Children in families of torture victims: transgenerational transmission of parents’ traumatic experiences to their children

Int J Soc Welfare 2005:

14

: 23–32

© Blackwell Publishing Ltd and the International Journal of Social Welfare 2005.Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA

23

INTERNATIONAL

J O U R NA L O F

SOCIAL WELFARE

ISSN 1369-6866

Daud A, Skoglund E, Rydelius P-A. Children in families oftorture victims: transgenerational transmission of parents’traumatic experiences to their childrenInt J Soc Welfare 2005: 14: 23–32 © Blackwell Publishing,2005.

This article details a study to test the hypothesis thatimmigrant children whose parents have been tortured beforecoming to Sweden suffer from depressive symptoms, post-traumatic stress symptoms, somatisation and behaviouraldisorders. Fifteen families where at least one of the parentshad experienced torture were compared with fifteen familiesfrom a similar ethnic and cultural background where theirparents might have experienced violence but not torture. Theparents were investigated using interviews, the KarolinskaScales of Personality (KSP) and Harvard/Uppsala TraumaQuestionnaire (H/UTQ). The children were assessed using theDICA-interview according to DSM-IV. On the H/UTQ test,traumatised parents scored higher with respect to post-traumaticstress disorder, depression, somatisation, anxiety and psychosocialstress symptoms. On the KSP, they scored higher on nine ofthe fifteen sub-scales. The fathers in the tortured groupscored higher than their wives only on the sub-scale for guilt.According to the DICA-interviews, the children of torturedparents had more symptoms of anxiety, depression, post-traumatic stress, attention deficits and behavioural disorderscompared with the comparison group. Social workers, psy-chiatrists, psychologists and teachers need to be aware of apossible transmission of parents’ traumatic experiences totheir children and to

develop treatment methods for childrenof torture victims.

Atia Daud, Erling Skoglund, Per-Anders Rydelius

Karolinska Institutet, Child and Adolescent Psychiatric Unit

,

Astrid Lindgren’s Children’s Hospital, Sweden

Children in families of torture victims: transgenerational transmission of parents’ traumatic experiences to their children

Key words: Diagnostic Interview for Children and Adolescents(DICA), Harvard/Uppsala Trauma Questionnaire (H/UTQ), KarolinskaScales of Personality (KSP), Post-Traumatic Stress Disorder(PTSD), psychic trauma, transgenerational study, torture victims

Atia Daud, Karolinska Institutet, Dept. of Woman and Child Health, Child and Adolescent Psychiatric Unit, Astrid Lindgren’s Children’s Hospital, SE-171 76 Stockholm, SwedenE-mail: [email protected]

Accepted for publication December 22, 2003

Many of the children (0–18 years of age) one meets atChildren’s Guidance Clinics come from non-Europeanethnic and cultural backgrounds, although some wereborn in Sweden. Of those born outside Sweden, somecome to the clinic accompanied by parents who hadbeen subjected to torture and acts of violence for aprolonged period of time in their home country. Someof these children are in need of emergency psychictreatment for a wide range of symptoms. This was thedirect reason for initiating a research programme toevaluate how parents’ experiences of torture and violenceaffect their children’s mental and emotional state andto study the relationship between the parents’ post-traumatic stress disorder (PTSD) and trauma-relatedsymptoms, and their children’s maladaptive disorders.Experiences of torture and violence, according to thepsychosocial stress theory (Rydelius, 1981, 1988; Terr,1991), give rise to a specific form of psychic trauma.

Undergoing a psychic trauma affects the parent’s abilityto function as a protective shield for their children.Danieli (1998), among others, has studied the intensityand duration of psychic trauma.

Theoretical basis of the study

Psychodynamic theory, including attachment theoryand psychosocial stress theory, and cognitive theoryconstitute the basis for this study.

Psychodynamic and attachment theories

Grubrich-Simitis (1981) used a psychoanalytic approachin a study of the effects on children of parents whosurvived concentration camps. The study brought tolight the so-called survival syndrome wherein severetraumatisation is considered to be a result of what has

Daud et al.

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© Blackwell Publishing Ltd and the International Journal of Social Welfare 2005

been called ‘cumulative trauma’. The survival syndromeis characterised by psychosis, borderline disorders andpsychosomatic symptoms.

Khan (1963) introduced the concept of cumulativetrauma and emphasised that it develops as a result ofrepeated frustration in the absence of a protective shield.He found that parents’ ability to provide a protectiveshield for their children is crucial for the developmentand stabilisation of the child’s intra-psychic

functions,and for the development of the child’s inner world. Heemphasised, furthermore, that individual cumulativetraumatic experiences might lead to severe psychiatricdisorders.

