identify every event where the mother was the perpetrator of the violent act. The questionnaire had previously been used in other cultural contexts with children [41, 42]. With the help of this checklist, the mothers’ previously experienced family violence during childhood and the children’s experienced family violence at home was assessed. For mothers, two items were added to assess intimate partner violence and conjugal rape.
For calculations of Pearson correlations and t-test the following symptom and event sum scores were used: maternal traumatic event types, children’s psychopathology, children’s experienced maternal violence. Group differences were calculated according to maternal PTSD diagnosis, defined according to DSM-IV criteria. In order to explore how different factors contribute to the psychopathology of the children and children’s experienced maternal violence at home, we calculated hierarchical linear regression model. These included potential confounding covariates, such as children’s gender, number of siblings, educational level (current school grade) and the family’s economical status, all of which did not significantly explain any further variance in children’s psychopathology. A priori there was insufficient knowledge to reasonably estimate the effect size, and the usefulness of post-hoc power analyses remains controversial . As Hoenig and Heisey  show, all post-hoc power analyses suffer from what is called the "power approach paradox". Given that post-hoc power is a function of the p-value attained, it adds little information. Analyses were performed with SPSS version 21 for Macintosh.
Violent experiences and PTSD in mothers
On the CFV nearly all mothers (n = 124, 99%) reported having experienced at least one event of familial violence during their childhood, counting 6.9 different event types on average (range = 0 – 18; SD = 4.71). Most of the mothers (n = 117, 94%) had been exposed to physical violence, 59% (n = 74) to emotional violence, 28% (n = 47) had experienced events of neglect, and 86% (n = 107) had witnessed violent acts committed against a family member. The most frequently mentioned items were being hit with an object (n = 116, 92%), having witnessed a family member being hit with an object (n = 96, 77%), and being slapped on the body, arms or legs (n = 64, 51%). More than every other mother (n = 67, 55%) who was married once in her life reported experiences of physical violence by her husband; 27% (n = 33) had been forced into sexual intercourse.
With the help of the adapted event list, the mothers reported an average of 11 different types of traumatic events in their lives (range = 4 – 21, SD = 4.31) of which 7 (range = 1 – 17, SD = 4.28) were associated with the genocide in 1994. The most frequently-reported traumatic event types were being forced to flee (n = 119, 95%), having witnessed an armed attack (n = 109, 87%), and needing to hide (n = 86, 69%). The majority (60%) of the traumatic events, which were described as the worst experience, occurred during the genocide in 1994. According to DSM-IV criteria, every fourth mother (n = 43, 26%) fulfilled the diagnosis for PTSD, assessed with the PSS-I.
Experiences of family violence in children
Questioned with the CFV, nearly all children (n = 124, 99%) reported at least one incident of family violence, counting 5.6 different violent events on average (range = 0 – 15, SD = 3.15). Physical violence was experienced by 99% (n = 124), emotional violence by 50% (n = 62), neglect by 22% (n = 27) and 81% (n = 101) witnessed family violence against another family member. The children identified the mother (n = 114, 91%), and older siblings (n = 62, 50%) as perpetrators of family violence. 39% (n = 47) of those children whose mother had ever been married, reported the father as perpetrator of family violence. Most frequently reported items were being hit with an object (n = 123, 98%), having witnessed a family member being hit with an object (n = 91, 73%), or slapped on the body, arms or legs (n = 77, 62%). The majority of the children felt terrified (55%) or helpless (51%) because of family violence.
