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Children of the postwar years: A two-generational multilevel risk assessment of child psychopathology in northern Uganda

Published online by Cambridge University Press:  27 November 2015

Regina Saile ,
Verena Ertl ,
Frank Neuner  and
Claudia Catani
Regina Saile*
Affiliation:
Bielefeld University and Vivo International
Verena Ertl
Affiliation:
Bielefeld University and Vivo International
Frank Neuner
Affiliation:
Bielefeld University and Vivo International
Claudia Catani
Affiliation:
Bielefeld University and Vivo International
*
Address correspondence and reprint requests to: Regina Saile, Bielefeld University, Ravensbergerstrasse 87, 33602 Bielefeld, Germany; E-mail: regina.saile@uni-bielefeld.de.
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Abstract

In postconflict settings risk factors at multiple levels of the social ecology, including community, family, and relationship factors, potentially affect children's mental health. In addition, intergenerational risk factors such as guardians’ history of childhood family violence, war exposure, and psychopathology may contribute to children's psychopathological symptoms. In this study, we aimed to identify risk constellations that predict child internalizing and externalizing behavior problems, depression, and posttraumatic stress symptoms in the postconflict setting of northern Uganda. In a cross-sectional epidemiological study, 513 second-grade students and their female guardians were interviewed using standardized clinical questionnaires. A higher exposure to traumatic events, more witnessed or experienced violence within the family, and lower child-reported care from female guardians independently predicted psychopathological symptoms in children. While controlling for intergenerational risk factors in female guardians, serial mediation modeling revealed that the effect of trauma exposure on children's psychopathological symptoms was partially mediated by higher exposure to family violence and lower child-perceived care from female guardians. The mediation appeared to be stronger for children's depression symptoms and internalizing and externalizing behavior problems than for posttraumatic stress symptoms. The current findings support the need for targeted interventions at the individual and family system levels that are matched to children's psychopathological symptoms.

Type
Regular Articles
Information
Development and Psychopathology , Volume 28 , Issue 2 , May 2016 , pp. 607 - 620
Copyright
Copyright © Cambridge University Press 2015 

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References

Achenbach, T. M. (1991). Integrative guide for the 1991 CBCL/4–18, YSR, and TRF profiles. Burlington, VT: University of Vermont, Department of Psychiatry.Google Scholar
Akello, G., Reis, R., & Richters, A. (2010). Silencing distressed children in the context of war in northern Uganda: An analysis of its dynamics and its health consequences. Social Science & Medicine, 71, 213–220. doi:10.1016/j.socscimed.2010.03.030 CrossRefGoogle ScholarPubMed
Allgaier, A.-K., Frühe, B., Pietsch, K., Saravo, B., Baethmann, M., & Schulte-Körne, G. (2012). Is the Children's Depression Inventory Short Version a valid screening tool in pediatric care? A comparison to its full-length version. Journal of Psychosomatic Research, 73, 369–374. doi:10.1016/j.jpsychores.2012.08.016 CrossRefGoogle ScholarPubMed
Amato, P. R. (1990). Dimensions of the family environment as perceived by children: A multidimensional scaling analysis. Journal of Marriage and Family, 52, 613–620.CrossRefGoogle Scholar
