Violence and hostility among families of Vietnam veterans with combat-related posttraumatic stress disorder

Intergenerational Transmission of Posttraumatic Stress Disorder in Australian Vietnam Veterans' Daughters and Sons: The Effect of Family Emotional Climate While Growing Up

Posttraumatic stress disorder (PTSD) in military veterans increases the risk of PTSD in their offspring, a concept known as "intergenerational transmission;" however, the mechanism by which this transmission may occur is, as yet, undetermined. The present study included a nonclinical sample of 197 Australian Army veterans of the Vietnam War who were interviewed 17 years before in-person interviews of their adult daughters (n = 163) and sons (n = 120) were conducted. Veterans' PTSD symptoms were assessed using the Mississippi Scale for Combat-Related PTSD. Approximately 17 years later, offspring PTSD symptoms were assessed using the Clinician-Administered PTSD Scale for DSM-IV. In addition, offspring described the family emotional climate during their youth; responses were coded using the Family Affective Attitude Rating Scale (FAARS) to produce scale scores of veterans' negative, positive, and family relationship styles. A path analysis was conducted via structural equation modeling to test for significant path coefficients between veteran PTSD, family emotional climate, and offspring PTSD symptoms. For daughters, significant path coefficients were observed between veteran PTSD scores and FAARS scores, path coefficient = -.268; FAARS scores and offspring CAPS severity scores, path coefficient = -.223; and veteran PTSD scores and daughters' CAPS severity scores, path coefficient = .186. No satisfactory model could be found for sons. The results suggest that a positive emotional climate while growing up may be a significant protective factor against the development of PTSD in veterans' daughters, but other factors remain significant in veteran-to-offspring intergenerational transmission.

Trauma Exposure, Posttraumatic Stress Disorder, and Aggression Among Civilian Females

Trauma exposure and posttraumatic stress disorder (PTSD) have evinced ties to increased risk for aggressive behavior. However, very little information is known regarding the relations between trauma exposure, PTSD, and aggression among non-veteran women. Furthermore, research has not examined the associations between trauma exposure, PTSD symptoms, and aggression using the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) PTSD criteria. The primary aim of the current study was to investigate the relationships between trauma exposure, PTSD symptoms, and aggression among women. The secondary aim was to examine the specific PTSD symptom clusters in relation to indices of aggression. A total of 217 civilian, trauma-exposed female undergraduate students participated in the study (M_age = 24.30, SD = 6.83, 63.2% White). Higher levels of trauma exposure and PTSD symptoms corresponded with anger (b = .47, 95% CI = [0.11-0.83]; b = .11, 95% CI = [0.05-0.16], respectively) and verbal aggression (b = .50, 95% CI = [0.21-0.78]; b = .06, 95% CI = [0.01-0.10], respectively). PTSD symptoms, but not cumulative trauma exposure, was associated with hostility (b = .23, 95% CI = [0.14-0.59]), whereas physical aggression was only related to trauma exposure (b = .69, 95% CI = [0.31-1.06]). Furthermore, there was a significant indirect effect of cumulative trauma through PTSD symptoms on anger and verbal aggression (b = .15, 95% CI = [0.05-0.32]; b = .09, 95% CI = [0.02-0.20], respectively). Trauma-exposed civilian females with higher levels of PTSD symptoms may be at increased risk for several indices of aggressive behavior. Furthermore, PTSD symptoms may better account for some, but not all, aspects of aggression in trauma-exposed women.

Impact of Parental Exposure on Offspring Health in Humans

The possibility that parental life experiences and environmental exposures influence mental and physical health across generations is an important concept in biology and medicine. Evidence from animal models has established the existence of a non-genetic mode of inheritance. This form of heredity involves transmission of the effects of parental exposure to the offspring through epigenetic changes in the germline. Studying the mechanisms of epigenetic inheritance in humans is challenging because it is difficult to obtain multigeneration cohorts, to collect reproductive cells in exposed parents, and to exclude psychosocial and cultural confounders. Nonetheless, epidemiological studies in humans exposed to famine, stress/trauma, or toxicants have provided evidence that parental exposure can impact the health of descendants, in some cases, across several generations. A few studies have also started to reveal epigenetic changes in the periphery and sperm after certain exposures. This article reviews these studies and evaluates the current evidence for the potential contribution of epigenetic factors to heredity in humans. The challenges and limitations of this fundamental biological process, its implications, and its societal relevance are also discussed.

Hair Cortisol as a Marker of Intergenerational Heritage of War? A Study of Veterans and Their Offspring

OBJECTIVE

Posttraumatic stress disorder (PTSD) has been associated with lower circulating cortisol levels in specific subgroups, which have also been found in the offspring of people with PTSD. The analysis of hair cortisol concentrations (HCC) is a recent methodology which is used to assess long-term systemic cortisol levels. We aimed to study veterans with war-related lifetime PTSD and their respective offspring with regards to HCC. We also studied the influence of lifetime major depressive disorder (MDD), war experiences, and childhood adversities on HCC in these groups.

METHODS

31 male veterans with PTSD and 28 without PTSD and 69 adult offspring were studied. HCC were quantified by liquid chromatography tandem-mass spectrometry.

RESULTS

No differences in HCC were found between veterans with and without PTSD, or between their respective offspring. Veterans without MDD showed a positive association between total war exposure and HCC. Veterans reporting more frequent childhood physical abuse had lower HCC. Veterans-with-PTSD's offspring with MDD had increased HCC compared to offspring without MDD. Offspring's exposure to more frequent childhood physical abuse was negatively associated with HCC in those without MDD.

CONCLUSION

HCC did not appear to constitute a marker of intergenerational heritage of war-related PTSD, except in the case of veteranswith-PTSD's offspring with MDD. Our data suggest that HCC is a marker of adult reported childhood physical abuse.

Lifetime PTSD is associated with impaired emotion recognition in veterans and their offspring

PTSD is associated with emotion dysregulation. Studies have found inconsistent impaired facial emotion recognition ability (ERA) in patients with PTSD and intergenerational transmission of PTSD has been reported, although no studies exist regarding ERA. Our objective was to characterise the facial ERA of a group of traumatised war veterans with, and without lifetime PTSD, and also of their respective adult offspring. Sixty-one veterans with, and without lifetime PTSD and 73 offspring were tested for ERA of seven basic facial emotions expressions, 40 years after veterans had been exposed to war-related trauma. Veterans with lifetime PTSD showed impairment of recognition of all emotions, irrespective of the type, when compared with veterans without PTSD. This result was maintained after adjusting for potential confounders-including depressive symptoms. Offspring of veterans with lifetime PTSD also showed impaired recognition of all emotions, including after adjustment for the same variables. Offspring of veterans with lifetime PTSD also showed specific impairment in recognising the emotions of happiness and disgust. These results confirm that PTSD has negative effects with regards to emotion regulation and also on the next generation. This could result in this population being at increased risk of suffering from relationship problems and psychopathology.

