Home > Public Resources > Trauma Blog > 2015 - October > Global Perspectives: Traumatic Stress and Parent-Child Relationships Global Perspectives: Traumatic Stress and Parent-Child Relationships October 27, 2015 Persistent intergenerational transmission of family violence accompanied by harsh parenting practices and low positive involvement between parents and children is one dimension of a complex set of consequences related to traumatic stress resulting from war and organized violence on family and community functioning. Although resilience is readily seen in communities affected by mass traumas, the lasting negative effects of traumatic stress on individual and family health is ubiquitous across multiple generations, particularly in low and middle-income countries. The sequelae of maladaptive coping that often includes mental health disturbances, substance abuse and intimate partner violence, are further exacerbated by poverty and social disparities that place these families on a delicate faultline. Traumatic Stress and Parent-Child Relationships A number of studies have begun to document the effects of traumatic stress, particularly related to war and violence, on family and parent-child relationships around the world. In Sri Lanka, Catani et al. (2008) found that even following war and tsunami, 14 percent of children reported an experience of family violence as the most distressing experience of their lives. This team also found that exposure to war and increased alcohol use by fathers predicted higher levels of child-reported abuse (Catani, Jacob, Schauer, Kohila, & Neuner, 2008). Similarly, in Northern Uganda, exposure to trauma was associated with family violence and substance use with children reporting that their worst traumatic experiences were related to family violence above exposure to war violence (Saile, Neuner, Ertl, & Catani, 2013). Still in Uganda, a comparative study of 2 generations of adolescents and their parents also concluded that the impact of child maltreatment on psychological disorders surpassed the damage of war trauma (Olema, Catani, Ertl, Saile, & Neuner, 2014). After the war in Bosnia, maternal mental health predicted child adjustment (Smith, Perrin, Yule, & Rabe-Hesketh, 2001) and a qualitative post-intervention study conducted with 125 Bosnian refugees in the United States documented drastic changes in positive family roles and relationships (Weine et al., 2004). In a sample of 200 Gulf War veterans in Kuwait, fathers’ PTSD symptoms positively related to children’s depression scores; children’s anxiety, depression, and abnormal behavior were all related to fathers’ combat experience and mothers’ PTSD, anxiety, and depression (Al-Turkait & Ohaeri, 2008). Siegel (2013) argued that indeed neuroscience research supports the saying that “violence begets violence” and that children who witness parental violence are at high risk for repeating family violence in their own adult intimate relationships. Two recent studies support this hypothesis. A qualitative study with 25 Burundian former child soldiers and 15 matched civilian parents, reported that war trauma may be transmitted to offspring via parenting practices that include severe parental emotional distress (Song, Tol & Jong, 2014). Likewise, in a cross sectional study with 409 school-aged children in Tanzania, Hecker, Hermenaua, Isele, & Elbert (2014) found further evidence that corporal punishment by parents or caregivers was positively related to children’s externalizing problems. A growing literature supports the unique links between parental PTSD and parent-child relationships. Parental PTSD is associated with an increase in self-reported aggressive parenting, indifference and neglect (Stover, Hall, McMahon, & Easton, 2012), lower parenting satisfaction (Samper, Taft, King, & King, 2004), challenges with couple adjustment and parenting (Gewirtz, Polusny, DeGarmo, Khaylis, & Erbes, 2010), trauma-related symptoms in children (Kilic, Kilic, & Aydin, 2011; Polusny et al., 2011), children’s anxiety and stress (Brand, Schechter, Hammen, Brocque, & Brennan, 2011), and children’s depression (Harpaz-Rotem, Rosenheck, & Desai, 2009). This literature substantiates the far-reaching effects of traumatic stress related to war and family violence on parent-child relationships and provides strong support for the importance of intervening with parents in post conflict settings. Parents are the most proximal resources to effectively intervene and affect child outcomes in these settings (Gewirtz, Forgatch, & Wieling, 2008; Siegel, 2013). Reinforcing this direction, the 2012 National Institute of Health report on grand challenges in mental health stated that advances in the prevention and identification of early interventions and the identification of root causes, risk and protective factors for populations stricken by poverty, violence, war and disaster are priority issues. Our research team believes that parenting interventions may provide needed support that will benefit parents and children in the present and potentially serve as a catalyst for a more positive long-term trajectory. Testing the Feasibility of Implementing a Parenting Intervention in a Post-Conflict Setting Our workgroup, Victim’s Voice (vivo) (www.vivo.org), has collaborated with post-conflict