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.Google Scholar
Belkin, G. S., Unützer, J., Kessler, R. C., Verdeli, H., Raviola, G. J., Sachs, K., et al. (2011). Scaling up for the “bottom billion”: “5 x 5” implementation of community mental health care in low-income regions. Psychiatric Services, 62, 1494–1502. doi:10.1176/appi.ps.000012011 CrossRefGoogle ScholarPubMed
Betancourt, T. S., McBain, R., Newnham, E. A., & Brennan, R. T. (2012). Trajectories of internalizing problems in war-affected Sierra Leonean youth: Examining conflict and postconflict factors. Child Development, 84, 455–470. doi:10.1111/j.1467-8624.2012.01861.x CrossRefGoogle ScholarPubMed
Betancourt, T. S., McBain, R. K., Newnham, E. A., & Brennan, R. T. (2015). The intergenerational impact of war: Longitudinal relationships between caregiver and child mental health in postconflict Sierra Leone. Journal of Child Psychology and Psychiatry. Advance online publication. doi:10.1111/jcpp.12389 CrossRefGoogle ScholarPubMed
Betancourt, T. S., McBain, R., Newnham, E. A., & Brennan, R. T. (2014). Context matters: Community characteristics and mental health among war-affected youth in Sierra Leone. Journal of Child Psychology and Psychiatry, 55, 217–226. doi:10.1111/jcpp.12131 CrossRefGoogle ScholarPubMed
Betancourt, T. S., Meyers-Ohki, S. I., Charrow, A. P., & Wietse, T. (2013). Interventions for children affected by war: An ecological perspective on psychosocial support and mental health care. Harvard Review of Psychiatry, 21, 3–8. doi:10.1097/HRP.0b013e318283bf8f CrossRefGoogle ScholarPubMed
Blake, D. D., Weathers, F. W., Nagy, L. M., Kaloupek, D. G., Gusman, F. D., Charney, D. S., et al. (1995). The development of a clinician-administered PTSD scale. Journal of Traumatic Stress, 8, 75–90.Google ScholarPubMed
Bolton, P., Bass, J., & Betancourt, T. (2007). Interventions for depression symptoms among adolescent survivors of war and displacement in northern Uganda. Journal of the American Medical Association, 298, 519–527. doi:10.1001/jama.298.5.519 CrossRefGoogle ScholarPubMed
Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Cambridge, MA: Harvard University Press.Google Scholar
Catani, C., Jacob, N., Schauer, E., Kohila, M., & Neuner, F. (2008). Family violence, war, and natural disasters: A study of the effect of extreme stress on children's mental health in Sri Lanka. BMC Psychiatry, 8, 33. doi:10.1186/1471-244X-8-33 CrossRefGoogle ScholarPubMed
Catani, C., Schauer, E., Elbert, T., Missmahl, I., Bette, J. P., & Neuner, F. (2009). War trauma, child labor, and family violence: Life adversities and PTSD in a sample of school children in Kabul. Journal of Traumatic Stress, 22, 163–171. doi:10.1002/jts.20415 CrossRefGoogle Scholar
Cummings, E. M., Merrilees, C. E., Schermerhorn, A. C., Goeke-Morey, M. C., Shirlow, P., & Cairns, E. (2012). Political violence and child adjustment: Longitudinal tests of sectarian antisocial behavior, family conflict, and insecurity as explanatory pathways. Child Development, 83, 461–468. doi:10.1111/j.1467-8624.2011.01720.x CrossRefGoogle ScholarPubMed
de Jong, J. T. V. M., Komproe, I. H., & Van Ommeren, M. (2003). Common mental disorders in postconflict settings. Lancet, 361, 2128–2130. doi:10.1016/S0140-6736(03)13692-6 CrossRefGoogle ScholarPubMed
Derogatis, L. R., Lipman, R. S., Rickels, K., Uhlenhuth, E. H., & Covi, L. (1974). The Hopkins Symptom Checklist (HSCL): A measure of primary symptom dimensions. Modern Problems of Pharmacopsychiatry, 7, 79–110.CrossRefGoogle ScholarPubMed
Elbert, T., Schauer, M., Schauer, E., Huschka, B., Hirth, M., & Neuner, F. (2009). Trauma-related impairment in children—A survey in Sri Lankan provinces affected by armed conflict. Child Abuse & Neglect, 33, 238–246. doi:10.1016/j.chiabu.2008.02.008 CrossRefGoogle ScholarPubMed