Couple and family therapies for post-traumatic stress disorder (PTSD)

BACKGROUND

Post-traumatic stress disorder (PTSD) refers to an anxiety or trauma- and stressor-related disorder that is linked to personal or vicarious exposure to traumatic events. PTSD is associated with a range of adverse individual outcomes (e.g. poor health, suicidality) and significant interpersonal problems which include difficulties in intimate and family relationships. A range of couple- and family-based treatments have been suggested as appropriate interventions for families impacted by PTSD.

OBJECTIVES

The objectives of this review were to: (1) assess the effects of couple and family therapies for adult PTSD, relative to 'no treatment' conditions, 'standard care', and structured or non-specific individual or group psychological therapies; (2) examine the clinical characteristics of studies that influence the relative effects of these therapies; and (3) critically evaluate methodological characteristics of studies that may bias the research findings.

SEARCH METHODS

We searched MEDLINE (1950- ), Embase (1980- ) and PsycINFO (1967- ) via the Cochrane Common Mental Disorders Controlled Trials Register (CCMDCTR) to 2014, then directly via Ovid after this date. We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Library. We conducted supplementary searches of PTSDPubs (all available years) (this database is formerly known as PILOTS (Published International Literature on Traumatic Stress)). We manually searched the early editions of key journals and screened the reference lists and bibliographies of included studies to identify other relevant research. We also contacted the authors of included trials for unpublished information. Studies have been incorporated from searches to 3 March 2018.

SELECTION CRITERIA

Eligible studies were randomised controlled trials (RCTs) of couple or family therapies for PTSD in adult samples. The review considered any type of therapy that was intended to treat intact couples or families where at least one adult family member met criteria for PTSD. It was required that participants were diagnosed with PTSD according to recognised classification systems.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures prescribed by Cochrane. Three review authors screened all titles and abstracts and two authors independently extracted data from each study deemed eligible and assessed the risk of bias for each study. We used odds ratios (OR) to summarise the effects of interventions for dichotomous outcomes, and standardised mean differences (SMD) to summarise post-treatment between-group differences on continuous measures.

MAIN RESULTS

We included four trials in the review. Two studies examined the effects of cognitive behavioural conjoint/couple's therapy (CBCT) relative to a wait list control condition, although one of these studies only reported outcomes in relation to relationship satisfaction. One study examined the effects of structural approach therapy (SAT) relative to a PTSD family education (PFE) programme; and one examined the effects of adjunct behavioural family therapy (BFT) but failed to report any outcome variables in sufficient detail - we did not include it in the meta-analysis. One trial with 40 couples (80 participants) showed that CBCT was more effective than wait list control in reducing PTSD severity (SMD -1.12, 95% CI -1.79 to -0.45; low-quality evidence), anxiety (SMD -0.93, 95% CI -1.58 to -0.27; very low-quality evidence) and depression (SMD -0.66, 95% CI -1.30 to -0.02; very low-quality evidence) at post-treatment for the primary patient with PTSD. Data from two studies indicated that treatment and control groups did not differ significantly according to relationship satisfaction (SMD 1.07, 95% CI -0.17 to 2.31; very low-quality evidence); and one study showed no significant differences regarding depression (SMD 0.28, 95% CI -0.35 to 0.90; very low-quality evidence) or anxiety symptoms (SMD 0.15, 95% CI -0.47 to 0.77; very low-quality evidence) for the partner of the patient with PTSD. One trial with 57 couples (114 participants) showed that SAT was more effective than PFE in reducing PTSD severity for the primary patient (SMD -1.32, 95% CI -1.90 to -0.74; low-quality evidence) at post-treatment. There was no evidence of differences on the other outcomes, including relationship satisfaction (SMD 0.01, 95% CI -0.51 to 0.53; very low-quality evidence), depression (SMD 0.21, 95% CI -0.31 to 0.73; very low-quality evidence) and anxiety (SMD -0.16, 95% CI -0.68 to 0.36; very low-quality evidence) for intimate partners; and depression (SMD -0.28, 95% CI -0.81 to 0.24; very low-quality evidence) or anxiety (SMD -0.34, 95% CI -0.87 to 0.18; very low-quality evidence) for the primary patient. Two studies reported on adverse events and dropout rates, and no significant differences between groups were observed. Two studies were classified as having a 'low' or 'unclear' risk of bias in most domains, except for performance bias that was rated 'high'. Two studies had significant amounts of missing information resulting in 'unclear' risk of bias. There were too few studies available to conduct subgroup analyses.

AUTHORS' CONCLUSIONS

There are few trials of couple-based therapies for PTSD and evidence is insufficient to determine whether these offer substantive benefits when delivered alone or in addition to psychological interventions. Preliminary RCTs suggest, however, that couple-based therapies for PTSD may be potentially beneficial for reducing PTSD symptoms, and there is a need for additional trials of both adjunctive and stand-alone interventions with couples or families which target reduced PTSD symptoms, mental health problems of family members and dyadic measures of relationship quality.

The mental health of sons and daughters of Australian Vietnam veterans

Background

War service increases the risk of post-traumatic stress disorder (PTSD) to combatants, and has been shown to increase the risk of PTSD in their offspring. The extent to which there is an excess compared with the general population is not yet established, nor whether PTSD increases the risk of other psychiatric problems.

Methods

A national sample of 133 sons and 182 daughters of a cohort of 179 Australian Vietnam veterans' families were assessed in person, using structured psychiatric interviews. The prevalence of trauma exposures, DSM-IV (Diagnostic and Statistical Manual of Mental Disorders Fourth Edition) diagnoses and suicidality were compared with the Australian Bureau of Statistics' 2007 National Survey of Mental Health and Wellbeing data matched for age and sex. The risk of mental health problems potentially attributable to PTSD was also assessed.

Results

Sons and daughters were more likely than population expectations to report exposures to natural disasters, fire or explosions and transport accidents, and sons more likely to report exposure to toxic chemicals whereas daughters were more likely to report sexual assault. Sons and daughters had higher prevalences of alcohol and other substance dependence, depression and anxiety, and PTSD, and children's PTSD was associated with substance dependence, depression and suicidal ideation. There were strong associations between children's PTSD and comorbid conditions of substance use disorders, depression and anxiety.

Conclusions

Higher rates of mental health problems in veterans' families, together with comorbidity with PTSD and the link between veterans' and children's PTSD, suggest that the effects of trauma may continue into subsequent generations.

Intergenerational transmission of war-related trauma assessed 40 years after exposure

BACKGROUND

The intergenerational transmission of posttraumatic stress disorder (PTSD) from parent to offspring has been suggested in the literature, but this is highly controversial. We aimed to study the association between veterans' war exposure and lifetime PTSD and the psychological characteristics of their respective offspring, 40 years after war-related trauma.