In his attachment theory, Bowlby (1962, 1988)maintained that there is a connection between the lossof the mother in childhood and the development ofpsychiatric disorders in adulthood. Insecure attachmentin childhood is also related to psychiatric disorders inadulthood. Mary Ainsworth and associates (Ainsworth,Blehar, Walters & Wall, 1978), in what they termedthe ‘strange situation’ experiment, identified four typesof attachment: (1) secure attachment; (2) insecure attach-ment characterised by avoidance; (3) insecure attachmentcharacterised by ambivalence; and (4) disorganisedattachment.

The findings of the ‘strange situation’ experimentwere verified by Grossman and Grossman (1991), vanIjzendoorn and Kroonenberg (1988), and Main andWeston (1982). The ‘strange situation’ experiment provedto be a valid and reliable instrument (see Table 1).

Bowlby and his followers pointed at the strongrelationship between parents’ relative ability or inabilityto create a secure attachment during the child’s earlyyears and the development of psychopathology later inchildhood or adulthood.

Psychosocial stress theory

Rydelius (1981, 1983a, 1983b, 1988, 1994) found in aseries of longitudinal follow-up studies that psychosocial

stress factors in families with parental alcohol and drugabuse and/or violent behaviour have an especially adverseeffect on genetically vulnerable boys who display im-pulsiveness as a personality trait. Growing up in sucha family puts these children at great risk of develop-ing delinquency tendencies and antisocial behaviour inadolescence. These results suggest that there is a needto investigate further the concordance between poorparenting as a result of psychosocial stress factors andself-destructive behaviour on the part of the children,described as suicidal ideation with impulsive behaviourpatterns during adolescence.

Terr (1991) defined childhood trauma as resultingfrom unpredictable extreme events that overwhelmthe child’s physiological and psychological shield. Thechild’s coping strategies and defence mechanisms aresuppressed. She identified two types of trauma: Type ITrauma, without the occurrence of severe personalitydisorders; and Type II Trauma, characterised by extremeevents in which the responses of the child’s caregiverare both physiologically and psychologically inadequate.

Earls, Smith, Reich and Jung (1988), in their studyof the relationship between parents’ symptoms and thoseof their children, using DICA for both groups, found astrong association, but were unable to demonstrate acausal relationship. Macksoud and Aber (1996), in theirstudy of war children in Lebanon and the developmentof prosocial personality traits, found that the disruptionof the family system was related to the children’sproblems to develop prosocial traits, whereby theyshowed a tendency towards overt aggressiveness and aninadequate capacity to foresee the psychosocial riskfactors of their own behaviour.

Rosenheck and Nathan (1985) studied the childrenof war veterans who were suffering from PTSD. Theyfound that the children suffered from insomnia, psycho-somatic symptoms, anxiety syndrome with nightmaresand ‘near-death’ experiences. The children showed othersymptoms as well, such as a short attention span, con-centration problems, helplessness and learning disabilities.

Table 1. The continuity of secure and insecure attachment.

Pregnant mother

Infants 0–1 Babies 1 year 2-year-olds 6-year-olds 10-year-olds

Classification Secure Responsive Mother looks more Mother picks up more quickly

Secure Call for mother when needed, use tools confidently

Concentrated playSocially resilient

Coherent memoriesStories of conflict resolution

InsecureEntangled

Inconsistent mothers InsecureAmbivalent

Dependency Under-controlled Incoherent storiesSadness

Test AAI Observation of mothers

Strange situation

Observation in school

Rep. strange situation

Autobiography

Reference Fonagy et al., 1991

Ainsworth et al., 1978

Ainsworth et al., 1978

Bretherton, 1985 Grossman et al., 1991

Main, 1991

Source: Holmes (1993).

Children in families of torture victims


25

The association between the symptoms of the childrenof traumatised parents and the parent’s own symptomshas been described by some researchers as secondarytraumatisation, and by others as transgenerationaltransmission.

Transgenerational transmission of trauma

Krystal and Neiderland (1968), Rakoff, Sigal andEpstein (1966) and Sigal and Rakoff (1971) have allstudied children whose parents were survivors fromconcentration camps, with the aim of describing thechildren’s psychopathology. One finding was that conductdisorders and a specific type of avoidance regardingthe capacity to separate from their parents were overlyrepresented among these children.