communities for over a decade, primarily providing treatment for Posttraumatic Stress Disorder (PTSD). One of these communities is Northern Uganda, the setting of a brutal civil war that lasted nearly two decades through 2006. Involvement in this community revealed a critical need for parent and family-level interventions in addition to PTSD treatment. The next section of this article will report the findings included in two recent publications documenting early stages of our parenting work in Uganda. The parenting intervention we called Enhancing Family Connection (EFC) was a 9-session visually manualized -- to account for illiteracy -- intervention developed to fit the cultural and contextual characteristics of families in the region. EFC parenting components were adapted from the Parent Management Training, Oregon model (PMTO; Patterson, 2005) evidence-based intervention, which include encouragement, positive involvement, setting limits, monitoring, and problem solving. Additional EFC content areas included psychoeducation on the individual and relational effects of traumatic stress as well as sessions related to intergenerational transmission of violence, substance abuse, and other risk-taking behaviors. We began the parenting work in 2010 by holding several parent focus groups, testing our observational parent-child measures, and culturally adapting the intervention for this population. In 2012, members of our research team successfully implemented EFC in Northern Uganda with 14 mothers conducted in two parent groups. Mothers were selected for the study because they identified adverse and serious struggles with at least one focal child between the 7-13 years of age. The first paper (Wieling et al., 2015) elaborates on three interrelated areas of feasibility testing: (a) acceptability, (b) usability, and (c) limited efficacy. Mother-child dyads completed multi-method assessments that included a battery of self-report standardized questionnaires, six observational structured interaction tasks, and semi-structured ethnographic interviews at pre-, post-intervention, and at 5-month follow-up. Regarding implications for limited efficacy of the intervention, mothers and children showed evidence of changes that demonstrate the potential efficacy of EFC in changing parenting behaviors in this community. Changes clustered around (1) the use of positive reinforcement, encouragement and praise – mothers reported noticing and giving praise for pro-social behaviors in ways that were unprecedented and children reported changes in their mothers and in their own behaviors; (2) changes in discipline behavior – mothers and children reported less use of harsh punishment and beatings and greater use of alternative discipline strategies such as removal of privileges; and (3) changes in parental involvement – mothers reported more love and calm in the family that was often related to learning how to regulate their emotions and having acquired the skills to communicate more effectively with their children. The second paper (Wieling et al., in press) is process oriented and documents early adoption efforts necessary to establish effective implementation and sustainability of the intervention (Forgatch, Patterson, & Gewirtz, 2013). The processes our workgroup undertook to assess community-level parenting needs and desire for a parenting intervention are elaborated upon along with descriptions of initial stages of model development, evaluation of the promise of efficacy and effectiveness with this population, and testing the feasibility of the manualized intervention. We believe that our early feasibility research with parents in Uganda and additional preliminary work with various war-affected communities worldwide hold promise of interrupting intergenerational transmission of violence. We have envisioned the long-term development and testing of an ecosystemic model that would span across individual, couple, parental, family and community levels. This is undoubtedly an ambitious research agenda that will depend on the sustained commitment of multiple generations of scholars towards this effort. The global challenges that create and perpetuate inextricable disruptions in family life must be met with interventions aimed at repairing and strengthening core family relationships. Preventing current generations from succumbing to the consequences of war and cycle of violence might be one of the most powerful strategies in combating future war and social inequality. About the Author Elizabeth Wieling, PhD, LMFT, is associate professor in the Department of Family Social Sciences at the University of Minnesota. She is concurrently pursuing a research agenda that involves integrating her previous cross-cultural and prevention background to develop multi-component systemic oriented interventions that cut across individual, family, and community levels for intervening with populations exposed to traumatic stress – particularly related to war and organized violence. This research is being conducted with immigrant and refugee populations in the United States and in several international post-conflict contexts. Related Articles Wieling, E., Mehus, C., Yumbul, C., Möllerherm, J., Ertl, V., Laura, A., Forgatch, M., Neuner, F., Catani, C. (in press). Preparing