METHODS

Forty-four adult offspring of veterans with PTSD and 29 offspring of veterans without PTSD were included in the study, from a total of 46 veterans. War exposure intensity, lifetime PTSD, and the general psychopathology (with Brief Symptom Inventory-BSI) of the veterans were studied, as were childhood trauma, attachment, and the general psychopathology (with BSI) of their offspring.

RESULTS

Veterans' war exposure was associated with BSI in the offspring with regard to somatisation (β = 0.025; CI 0.001, 0.050), phobic anxiety (β = 0.014; CI: 0.000, 0.027), Global Severity Index (GSI) (β = 0.022; CI 0.005, 0.038), and Positive Symptom Distress Index (β = 0.020; CI 0.006, 0.033). The fathers' GSI mediated only 18% of the effect of the veterans' total war exposure on offspring's GSI. Fathers' war exposure was associated with offspring's physical neglect as a childhood adversity, although non-significantly (p = 0.063). None of the other variables was associated with veterans' war exposure, and veterans' lifetime PTSD was not associated with any of the variables studied.

CONCLUSIONS

The offspring of war veterans showed increased psychological suffering as a function of their fathers' war exposure intensity, but not of their fathers' lifetime PTSD. These results could be used to suggest that mental health support for veterans' offspring should consider the war exposure intensity of their fathers, and not just psychopathology. This could spare offspring's suffering if this mental health support could be delivered early on, after veterans return from war.

Deficits in Inhibitory Control May Place Service Members at Risk for Posttraumatic Stress Disorder and Negative Parenting Behavior Following Deployment-Related Trauma

This study examined the mediating role of posttraumatic stress disorder (PTSD) symptoms in the association between deployment-related trauma exposure and parenting behaviors in reserve-component military service members and whether this association was contingent upon parent inhibitory control (IC). Participants were 181 postdeployed fathers and their children. Fathers completed a neurospychological test of IC and self-report measures of trauma exposure and PTSD symptoms. Measures of parenting behaviors (positive engagement and reactivity coercion) were obtained from direct observation of father-child interaction. Results demonstrated that (a) fathers' PTSD symptoms indirectly mediated the effect of trauma exposure on both measures of parenting (i.e., negative indirect effect for positive engagement, point estimate = -.0045, 95% CI [-.0107, -.0003], and positive indirect effect for reactivity coercion, point estimate = .0061, 95% CI [.0007, .0146]); (b) fathers' IC skills moderated the association between trauma exposure and PTSD, β = .14, p = .043, such that the association was positive and significant for fathers with high and medium IC but nonsignificant for fathers with low IC; and (c) the indirect effect of trauma exposure on both parenting measures through PTSD was dependent upon IC, point estimate = .0341, 95% CI [.0005, .0687]. These findings indicate that fathers with low IC skills tended to have higher rates of PTSD symptoms and related negative parenting behaviors, even for individuals with relatively low degrees of deployment-related trauma exposure. Results highlight the importance of IC as a potential moderating factor in the association between trauma exposure, PTSD, and parenting.

Growing up with a father with PTSD: The family emotional climate of the children of Australian Vietnam veterans

A non-clinical sample of male Australian Vietnam veterans, their wives, and adult offspring were interviewed in-person in a national epidemiological study to assess the relationship between the mental ill-health of veterans and the emotional climate of the family while the children were growing up. Veterans were assessed 17 years before their children using standardised psychiatric diagnostic interviews. Family emotional climate was assessed using offspring ratings of parental attachment, and codings of positive and negative family relationship styles based on five minute speech samples provided by the offspring. Sons and daughters had different views of their mothers and fathers, and were less positive towards their fathers particularly if he had posttraumatic stress disorder (PTSD). Veteran PTSD and depression significantly negatively impacted the family emotional climate, while mothers' mental health was not related. Veteran PTSD symptoms were lowest in secure attachment to the veteran and highest in inconsistent attachment for both sons and daughters, but were not related to attachment to the mother. Veteran PTSD was related to daughters' but not sons' perceptions of family emotional climate. The impact of veterans' PTSD on their families' emotional climate is more marked for daughters than sons.

Transgenerational Epigenetics of Traumatic Stress

Traumatic stress is a type of environmental experience that can modify behavior, cognition and physiological functions such as metabolism, in mammals. Many of the effects of traumatic stress can be transmitted to subsequent generations even when individuals from these generations are not exposed to any traumatic stressor. This book chapter discusses the concept of epigenetic/non-genomic inheritance of such traits involving the germline in mammals. It includes a comprehensive review of animal and human studies on inter- and transgenerational inheritance of the effects of traumatic stress, some of the epigenetic changes in the germline currently known to be associated with traumatic stress, and possible mechanisms for their induction and maintenance during development and adulthood. We also describe some experimental interventions that attempted to prevent the transmission of these effects, and consider the evolutionary importance of transgenerational inheritance and future outlook of the field.

Risk factors for concurrent suicidal ideation and violent impulses in military veterans

Suicide and violence are significant problems in a subset of Iraq/Afghanistan-era veterans. This study investigates how posttraumatic stress disorder (PTSD) and resilience in veterans are associated with suicidal ideation and violent impulses while controlling for known covariates of both adverse outcomes. Structured clinical interviews were conducted of N = 2,543 Iraq/Afghanistan-era U.S. veterans. Compared with veterans denying suicidal ideation or violent impulses (n = 1,927), veterans endorsing both (n = 171) were more likely to meet diagnostic criteria for PTSD, report childhood abuse, combat exposure, physical pain symptoms, and drug misuse, and less likely to endorse self-direction/life purpose. Veterans reporting concurrent suicidal ideation and violent impulses had higher odds of misusing drugs and reporting pain symptoms relative to veterans reporting suicidal ideation only (n = 186) and had lower odds of endorsing self-direction/life purpose compared with veterans reporting violent impulses only (n = 259). The findings underscore the importance of examining drug abuse, physical pain symptoms, and self-direction/life purpose, as well as PTSD and history of trauma, in the context of clinical assessment and empirical research aimed at optimizing risk management of suicide and violence in military veterans. (PsycINFO Database Record

Intergenerational transmission of post-traumatic stress disorder in Australian Vietnam veterans' families

OBJECTIVE

To assess the association between parental post-traumatic stress disorder (PTSD) and offspring PTSD and its specificity for other disorders in a non-clinical epidemiological cohort of Australian Vietnam veterans, their partners and their sons and daughters.

METHOD

Veterans were interviewed twice, in 1992-1994 and 2005-2006; partners were interviewed in 2006-2007, and their offspring in 2012-2014. A total of 125 sons and 168 daughters were interviewed from 197 families, 137 of which also included partners who were the mothers of the children. Statistical analysis used multi-level modelling to compute odds ratios and 95% confidence intervals while controlling for clustering effects within families. Parent PTSD diagnoses were examined for associations with offspring trauma exposure, PTSD and other psychiatric diagnoses.