Children’s psychopathology in association with maternal traumatic experiences
Children’s psychopathology in association with maternal PTSD
Children’s psychopathology in association with maternal violence at home
Linear regression model with children’s psychopathology as dependent variable
Hierarchical regression model with children’s psychopathology score as dependent variable and children’s reported family violence conducted by the mother (event sum score) and maternal PTSD symptom score as independent variables
Children’s experienced maternal violence at home (sum score of event types)
Children’s experienced maternal violence at home (sum score of event types)
Mother’s PTSD symptom score
Maternal violence at home in association with maternal PTSD
Maternal violence at home in association with mothers own experiences of family violence during her childhood
Linear regression model with maternal violence at home as dependent variable
Hierarchical regression model with children’s experienced maternal violence at home (sum score of event types) as dependent variable and mother’s experienced family violence during her own childhood (sum score of event types) and maternal PTSD symptom score as independent variables
Mother’s experienced family violence during childhood (sum score of event types)
Mother’s experienced family violence during childhood (sum score of event types)
Mother’s PTSD symptom score
Our study did not identify an association between children’s psychopathology and maternal traumatic experiences and maternal PTSD. Instead, a significant relationship was found for children’s psychopathology and their experienced maternal violence at home. Furthermore, maternal violence against the child was related not only with child’s psychopathology but also with mother’s own experiences of family violence during their childhood.
The key finding of our study constitutes the missing association of children’s psychopathology with maternal PTSD. This result contradicts the common assumption of a direct trans-generational trauma transmission. Obviously, a large-scale catastrophe as the genocide is not necessarily specifically damaging the mental health of the children of survivors. This finding is supported by a number of review articles [45–47] and a comprehensive meta analysis on studies of children of Holocaust survivors, which states that the influence of the parents’ traumatic experiences on their children seems to be restricted to studies on clinical participants and cannot be viewed as a common phenomenon . It has also been suggested that the behaviour of Holocaust survivor offspring may not be clinically distinctive but rather a specific personality configuration .
The second important finding of our study is that family violence affects the mental health and wellbeing of the children as opposed to maternal PTSD. Our study indicated an association of children’s mental health status and their experienced amount of maternal violence at home. Likewise, a number of studies identified psychological consequences of family violence for the children, such as anxiety [49, 50], antisocial behaviour [21, 51], aggression , and depression . The explicit negative psychological consequences of family violence for a child may be explained not only by the experience of a frightening situation in an intimate familial environment but also by the absence of an adequate reaction from the parent and the lack of a trustful relationship. Abusive child-rearing practices do not provide a model for the child to develop adequate emotional regulation mechanisms and interpersonal relatedness, which in turn may lead to antisocial behaviour, such as aggression or Oppositional Deviant Disorder [53, 54].
Furthermore, our study shows that children‘s experienced maternal violence is not associated with maternal PTSD symptom profiles, but with the amount of the mother‘s own experiences of family violence during her childhood. This sheds a new light on studies that reported that parental PTSD is associated with child rearing practices such as family violence [12–15]. It may not be the PTSD of the mother per se, but the family violence experienced by the mother, that increases the risk for both, the PTSD in the mother and the exposure to family violence in the child. This would support the notion of a Cycle of Violence and fit with results of a series of other studies [52, 55–57]. The social learning process was assumed to represent the mechanisms behind this association . Abusive parents represent a role model for abusive behaviour and the moral assurance that such behaviour is appropriate; furthermore, children growing up in an abusive household lack alternative non-violent conflict resolution strategies . As family violence is mostly embedded in other family pathology , we assume additional risk factors, such as a violent social environment or lack of family support, which are not assessed in our study but which latently explain the impact of family violence on the children’s mental health. Furthermore, it is important to consider that child maltreatment cannot be separated from other disadvantaging factors, such as high everyday life stress or social isolation [60, 61].
Some limitations warrant mention. As our data collection was cross-sectional, the cause and effect of relationships cannot be demonstrated. It is therefore possible that family violence was as much a cause as an effect of children’s symptoms. Furthermore, data about the father were not assessed, which might have explained additional variance of children’s symptoms.
The assessment of children’s psychopathology was also limited. Children’s anxiety symptoms were measured with the HSCL-25, an instrument designed for adults. Assessment of antisocial behaviour should use different sources of information, such as a parent or a teacher, providing different aspects of a child’s functioning [64, 65]. As the amount of children’s stressful experiences might also represent an important predictor of children’s mental wellbeing, children’s traumatic experiences should have been assessed. Similarly, school and community violence may play an important role and should be assessed as well.
