Behavioral Problems and Emotional Difficulties at Children and Early Adolescents of the Veterans of War with Post-Traumatic Stress Disorder.

INTRODUCTION: Behavioral problems and emotional difficulties at children of the veterans of war with post-traumatic stress disorder (PTSD) have not been researched entirely. In our country, which has a lot of persons suffering from some psychological traumas, this trauma seems to continue. AIM: The aim of this study was to determine the exposure, manifestations of behavioral problems and emotional difficulties at children and early adolescents, whose fathers were the veterans of war demonstrating post-traumatic stress disorder symptoms. RESPONDENTS AND METHODS: The analyzed group comprised 120 school age children (10-15 years of age), whose parents/fathers were the veterans of war. The children were divided into two groups, and each group into the following two age sub-groups: 10-12 (children) and 13-15 (early adolescents) according to PTSD presence at their fathers - veterans of war. PTSD symptoms at fathers, veterans of war, were assessed using the Harvard Trauma Questionnaire-Bosnia and Herzegovina version and MKB-10 - audit of criteria. To assess the behavioral problems of children, the Child Behavior Checklist for parents was used, and to evaluate the neuroticism at children Hanes-Scale of neuroticism-extraversion was used while the depression level was evaluated using the Depression self-rating scale (DSRS). To analyze the obtained results, SPSS 17 program was used. The value p <0. 05 is considered significant.
RESULTS: Children of fathers, the veterans of war, demonstrating the PTSD symptoms show more problems in activity, social and school conduct as well as in symptoms of behavioral problems compared to the children whose fathers do not demonstrate the PTSD symptoms (p<0. 001). Children of the war veterans demonstrating the symptoms of the post-traumatic stress disorder show significant difference at neuroticism sub-scales (p<0.001). Negative correlation between PTSD and activity, social and school conduct has been determined (p <0. 01), while positive correlation was determined between PTSD of war veterans with symptoms and neuroticism at children (p <0. 01). Depression symptoms are found at 17.5% children, while 28.3% are in the risky group and the girls demonstrate higher depression level.
CONCLUSION: Children and early adolescents of fathers - veterans of war with post-traumatic stress disorder show significant differences in competencies, behavior, emotional difficulties and neuroticism. Significant correlation was found between psychopathology of parents - fathers the veterans of war and their children. Impact of psychological conditions of fathers - the veterans of war with post-traumatic stress disorder to children is strong and they represent a significant risky group for development of mental disorders.

1. INTRODUCTION

War as disastrous and largely present social phenomenon includes lots of provoking factors / stressors, which directly jeopardize all models of psycho-biological, psycho-physiological and psychological defenses (1). War post-traumatic stress disorder (PTSD) is a complex group of painful and disturbing affective and cognitive reactions, as well as reactions that provoke, have cyclic, self-renewable own flow, which is only occasionally connected to outside world (2). Numerous authors addressed the problems of traumatized veterans and their families 3, 4, 5). After the war in Bosnia and Herzegovina, where there are still plenty of traumatized persons (6, 7), psychological trauma has continued in some way (8, 9, 10). Post-traumatic stress disorder significantly influences general health of individual and decreases his functionality at family, social and work level (13). Negative impact of psychological trauma to persons close to the individual suffering from PTSD is conceptualized as a secondary traumatization (14, 15). Theories of secondary trauma indicate that individual stress symptoms are transferable and persons living with traumatized individual “imitate” the symptoms of trauma victim (16). Family members start adopting the symptoms of traumatized person and experiencing their own stress reactions as a response to interaction with traumatized person in family (17). Those effects are considered “secondary” because they occur at the persons who were not directly exposed to traumatic events. Those effects frequently represent PTSD symptoms, but are usually less intensive (18, 19). Secondary traumatization occurs as a result of close emotional connection and care for someone who shows PTSD symptoms or as a result of cognition or witnessing the traumatic event experienced by a person who is important to us (20,21). In narrow sense, secondary traumatization pertains to transfer of intrusive symptoms to persons in their vicinity (nightmares, intentional thoughts and memories) as well as other symptoms typically experienced by traumatized persons. In wider sense, it pertains to any transfer of distress from someone who experiences trauma to those in his vicinity, and includes a wide range of distress manifestations (22). The researches show that the way parents handle trauma and symptoms of traumatic reactions influence the psychological development of child and the way the child respond (cope) to internal and external stress factors (11, 12). Psychopathological symptoms at children of the veterans suffering from PTSD occur as a result of interaction between different biological, psychological, environmental factors and age, and may be manifested at psychological, behavioral, somatic and cognitive plan (23).

