Resilience and vulnerability among refugee children of traumatized and non-traumatized parents

Children in families that have suffered trauma constitute a risk group for developing psychiatric illness, dysfunctional behavior and inadequate academic achievement. Child maladaptive stress syndrome has been shown to be associated with parental psychiatric illness [1].

The association between parental trauma and children's symptomatology has been explored among children of Holocaust survivors [2]. Findings of the Holocaust study indicated that there is a relationship between parental trauma and their children's PTSD symptoms, which gives support to the hypothesis of a transgenerational transmission of trauma impact. Research has shown the importance of including the family's history of psychopathology as environmentally mediated psychosocial risk factors and as determinants in the child's development of cognitive/affective internal working models [3–5]. Otto and associates [6] investigated the association between PTSD symptoms and children's television viewing in the USA. One of their findings was that some 5% of the children who had seen the 9/11 tragedy on television developed symptoms of PTSD. This finding supports the hypothesis of indirect traumatization in children.

A recent study has shown that, as a response to life stressors, such as exposure to violence or a death in the family, adolescents may develop internalizing symptoms such as depression, PTSD, and anxiety and/or externalized symptoms such as substance use, aggression, and delinquency [7]

Resilience in children has been operationalised in various ways. Garmezy et al. [8] defined resilience as the manifestation of competence in children although they have been exposed to stressful events. Gordon [9] emphasized the individual's capacity to thrive, mature, and develop competence despite adverse circumstances. For Crawford and associates [10], resilience means that the individual has the ability to adapt under stress, particularly in the context of severe hardship and disadvantageous life circumstances. Garmezy [11] formulated three factors that in particular promote the development of resilience in children: 1) the child's personality dispositions; 2) a supportive family environment; and 3) a support system outside the family that encourages and reinforces the child's efforts to cope and instills in the child positive values.

Close affirmative relationships, continuous and personalized care-giving, appropriate teaching and learning experiences, and an external social group with a supportive ethos and behavioral styles are all factors that protect the child from developing maladaptive behavioral patterns [12].

Resilience and protective factors have also been conceptualized [13] as the antithesis to vulnerability and risk factors. In the context of the present study, vulnerability means heightened susceptibility to develop PTSD/PTSS or a clinical picture dominated by PTSD-related symptoms. The risk factors that can lead to a negative developmental outcome include emotionally stressful relations in the family, the lack of continuity in care-giving, the lack of appropriate teaching and learning experiences, and participation in a social group with a deviant ethos or behavioral styles [11]. An example of research in this field of inquiry is Rydelius' ([3, 4] longitudinal study of psychosocial risk factors among a group of children with alcoholic fathers. This research accentuated the significance of psychosocial stress factors in the development of psychopathology [15].

Although it is important to identify risk factors, it is equally important to identify the protective factors that are present in the family, peer group, and school environment. In a study of protective factors within the family, Rutter [16] showed that psychosocial investigations of families need to include the family's past experiences as well as their current life circumstances.

Resilience has also been conceptualized as a universal human capacity to cope with traumatic events, but that this capacity needs encouragement and support within a facilitative environment to enable resilience to win over vulnerability and risk [14]. This conceptualization has shifted the focus away from individual deficits to individual strengths, competencies, and capacities and was a critical step in understanding resilience within the context of the individual and the family [14].

Resilient children are socially competent, have a positive self-esteem, and a sense of their own efficacy and ability. They possess above average intelligence expressed in terms of IQ, which may enhance their coping strategies, and they are able to understand and express a wide range of emotions in a socially appropriate manner. [17, 18].

In summary, resiliency has been regarded as the individual's capacity to adapt in the face of threatening circumstances and to develop strategies to cope with conditions of prolonged or severe adversity [13]. Werner and Smith [13] suggested that this works through the interaction of factors comprising: (i) dispositional attributes of the child, such as intelligence, sociability, effective coping strategies, and communication skills; (ii) family characteristics such as warm relationships, cohesion, structure, emotional support, secure attachment, and a close bond to at least one caregiver; and (iii) external support factors such as positive school experiences, good peer relations, and positive relations with other adults.