RESULTS

Veteran PTSD increased the risk of PTSD and no other disorder in both sons and daughters; partner PTSD did not. Veteran depression was also a risk factor for sons' PTSD, and alcohol disorder was linked to alcohol dependence in sons and PTSD in daughters, but not when controlling for veteran PTSD.

CONCLUSION

We conclude that PTSD in a Vietnam veteran father increases the risk specifically for PTSD in his sons and daughters.

A Daily Diary Study of Posttraumatic Stress Symptoms and Romantic Partner Accommodation

Little is known about the role of romantic partner symptom accommodation in PTSD symptom maintenance. To explore the bidirectional associations of posttraumatic stress disorder (PTSD) symptoms and romantic partner symptom accommodation over time, military servicemen (n=64) with symptoms of PTSD and their cohabiting heterosexual civilian romantic partners (n=64) completed a 2-week daily diary study. Cross-lagged, autoregressive models assessed the stability of men's PTSD symptoms and partners' accommodation, as well as the prospective associations of earlier PTSD symptoms with later accommodation and vice versa. Analyses used Bayesian estimation to provide point estimates (b) and Credible Intervals (CIs). In all models, PTSD symptoms (total and individual clusters) were highly stable (b=0.91; CI: 0.88-0.95), and accommodation was moderately stable (b=0.48; CI: 0.40-0.54). In all models, earlier PTSD symptoms (total and clusters) were significantly, positively associated with later accommodation (b=0.04; CI: 0.02-0.07). In contrast, earlier accommodation was significantly associated only with later situational avoidance (b=0.02; CI: 0.00-0.07). Thus, PTSD symptoms may lead to subsequent accommodating behaviors in romantic partners, but partner accommodation seems to contribute only to survivors' future situational avoidance symptoms. The findings reinforce the notion that PTSD symptoms have an impact on relationship behaviors, and that accommodation from partners may sustain avoidant behaviors in particular. Clinicians should attend to romantic partners' accommodating behaviors when working with survivors.

Veterans are not the only ones suffering from posttraumatic stress symptoms: what do we know about dependents' secondary traumatic stress?

PURPOSE

Previous research has mainly focused on veterans' mental health problems, especially on posttraumatic stress disorder (PTSD). Less is known about the impact that the veteran's experienced potentially traumatic events (PTEs) might have on their significant others. Therefore, we reviewed the scientific literature to find out what is known about the prevalence of secondary traumatic stress (STS) in significant others of veterans.

METHODS

We systematically searched Pubmed, PsycINFO, Embase, Cochrane Library and PILOTS for relevant articles. This search resulted in 3100 records from which we included 48 articles.

RESULTS

Two studies that reported on parental PTSD did not find evidence that parents were affected by their offspring's experience. Nine studies that reported on PTSD in mainly adult children of veterans found only scant evidence that children were affected by their parent's experienced PTE. Twenty-seven studies investigated PTSD symptoms in partners of veterans. Here results varied largely between studies with PTSD rates between 0 and 51 %.

CONCLUSIONS

Overall, we found the strongest evidence of STS in partners of help-seeking veterans with PTSD. The lack of clarity provided by the currently available evidence suggests a pressing need for further work to examine this subject in more detail.

Role of neuroinflammation and sex hormones in war-related PTSD

The susceptibility to develop posttraumatic stress disorder (PTSD) is greatly influenced by both innate and environmental risk factors. One of these factors is gender, with women showing higher incidence of trauma-related mental health disorders than their male counterparts. The evidence so far links these differences in susceptibility or resilience to trauma to the neuroprotective actions of sex hormones in reducing neuroinflammation after severe stress exposure. In this review, we discuss the impact of war-related trauma on the incidence of PTSD in civilian and military populations as well as differences associated to gender in the incidence and recovery from PTSD. In addition, the mutually influencing role of inflammation, genetic, and sex hormones in modulating the consequences derived from exposure to traumatic events are discussed in light of current evidence.

Mental Health in Offspring of Traumatized Refugees with and without Post-traumatic Stress Disorder

Intergenerational transmission of psychological trauma and the impact of parental post-traumatic stress disorder (PTSD) on offspring are controversially discussed. We studied 50 offspring (36 women and 14 men, mean age 42.1 years) of refugees who were severely traumatized as children at the end of World War II. From these, 25 of the refugees currently suffered from chronic PTSD, and 25 had no PTSD. Parental PTSD status did not significantly influence mental health [as per the Symptom Checklist (SCL)-90-R] or quality of life (assessed by the 36-item Short-form Health Survey) in their children. In the entire sample, frequency of talking with the mother about the flight correlated with phobic anxiety (r = 0.67, p = 0.03). Interestingly, the stated burden of having a parent with a history of flight significantly (p < 0.05) correlated with almost all subscales of the SCL-90-R. These results in a non-clinical sample do not support a specific role of parental PTSD in intergenerational trauma transmission. Our other remarkable, but preliminary, results need to be studied in larger samples using more subtle interaction or schema analyses. Copyright © 2015 John Wiley & Sons, Ltd.

Relationship Functioning in Vietnam Veteran Couples: The Roles of PTSD and Anger

OBJECTIVE

Posttraumatic stress disorder (PTSD) and anger have been implicated separately in relationship dysfunction for veterans; however, no studies have simultaneously examined the roles of each of these constructs.

METHOD

This study examined the roles of PTSD and anger in the relationships of Vietnam veterans and their partners (n = 33 couples) with actor-partner interdependence modeling (APIM). Couples in which the veteran was diagnosed with PTSD (PTSD-positive; n = 20) were compared to couples in which the veteran did not have PTSD (PTSD-negative; n = 13) on measures of frequency of anger and relationship functioning.

RESULTS

PTSD-positive and PTSD-negative couples reported similar levels of relationship functioning, yet PTSD-positive veterans reported experiencing anger significantly more often than PTSD-negative veterans. Across groups, anger was predictive of relationship functioning, but PTSD severity was not.

CONCLUSIONS

Trait anger may have a more deleterious effect on relationship functioning than PTSD symptoms. Theoretical and clinical implications are discussed.

