For the assessment of adverse childhood experiences at home we created a questionnaire by selecting items about physical, sexual and emotional abuse as well as neglect from two standard checklists for trauma exposure in childhood: the Early Trauma Inventory [ 29 ] and the Childhood Trauma Questionnaire [ 30 ]. Following an in-depth discussion with local counselors and experts, the most suitable items for Sri Lankan culture were chosen and the wording was adapted.
It is important to note that with respect to both the war and the family violence event lists, items referred to different types of events, not to the number of events.
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Given the frequency of repeated events such as bombings or being slapped at home, it would have been impossible to obtain an accurate count of the number of times these events had occurred. Instead, the number of different event types was established by differentiating between war-related events that happened during the 12 months preceding the interview scored as "last year" and those that happened more than 12 months prior to the interview scored as "ever". The family violence questions were aimed at determining if events had happened "last month" or "ever".
Thus, it was possible to determine the number of cases in which there was ongoing family violence. The UPID has proven good psychometric properties and it has been used in a wide variety of cultural settings [ 32 ]. In a previous study, this instrument was translated into Tamil following standard principles of instrument translation and it has subsequently been used with Tamil child survivors of the Tsunami [ 14 ]. Rather than relying on a cut-off criterion, we established the diagnosis of PTSD according to ful?
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For this purpose, we added six items related to problems in functioning in different areas of children's life. For each single DSM-IV symptom, its occurrence within the last month is scored on a scale ranging from 0 none of the time to 4 most of the time. Thus, an overall PTSD severity score can be calculated by summing the scores for each question that corresponds to a symptom resulting in a maximum possible score of Kid version Mini-International Neuropsychiatric Interview [ 33 ] were additionally administered to the children.
Drug use by fathers appeared to be very prevalent in Sri Lanka, with Among the other drugs, betel nut In the majority of cases, frequent alcohol use was reported with Only 0. This use seemed to be infrequent, however, since all children reported that their mothers use these substances less than once a month.
In no single case, children reported using alcohol or any other drug themselves. Almost half of the interviewed sample The majority of children The most frequent event types reported by the children were seeing a dead or mutilated body Almost all children In On average, children reported to have experienced or witnessed 5. Figure 1 illustrates the frequency of specific types of events described by children again indicating a high level of aggression carried out by the Sri Lankan caregivers.
Percentages of children exposed to different incidents of violence at home. Amongst these children, On average, the Tsunami severity score was 2.
PTSD prevalence was very high with The analysis of the M. To examine potential predictors for violence experienced by a child at home, we calculated a linear regression model. The dependent variable is the total number of family violence event types reported by the children. Results of the analyses are presented in table 1.
Whereas alcohol use by fathers and the amount of previous war experiences were found as significant positive predictors of family violence, economic status and Tsunami exposure showed a negative relationship with the outcome measure. The amount of exposure to different types of war events as well as to different forms of family violence together with Tsunami severity resulted as the strongest predictors for PTSD symptom severity.
To further investigate the clear relationship between the number of previous stressful and traumatic life events and a current PTSD diagnosis, we divided the whole sample of children into different groups based on the number of stressful event types reported. Aversive experiences related to the war, family violence and the Tsunami were added up to create a global indicator of stressful event load.
Psychological effects of disaster on children
The initial division was made as follows: the first group consisted of respondents endorsing 0—3 event types, the second group consisted of individuals endorsing 4—7 event types. Each following group endorsed an additional three event types. Because the number of individuals in the groups of 16—19, 20—23, 24—27 and 28—30 event types was very small, these groups were merged to two groups of 16—20 and 21—30 event types.
Figure 2 shows the number of individuals and the prevalence of PTSD in these groups. The number of aversive event types experienced by the children seems to be related to an increased risk of being diagnosed with PTSD. The cumulative trauma threshold in children identified here was 21 events, which means that any child who reported 21 or more different aversive event types was diagnosed with PTSD. Prevalence of PTSD for children grouped by number of stressful event types.
Statistical analyses were conducted to compare children with and without PTSD with respect to somatic complaints and the diagnoses of Major Depressive Disorder and present suicidal ideation. Average values and percentages for each subgroup are listed in table 3. One key finding of the present study was the significant relationship between previous war events and the amount of family violence experienced by the children.
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Together with fathers' alcohol use, exposure to the war resulted as a strong predictor for violence taking place at home. Both violence associated with the war and with parental behavior were in turn related to the diagnosis of PTSD in children. A clear dose-effect relationship between the exposure to different types of stressors war, Tsunami, and family violence and PTSD severity was found, suggesting that that the experience of cumulative stress has a harmful effect on children's mental health. The past and current political situation of Sri Lanka's North East was reflected in the outcomes related to war exposure.
The average Tsunami severity score of 2. Furthermore, children had experienced or witnessed a mean of 5. Physical punishment was found to be very common with A comparison of data from this study to rates of family violence reported in industrialized countries is difficult as the definition of domestic violence or child maltreatment is still controversial [ 34 , 35 ] and there is a paucity of representative data on child maltreatment prevalence rates [ 36 ].