A closely related concept is hardiness. Kobasa [19] defined hardiness as a constellation of personality traits that facilitates the development of strategies for coping with stressful life events, also as an adaptive attribute based on early learned social cognition and characterized by rich and varied experiences. However, Kobasa [19] expanded the definition of hardiness to encompass commitment, a sense of meaning, purpose, and perseverance associated with one's existence; control, a sense of autonomy, endurance, and the ability to influence one's own life course; and challenge, the perception of change as a normal aspect of life and as an opportunity for growth (see also [20]). Bartone [21] investigated the relationship between hardiness, combat exposure, and PTSD symptoms in veterans of the Gulf War and found that the 'hardy' veterans displayed fewer PTSD symptoms. The risk of developing PTSD among the Gulf War veterans was aggravated by such factors as family instability, poor family relations in general, as well as their particular war-zone experiences [22]. Social support, i.e. the interpersonal resources that promote hardiness, was a resilience factor. Another important factor was the availability of sources of support in the environment, which further enhanced the individual's possibility to develop hardiness, decreased the likelihood of developing PTSD symptomatology, and created opportunities for developing resilience.

The occurrence and absence of trauma-related psychopathology, primarily PTSD or PTSS, in the children of traumatized parents [1] raised the question of which dispositional features of the child's personality and what environmental factors were at work to explain why some children did not show PTSD-related symptoms.

The aim of the present study was to explore resiliency among children who did not develop PTSD-related symptoms despite a history of parental PTSD.

In the present study, prosocial behavior and psychological wellbeing are hypothesized as reflecting person-related attributes, which can strengthen a good to relation to family, which in turn functions as an environmental protective factor. An adequate self-esteem in the present study, measured by the ITIA with results according to Stanine -Scale above 5 Stanine, is assumed to facilitate the person-related components in the concept of resilience.

Three hypotheses were formulated: (i) that self-esteem, including prosocial behavior, psychological wellbeing, and IQ were factors that facilitated resilience; (ii) that adequate relation to family, measured by ITIA, was a protective factor; and (iii) that resilient children in the traumatized parents group, i.e. children without PTSD-related symptoms, will have higher scores on the SDQ regarding emotionality variable and on the peer problems variable than the children in the same group with PTSD-related symptoms.

In all, five instruments were used in the study:

The revised version of the Diagnostic Interview for Children and Adolescents (DICA-R). This semi-structured clinical interview schedule was used to assess the presence of PTSD-related symptoms among the 80 children in the sample.

Children's self-rating on the Post-Traumatic Stress Symptoms checklist [23, 24].

The Wechsler Intelligence Scales for Children, Third edition (WISC-III). The raw scores of the WISC-III measured the IQs of all 80 children with respect to VIQ (Verbal IQ), PIQ (Performance IQ), and FSIQ (Full scale IQ).

The 'I think I Am' (ITIA) Questionnaire, which is also a self-report instrument for the purpose of measuring children's self-esteem.

Teacher ratings according to the Strengths and Difficulties Questionnaire (SDQ) [24] were used to assess children's emotional symptoms, behavioral problems, hyperactivity, and peer problems.

In summary, the children of these families were examined concerning (i) self-esteem and (ii) IQ as main factors that may influence resilience. The children's vulnerability, operationalized in terms of developing PTSD-related symptoms was examined. The children in the traumatized parents group were divided into those with PTSD-related symptoms and those without PTSD-related symptoms. Self-esteem was assessed using the children's self-reports on the 'I Think I Am' (ITIA) Questionnaire. IQ was measured using the WISC-III. Vulnerability, expressed as PTSD-related symptoms, was measured using the Diagnostic Interview for Children and Adolescents Revised (DICA-R) and the children's self-ratings on the Post-Traumatic Stress Symptoms checklist.