The aim of this study is to determine the frequency and manifestations of behavioral problems, emotional difficulties at children and early adolescents of fathers veterans of war with post-traumatic stress disorder and to determine the correlation between the symptoms of post-traumatic stress disorder of the veterans of war and psychological problems of their children.

2. RESPONDENTS AND METHODS

This study includes 120 respondents – children and early adolescents from Tuzla canton whose parents/fathers are the veterans of war treated at the Psychiatric clinic and who demonstrate the post-traumatic stress disorder symptoms and who meet the requirements of Harvard trauma questionnaire, version for Bosnia and Herzegovina, including criteria MKB-10-R as well as children and early adolescents whose parents/fathers are the veterans of war from general population group who do not demonstrate the symptoms of post-traumatic stress disorder, nor are treated as psychiatric patients (24). For assessment of children and early adolescents, the scale of the Child Behavior Checklist for parents of children aged 6 to 18 (CBCL) comprising two sub-scales including: competencies scale and symptoms & problems scale (25). was used; for assessment of neuroticism the Hanes scale of neuroticism – extroversion was used (26), while the depression level was assessed at DSRS scale (27). Harvard trauma questionnaire – version for Bosnia and Herzegovina comprises four parts: information on possible traumatic events and experiences, respondent’s description of the worst experience s/he had, questions related to head injury, questions related to psycho-social difficulties caused by (related to) trauma. Result for PTSD and/or total result >2.5 is considered «positive» for PTSD. The values of total result reflect the actual severity of PTSD, because that result pertains to symptoms and functional status. The scale of the Child Behavior Checklist for parents of children aged 6 to 18 (CBCL) comprises two sub-scales including: a) competencies scale and b) symptoms & problems scale. The competencies scale includes: activities, sociability and school conduct. The symptoms scale includes: anxiety / depression; withdrawal / depression; bodily difficulties / complaints; social problems; problems in opinion; problems with attention; violation of rules; aggressive behavior; other problems. Internalization is the sum of syndrome scales: anxiety/depression; withdrawal / depression; bodily difficulties/complaints; while externalization is the sum of syndrome scales: violation of rules; aggressive behavior.

Hamburg scale of neuroticism and extroversion for children and youth (HANES) is the questionnaire where “neuroticism” in fact “emotional lability” and “extroversion-introversion” are determined as personality traits at children and youth aged 8-16 using the self-description method. The questionnaire is standardized for former Yugoslavia, and it was designed and adjusted for this region by Bele-Potočnik with associates in 1977.

Depression self-rating scale (DSRS) estimates the presence of depressive reactions. It comprises 18 items. Each respondent at three-level scale («never», «sometimes», «frequently») estimates the frequency of his/her difficulties. Result from 0-10 points reflects the status without depression, 11-15 points reflects the risky group, and result above 16 points – symptoms of depression. SPSS program 17 (Statistical Package for Social Sciences, Inc., IL) was used for analysis of obtained results. The value p<0.05 was considered significant.

3. RESULTS

The average age of the assesses is 12.69±1.46 years. Majority of the assesses, 94.2%, live in the 3-5 member family, while 64.2%, live in a family with two children. Statistically significant discrepancy was determined per impact of psychological conditions of the parent – veteran of war to the child (Table 1). Per activity, social and school conduct of children and early adolescents of the veterans of war treated for PTSD and children of the veterans of war who were not treated, there is statistically significant discrepancy (p<0.001), as well as symptoms and problems at the Child Behavior Checklist (Table 2).