In her work with clinical observations of childrenof traumatised parents, Danieli (1998) reviewed theempirical literature from two aspects: studies of thechildren of survivors of concentration camps; andstudies of war veterans. The outcome of these studieswas that children’s psychopathology and vulnerabilitywere related to experiences of extreme stress. Harkness(1991) studied the relationship between PTSD andviolence among the children of American veterans ofthe Vietnam War. Her findings clearly showed thatthese children suffered from depression and anxietywith schizoid personality traits, that they had a non-communicative style of interaction, were aggressive andhyperactive, and had more psychosomatic symptomsthan did other children.

Cognitive theory

Information Processing Theory introduced the conceptof schemata to describe the transmission of the effectsof trauma from parents to children. The schemata conceptrepresents a mental structure within a defined frameof reference based on previous interaction between thechild and the caregiver, in which the child developsself-confidence and has inner representations of him-/herself and others in interactions.

Janoff-Bulman (1992) and McCann and Pearlman(1990) have both proposed a theoretical frame of referencewhereby the development of self-confidence is of primeimportance in traumatised parents’ communication withtheir children. According to these authors, parents’ ex-periences of torture and violence lead to the destructionof a fundamental way of relating to the world and theself, specifically that the world is good and meaningfuland that the own self has value. The destruction of thesefundamental ways of relating because of torture andexposure to violence leads to the development in thechildren of the feeling that world is insecure.

McCann and Pearlman (1990) also introduced a self-development theory and postulated that the self, as the

foundation of the individual’s identity and innerrepresentation, develops as a result of reflection, inter-action with others, and reflection over one’s interactionwith others. The self-concept has four fundamentalelements: (1) the capacity to manifest an inner identityand self-assertiveness; (2) ego-resources that facilitateinteraction with others; (3) psychological needs thatmotivate this behaviour; and (4) cognitive schemata thatfacilitate the development of specific work models forsatisfying fundamental needs.

McCann and Pearlman (1990) argued that traumaticexperiences influence the following developmentalaspects of the identity: frame of reference; sense ofsecurity; self-confidence; self-assertiveness; autonomy;and intimate relationships. Trauma resulting from tortureand violence devastates fundamental human needs andthe schemata that are manifestations of these needs.

Chrestman (1994) and Danieli (1998) asserted that thedistinction between primary and secondary traumatisationis academic. Children of traumatised parents display thesame symptoms as their parents, e.g. daydreaming; theyalso have fantasies about their parents’ trauma experiencesand act out them in their playing. The idea of primaryand secondary traumatisation transmission is based onthe severity of the traumatic experiences, the extent towhich the individual’s schemata have been devastatedand the parents’ integration of the traumatic events.

The authors above described some of the mechanismsby which the effects of trauma are transmitted fromparents to children:

1.

Parents’ silence

: family members avoid discussingwhat happened in an effort to avoid awakening theparents’ feelings of aggression; the children fantasiseabout what were the actual events, i.e. they live in atraumatic fantasised world.

2.

Identification

: the children seek their parents’acceptance and recognition by avoiding talking aboutwhat happened. Janoff-Bulman (1992) argued thatchildren’s guilt feelings correspond to those of theirtraumatised parents’ PTSD.

3.

Overdisclosure

: the child tries to protect his/herparents by maintaining total silence and repressingtraumatic memories.

4.

Re-enactment

: the traumatised parents try to retestthe validity of the new world-view they acquired inthe aftermath of the traumatic experiences.

Munroe et al. (1995) proposed that it is not only thetraumatised people themselves who intentionally re-enactthe traumatic experiences; those close to trauma survivorsalso tend to think, feel and behave as if they too hadexperienced severe trauma. This could mean, as Ancharoff,Munroe and Fisher (1998) have pointed out, that theisomorphic re-enactment produces parallel thoughtsand behaviours as well as feelings. Catherall (1992)described the affective experiences of this participation

Daud et al.

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as ‘projective identification’ and Wilson and Lindy(1994) termed the phenomenon ‘counter-transference’.

PTSD and KSP variables

The essential features of PTSD according to DSM-IVare the development of characteristic symptoms followingexposure to an extreme traumatic stressor involvingdirect personal experiences of an event that involvesactual or threatened death or serious injury, or otherthreat to the individual’s physical integrity; or witnessingan event that involves death, injury or violent death,serious harm or threat of death or injury experiencedby a family member or other close associate (AmericanPsychiatric Association, 1994).

In establishing the PTSD diagnosis, the followingcriteria must be met:

1. The patient avoids activities, situations or peoplethat arouse recollections of the traumatic event. Thisavoidance may include amnesia for an importantaspect of the traumatic event.