Sexual dysfunction and neuroendocrine correlates of posttraumatic stress disorder in combat veterans: Preliminary findings

Sexual dysfunction is not a symptom of PTSD but is a common clinical complaint in trauma survivors with this disorder. In that there are biological parallels in the neuroendocrine processes underlying both PTSD and sexual behavior, we conducted an exploratory investigation of the relationship of PTSD and related neuroendocrine indicators with sexual dysfunction in armed service veterans. Major Depressive Disorder, highly comorbid with PTSD and sexual dysfunction, was also assessed. In veterans with PTSD, sexual problems were associated with plasma DHEA and cortisol, urinary catecholamines, and glucocorticoid sensitivity, even when controlling for the effects of comorbid depression. In a subsample analysis, testosterone levels did not distinguish PTSD or sexual dysfunction, suggesting that sexual problems reported by veterans in this sample were not the result of organic disorder. PTSD did predict higher dihydrotestosterone (DHT) levels, which were associated with sexual problems. More detailed assessment of sexual dysfunction in biologically informed studies of PTSD is warranted to clarify the relationships of PTSD symptomatology and related neurobiology with sexual dysfunction.

Weapon carrying, physical fighting and gang membership among youth in Washington state military families

To examine associations between parental military service and school-based weapon carrying, school-based physical fighting and gang membership among youth. We used cross-sectional data from the 2008 Washington State Healthy Youth Survey collected in 8th, 10th, and 12th grades of public schools (n = 9,987). Parental military service was categorized as none (reference group), without combat zone deployment, or deployed to a combat zone. Multivariable logistic regression was used to test associations between parental military service and three outcomes: school-based weapon carrying, school-based physical fighting and gang membership. Standard errors were adjusted for the complex survey design. In 8th grade, parental deployment was associated with higher odds of reporting gang membership (OR = 1.8) among girls, and higher odds of physical fighting (OR = 1.6), and gang membership (OR = 1.9) among boys. In 10th/12th grade, parental deployment was associated with higher odds of reporting physical fighting (OR = 2.0) and gang membership (OR = 2.2) among girls, and physical fighting (OR = 2.0), carrying a weapon (OR = 2.3) among boys. Parental military deployment is associated with increased odds of reporting engagement in school-based physical fighting, school-based weapon carrying, and gang membership, particularly among older youth. Military, school, and public health professionals have a unique, collaborative opportunity to develop school- and community-based interventions to prevent violence-related behaviors among youth and, ultimately, improve the health and safety of youth in military families. Ideally, such programs would target families and youth before they enter eighth grade.

Family composition and symptom severity among Veterans with comorbid PTSD and substance use disorders

Posttraumatic stress disorder (PTSD) and substance use disorders (SUD) frequently co-occur and affect a substantial proportion of military Veterans. Although the impact of parental PTSD and SUD on child development is well-documented, little is known about the influence of family composition on PTSD/SUD symptom severity. The present study investigated children in the home as an independent risk factor for symptom severity in a sample of treatment-seeking Veterans (N = 94; 92% male) with comorbid PTSD/SUD. Twenty-seven percent of the sample had minor children (age 18 or younger) living in the home. Veterans with children in the home evidenced significantly higher PTSD symptomatology as measured by the Clinical Administered PTSD Scale (CAPS; M = 82.65 vs. M = 72.17; t = -2.18; p < .05), and reported using marijuana more frequently than Veterans without children in the home (34% vs. 13% of past 60 days; t = -2.35, p < .05). In a multivariate model, having children in the home accounted for unique variance (ΔR(2) = .07) in PTSD severity after accounting for a range of covariates; however, having children in the home did not account for unique variance in substance use. Directions for future research as well as potential clinical implications for parents seeking treatment for PTSD/SUD are discussed.

A Methodological Review of Intimate Partner Violence in the Military: Where Do We Go From Here?

A significant number of military personnel report engaging in or experiencing intimate partner violence (IPV). To advance current research and understanding of this behavior, we conducted a methodological review of the literature on IPV in military personnel and veterans. Research from 1980 to the present, which consisted of 63 empirical studies, was objectively coded by two independent raters on a number of variables important to the methodological quality of research on IPV in the military. In addition, areas of importance to the future of IPV research are presented.

Correlates of Recent and Lifetime Aggression among Veterans with Co-Occurring PTSD and Substance Use Disorders

OBJECTIVE

Aggressive behavior is strongly associated with both posttraumatic stress disorder (PTSD) and substance use disorders (SUD) among civilians. However, little research has examined correlates of aggression among Veterans with co-occurring PTSD and SUD.

METHODS

This exploratory study examined the prevalence and correlates of recent (i.e., past 30 days) and lifetime aggressive behavior among a sample of U.S. Veterans (N=97) enrolled in a study examining integrated psychosocial treatment of co-occurring PTSD/SUD.

RESULTS

The findings revealed high rates of recent and lifetime aggressive behaviors (39.2% and 57.7%, respectively). Participants who endorsed recent aggressive behaviors were younger, had less education, more severe PTSD numbing and hyperarousal symptoms, were more likely to report recent suicidal ideation, more frequent alcohol and marijuana use, had higher rates of physical and sexual abuse, greater combat exposure, and more severe aftermath of battle experiences. Participants who endorsed lifetime aggression were younger, reported more total PTSD symptom severity, PTSD re-experiencing severity, depression severity, and fewer post-deployment stressors compared to those who did not. Logistic regression analyses indicated that education and number of drinking days were correlated with recent aggression while depression and post-deployment stressors were correlated with lifetime aggression.

CONCLUSIONS

The findings demonstrate high rates of aggressive behaviors among Veterans with PTSD/SUD, as well as clinically relevant correlates of aggressive behaviors. Although preliminary, the findings suggest potential targets for improving assessment and treatment of Veterans with PTSD/SUD.

Exploring interpersonal issues and challenges confronting ex-combatant fathers and their sons in post-apartheid South Africa

This study explores interpersonal issues and challenges confronting ex-combatant fathers and their sons in post-apartheid South Africa. It draws on life-story interviews conducted with six father–son pairs. The interviews were subjected to a thematic interpretive analysis, which revealed a number of salient themes. Some of these were shared by both fathers and sons, while others were specific to each cohort. Shared themes were the nature of the father–son relationship and silence. The need for psychosocial support was specific to the fathers, while substitute fathers and emotional–behavioural difficulties were specific to the sons. The study holds important policy implications for addressing the needs of ex-combatant families.

Association between parents' PTSD severity and children's psychological distress: a meta-analysis

The authors conducted a meta-analysis of studies on the correlation between parents' PTSD symptom severity and children's psychological status. An extensive search of the literature yielded 550 studies that were screened for inclusion criteria (i.e., parent assessed for PTSD, child assessed for distress or behavioral problems, associations between parent PTSD and child status examined). Sixty-two studies were further reviewed, resulting in a final sample of 42 studies. Results yielded a moderate overall effect size r = .35. The authors compared effect sizes for studies where only the parent was exposed to a potentially traumatic event to studies where both parents and children were exposed. A series of moderators related to sample characteristics (sex of parent, type of traumatic event) and study methods (self-report vs. diagnostic interview, type of child assessment administered) were also evaluated. The only significant moderator was type of trauma; the effect size was larger for studies with parent-child dyads who were both exposed to interpersonal trauma (r = .46) than for combat veterans and their children (r = .27) and civilian parent-child dyads who were both exposed to war (r = .25). Results support the importance of considering the family context of trauma survivors and highlight areas for future research.