Ertl, V., Pfeiffer, A., Saile, R., Schauer, E., Elbert, T., & Neuner, F. (2010). Validation of a mental health assessment in an African conflict population. Psychological Assessment, 22, 318–324. doi:10.1037/a0018810 Google Scholar
Ertl, V., Pfeiffer, A., Schauer, E., Elbert, T., & Neuner, F. (2011). Community-implemented trauma therapy for former child soldiers in northern Uganda. Journal of the American Medical Association, 306, 503–512. doi:10.1001/jama.2011.1060 Google Scholar
Ertl, V., Pfeiffer, A., Schauer-Kaiser, E., Elbert, T., & Neuner, F. (2014). The challenge of living on: Psychopathology and its mediating influence on the readjustment of former child soldiers. PLOS ONE, 9. doi:10.1371/journal.pone.0102786 CrossRefGoogle ScholarPubMed
Flaherty, J. A., Gaviria, F. M., Pathak, D., Mitchell, T., Wintrob, R., Richman, J. A., et al. (1988). Developing instruments for cross-cultural psychiatric research. Journal of Nervous and Mental Disease, 176, 257. Retrieved from http://archive.biomedcentral.com/1745-0179/pubmed/3367140 CrossRefGoogle ScholarPubMed
Foa, E. B. (1995). Posttraumatic Stress Diagnostic Scale. Minneapolis, MN: National Computer Systems.Google Scholar
Gewirtz, A., Forgatch, M., & Wieling, E. (2008). Parenting practices as potential mechanisms for child adjustment following mass trauma. Journal of Marital and Family Therapy, 34, 177–192. doi:10.1111/j.1752-0606.2008.00063.x CrossRefGoogle ScholarPubMed
Goodman, R. (1997). The Strengths and Difficulties Questionnaire: A research note. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 38, 581–586.CrossRefGoogle ScholarPubMed
Haj-Yahia, M. M., & Abdo-Kaloti, R. (2003). The rates and correlates of the exposure of Palestinian adolescents to family violence: Toward an integrative-holistic approach. Child Abuse & Neglect, 27, 781–806. doi:10.1016/S0145-2134(03)00119-4 CrossRefGoogle ScholarPubMed
Hayes, A. F. (2012). PROCESS: A versatile computational tool for observed variable mediation, moderation, and conditional process modeling. Columbus, OH: Author.Google Scholar
Hinterding, L. (2011). A validation study of the Strengths and Difficulties Questionnaire (SDQ) in Ugandan school children. Bielefeld, Germany: Bielefeld University.Google Scholar
Hovil, L., & Moorhead, A. (2002). War as normal: The impact of violence on the lives of displaced communities in Pader district, Northern Uganda. Kampala: Refugee Law Project. Retrieved from http://www.refugeelawproject.org/resources/working-papers/79-war-as-normal-the-impact-of-violence-on-the-lives-of-displaced-communities-in-pader-district,-northern-uganda.html Google Scholar
Karimli, L., Ssewamala, F., & Ismayilova, L. (2012). Extended families and perceived caregiver support to AIDS orphans in Rakai district of Uganda. Children and Youth Services Review, 34, 1351–1358. doi:10.1016/j.childyouth.2012.03.015.Extended Google Scholar
Kessler, R. C., McLaughlin, K. A., Green, J. G., Gruber, M. J., Sampson, N. A., Zaslavsky, A. M., et al. (2010). Childhood adversities and adult psychopathology in the WHO World Mental Health Surveys. British Journal of Psychiatry, 197, 378–385. doi:10.1192/bjp.bp.110.080499 CrossRefGoogle ScholarPubMed
Klasen, F., Oettingen, G., Daniels, J., & Adam, H. (2010). Multiple trauma and mental health in former Ugandan child soldiers. Journal of Traumatic Stress, 23, 573–581. doi:10.1002/jts.20557 Google Scholar
Kovacs, M. (1992). Manual for the Children's Depression Inventory. North Tonawanda, NY: Multi-Health Systems.Google Scholar