2. The patient has persistent symptoms of anxiety orincreased arousal and at least two of the followingsymptoms: difficulty falling asleep, irritability oroutbursts of rage, difficulty concentrating or com-pleting tasks, hyper-vigilance and an exaggeratedstartle response.

KSP items concerning detachment, muscle tensionand guilt are associated with the criteria found in PTSDresearch. However, more study is required to determinepossible PTSD-personality aspects.

Aims of the study

The aims of the study were to elucidate and test thefollowing hypotheses:

1. Children of traumatised parents display symptomsof psychopathological disorder; furthermore, thesesymptoms are statistically significant compared withthe symptoms of children in families with non-traumatised parents but who come from a similarethnic and cultural background.

2. There is a correlation or association between chil-dren’s and parents’ symptoms in families where theparents were subjected to torture or acts of violence,compared with families with a similar ethnic andcultural background but where the parents had notexperienced torture or systematic acts of violence.

Method

The subjects of the study

The group under study (families with traumatisedparents) consisted of 15 families who came to Sweden

from Iraq and Lebanon with a total of 45 childrenbetween the ages of 6 and 17 years. The mean age ofthe 29 boys in the group was 12 years and that ofthe 16 girls 11.3 years. The traumatised parent groupconsisted of 30 parents (n

=

30). The mean age for thefathers in this group was 43.5 years and for the mothers38.7 years. All the families had been living inStockholm for at least two years at the time of the study.To be included in the study one parent must haveexperienced episodes of torture in the home countryof at least one month’s duration prior to coming toSweden. Several of the families had in the past or werecurrently receiving psychotherapeutic treatment throughthe auspices of the Swedish Red Cross’ Centre forTortured Refugees and the Centre for Trauma Treatmentand Diagnostics in Stockholm (CTD).

The comparison group consisted of 15 families witha total of 31 children between the ages of 6 and 17years. The mean age of the 15 boys in this group was11 years and of the 16 girls 12.6 years. Of the 26parents in the comparison group, the mean age of thefathers was 45.8 years and of the mothers 38.7 years.These parents may have experienced violence in someform, but they had not been subjected to systematictorture. These families had also been living inStockholm for at least two years prior to the study.

Instruments

The parents in both groups were studied using:

1. A semi-structured clinical interview to identify thefamily’s socioeconomic status, ethnicity/nationality,educational background and whether or not theparents had been subjected to torture prior to comingto Sweden. The interviews paid special attention topsychosocial stress factors concerning the parents’everyday functions at home with their children andwith other adults. Somatisation symptoms/diagnoseswere elicited by the KSP sub-scale muscular tension,and PTSD by the H/UTQ test.

2. The Karolinska Scale of Personality (KSP), a bio-psychological personality inventory consisting of15 sub-scales. Some of the scales were postulated tocorrelate with symptoms of trauma and PTSD dis-played by parents in the traumatised parent group.

3. The Harvard/Uppsala Trauma Questionnaire modi-fied by the authors of this study to match DSM-IVand used to identify PTSD, psychosocial stress factors,somatisation, anxiety syndrome, severe depressionand psychotic symptoms. A factor analysis withvarimax rotation was performed for the H/UTQ-items.

The children in both groups were studied using botha short anamnesis and the Diagnostic Interview forChildren and Adolescents (DICA) in two versions, onefor 6–12-year-olds and one for 13–17-year-olds.



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Procedure

This study is intended to shed light on a number ofissues. The first concerns the extent to which parentsin the traumatised group displayed symptoms ofPTSD. The second issue is whether there is a cor-relation between the traumatised parents’ symptomsand those of their children when we compare this groupwith the comparison group. This second question wasstudied using the Diagnostic Interview for Children andAdolescents (DICA), based on DSM-IV as a descriptiveanalysis for children, and by the Harvard/UppsalaTrauma Questionnaire (H/UTQ) for parents, which wasused in both groups of families. A third issue raised inthe study is whether the personality structures of theparents in the traumatised group differ from those ofthe parents in the comparison group. This question wasexplored using the Karolinska Scales of Personality(KSP).

Analysis of traumatic severity

The factor analysis resulted in five factors (see Table 2)with factor loadings of

>

0.5. The following describesthe categories making up the factors and the respectivepercentage explained variance of the different factorswith respect to the traumatic experiences of the parentsin the traumatised group:

Factor I: consists of the three categories ‘Forcedseparation’, ‘Imprisonment’ and ‘Near-deathexperiences’ and constitutes 38.9 per centexplained variance of the traumatic experi-ences of parents in the traumatised group.