Still, this study explores the assumption of transgenerational trauma transmission and provides systematic information on two generations, assessed by local B.A. psychologists in a conflict region. All participants are from the same cultural background and allow a comparison of the children of traumatized and non-traumatized mothers. Furthermore, family violence was not just reported by the parents but the children, assuming less bias through social desirability.
The Rwandan women were highly motivated to participate in the study. In our experience, people in resource-poor regions are often highly motivated to make their voice “heard”. Usually most people want to contribute to a survey that may document daily living conditions and daily sufferings.
Our findings do not support the common hypothesis of trans-generational consequences of parental PTSD, as we did not find evidence for an association between maternal PTSD and children’s mental health. Instead, experiences of maternal violence represented the most important predictor of children’s depression, anxiety, aggression and antisocial behaviour. In contrast with the theory on trans-generational trauma transmission children’s experience of maternal violence at home was not associated with maternal PTSD but with mothers own experience of family violence during her own childhood, a result that is in congruence with the hypothesis of the Cycle of Violence. We assume that there might be far more factors affecting child rearing practices and children’s mental wellbeing, factors which concern general life and not exclusively PTSD and traumatic past. Our results call for attention for the psychological consequences of family violence in African countries, where family violence is socially accepted as a fundamental child rearing practice. Additionally, our results confirm studies of other countries in the world investigating the Cycle of Violence and therefore support generalization of this hypothesis. The devastating consequences of family violence can be taught to parents, together with alternative child-rearing practices.
We are grateful to all mothers and children, who participated in this study, and to the B.A. psychologists Primitive Mukantwari, Télesphore Nambajimana, Marthe Niyomsaba, Agnes Nyirabizimana, Anatole Nzabakurana, and Pierre Bisengimana, who conducted the interviews and supported the study with valuable discussions and personal engagement. The study was supported by DFG (Deutsche Forschungsgemeinschaft) and the European Refugee Fund. The authors would like to thank Prof. Jean-Pierre Duzingizemungu, Department of Psychology and Education at the National University of Rwanda, for helpful advices. Furthermore, the authors would like to thank Anna Mädl, Susanne Schaal, Heide Rieder and Katy Robjant for editing and valuable criticisms.
- Caselli LT, Motta RW: The effect of PTSD and combat level on Vietnam veterans’ perceptions of child behavior and marital adjustment. J Clin Psychol 1995,51(1):4–12.PubMedView Article
- Jordan BK, Marmar CR, Fairbank JA, Schlenger WE, Kulka RA, Hough RL, Weiss DS: Problems in families of male Vietnam veterans with posttraumatic stress disorder. J Consult Clin Psychol 1992,60(6):916–926.PubMedView Article
- Zalihic A, Zalihic D, Pivic G: Influence of posttraumatic stress disorder of the fathers on other family members. Bosn J Basic Med Sci 2008,8(1):20–26.PubMed
- Al-Turkait FA, Ohaeri JU: Psychopathological status, behavior problems, and family adjustment of Kuwaiti children whose fathers were involved in the first gulf war. Child Adolesc Psychiatry Ment Health 2008,2(1):12.PubMed CentralPubMedView Article
- Dansby VS, Marinelli RP: Adolescent children of Vietnam combat veteran fathers: a population at risk. J Adolesc 1999, 22:329–340.PubMedView Article
- Daud A, Skoglund E, Rydelius P-A: Children in families of torture victims: transgenerational transmission of parents’ traumatic experiences to their children. Int J Soc Welf 2005, 14:23–32.View Article
- Sack WH, Clarke GN, Seeley J: Posttraumatic stress disorder across two generations of Cambodian refugees. J Am Acad Child Adolesc Psychiatry 1995,34(9):1160–1166.PubMedView Article
- Davidson AC, Mellor DJ: The adjustment of children of Australian Vietnam veterans: is there evidence for the transgenerational transmission of the effects of war-related trauma? Aust N Z J Psychiatry 2001,35(3):345–351.PubMedView Article
- Lauterbach D, Bak C, Reiland S, Mason S, Lute MR, Earls L: Quality of parental relationships among persons with a lifetime history of posttraumatic stress disorder. J Trauma Stress 2007,20(2):161–172.PubMedView Article
- Ruscio AM, Weathers FW, King DW: Male war-zone veterans’ perceived relationship with their children: the importance of emotional numbing. J Trauma Stress 2002,15(5):351–357.PubMedView Article
- Schechter DS: Intergenerational communication of maternal violent trauma. In September 11: trauma and human bonds. Edited by: Coates SW. New York: Analytic Press; 2003:115–142.