Krug, E. G., Dahlberg, L. L., Mercy, J. A., Zwi, A. B., & Lozano, R. (2002). World report on violence and health. Geneva: World Health Organization. Retrieved from http://www.who.int/violence_injury_prevention/violence/world_report/en/ CrossRefGoogle ScholarPubMed
Lieberman, A. F., Van Horn, P., & Ippen, C. G. (2005). Toward evidence-based treatment: Child–parent psychotherapy with preschoolers exposed to marital violence. Journal of the American Academy of Child & Adolescent Psychiatry, 44, 1241–1248. doi:10.1097/01.chi.0000181047.59702.58 CrossRefGoogle ScholarPubMed
Lynch, M., & Cicchetti, D. (1998). An ecological–transactional analysis of children and contexts: The longitudinal interplay among child maltreatment, community violence, and children's symptomatology. Development and Psychopathology, 10, 235–257.Google Scholar
Lynch, M., & Cicchetti, D. (2002). Links between community violence and the family system: Evidence from children's feelings of relatedness and perceptions of parent behavior. Family Process, 41, 519–532. doi:10.1111/j.1545-5300.2002.41314.x CrossRefGoogle ScholarPubMed
Masten, A. S., & Narayan, A. J. (2012). Child development in the context of disaster, war, and terrorism: Pathways of risk and resilience. Annual Review of Psychology, 63, 227–257. doi:10.1146/annurev-psych-120710-100356 CrossRefGoogle ScholarPubMed
Miller, K. E., & Rasmussen, A. (2010). War exposure, daily stressors, and mental health in conflict and post-conflict settings: Bridging the divide between trauma-focused and psychosocial frameworks. Social Science & Medicine, 70, 7–16. doi:10.1016/j.socscimed.2009.09.029 CrossRefGoogle ScholarPubMed
Muris, P., Meesters, C., Eijkelenboom, A., & Vincken, M. (2004). The self-report version of the Strengths and Difficulties Questionnaire: Its psychometric properties in 8- to 13-year-old non-clinical children. British Journal of Clinical Psychology, 43, 437–448. doi:10.1348/0144665042388982 Google Scholar
Nader, K. O., Newman, E., Weathers, F. W., Kaloupek, D. G., Kriegler, J. A., & Blake, D. D. (2004). National Center for PTSD Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA) interview booklet. Los Angeles: Western Psychological Services.Google Scholar
Palosaari, E., Punamäki, R.-L., Qouta, S., & Diab, M. (2013). Intergenerational effects of war trauma among Palestinian families mediated via psychological maltreatment. Child Abuse & Neglect. Advance online publication. doi:10.1016/j.chiabu.2013.04.006 CrossRefGoogle Scholar
Panter-Brick, C., Eggerman, M., Gonzalez, V., & Safdar, S. (2009). Violence, suffering, and mental health in Afghanistan: A school-based survey. Lancet, 374, 807–816. doi:10.1016/S0140-6736(09)61080-1 CrossRefGoogle ScholarPubMed
Panter-Brick, C., Goodman, A., Tol, W., & Eggerman, M. (2011). Mental health and childhood adversities: A longitudinal study in Kabul, Afghanistan. Journal of the American Academy of Child & Adolescent Psychiatry, 50, 349–363. doi:10.1016/j.jaac.2010.12.001 Google ScholarPubMed
Panter-Brick, C., Grimon, M.-P., & Eggerman, M. (2014). Caregiver-child mental health: A prospective study in conflict and refugee settings. Journal of Child Psychology and Psychiatry, 55, 313–327. doi:10.1111/jcpp.12167 CrossRefGoogle ScholarPubMed
Parker, G. (1998). The parental bonding instrument. Sydney: Black Dog Institute. Retrieved from http://www.blackdoginstitute.org.au/docs/PBI_AnnotatedBibliography.pdf Google Scholar
Parker, G., Tupling, H., & Brown, L. B. (1979). A Parental Bonding Instrument. British Journal of Medical Psychology, 52, 1–10. doi:10.1111/j.2044-8341.1979.tb02487.x CrossRefGoogle Scholar