Factor II: consists of the categories ‘Catastrophic’ and‘Other’ (persecution and flight) and consti-tutes 17.4 per cent explained variance

Factor III: consists of the categories ‘Held hostage’,‘Tortured’, ‘Brainwashing’ and ‘Unexplaineddisappearances’ and constitutes 12.4 per centexplained variance.

Factor IV: consists of the categories ‘Kidnappings’,‘Robberies’, ‘Enforced police custody’ andconstitutes 9.7 per cent explained variance.

Factor V: consists of the categories ‘Homicide’ and‘Rape’ and constitutes 7.3 per cent explainedvariance of this group’s traumatic experiences.

Accumulated traumatic experiences

The analysis and distribution of traumatic experiencesin relation to the time interval showed a relativeoverloading of traumatic experiences for both parentsin the family. As measured by the H/UTQ test, thefathers’ group had a total of 260 traumatic experi-ences with an average of 17.3 such experiences overa five-year period, and the mother’s group had a totalof 224 traumatic experiences with an average of 15.0over the same time period. The corresponding aver-age for the traumatised parent group as a wholewas 16.2.

The results of the H/UTQ text showed that thetraumatised parent group had experienced severetraumatic experiences over a long time interval. Themain traumatic events were near-death experiences andtorture during interrogation or while imprisoned, andforced separation from family members.

Results

Semi-structured interviews with parents in both thetraumatised parent group and the comparison groupwere carried out in the family’s home. The two groups

Table 2. Principal Components Analysis for the traumatic categories of the H/UTQ-items with varimax rotation. Factor loading.

Traumatic categories Factor 1 Factor 2 Factor 3 Factor 4 Factor 5 Communalities

Forced separation 0.96 0.71Imprisonment 0.74 0.81Near-death experiences 0.72 0.66Catastrophes 0.72 0.60Other (persecution, flight) 0.83 0.39Kept hostage 0.80 0.89Torture 0.94 0.62Forced isolation 0.73 0.79Brainwashing 0.64 0.71Disappearances 0.58 0.73Kidnapping 0.94 0.88Robbery 0.86 0.85Forced police custody 0.54 0.61Homicide 0.88 0.78Rape/sexual torture 0.71 0.64Eigenvalues 5.84 2.61 1.86 1.46 1.10Explained variation (%) 38.90 17.40 12.40 9.70 7.30

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were largely similar with respect to socioeconomicvariables, ethnicity/nationality and educational background.

Results of the Karolinska Scales of Personality (KSP)

The KSP was used to investigate the personality structureof the parents in the traumatised group compared withthe personality structure of the parents in the comparisongroup. One aim was to ascertain whether traumatisedindividuals displayed any trauma-related personalityconstellations. The hypothesis was:

the parents withtraumatic experiences accumulated over a long timeinterval will exhibit in their responses a constellation ofvariables that are typical for severely tortured individuals.Hypothetically, this constellation of variables consists ofhigh detachment, low socialisation and social desirability,and low scores on the aggression scale.

Furthermore, itwas hypothesised that there are significant differencesbetween the fathers and the mothers in the traumatisedgroup.

The results showed that there were statisticallysignificant differences between the fathers and themothers in the traumatised parent group with respect tothe sub-scale guilt (G)

p

<

0.01 (see Table 3).Furthermore, the whole group responded with low

scores on the sub-scales detachment (DE), socialisation(SO), social desirability (SD) and monotony avoidance(MA), and high scores on the sub-scales somatic anxiety(SA), psychic anxiety (PA), muscular tension (MT)and psychasthenia (PS). These KSP results revealed anumber of relevant personality variables characterisingparents in the traumatised group. These constellationsare based on the hypothesised theoretical frame ofreference about certain possible PTSD personality aspectsconsisting of high scores on muscular tension, soma-

tisation and detachment, and low scores on socialisation,social desirability and internalised aggression. Furtherresearch is needed to more fully test this hypothesis.

The KSP results showed statistically significantdifferences at the 99 per cent level between the parentsin the traumatised group and those in the comparisongroup with respect to detachment, muscular tension andguilt. There were no significant differences with respectto the aggression-related scales (see Table 4). Theresults display a cluster formation, which in this studyis hypothetically considered to constitute aspects of thepost-traumatic personality. These aspects are referred toin KSP as detachment, muscular tension, somatisationand guilt and constitute variables in the symptomatologyderived from the descriptive diagnostic formations inDSM-IV (American Psychiatric Association, 1994).

As mentioned earlier, the 45 children in thetraumatised parent group and the 31 children in thecomparison group were studied using the DICA, andthe parents in both groups were studied using the H/UTQ. The same diagnostic features were chosen tofacilitate the comparison between the two children’sgroups and the two respective parent groups.