The impact of parental deployment to war on children: the crucial role of parenting

It is estimated that approximately 2 million children have been affected by military deployment, yet much of what is known about the adjustment of children experiencing a parent's combat deployment has emerged only within the past 5-10 years. The extant literature on associations of parental deployment and children's adjustment is briefly reviewed by child's developmental stage. Applying a family stress model to the literature, we propose that the impact of parental deployment and reintegration on children's adjustment is largely mediated by parenting practices. Extensive developmental literature has demonstrated the importance of parenting for children's resilience in adverse contexts more generally, but not specifically in deployment contexts. We review the sparse literature on parenting in deployed families as well as emerging data on empirically supported parenting interventions for military families. An agenda for future research in this area is proffered.

Offspring psychological and biological correlates of parental posttraumatic stress: review of the literature and research agenda

Millions of individuals with posttraumatic stress disorder (PTSD) are parents. A burgeoning literature suggests that offspring of parents with this condition may be at increased risk for psychological problems. The current paper provides an integrative and comprehensive review of the diverse research literature examining the sequelae of parental posttraumatic stress among offspring. Over 100 studies that evaluated psychological and/or biological variables among children of parents with PTSD are reviewed. Findings suggest parental symptoms of posttraumatic stress are uniquely related to an array of offspring outcomes, including internalizing-type problems, general behavioral problems, and altered hypothalamic-pituitary-adrenal axis functioning. Although very little work has directly evaluated mechanisms of transmission, there is increasing support for genetic and epigenetic effects as well as parenting behaviors. These and other mechanisms are discussed; drawing upon findings from other literatures to consider how parental PTSD may impart psychobiological vulnerability upon offspring. We conclude with a detailed discussion of the methodological strengths and challenges of the extant research, along with a recommended agenda for future research in this important area of study.

The causal effects of Vietnam-era military service on post-war family dynamics

Past work has suggested a lasting impact of military service on the lives of veterans. By intervening at a critical stage in the lives of young men, service may open up opportunities for disadvantaged youth. In contrast, the negative consequences of exposure to combat may offset these presumed advantages. Induction into the military is also a nonrandom process that makes identifying the effects of service exceedingly difficult. In this study we use an instrumental variable (IV) approach to model the causal impact of Vietnam-era military service on two outcomes, marital stability and co-residence with adult offspring. We find limited evidence to suggest that military service may have a lasting effect on family life. In particular, we find that service reduces the probability of marital dissolution for white men. Service also significantly increases the probability of filial co-residence for men of other races.

Understanding interpersonal function in psychiatric illness through multiplayer economic games

Interpersonal factors play significant roles in the onset, maintenance, and remission of psychiatric conditions. In the current major diagnostic classification systems for psychiatric disorders, some conditions are defined by the presence of impairments in social interaction or maintaining interpersonal relationships; these include autism, social phobia, and the personality disorders. Other psychopathologies confer significant difficulties in the social domain, including major depression, posttraumatic stress disorder, and psychotic disorders. Still other mental health conditions, including substance abuse and eating disorders, seem to be exacerbated or triggered in part by the influence of social peers. For each of these and other psychiatric conditions, the extent and quality of social support is a strong determinant of outcome such that high social support predicts symptom improvement and remission. Despite the central role of interpersonal factors in psychiatric illness, the neurobiology of social impairments remains largely unexplored, in part due to difficulties eliciting and quantifying interpersonal processes in a parametric manner. Recent advances in functional neuroimaging, combined with multiplayer exchange games drawn from behavioral economics, and computational/quantitative approaches more generally, provide a fitting paradigm within which to study interpersonal function and dysfunction in psychiatric conditions. In this review, we outline the importance of interpersonal factors in psychiatric illness and discuss ways in which neuroeconomics provides a tractable framework within which to examine the neurobiology of social dysfunction.

Helping military families through the deployment process: Strategies to support parenting

Recent studies have highlighted the impact of deployment on military families and children and the corresponding need for interventions to support them. Historically, however, little emphasis has been placed on family-based interventions in general, and parenting interventions in particular, with returning service members. This paper provides an overview of research on the associations between combat deployment, parental adjustment of service members and spouses, parenting impairments, and children's adjustment problems, and provides a social interaction learning framework for research and practice to support parenting among military families affected by a parent's deployment. We then describe the Parent Management Training-Oregon model (PMTO(™)), a family of interventions that improves parenting practices and child adjustment in highly stressed families, and briefly present work on an adaptation of PMTO for use in military families (After Deployment: Adaptive Parenting Tools, or ADAPT). The article concludes with PMTO-based recommendations for clinicians providing parenting support to military families.

Posttraumatic stress symptoms among National Guard soldiers deployed to Iraq: associations with parenting behaviors and couple adjustment

OBJECTIVE

In this article, we report findings from a 1-year longitudinal study examining the impact of change in posttraumatic stress disorder (PTSD) symptoms following combat deployment on National Guard soldiers' perceived parenting and couple adjustment 1 year following return from Iraq.

METHOD

Participants were 468 Army National Guard fathers from a brigade combat team (mean age = 36 years; median deployment length = 16 months; 89% European American, 5% African American, 6% Hispanic American). Participants completed an in-theater survey 1 month before returning home from Operation Iraqi Freedom deployment (Time 1) and again 1 year postdeployment (Time 2). The PTSD Checklist-Military Version (PCL-M; Weathers, Litz, Herman, Huska, & Keane, 1993) was gathered at both times, and 2 items assessing social support were gathered at baseline only. At Time 2, participants also completed self-report measures of parenting (Alabama Parenting Questionnaire-Short Form; Elgar, Waschbusch, Dadds, & Sigvaldason, 2007), couple adjustment (Dyadic Adjustment Scale-7; Sharpley & Rogers, 1984; Spanier, 1976), parent-child relationship quality (4 items from the Social Adjustment Scale-Self-Report; Weissman & Bothwell, 1976), alcohol use (Alcohol Use Disorders Identification Test; Babor, Higgins-Biddle, Saunders, & Monteiro, 2001), and items assessing injuries sustained while deployed.

RESULTS

Structural equation modeling analyses showed that increases in PTSD symptoms were associated with poorer couple adjustment and greater perceived parenting challenges at Time 2 (both at p < .001). Furthermore, PTSD symptoms predicted parenting challenges independent of their impact on couple adjustment.

CONCLUSIONS

Findings highlight the importance of investigating and intervening to support parenting and couple adjustment among combat-affected National Guard families.