Phuong, T. B., Huong, N. T., Tien, T. Q., Chi, H. K., & Dunne, M. P. (2013). Factors associated with health risk behavior among school children in urban Vietnam. Global Health Action, 6, 1–9. doi:10.3402/gha.v6i0.18876 CrossRefGoogle ScholarPubMed
Punamäki, R.-L., Qouta, S., & El Sarraj, E. (1997). Relationships between traumatic events, children's gender, and political activity, and perceptions of parenting styles. International Journal of Behavioral Development, 21, 91–110. doi:10.1080/016502597385009 Google Scholar
Pynoos, R. S., Rodriguez, N., Steinberg, A., Stuber, M., & Frederick, C. (1998). The UCLA PTSD reaction index for DSM IV (Revision 1). Los Angeles: UCLA Trauma Psychiatry Program.Google Scholar
Pynoos, R. S., Steinberg, A. M., Layne, C. M., Briggs, E. C., Ostrowski, S. A., & Fairbank, J. A. (2013). DSM-V PTSD diagnostic criteria for children and adolescents: A developmental perspective and recommendations. Journal of Traumatic Stress, 22, 391–398. doi:10.1002/jts Google Scholar
Pynoos, R. S., Steinberg, A. M., & Piacentini, J. C. (1999). A developmental psychopathology model of childhood traumatic stress and intersection with anxiety disorders. Society of Biological Psychiatry, 46, 1542–1554.CrossRefGoogle ScholarPubMed
Qouta, S., Punamäki, R.-L., & El Sarraj, E. (2005). Mother-child expression of psychological distress in war trauma. Clinical Child Psychology and Psychiatry, 10, 135–156. doi:10.1177/1359104505051208 CrossRefGoogle Scholar
Qouta, S., Punamäki, R.-L., Montgomery, E., & El Sarraj, E. (2007). Predictors of psychological distress and positive resources among Palestinian adolescents: Trauma, child, and mothering characteristics. Child Abuse & Neglect, 31, 699–717. doi:10.1016/j.chiabu.2005.07.007 CrossRefGoogle ScholarPubMed
Reed, R. V, Fazel, M., Jones, L., Panter-Brick, C., & Stein, A. (2012). Mental health of displaced and refugee children resettled in low-income and middle-income countries: Risk and protective factors. Lancet, 379, 250–265. doi:10.1016/S0140-6736(11)60050-0 CrossRefGoogle ScholarPubMed
Renner, W., Salem, I., & Ottomeyer, K. (2006). Cross-cultural validation of measures of traumatic symptoms in groups of asylum seekers from Chechnya, Afghanistan, and West Africa. Social Behavior and Personality, 34, 1101–1114. doi:10.2224/sbp.2006.34.9.1101 CrossRefGoogle Scholar
Roberts, A. L., Galea, S., Austin, S. B., Cerda, M., Wright, R. J., Rich-Edwards, J. W., et al. (2012). Posttraumatic stress disorder across two generations: Concordance and mechanisms in a population-based sample. Biological Psychiatry, 72, 505–511. doi:doi:10.1016/j.biopsych.2012.03.020 Google Scholar
Roberts, B., Ocaka, K. F., Browne, J., Oyok, T., & Sondorp, E. (2008). Factors associated with post-traumatic stress disorder and depression amongst internally displaced persons in northern Uganda. BMC Psychiatry, 8, 38. doi:10.1186/1471-244X-8-38 CrossRefGoogle ScholarPubMed
Roberts, B., Ocaka, F. K., Browne, J., Oyok, T., Sondorp, E., & Ocaka, K. F. (2011). Alcohol disorder amongst forcibly displaced persons in northern Uganda. Addictive Behaviors, 36, 870–873. doi:10.1016/j.addbeh.2011.03.006 Google Scholar
Saile, R., Ertl, V., Neuner, F., & Catani, C. (2014). Does war contribute to family violence against children? Findings from a two-generational multi-informant study in Northern Uganda. Child Abuse & Neglect, 38, 135–146. doi:10.1016/j.chiabu.2013.10.007 CrossRefGoogle ScholarPubMed
Saile, R., Neuner, F., Ertl, V., & Catani, C. (2013). Prevalence and predictors of partner violence against women in the aftermath of war: A survey among couples in Northern Uganda. Social Science & Medicine, 86, 17–25. doi:10.1016/j.socscimed.2013.02.046 CrossRefGoogle Scholar