Differences in DICA scores between the two children’s groups

The children in both groups were compared withrespect to the following symptoms: attention deficiency(ADHD) symptoms, maladaptive with depressive aspects,anxiety, post-traumatic stress symptoms (PTSS), som-atisation and psychosocial stress symptoms (PSS) (seeFigure 1). The results showed that, compared withthe children in the comparison group, the children inthe traumatised parent group had more symptoms with

Table 3. Comparison of the KSP T-scores between the fathers and the mothers in the traumatised parent group (n = 30).

Variables Traumatised parent group n = 30

Fathers Mothers

M sd M sd t-score p-value

I-Impulsiveness 61.5 10.9 55.0 8.0 1.7 nsM-Monotony avoidance 55.1 13.1 55.6 8.6 0.15 nsDE-Detachment 60.4 5.3 65.7 14.0 1.5 nsSO-Socialisation 29.1 13.5 34.0 14.8 1.5 nsSD-Social desirability 61.3 7.2 65.9 14.4 1.3 nsSA-Somatic anxiety 81.5 18.5 86.1 18.2 0.95 nsMT-Muscular tension 92.2 23.5 87.2 18.1 0.81 nsPA-Psychic anxiety 74.4 11.6 68.9 13.9 1.3 nsPT-Psychasthenia 77.6 12.1 72.7 13.1 1.5 nsINHIB-Inhib.of aggression 59.9 7.4 61.8 7.8 0.68 nsVA-Verbal aggression 57.9 14.9 57.6 13.8 0.12 nsIA-Indirect aggression 59.9 7.4 61.8 7.8 0.68 nsIRR-Irritability 56.2 14.8 55.5 11.2 0.19 nsS-Suspicion 63.0 10.1 66.3 10.7 1.3 nsG-Guilt 66.5 10.6 61.9 8.4 2.6 p < 0.01



29

respect to attention deficiency, maladaptive behaviourwith depressive aspects and post-traumatic stress sym-ptoms. They even showed more anxiety symptoms andmore psychosocial stress symptoms, based on DSM-IVcriteria (American Psychiatric Association, 1994).

The results also showed that although there werestatistically significant differences between the childrenin the traumatised parent group and those in thecomparison group, there were also some similarities

as well. Depressiveness, for example, was a commonfactor shared by the children in the two groups. Attentiondeficiencies and maladaptive behaviour are real problemsin school and during leisure time. Some childrenexternalise (act out) their inner feelings while othersinternalise (somatise) them (see Table 5).

Differences in H/UTQ scores between the two parent groups

The results showed, furthermore, that there werestatistically significant differences between parents inthe traumatised group and those in the comparisongroup with respect to the following symptoms: PTSD,somatisation, anxiety and psychosocial stress symptomswere at the

p

<

0.001 level and depression diagnosis atthe

p

<

0.05 level. These results showed the severity andintensity of the symptoms displayed by the traumatisedparents. One might well ask: How can we expect theseparents to be good enough parents, considering whatthey have experienced? (see Table 6).

Additional results were that the children in thetraumatised parent group displayed more symptoms thantheir parents did with respect to maladaptive behaviourwith depressiveness and psychosocial stress factors.The children’s symptoms on PTSD/PTSS were less thanthose of either parent. These results suggest that thereis a correlation between the symptoms of the parentsand those of their children, but that the relationship isnot necessarily causal (see Table 7).

The traumatised parents, both mothers and fathers,had similar scores with respect to anxiety, somatisationand PTSD. It should be noted that both parents had notnecessarily been exposed to torture or acts of violence;at least one family member had such experiences.

Table 4. Comparison of KSP T-scores of both parents in the traumatised group (n = 30) and both parents in the comparison group (n = 26).

Variables Traumatised parentgroup (n = 30)

Comparison group (n = 26)

Results

M sd M sd t-score p-value

I-Impulsiveness 58.3 9.9 53.3 7.9 2.10 nsMA-Monotony avoidance 55.4 10.9 47.8 8.3 2.90 p < 0.05DE-Detachment 63.1 10.7 52.2 11.3 3.70 p < 0.01SO-Socialisation 31.5 14.1 45.5 14.0 3.70 p < 0.01SD-Social desirability 63.6 11.4 64.9 13.6 3.80 nsSA-Somatic anxiety 83.8 18.3 62.1 19.1 4.30 p < 0.001MT-Muscular tension 89.7 20.7 63.4 17.9 5.10 p < 0.001PA-Psychic anxiety 71.6 12.9 56.9 15.7 3.80 p < 0.001PT-Psychasthenia 75.2 12.6 60.5 14.3 4.10 p < 0.001INHIB Inh. of aggression 60.9 7.5 53.6 13.0 2.50 nsVA-Verbal aggression 57.7 14.1 49.0 12.0 2.50 nsIA-Indirect aggression 60.9 7.5 53.6 13.0 2.50 nsIRR-Irritability 55.8 13.0 44.9 12.7 3.20 p < 0.01S-Suspicion 64.6 10.4 57.6 13.4 2.20 nsG-Guilt 64.2 9.7 52.0 10.1 4.60 p < 0.001