- Banyard VL, Williams LM, Siegel JA: The impact of complex trauma and depression on parenting: an exploration of mediating risk and protective factors. Child Maltreat 2003,8(4):334–349.PubMedView Article
- Cohen LR, Hien DA, Batchelder S: The impact of cumulative maternal trauma and diagnosis on parenting behavior. Child Maltreat 2008,13(1):27–38.PubMed CentralPubMedView Article
- Kellermann NPF: Perceived parental rearing behavior in children of holocaust survivors. Isr J Psychiatry Relat Sci 2001,38(1):58–68.PubMed
- Margolin G, Gordis EB: Children’s exposure to violence in the family and community. Am Psychol Soc 2004,13(4):152–155.
- Taft CT, Kaloupek DG, Schumm JA, Marshall AD, Panuzio J, King DW, Keane TM: Posttraumatic stress disorder symptoms, physiological reactivity, alcohol problems, and aggression among military veterans. J Abnorm Psychol 2007,116(3):498–507.PubMedView Article
- Harkness LL: Transgenerational transmission of war-related trauma. In International handbook of traumatic stress syndrome. Edited by: Wilson JP, Raphael B. New York: Plenum Press; 1993:635–543.View Article
- Mollica RF, McInnes K, Poole C, Tor S: Dose-effect relationships of trauma to symptoms of depression and post-traumatic stress disorder among Cambodian survivors of mass violence. Br J Psychiatry 1998, 173:482–488.PubMedView Article
- Neuner F, Schauer M, Karunakara U, Klaschik C, Robert C, Elbert T: Psychological trauma and evidence for enhanced vulnerability for posttraumatic stress disorder through previous trauma among West Nile refugees. BMC Psychiatry 2004, 4:34.PubMed CentralPubMedView Article
- Grych JH, Jouriles EN, Swank PR, McDonald R, Norwood WD: Patterns of adjustment among children of battered women. J Consult Clin Psychol 2000,68(1):84–94.PubMedView Article
- Smith C, Thornberry TP: The relationship between childhood maltreatment and adolescent involvement in delinquency. Criminology 1995,33(4):451–481.View Article
- Prunier G: Africa’s world war. Congo, the Rwandan genocide, and the making of a continental catastrophe. Oxford: Oxford Univ. Press; 2009.
- Hagengimana A, Hinton D, Bird B, Pollack M, Pitman RK: Somatic panic-attack equivalents in a community sample of Rwandan widows who survived the 1994 genocide. Psychiatry Res 2003,117(1):1–9.PubMed CentralPubMedView Article
- Onyut LP, Neuner F, Schauer E, Ertl V, Odenwald M, Schauer M, Elbert T: The Nakivale Camp mental health project: building local competency for psychological assistance to traumatised refugees. Interv 2004,2(2):90–107.
- Pham PN, Weinstein HM, Longman T: Trauma and PTSD symptoms in Rwanda - implications for attitidues toward justice and reconciliation. JAMA 2004,292(5):602–612.PubMedView Article
- Schaal S, Elbert T: Ten years after the genocide: trauma confrontation and posttraumatic stress in Rwandan adolescents. J Trauma Stress 2006,19(1):95–105.PubMedView Article
- Bolton P, Neugebauer R, Ndogoni L: Prevalence of depression in rural Rwanda based on symptom and functional criteria. J Nerv Ment Dis 2002,190(9):631–637.PubMedView Article
- Ancharoff MR, Munroe JF, Fisher LM: The legacy of combat trauma – Clinical implications of intergenerational transmission. In International handbook of multigenerational legacies of trauma. Edited by: Danieli Y. New York: Plenum Press; 257–27.