Salloum, A., & Overstreet, S. (2012). Grief and trauma intervention for children after disaster: Exploring coping skills versus trauma narration. Behaviour Research and Therapy, 50, 169–179. doi:10.1016/j.brat.2012.01.001 CrossRefGoogle ScholarPubMed
Scheeringa, M. S., Myers, L., Putnam, F. W., & Zeanah, C. H. (2012). Diagnosing PTSD in early childhood: An empirical assessment of four approaches. Journal of Traumatic Stress, 25, 359–367. doi:10.1002/jts CrossRefGoogle ScholarPubMed
Serbin, L. A., & Karp, J. (2004). The intergenerational transfer of psychosocial risk: Mediators of vulnerability and resilience. Annual Review of Psychology, 55, 333–363. doi:10.1146/annurev.psych.54.101601.145228 CrossRefGoogle ScholarPubMed
Sheehan, D. V, Lecrubier, Y., Sheehan, K. H., Amorim, P., Janavs, J., Weiller, E., et al. (1998). The Mini-International Neuropsychiatric Interview (MINI): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59, 22–33.Google ScholarPubMed
Silove, D. (2013). The ADAPT model: A conceptual framework for mental health and psychosocial programming in post conflict settings. Intervention, 11, 237–248. doi:10.1097/WTF.0000000000000005 Google Scholar
Skinner, M. K. (2014). Environmental stress and epigenetic transgenerational inheritance. BMC Medicine, 12, 153. doi:10.1186/s12916-014-0153-y CrossRefGoogle ScholarPubMed
Thabet, A. A. M., Abu Tawahina, A., El Sarraj, E., & Vostanis, P. (2008). Exposure to war trauma and PTSD among parents and children in the Gaza Strip. European Child & Adolescent Psychiatry, 17, 191–199. doi:10.1007/s00787-007-0653-9 CrossRefGoogle ScholarPubMed
Thornberry, T. P., Knight, K. E., & Lovegrove, P. J. (2012). Does maltreatment beget maltreatment? A systematic review of the intergenerational literature. Trauma, Violence & Abuse, 13, 135–152. doi:10.1177/1524838012447697 CrossRefGoogle ScholarPubMed
Tsaousis, I., Mascha, K., & Giovazolias, T. (2012). Can parental bonding be assessed in children? Factor structure and factorial invariance of the Parental Bonding Instrument (PBI) between adults and children. Child Psychiatry and Human Development, 43, 238–253. doi:10.1007/s10578-011-0260-3 CrossRefGoogle ScholarPubMed
Uganda Bureau of Statistics & Macro International Inc. (2007). Uganda Demographic and Health Survey, 2006. Calverton, Maryland: Author. Retrieved from http://www.measuredhs.com/pubs/pdf/FR194/FR194.pdf Google Scholar
Uganda Ministry of Gender Labour and Social Development. (2009). Child protection recovery strategy for northern Uganda, 2009–2011. Kampala, Uganda. Retrieved from http://cpwg.net/wp-content/uploads/2012/09/Uganda-CP-Recovery-Strategy-2009-2011-ENG.pdf Google Scholar
Uganda Ministry of Gender Labour and Social Development. (2011). National strategic programme plan of interventions for orphans and other vulnerable children 2011/12—2015/16. Kampala, Uganda. Retrieved from http://www.mglsd.go.ug/ovcmis/docs/document_1.pdf Google Scholar
UNOCHA. (n.d.). Uganda humanitarian profile, 2011. Geneva: United Nations. Retrieved from http://www.ugandaclusters.ug/profile-2011.htm Google Scholar
Van Ee, E., Kleber, R. J., & Mooren, T. T. M. (2012). War trauma lingers on: Associations between maternal posttraumatic stress disorder, parent-child interaction, and child development. Infant Mental Health Journal, 33, 459–468. doi:10.1002/imhj Google Scholar
Van Ommeren, M., Sharma, B., Thapa, S., Makaju, R., Prasain, D., Bhattarai, R., et al. (1999). Preparing instruments for transcultural research: Use of the translation monitoring form with Nepali-speaking Bhutanese refugees. Transcultural Psychiatry, 36, 285–301.CrossRefGoogle Scholar