the field for feasibility testing of a parenting intervention for war-affected mothers in Northern Uganda. Family Process. Wieling, E., Mehus, C., Möllerherm, J., Neuner, F., Achan, L., Catani, C. (2015). Assessing the Feasibility of Providing a Parenting Intervention for War-Affected Families in Northern Uganda. Family and Community Health, 38(3), 253–268. doi: 10.1097/FCH.0000000000000064. References Al-Turkait, F., Ohaeri, J. (2008). Psychopathological status, behavior problems, and family adjustment of Kuwaiti children whose fathers were involved in the first gulf war. Child and Adolescent Psychiatry and Mental Health, 2(12), 1-12. doi:10.1186/1753-2000-2-12 Brand, S. R., Schechter, J. C., Hammen, C. L., Brocque, R. L., & Brennan, P. A. (2011). Do adolescent offspring of women with PTSD experience higher levels of chronic and episodic stress? Journal of Traumatic Stress, 24(4), 399-404. doi:10.1002/jts.20652 Caselli. L. T., & Motta, R. W. (1995). The effect of PTSD and combat level on Vietnam veterans’ perceptions of child behavior and marital adjustment. Journal of Clinical Psychology, 51(1), 4-12. doi:10.1002/10974679(199501)51 Catani, C., Jacob, N., Schauer, E., Kohila, M., & Neuner, F. (2008). Family violence, war, and natural disaster: A study of the effect of extreme stress on children’s mental health in Sri Lanka. BMC Psychiatry, 8(33), 1-10. doi:10.1186/1471-244X-8-33. Hecker, T., Hermenaua, K., Isele, D., & Elbert, T. (2014). Corporal punishment and children’s externalizing problems: A cross-sectional study of Tanzanian primary school aged children. Child Abuse & Neglect, 38(2014), 884–892. doi:10.1016/j.chiabu.2013.11.007 Forgatch, M.S., Patterson, G.R., & Gewirtz, A.H. (2013). Looking forward: The promise of widespread implementation of parent training programs. Perspectives on Psychological Science, 8(6), 682-694. doi:10.1177/174569161350347 Gewirtz, A. H., Erbes, C., Polusny, M. A., Forgatch, M. S., & DeGarmo, D. S. (2011). Helping military families through the deployment process: Strategies to support parenting. Professional Psychology: Research and Practice, 42, 56-62. Gewirtz, A.H., Polusny, M., DeGarmo, D., Khaylis*, A., & Erbes, C. (2010). Parenting, family relationships and posttraumatic distress symptoms among National Guard members deployed to Operation Iraqi Freedom. Journal of Consulting and Clinical Psychology, 78(5), 599-610. Gewirtz, A., Forgatch, M., & Wieling, E. (2008). Parenting practices as potential mechanisms for children’s adjustment following mass trauma: Literature review and prevention research framework. Journal of Marital and Family Therapy, 34(2), 177-192. doi:10.1111/j.1752-0606.2008.00063.x Harpaz-Rotem, I., Rosenheck, R. A., & Desai, R. (2009). Assessing the effects of maternal symptoms and homelessness on the mental health problems in their children. Child and Adolescent Mental Health, 14(4), 168-174. doi: 10.1111/j.1475-3588.2008.00519.x Kilic, C., Kilic, E. Z., & Aydin, I. O. (2011). Effect of relocation and parental psychopathology on earthquake survivor-children’s mental health. Journal of Nervous and Mental Disease, 199(5), 335-341. doi:10.1097/NMD.0b013e3182174ffa Mehus, C. (2015). Fathering and substance use in northern Uganda. (Unpublished doctoral dissertation). University of Minnesota, St. Paul, Minnesota. Olema, D. K., Catani, C., Ertl, V., Saile, R. & Neuner, F. (2014). The hidden effects of child-maltreatment in a war-region: Predictors of psychopathology in two generations living in Northern Uganda. Journal of Traumatic Stress, 27(1), 35-41. doi:10.1002/jts.21892 Patterson, G. R. (2005). The next generation of PMTO models. Behavior Therapist, 28(2), 25-32. Polusny, M., Ries, B., Meis, L., DeGarmo, D., McCormick-Deaton, C., Thuras, P., & Erbes, C. (2011). Effects of parents' experiential avoidance and PTSD on adolescent disaster-related posttraumatic stress symptomatology. Journal of Family Psychology, 25(2), 220-229. Saile, R., Neuner, F., Ertl, V., Catani, C. (2013). Prevalence and predictors of partner violence against women in the aftermath of war: A survey among couples in Northern Uganda, Social Science and Medicine, 86, 17-25. doi:10.1016/j.socscimed.2013.02.046. Samper, R. E., Taft, C. T., King, D. W., & King, L. A. (2004). Posttraumatic stress disorder symptoms and parenting satisfaction among a national sample of male Vietnam veterans. Journal of Traumatic Stress, 17(4), 311-315. doi:10.1023/B:JOTS.0000038479.30903.ed Siegel, J. (2013). Breaking the links in intergenerational violence: An emotional regulation perspective. Family Process, 52(2), 163-178. doi:10.1111/famp.12023 Smith, P., Perrin, S., Yule, W., & Rabe-Hesketh, S. (2001). War exposure and maternal reactions in the psychological adjustment of children from Bosnia-Hercegovina. Journal of Child Psychology and Psychiatry, 42(3), 395-404. doi:10.1111/1469-7610.00732 Song, S., Tol, W., & Jong, J. (2014). Indero: Intergenerational trauma and resilience between Burundian former child soldiers and their children. Family Process, 53(2), 239-251. doi: 10.1111/famp.12071 Stover, C. S., Hall, C., McMahon, T. J., & Easton, C. J. (2012). Fathers entering substance abuse treatment: An examination of substance abuse, trauma symptoms and parenting behaviors. 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