- Baranowski A, Young M, Johnson-Douglas S, Williams-Keeler L, McCarrey M: PTSD Transmission: a review of secondary traumatization in holocaust survivors families. Can Psychol 1998,39(4):247–265.View Article
- Schaal S, Jacob N, Dusingizemungu J-P, Elbert T: Rates and risks for prolonged grief disorder in a sample of orphaned and widowed genocide survivors. BMC Psychiatry 2010,10(55):9p.
- Foa EB, Riggs DS, Dancu CV, Rothbaum BO: Reliability and validity of a brief instrument for assessing post-traumatic stress disorder. J Trauma Stress 1993, 6:459–473.View Article
- Ertl V, Pfeiffer A, Saile R, Schauer E, Elbert T, Neuner F: Validation of a mental health assessment in an African conflict population. Psychol Assess 2010, 22:318–324.PubMedView Article
- Odenwald M, Lingenfelder B, Schauer M, Neuner F, Rockstroh B, Hinkel H, Elbert T: Screening for posttraumatic stress disorder among somali ex-combatants: a validation study. Confl Heal 2007, 1:10.View Article
- Elbert T, Schauer M: Psychological trauma: burnt into memory. Nature 2002, 419:883.PubMedView Article
- Derogatis LR: Hopkins symptom checklist. In Encyclopedia of psychology. Volume 4. Edited by: Kazdin AE. Washington D.C: American Psychological Association; 2000:157–158.
- Sitarenios G, Kovacs M: Use of the children’s depression inventory. In The use of psychological testing for treatment planning and outcome assessment. Edited by: Maruish M. Mahwah: Lawrence Erlbaum Association Publishers; 1999:267–298.
- Mollica RF, Wyshak G, de Marneffe D, Khuon F, Lavelle J: Indochinese versions of the Hopkins symptom checklist-25: a screening instrument for the psychiatric care of refugees. Am J Psychiatry 1987,144(4):497–500.PubMed
- Sheehan DV, Lecrubier MD, Sheehan KH, Amorim P, Janavs J, Weiller E, Hergueta T, Baker R, Dunbar GC: The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998,59(Suppl 20):22–33.PubMed
- Buss AH, Perry M: The aggression questionnaire. J Pers Soc Psychol 1992,63(3):452–459.PubMedView Article
- Ruf M, Elbert T: Posttraumatische Belastungsstörung im Kindes- und Jugendalter. In Lehrbuch der Verhaltenstherapie – Materialien für die Psychotherapie, Volume 4. Edited by: Meinlschmidt G, Schneider S, Margraf J. Berlin, Heidelberg, New York, Tokio: Springer; 2012.
- Catani C, Jacob N, Schauer E, Kohila M, Neuner F: Family violence, war, and natural disaster: a study of the effect of extreme stress on children’s mental health in Sri Lanka. BMC Psychiatry 2008,8(33):10.
- Catani C, Schauer E, Elbert T, Missmahl I, Bette J-P, Neuner F: War trauma, child labor, and family violence: life adversitities and PTSD in a sample of school children in Kabul. J Trauma Stress 2009,22(3):163–171.PubMedView Article
- Thomas L: Retrospective power analysis. Conserv Biol 1997,11(1):276–280.View Article
- Hoenig JM, Heisey DM: The abuse of power. Am Stat 2001,55(1):19–24.View Article
- Solkoff N: Children of survivors of the Nazi holocaust: a critial review of the literature. Am J Orthopsychiatry 1992,62(3):342–358.PubMedView Article
- Solomon Z: Transgenerational effects of the holocaust - the Israeli research perspective. In International handbook of multigenerational legacies of trauma. Edited by: Danieli Y. New York: Plenum Press; 1998:69–83.View Article
- Felsen I: Transgenerational transmission of effects of the holocaust – the North American research perspective. In International handbook of multigenerational legacies of trauma. Edited by: Danieli Y. New York: Plenum Press; 1998:43–68.View Article
- Ijzendoorn VMH, Bakermans-Kranenburg MJ, Sagi-Schwartz A: Are children of holocaust survivors less well-adapted? - a meta-analytic investigation of secondary traumatization. J Trauma Stress 2003,16(5):159–169.