Association between exposure to combat-related stress and psychological health in aging men: the Atherosclerosis Risk in Communities (ARIC) Study

Exposure to military combat has been associated with myriad adverse health effects. Mechanisms are not well understood, but may include negative emotional states. The authors investigated the relationship between combat and trait anger and vital exhaustion among 5,347 middle-aged male participants in the Atherosclerosis Risk in Communities Study. Combat was significantly associated with trait anger, although results were limited to men of the Korean and Vietnam War eras. Among men of the Korean War era, combat- and noncombat veterans, compared to their nonveteran counterparts, reported more trait anger. Compared to their noncombat and nonveteran counterparts, Vietnam War era combat veterans reported more trait anger. Noncombat veterans from the World War II and Vietnam War eras reported lower vital exhaustion compared to nonveterans. Anger proneness may be a mechanism through which combat stress is associated with adverse health outcomes.

Improving risk assessment of violence among military veterans: an evidence-based approach for clinical decision-making

Increased media attention to post-deployment violence highlights the need to develop effective models to guide risk assessment among military Veterans. Ideally, a method would help identify which Veterans are most at risk for violence so that it can be determined what could be done to prevent violent behavior. This article suggests how empirical approaches to risk assessment used successfully in civilian populations can be applied to Veterans. A review was conducted of the scientific literature on Veteran populations regarding factors related to interpersonal violence generally and to domestic violence specifically. A checklist was then generated of empirically-supported risk factors for clinicians to consider in practice. To conceptualize how these known risk factors relate to a Veteran's violence potential, risk assessment scholarship was utilized to develop an evidence-based method to guide mental health professionals. The goals of this approach are to integrate science into practice, overcome logistical barriers, and permit more effective assessment, monitoring, and management of violence risk for clinicians working with Veterans, both in Department of Veteran Affairs settings and in the broader community. Research is needed to test the predictive validity of risk assessment models. Ultimately, the use of a systematic, empirical framework could lead to improved clinical decision-making in the area of risk assessment and potentially help prevent violence among Veterans.

Parental combat injury and early child development: a conceptual model for differentiating effects of visible and invisible injuries

The injuries (physical and emotional) sustained by service members during combat influence all members of a family system. This review used a systemic framework to conceptualize the direct and indirect effects of a service member's injury on family functioning, with a specific focus on young children. Using a meta-ethnographic approach to synthesize the health research literature from a variety of disciplines, this review makes relevant linkages to health care professionals working with injured veterans. Studies were included that examined how family functioning (psychological and physical) is impacted by parental illness; parental injury; and posttraumatic stress disorder. The synthesis of literature led to the development of a heuristic model that illustrates both direct and indirect effects of parental injury on family functioning and the development of young children. It further illustrates the contextual factors or moderating variables that buffer detrimental effects and promote family resilience. This model can be a foundation for future research, intervention, and policy.

Military-related PTSD and intimate relationships: from description to theory-driven research and intervention development

Military operations in Iraq and Afghanistan have brought heightened awareness of military related PTSD, as well as the intimate relationship problems that accompany the disorder and can influence the course of veterans' trauma recovery. In this paper, we review recent research that documents the association between PTSD and intimate relationship problems in the most recent cohort of returning veterans and also synthesize research on prior eras of veterans and their intimate relationships in order to inform future research and treatment efforts with recently returned veterans and their families. We highlight the need for more theoretically-driven research that can account for the likely reciprocally causal association between PTSD and intimate relationship problems to advance understanding and inform prevention and treatment efforts for veterans and their families. Future research directions are offered to advance this field of study.

Darfur refugees in Cairo: mental health and interpersonal conflict in the aftermath of genocide

Hundreds of thousands of Darfur people affected by the Sudanese genocide have fled to Cairo, Egypt, in search of assistance. Collaborating with Africa and Middle East Refugee Assistance (AMERA), the authors conducted a mental health care needs assessment among Darfur refugees in Cairo. Information was collected using individual and focus group interviews to identify gaps in mental health care and develop understandings of emotional and relationship problems. The refugee mental health care system has a piecemeal structure with gaps in outpatient services. There is moderate to severe emotional distress among many Darfur refugees, including symptoms of depression and trauma, and interpersonal conflict, both domestic violence and broader community conflict, elevated relative to pregenocide levels. Given the established relationships between symptoms of depression/traumatic stress and interpersonal violence, improving mental health is important for both preventing mental health decompensation and stemming future cycles of intra- and intergroup conflict.

Psychological and relationship distress among partners of civilian PTSD patients

Significant others of individuals with posttraumatic stress disorder (PTSD) may experience both intrapersonal and interpersonal distress as caregivers. The aim of the present study is 3-fold: (1) to examine symptoms of psychological and relationship distress (anxiety, depression, and dyadic adjustment) among partners of civilian patients with PTSD, (2) to investigate the links between partners' distress and PTSD patients' symptoms (severity; intrusion, avoidance, and arousal subscales), and (3) to explore the perception of mental and physical health, types of trauma and compare partners and PTSD patients' measures. Fifty-seven PTSD patients and their partners filled out 4 questionnaires: Marital Adjustment Test, Beck Anxiety Inventory, Beck Depression Inventory-II, and Medical Outcome Survey-Short Form-12. Results showed that only a minority of partners presented clinical levels of depression (16.7%), anxiety (14.8%), and relationship distress (37%). Pearson correlations analyses revealed an absence of statistically significant relationship between partners' distress and PTSD patients' symptoms. In conclusion, although our study is not a direct validation of the secondary traumatic stress model, our findings fail to provide strong support to the secondary traumatic stress hypothesis among partners of civilian PTSD patients.

Safety and efficacy of sildenafil citrate in treating erectile dysfunction in patients with combat-related post-traumatic stress disorder: a double-blind, randomized and placebo-controlled study

OBJECTIVE

To evaluate the safety and efficacy of sildenafil citrate for treating erectile dysfunction (ED) in patients with combat-related post-traumatic stress disorder (PTSD).

PATIENTS AND METHODS

In all, 266 combat-exposed war veterans with ED (aged 37-59 years) were recruited. They met the Diagnostic and Statistical Manual of Mental Disorders-IV criteria for PTSD according to the Structured Clinical Interview for Patients, Investigator Version. The patients were also evaluated with the Clinician-Administered PTSD Scale, both to establish the diagnosis of PTSD and to measure symptom severity. Only patients with psychogenic ED were included in the study. Patients with comorbid conditions (diabetes mellitus, hypercholesterolaemia, hypertension, Peyronie's disease) and smokers of more than five cigarettes daily were excluded. The patients were randomly divided into a group of 133 who received 100 mg of on-demand sildenafil 0.75-2 h before sexual stimulation, and 133 who received placebo. Patients were asked to use > or =16 doses or attempts at home. The efficacy of the treatments was assessed every four attempts during treatment, and at the end of the study, using responses to the 15-question International Index of Erectile Function (IIEF), Sexual Encounter Profile diary questions 2 and 3, Erectile Dysfunction Inventory of Treatment Satisfaction questionnaire, patients' event logs of sexual activity, and a Global Assessment Question about erections.