Figure 1. Comparison of DICA results for the children in the trau-matised parent group (n = 45) and the children in the comparisongroup (n = 31).Notes: ADHD = Attention deficit /hyperactivity; DEPT = Depressivesymptoms; ANX = Anxiety; SOMAT = Somatisation; PTSDS =Post-traumatic stress disorder/symptoms; PSS = Psychosocial stressfactors.

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Discussion and conclusions

The hypotheses put forward are supported by theresults. It would appear that children from familieswhere at least one parent has experienced torture dis-play psychopathological symptoms, such as depressivesymptoms, post-traumatic stress symptoms, somatisationand behavioural disorders more often than do children

from families where neither of the parents haveexperienced torture.

There is also an association between children’s andparents’ symptoms in these families. The results of thisstudy regarding the parents’ psychopathology supportthe view that psychiatric and psychological problemsmay indeed impair the parenting capacities of personswho have experienced grievous and prolonged trauma.

Table 5. Comparison of DICA results for children in the traumatised parent group (n = 45) and the children in the comparison group (n = 31).

Table 6. Comparison of H/UTQ results for parents in the traumatised group (n = 30) and parents in the comparison group (n = 26)

Table 7. Comparison between children and parents in the traumatised parent group concerning five diagnoses elicited by DICA for children and H/UTQ for parents. Chi-square analysis is used. (Children n = 45; parents n = 30).

Diagnosis*/symptom** Children under study n = 76

Traumatised parentgroup n = 45

Comparison group n = 31

M sd M sd t-value p-value

Attention deficit /hyperactivity (ADHD) 6.7 4.1 3.1 3.2 4.20 p < 0.001Maladaptive behaviour with depressive features (Mal/DEP.) 15.5 6.2 10.7 6.5 3.20 p < 0.001Anxiety 9.3 6.3 5.2 4.0 3.50 p < 0.001Post-traumatic stress disorders/symptoms (PTSD/PTSS) 7.4 7.6 1.4 3.4 4.70 p < 0.001Somatisation (SOMAT) 5.0 5.2 1.4 2.5 3.90 p < 0.001Psychosocial stress (PSS) 7.6 4.1 2.2 2.1 7.70 p < 0.001

Notes: * Diagnosis means that the child fulfilled the criteria for the diagnosis according to DSM-IV.** DICA symptoms when the child displays some of the symptoms but not enough to fulfil all the diagnosis criteria according to DSM-IV.

Parent’sdiagnosis/symptoms

Traumatised parent group n = 30

% Comparison group n = 26

% PearsonChi-square

p-value

Maladaptive behaviour disorder 10 33.3 0 0 10.6 p < 0.01Depression 6 20.0 0 0 5.8 p < 0.05Post-traumatic stress disorder 29 96.7 *5 19.2 35.0 p < 0.001Psychotic symptoms 19 63.3 1 3.8 21.5 p < 0 001Somatisation 26 86.7 4 15.4 28.5 p < 0.001Anxiety 26 86.7 4 15.4 28.5 p < 0.001Psychosocial stress factors 14 46.7 0 0 16.2 p < 0.001

Note: * These subjects have been included because the PTSD symptomology is commonly present among refugee groups in general, which confirms the necessity to develop specific treatment strategies, particularly for non-European groups.

Diagnosis/symptoms Child Father Mother

% n = 45 % n = 15 % n = 15 p -value

Maladaptive problems withdepressiveness (MAL/DEP.)

97.8 44 20 3 20.0 3 c > f, m***

Post-traumatic stress disorder/symptoms (PTSD/PTSS)

48.9 22 100 15 93.3 14 ns

Anxiety 68.9 31 86.7 13 86.7 13 nsSomatisation (SOMAT) 46.7 21 86.7 13 86.7 13 nsPsychosocial stress factors (PSS) 73.3 33 53.3 8 40.0 6 c > m*

Notes: Diagnosis means that the child/parents fulfilled the diagnosis criteria according to DSM-IV.DA symptoms: the child/parent displays some symptoms but not enough to fulfil the diagnosis according to DSM-IV.c = Child; f = father; m = mother* p < 0.05; ** p < 0.01; *** p < 0.001.