For readers outside Scandinavia, it might be appropriate to describe the ITIA instrument in more detail. The 'I think I Am' (ITIA) Questionnaire' for measuring self-esteem is a Swedish self-report scale developed and standardized on a sample of over 3,465 children between 8–16 years of age [25]. It consists of 72 items divided into five factors that measure the child's ideation about him-/herself with respect to: physical components, skills and talents, psychological wellbeing, relation to family, relation to others; and lastly, the child's total score. The child is asked to choose from among four alternatives: 'Exactly like me', 'Almost like me', 'Not quite like me' and 'Not at all like me'. The ITIA total composite score ranges between +144 and -144. A high score on the ITIA questionnaire indicates that the child has adequate mental health.

The theoretical basis of the ITIA questionnaire rests on the work that has been done on the concept of self-esteem [27], on measures of children's self-concept [27], and on measures of children's self-image [28]. The validity and reliability of the ITIA have been extensively investigated [29], as the ITIA is widely used in clinical settings in Sweden to investigate the psychological wellbeing of children suffering from somatic illness [30–32].

The Strengths and Difficulties Questionnaire (SDQ) [25] is available in a Swedish version. Teacher ratings of the established SDQ scales were used to assess children's resiliency/vulnerability: emotional symptoms, behavioral problems, hyperactivity, peer problems, prosociality, and total difficulty. In accordance with the on-line Swedish SDQ instructions, the following categorization was used:"Normality," "Borderline," and "Abnormality."

The parents in both groups had been assessed in an earlier study [1] regarding PTSD using a semi-structured clinical interview administered by a psychiatrist, and the H/UTQ administrated by the first author (A.D.). This was done to re-assess the psychiatric status of the parents in the traumatized group who had had clinical treatment and to assess the non-traumatized parents for PTSD/PTSS. The parents were also investigated using the Karolinska Scales of Personality (KSP). However, no IQ tests were performed on the parents. Because there were no histories of new parental traumatic experiences since the earlier study, no re-assessment of the parents was made for the present study.

In summary, the children's assessment for PTSD-related symptoms was made by a psychiatrist and the IQ and ITIA tests were conducted by a clinical psychologist. SDQ ratings were made by the teachers and were computed by clinicians, and, finally, the KSP questionnaires used in the earlier study were conducted by a clinical psychologist.

The study design included two steps. In Step1, all the children were first assessed using the five instruments/questionnaires described above. The possible presence of PTSD-related symptoms among the 80 children was assessed by means of the Diagnostic Interview for Children and Adolescents (DICA-R) and the children's self-rating on PTSS checklist. The cut-off score for posttraumatic symptoms according to DICA is > than five symptoms, besides the answer yes to the question of whether they had heard about horrifying events affecting their family. The rationale for using the cut-off procedure with more than five symptoms was based on the DSM-IV TR. system.

All the children were investigated using both the children's native language and the Swedish language. There was nothing in the histories of either group of children to indicate that any of them had personally experienced traumatic events such as torture, parental abuse, or domestic violence.

The raw scores of the WISC-III were used to measure VIQ (Verbal IQ), PIQ (Performance IQ), and FSIQ (Full-Scale IQ) among the whole sample. The self-rated ITIA and the WISC-III tests took three hours per child to complete and were conducted at the children's respective schools.

The children completed the ITIA questionnaire individually and their teachers, who were not informed of the purpose of the study, rated the SDQ for each child. This procedure was completed in the middle of the academic year to give the teachers time to form an objective opinion of the child.

High scores (> 5 "Stanine Scale") on the ITIA sub-scales psychological wellbeing, relation to family, and relation to others, together with scoring < the abnormal level on the SDQ sub-scales prosocial behavior and peer relations are conceptualized as environmentally moderated components that enhance the development of resilience and are assumed to reflect protective factors characterized by supportive family relationships and external social support.

Resilience was operationalized and defined in the study as the child's high scores on the 'I think I Am' (ITIA) questionnaire and as the child's low score [31] on the sub-scales of the Strengths and Difficulties Questionnaire (SDQ) apart from the sub-scale 'prosocial behavior,' on which a high score is positive.