Several predictors for children's exposure to family violence emerged from the calculation of a linear regression model. Poverty and parental substance abuse were commonly found as risk factors of child maltreatment in industrialized countries [ 24 , 35 , 38 ] and could be confirmed as risk factors in our sample.
Given that no systematic survey on family violence inflicted on children in post-conflict countries has been published to date, an essential finding of the present study is the strong relationship between previous war exposure of children and the amount of violence occurring at home. This result gives rise to two possible interpretations. One explanation might be that the parents of the war-affected children in Sri Lanka have experienced more war events themselves.
Therefore, the outcome may be in line with previous studies that argue for a link between the traumatizing effects of warfare on men's propensity for domestic abuse [ 20 , 21 ]. Taking into account the potential relationship between war trauma and substance abuse [ 25 ], the alcohol intake in fathers, as reported by the children here, could be related to the individual problems associated with war trauma as suggested by the "self-medication" hypothesis [ 26 ].
Another interpretation could be that a higher traumatization is related to a higher occurrence of trauma-related symptoms in the affected children—e. However, the finding that the Tsunami experience was not predictive of higher levels of family violence, but even inversely related to family violence indicates that the relationship between mass traumas and family violence is more complex.
Resilience in Children Exposed to Trauma, Disaster and War: Global Perspectives
Factors like the duration and nature of mass traumatic event might be crucial for the impact of the events on the family level. One might speculate that the Tsunami as a recent event of short duration has fostered a period of family cohesion whereas the repetitive and chronic stress of war event had a deteriorating effect on family functioning. Consequences of the extensive amount of stress due to organized as well as family-related violence reported by our sample are reflected in high prevalence rates of psychiatric disorders.
These findings are in line with previous studies showing increased rates of mental disorders, and particularly PTSD, in children traumatized by violent conflicts [ 3 , 5 ] as well as in child and adolescent victims of natural disasters including the recent Tsunami [ 10 , 14 ]. In this study, we found both the number of aversive experiences related to war and exposure to the Tsunami to be strong predictors for the development of PTSD in the children.
The amount of family violence was identified as an even stronger predictor of PTSD in children than previous exposure to the war. This result highlights the importance that family violence plays in the context of organized violence.
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Furthermore, there is growing evidence to suggest that being a witness to domestic violence is a stressor severe enough to lead to PTSD in children [ 41 , 42 ]. In the context of severe adversity our data revealed that if the cumulative exposure to stressful events is high enough, any affected child will develop chronic PTSD.
Similarly to what has been found for traumatized adults [ 13 ], the results support the notion that the repeated occurrence of traumatic stress has a cumulative damaging effect on the mental health of child victims as well as adults. Consequences of PTSD were found for both physical as well as psychological symptoms. The latter result is in line with a number of studies reporting depression to be a frequent comorbid disorder among traumatized refugee children [ 43 ] as well as among children in tsunami-affected areas [ 44 ].
Limitations of the present study are the relatively small sample size and the fact that, due to the unsafe situation and political restrictions given at that time, schools could not be selected on a random basis. However, even without a large sample representing the entire North East of the country we could obtain enough statistical power to answer our initial key question regarding the predictors and effect of traumatization in children living in a conflict region.
Interviews with parents could not be obtained in the present study due to logistical reasons. Ideally, future investigations will utilize a design which allows for information on substance use and family violence to be obtained from parents as well as children. Interviews with both parents and their children would also be needed to investigate the hypothesized link between war exposure, increased use of alcohol or other substances, and an increased level of abusive behavior towards children.
The present findings should be seen as a first step towards defining a relationship between war and family violence and therefore stimulate more research in the area of indirect consequences of war and organized violence on children with a particular focus on family violence.
go to site Based on the present findings, it can be asserted that children in post-war societies might not only be affected by aversive events occurring within the framework of organized violence, but also by family-related stressors, such as violence at home and parental substance use. A particularly important outcome was the association between previous war violence and the amount of violent behavior inflicted on children in their families. The high rate of PTSD found in the children was strongly linked to the amount of exposure to war, natural disaster, and family violence, thus highlighting the extremely detrimental effect that the experience of cumulative stress can have on children's mental health.
Findings of the present study point towards an urgent need for targeted interventions. Psychological treatment approaches for children in post-conflict settings should be carefully tailored to fit the specific requirements of the given population and address not only the war trauma but also psychosocial problems present at the family and community level which arise as consequences of the violent conflict. Such approaches could include trauma-focused treatment modules for the children as well as programs of stress management for the entire family that might have a beneficial effect on parental discipline method.
Anbarasan E: Analysis: Sri Lanka talks failure. Kaldor M: New and old wars: organized violence in a global area. Saigh PA: The development of posttraumatic stress disorder following four different types of traumatization. Behav Res Ther. Schaal S, Elbert T: Ten years after the genocide: trauma confrontation and posttraumatic stress in Rwandan adolescents. J Trauma Stress.