Table 1

Distribution of assesses per influence of psychological condition of the veterans of war to children and early adolescents and per groups in sample. X2= 61.801, df=12, p=0.000. Children (10-12 years), Early adolescents (13-15 years), N=number of assesses

Table 2

Distribution of assesses per symptoms at the Child Behaviour Checklist and groups in sample. Children (aged 10-12), Early adolescents (aged 13-15), M – median value, SD- standard deviation, P – significance level

Significant negative correlation of PTSD symptom in HTQ and overall capabilities of their children was determined (p<0.01) as well as negative correlation (p<0.01) of the symptoms of post-traumatic stress disorder of the veterans of war at HTQ and overall capabilities of their children. Positive correlation was determined in the patterns of behavior and emotional problems Internalization – Externalization of children of the veterans of war with the symptoms of fathers veterans of war (p<0.01) (Table 3). At Hamburg Neuroticism and Extroversion Scale (HANES) among the assessed children and adolescents of the veterans of war treated for PTSD and children of the veterans of war who were not treated, statistically important discrepancy was found at neuroticism sub-scales (p<0.001). Actually, median values of neuroticism N1 (8.30±3.86), sociability E1 (6.36±2.56) and activity E2 (5.06±2.21) compared to reference values are within the higher level limits, and children of the veterans of war who are not treated (5.20±=1.82) and early adolescents (6.73±1.99) within the average level limits. Early adolescents of the veterans of war treated for PTSD show higher level of neurotic features with psychosomatic reactions at extroversion – socially passive behavior sub-scale, while at extroversion–activity sub-scale no significant discrepancy was found (p>0.05) (Table 4).

Table 3

Correlation of capabilities and symptoms at the Child Behaviour Checklist and post-traumatic stress disorder at Harvard trauma questionnaire of the veterans of war. Pearson correlation coefficient **p<0.01; *p<0.05; HTQ–Harvard trauma questionnaire; CBCL–Child Behaviour Checklist

Table 4

Distribution of assesses according to neuroticism and extra-introversion scale and groups in sample. M – median value, SD – standard deviation, P – significance level

Significant positive correlation was determined between neuroticism and severity of PTSD, functionality of PTSD, total PTSD (p<0.01). Negative correlation was determined between sociability and severity of PTSD, functionality of PTSD, total PTSD (p<0.01) (Table 5).

Table 5

Correlation of the severity of post-traumatic stress disorder of the veterans of war at Harvard trauma questionnaire with neurotisation at neuroticism and extra-introversion scale. Pearson’s correlation coefficient, **p<0.01; Harvard trauma questionnaire

In terms of gender, group and depression level, no statistically significant discrepancy was determined (p>0.05). The obtained results show that girls and boys aged 13-15 in the group of early adolescents of the veterans of war treated for PTSD show the depression symptoms; in the risky group, the most emphasized are the boys aged 10-12 of the veterans treated for PTSD and early female adolescents aged 13-15 of the veterans of war who are not treated. In the whole sample, 54.2% do not show the depression symptoms, 28.3% are in the risky group, while 17.5% show the depression symptoms. In the whole sample, 21.7% of the respondents show the depression symptoms, of which 14.2% girls, and 7.5% boys, while 26.7% children are in the risky group. Negative correlation is determined in all other PTSD symptoms of the veterans of war at HTQ and DSRS depression, but without statistically significant discrepancy (Table 6).

Table 6

Distribution of assesses per depression level at Depression Self-Rating Scale gender and groups in sample. X2=63.06, df=66, p=0.580. M=male, F=female, N=number of assesses

4. DISCUSSION

Researches on persons who experienced mass traumatization such as Holocaust and Vietnam war as well as phenomenon of so called “selected trauma”, initiated the discussions whether and how the traumatic experience may be transferred to the following generations (28). Growing up in trauma environment, very often such as family secrets, surely leaves a trace even if trauma did not result with psychopathology of parents. The trace is left in upbringing models used by parents, as well as in fantasies developed by child about causes of “something important and untold” in the family (29).