RESULTS

Sildenafil did not produce significantly and substantially greater improvement than placebo in each of the primary and secondary outcome measures (P = 0.08). A normal EF domain score (> or =26) at endpoint was reported by 13 (9.8%), and 11 (8.3%) of patients on the sildenafil and placebo regimens, respectively (P = 0.09). Patients treated with sildenafil had no statistically significantly greater improvement in the five sexual function domains of the IIEF questionnaire than those treated with placebo (P = 0.08). The incidences of treatment-emergent adverse events were significantly greater in the sildenafil arm than in the placebo group (P = 0.01).

CONCLUSIONS

Sildenafil is no better than placebo in treating PTSD-emergent ED. Further randomized clinical trials are warranted in combat veterans and other populations with PTSD to better elucidate the role of phosphodiesterase type 5 inhibitors in treating PTSD-emergent ED.

Psychopathological status, behavior problems, and family adjustment of Kuwaiti children whose fathers were involved in the first gulf war

OBJECTIVES

Following the end of the Gulf War that resulted in the liberation of Kuwait, there are no reports on the impact of veterans' traumatic exposure and posttraumatic stress disorder (PTSD) on their children. We compared the severity of anxiety, depression, deviant behavior and poor family adjustment among the children of a stratified random sample of four groups of Kuwaiti military men, viz: the retired; an active -in-the-army group (AIA) (involved in duties at the rear); an in-battle group (IB) (involved in combat); and a prisoners -of- war (POWs) group. Also, we assessed the association of father's PTSD/combat status and mother's characteristics with child psychosocial outcomes.

METHOD

Subjects were interviewed at home, 6 years after the war, using: the Child Behavior Index to assess anxiety, depression, and adaptive behavior; Rutter Scale A2 for deviant behavior; and Family Adjustment Device for adjustment at home. Both parents were assessed for PTSD.

RESULTS

The 489 offspring (250 m, 239 f; mean age 13.8 yrs) belonged to 166 father-mother pairs. Children of POWs tended to have higher anxiety, depression, and abnormal behavior scores. Those whose fathers had PTSD had significantly higher depression scores. However, children of fathers with both PTSD and POW status (N = 43) did not have significantly different outcome scores than the other father PTSD/combat status groups. Mother's PTSD, anxiety, depression and social status were significantly associated with all the child outcome variables. Parental age, child's age and child's level of education were significant covariates. Although children with both parents having PTSD had significantly higher anxiety/depression scores, the mother's anxiety was the most frequent and important predictor of child outcome variables. The frequency of abnormal test scores was: 14% for anxiety/depression, and 17% for deviant behavior.

CONCLUSION

Our findings support the impression that child emotional experiences in vulnerable family situations transcend culture and are associated with the particular behavior of significant adults in the child's life. The primacy of the mother's influence has implications for interventions to improve the psychological functioning of children in such families. Mental health education for these families has the potential to help those in difficulty.

Family violence, war, and natural disasters: a study of the effect of extreme stress on children's mental health in Sri Lanka

BACKGROUND

The consequences of war violence and natural disasters on the mental health of children as well as on family dynamics remain poorly understood. Aim of the present investigation was to establish the prevalence and predictors of traumatic stress related to war, family violence and the recent Tsunami experience in children living in a region affected by a long-lasting violent conflict. In addition, the study looked at whether higher levels of war violence would be related to higher levels of violence within the family and whether this would result in higher rates of psychological problems in the affected children.

METHODS

296 Tamil school children in Sri Lanka's North-Eastern provinces were randomly selected for the survey. Diagnostic interviews were carried out by extensively trained local Master level counselors. PTSD symptoms were established by means of a validated Tamil version of the UCLA PTSD Index. Additionally, participants completed a detailed checklist of event types related to organized and family violence.

RESULTS

82.4% of the children had experienced at least one war-related event. 95.6% reported at least one aversive experience out of the family violence spectrum. The consequences are reflected in a 30.4% PTSD and a 19.6% Major Depression prevalence. Linear regression analyses showed that fathers' alcohol intake and previous exposure to war were significantly linked to the amount of maltreatment reported by the child. A clear dose-effect relationship between exposure to various stressful experiences and PTSD was found in the examined children.

CONCLUSION

Data argue for a relationship between war violence and violent behavior inflicted on children in their families. Both of these factors, together with the experience of the recent Tsunami, resulted as significant predictors of PTSD in children, thus highlighting the detrimental effect that the experience of cumulative stress can have on children's mental health.

Influence of posttraumatic stress disorder of the fathers on other family members

The purpose of this work is to analyze the frequency of depression and anxiety and children behaviour in families whose heads of the family (father) suffer from post-traumatic stress disorder (PTSD). The study was conducted from September 2005 until July 2006, with patients living in Mostar. The frequency of depression and anxiety in family members older than 18 years, and changes of the behaviour in children younger than 18 years of age were measured. The data were collected from 60 men and their families who had been diagnosed with PTSD by their psychiatrist. The control group was formed using matching criteria (age of the head of the family, his education, religion, family income and number of children). In this study, three questionnaires were used: one specially designed for this study, covering general information about family members, and a personal opinion of each family member about the family situation and relations within the family; Hopkins symptoms checklist - 25 (HSCL-25) for evaluation of depression and anxiety for subjects older than 18; and General Health Questionnaire (GHQ) for children 5 to 18 years of age, which was completed by their mothers. More wives from the PTSD families had depression than wives from the controlled group (chi2=21,099; df=1; P<0,050). There was no difference between groups in frequency of depression and anxiety (chi2=0,003; df=1; P=0,959) for children older than 18 years. No difference in answers between groups of children younger than 18 years were found in the General Health Questionnaire. However, we found significant differences in separate questions. Mothers, who filled the questionnaire form, reported that children from fathers who had PTSD experienced stomach pain more often (chi2=10,474;df=2; P=0,005), eating problems (chi2=14,204;df=2; P=0,001) and breathing problems (chi2=9,748;df=2; P=0,008), than children from fathers who did not have PTSD. Children from fathers with PTSD were more easily upset (chi2=7,586; df=2; P=0,023) and worried more often (chi2=12,093; df=2; P=0,002), they were also more aggressive towards other children (chi2=6,156; df=1; P=0,013). The controlled group of children who wanted to help with the house work was larger than the tested group (chi2=10,383; df=2; P=0,006). More children from the controlled group missed school than from the other group of surveyed children (chi2=6,056; df=2; P=0,048). A significantly larger number of women, whose husbands had PTSD, were depressed, unlike women whose husbands were not ill. There was no significant difference in depression manifestation in a group of children older than 18, as well as in behaviour of a group of children younger than 18, but significant differences in some provided answers were found, that indicate the differences between controlled and tested groups.