© Blackwell Publishing Ltd and the International Journal of Social Welfare 2005 31

The attachment theory, as elaborated by Bowlbyin various works written between 1962 and 1988,emphasises the importance of the interaction betweenparents and children in determining how the child willattach to his/her parents. This in turn affects the child’sself-image, which fundamentally has to do with how thechild relates to his /her surroundings. Further researchis needed to ascertain what factors in traumatisedfamilies contribute to the development of maladaptivepsychological problems in their children, and todetermine if there is a relation between these factorsand the child’s experience of insecure attachment duringhis /her growing years.

Danieli (1998) writes about the silence that pervadesthe traumatised family and how it affects all familymembers. The children may create their own mythsabout their traumatised parents and subsequently act inaccordance with those myths. The child learns to accepta situation that he/she does not understand and that isbased on the parents’ silence. This study has generatedseveral crucial questions that need to be explored in futureresearch: How do children internalise their impressionsformed as a result of their parents’ silence (Danieli,1998), which, in turn, could lead to a lack of responseon the part of the parents? Do the children regard theirparents’ behaviour as a sign of indifference? How doesthe child’s self-image develop in relation to adults whotry hard to be good parents but fail in their ambition?

As reported above, the DICA results for the childrenin the traumatic parent groups showed that 96 per centof the boys and 85 per cent of the girls fulfilled the

criteria for maladaptive behaviour with depressivefeatures. This can be compared with the parents in thisgroup where 36 per cent of the fathers and 21 per centof the mothers fulfilled the DSM-IV criteria for thediagnosis depression.

In the traumatised parent group, 93 per cent of theadults fulfilled the DSM-IV criteria for the post-traumatic stress diagnosis (PTSD), anxiety syndromeand somatisation. Among the children in this group,38 per cent of the boys and 71 per cent of the girlsdisplayed PTSD symptoms, and 69 per cent of theboys and 71 per cent of the girls displayed symptomsof the anxiety syndrome. Furthermore, 46 per cent ofthe boys and 43 per cent of the girls showed signs ofsomatisation.

Among the adults, 43 per cent of the fathers and57 per cent of the mothers showed signs of psychosocialstress symptoms. The percentage for the children waseven higher: 69 per cent of the boys and 71 per cent ofthe girls. Furthermore, it was found that the children inthe traumatised parent group had significantly higherrates than their parents with respect to depression(p < 0.001), anxiety (p < 0.01) and psychosocial stress(p < 0.001).

The comparison between the children in the trauma-tised parent group and those in the comparison groupshowed statistically significant differences at the p <0.001 level with respect to the following key diagnoses:behavioural disturbances, adjustment problems withsigns of depression, post-traumatic stress disorder (PTSD),anxiety, somatisation and psychosocial stress factors.The question that emerges from these findings is: Towhat extent have psychological and cognitive aspects ofthe personality been affected negatively by the parents’diminished capacity to provide care and how doesthis circumstance affect the development of particularpathologies? As we have seen, there was a concordancebetween parents and children in the traumatised parentgroup. Furthermore, there were significant differencesbetween the children in the traumatised parent groupand those in the comparison group regarding the above-mentioned diagnoses/symptoms.

In conclusion, from a clinical point of view, childrenof tortured parents present a challenge to social workers,psychiatrists, psychologists and teachers. These profes-sionals need to be aware of the possible transmission ofparents’ traumatic experiences to their children and todevelop treatment methods for children of torture victims.

Acknowledgements

This study was financed in part by a grant from theSwedish National Board of Health and Welfare. Theresearch project (Dnr. 97-295, 2000-06-05) was approvedby the Local Ethical Committee at Karolinska Hospitalin Stockholm.

Figure 2. Comparison between fathers and mothers in the traumatisedparent group; diagnoses/symptoms according to H/UTQ. (Fathersn = 15; mothers n = 15).Notes: PSS = Psychosocial stress factors; DEP = Depressive symptoms;PTSD = Post-traumatic stress disorder; PSYCHIC = Psychotic (alikesymptoms/flashback); SOMAT = Somatisation; MAL = Maladaptiveproblems/behaviour problem.

Daud et al.

32 © Blackwell Publishing Ltd and the International Journal of Social Welfare 2005

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Children in families of torture victims: transgenerational transmission of parents’ traumatic experiences to their children