In this study, a significant discrepancy was determined between children ad early adolescents whose parents/fathers, the veterans of war, were treated and who demonstrated the symptoms of post-traumatic stress disorder and children and early adolescents whose parents/fathers, the veterans of war, come from general population group and do not show the symptoms of post-traumatic stress disorder, nor were treated as psychiatric patients (p<0.001). According to the influence of psychological condition of the veterans of war to children and early adolescents whose parents/fathers are the veterans of war and who demonstrate the symptoms of post-traumatic stress disorder, it is stated that they were influenced a lot, while children and early adolescents whose parents/fathers were the veterans of war from general population group and who do not show the symptoms of post-traumatic stress disorder were influenced insignificantly. According to the median values of symptoms among the assessed groups, statistically significant discrepancy was determined (p<0.001). Activities of children and early adolescents of the veterans of the war who show the PTSD symptoms is within the limits of clinically significant level, and social conduct is within the limits of normal values. In the group of Australian veterans of Vietnam war, the children of the veterans reported high level of conflict in their families, but there was no significant discrepancy in measured psychological distress and self-confidence within the control group (). Parsons and associates (32) determined at Vietnam veterans with PTSD that the level of dysfunctionality in social and emotional behavior of their children was elevated when establishing and maintaining friendships. Harkness (23) determined at children of Vietnam veterans with PTSD aged 4 to 16 that children with violent fathers had much more problems in behavior, poorer school performances and lower social competencies. Selimbabašić and associates (31, 32) found at children with parents suffering from PTSD significantly higher level of psycho-social problems manifesting in behavioral and emotional level, as well as problems in contracts with persons in the environment and dissatisfaction with contacts (34).

In this study, children and early adolescents whose parents/fathers are the treated veterans of war and who demonstrate the symptoms of post-traumatic stress disorder show higher level of emotional internalizing and externalizing problems, problems in opinion, difficulties in maintaining the attention and concentration and disturbances in social relations compared to children and early adolescents whose parents/fathers were the veterans of war from the general population group, were not treated and did not show the symptoms of post-traumatic stress disorder. Symptoms at children and early adolescents of the veterans of war are within the limits of normal values, except for anxiety/depression which is at the border limit within the group of children of the veterans of war treated for PTSD, aged 10-12. Male children and early adolescents show more intensively the features of the problems with attention and concentration compared to female ones (p<0.001). Long-term exposure of children to domestic violence, which is significantly present in the families of the veterans, has enormous negative consequences to their psychological, social and school conduct (33). Jordan and associates (34) determined at Vietnam veterans with PTSD the problems in adjustment and behavior of children aged 6 to 16 and connection between the war PTSD and family dysfunction, marital problems, psychopathology of family members. Watkins and associates (37) emphasize that in the group of female Vietnam veterans and their partners, physical and psychological aggressiveness is related to behavior of children, and that psychological distress at veterans and partners is not related to behavioral problems of children and is not the mediator of effects of physical and psychological aggressiveness. The experiences from Croatia (38, 46) are the indicators of serious difficulties in conduct of children at cognitive, social, and particularly at emotional level. Antelman and Cagginla (35) believe that it is the attempt to reduce or eliminate stress through intensified or adequate activity as a type of self-therapy. At children of parents with PTSD, neuroticism is much more emphasized and is within the normal values, while in terms of personality traits Extroversion-Introversion, no statistically significant discrepancy was found. The boys were demonstrating more introvert traits with emphasized passive behavior, while the girls were more extrovert and within the limits of normal values (31). Children of the veterans with PTSD in Bosnia and Herzegovina showed more depression and somatization symptoms, such as abdominal pains, eating and breathing problems, and were more concerned and disturbed than children of the veterans without PTSD (36). At children of fathers with PTSD, connection between emotional and behavioral problems in the group aged 10-15 was determined (31). Klarić and associates (39) indicate indirect or direct impact of PTSD of the veterans of war to their children, reflecting in the form of psychological problems and bio-psychosocial development. Souzza and Motta (40) determined in the group of orphans of Vietnam veterans more intensive correlation between intensity of combat exposure and intensity of emotional response. Children of the veterans with high level of combat stress show extended latent emotional effects and there is no significant statistical discrepancy in emotional distress and social development between the children of veterans and children in the control group (41,42, 43) More depression and anxiety was found at the orphans of fathers who experienced Vietnam war than at children whose fathers did not have such experience, and more behavioral and emotional problems were determined among those who had such experiences (43, 44, 45).

5. CONCLUSION

Children and early adolescents of the veterans of war with post-traumatic stress disorder demonstrate significant problems in behavior, emotional difficulties and neuroticism. Significant correlation between psychopathology of parents – veterans of war and their children has been determined. The influence on children and early adolescents is very strong, so therefore they are the risky group for development of mental disorders.