- Guille L: Men who batter and their children: an integrated review. Aggress Violent Behav 2004,9(2):129–163.View Article
- McCloskey LA, Walker M: Posttraumatic stress in children exposed to family violence and single-event trauma. Am Acad Child Adolesc Psychiatry 2000,39(1):108–115.View Article
- Zingraff MT, Leiter J, Myers KA, Johnson MC: Child maltreatment and youthful problem behavior. Criminology 1993,31(2):173–202.View Article
- Weaver CM, Borkowski JG, Whitman TL: Violence breeds violence: childhood exposure and adolescent conduct problems. J Community Psychol 2008,36(1):96–112.PubMed CentralPubMedView Article
- Cook A, Spinazzola J, Ford J, Lanktree C, Blaustein M, DeRosa R, Cloitre M, Hubbard R, Kagan R, Liautaud J, Mallah K, Olafson E, van der Kolk B: Complex trauma in children and adolescents. Psychiatr Ann 2005,35(5):390–398.
- Goldsmith RE, Barlow MR, Freyd JJ: Knowing and not knowing about trauma: inplications for therapy. Psychotherapy: Theor Res Pract Training 2004,41(4):448–463.View Article
- Pears KC, Capaldi DM: Intergenerational transmission of abuse: a two-generational prospective study of an at-risk sample. Child Abuse Negl 2001,25(11):1439–1461.PubMedView Article
- Elbert T, Rockstroh B, Kolassa IT, Schauer M, Neuner F: The influence of organized violence and terror on brain and mind: a co-constructive perspective. In Lifespan development and the brain: the perspective of biocultural co-constructivism. Edited by: Baltes PB, Reuter-Lorenz PA, Rösler F. New York: Cambridge University Press; 2006:326–349.View Article
- Kaufman J, Zigler E: Do abused children become abusive parents? Am J Orthopsychiatry 1987,57(2):186–192.PubMedView Article
- Straus MA, Gelles RJ, Steinmetz SK: Behind closed doors - violence in the American family. New York: Anchor Press/Doubleday; 1980.
- Schwartz JP, Hage SM, Bush I, Burns LK: Unhealthy parenting and potential mediators as contributing factors to future intimate violence: a review of literature. Trauma Violence Abuse 2006,7(3):206–221.PubMedView Article
- Henning K, Leitenberg H, Coffey P, Turner T, Bennett R: Long-term psychological and social impact of witnessing physical conflict between parents. J Interpers Violence 1996,11(1):35–51.View Article
- Buchanan A: Intergenerational child maltreatment. In International handbook of multigenerational legacies of trauma. Edited by: Danieli Y. New York: Plenum Press; 1998:535–552.View Article
- Calhoun LG, Tedeschi RG (Eds): Handbook of posttraumatic growth: research and practice. Mahwah, NJ: Erlbaum; 2006.
- Goldblatt H, Eisikovits Z: Role taking of youths in a family context: adolescents exposed to interparental violence. Am J Orthopsychiatry 2005, 75:644–657.PubMedView Article
- Bird HR: Epidemiology of childhood disorder in a cross-cultural context. J Child Psychol Psychiatry 1996,37(1):35–49.PubMedView Article
- Granero R, Expeleta L, Domenech JM, de la Osa N: What single reports from children and parents aggregate to attention deficit-hyperactivity disorder and oppositional defiant disorder diagnoses in epidemiological studies. Eur Child Adolesc Psychiatry 2008,17(6):352–364.PubMedView Article
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