Step 2. Based on the results from the DICA-interviews, the children in each parent group were to be divided into two sub-groups, those children with PTSD-related symptoms and those children without PTSD-related symptoms. The results from the DICA-interviews showed, however, that none of the children in the non-traumatized parents group had PTSD/PTSS. Therefore, for the further analysis the children were divided into three groups:

1) Children in the traumatized parents group with PTSD-related symptoms;

2) Children in the traumatized parents group without PTSD-related symptoms;

3) Children in the non-traumatized parents group (comparison group)

For significance testing of equality of means, the Student's t-test was used. The chosen significance level was 0.05. F-ratio for one-way ANOVA and significance (Tukey, 1%) for sub-group comparisons were computed. The Pearson correlation coefficients were used to estimate the association between PTSD symptoms and IQ variables, and to estimate the association between ITIA and SDQ variables. Significance level of 5% was chosen. The calculations were made using SPSS, version 11.0.

The local ethical committee at Karolinska Hospital in Stockholm approved the study

(Dnr 97–295, 2000-06-05). All parents were informed about the purpose of the research project and that their identities would be kept anonymous throughout the whole data processing and presentation of the findings. All the participating subjects gave their informed consent and their participation was wholly voluntary.

Children of traumatized parents as an overloaded group, especially with respect to their susceptibility to developing psychiatric disorders (mainly PTSD- or PTSD-related symptoms), were the target of an earlier investigation [1]. Living with a traumatized parent is in itself a very severe and threatening circumstance. The fear of losing the parent; the fear that the parent will re-experience the life-threatening event again even in the new country; the question of whether the parent's capacity to be 'good enough parent' is insufficient; all this threatens the fundamental secure base which is needed for the child's adequate psychological development in terms of secure attachment.

It was noted in the earlier study, however, that some of the children did not develop PTSD/PTSS. As was also found in the Ferren study [36], these children displayed salutogenic features (freedom from PTSD/PTSS) as a consequence of their resilience which was characterized by their maintaining adequate family and peer relations.

They also displayed adequate emotionality and had a low score on the total impairment measure. The children without PTSD-related symptoms in the traumatized parents group might have hardiness as main construct in the concept of protective factors enhancing these salutogenic outcomes. Goldstein and Brooks [43], in their Handbook of Resilience in Childhood from 2006, wrote: "Resilience is suggested as but one of a number of constructs that protect or reduce vulnerability. Lösel, Bliesener, and Köfrel (1998) suggested that other protective factors include hardiness, adaption, adjustment, mastery, good fit between the child and the environment and buffering of the environment by important adults in the child's life" (p. 5).

The findings in the present study also support the hypothesis that there is a relationship between high self-esteem as a main factor in resilience and the development of salutogenic features. Using self-esteem (prosocial behavior together with psychological wellbeing) as an indicator of resilience and the SDQ sub-scale peer relations as an environmental protective factor enabled us to investigate the quality of the children's relationship to their significant others according to the ITIA scales. Another finding indicates that the child's adequate relation to his/her family (the supportive family) promoted the development of salutogenic features, even in the face of the parents' own lack of wellbeing.

Children in the traumatized parents group who displayed PTSD/PTSS scored significantly lower on the prosocial behavior scale – i.e. the child's capacity to manage relations with others and to be helpful – than did the children in the same group without PTSD-related symptoms. It is likely that there is a relationship between these children's low scores on the prosocial behavior scale and their parents' symptomatology, but much unexplained variability remains. Some of the children in this group did not develop these dysfunctional behaviors. This is in line with results obtained in a study of male subjects with a history of childhood victimization [37]. The overall findings of the present study support the hypothesis that the presence of environmental protective factors which facilitate the children's social competence may have enhanced the development of a functional salutogenic/protective mechanism and resilience factors among children in the traumatized parents group without PTSD-related symptoms. The parents' lack of wellbeing does not seem to have affected these children's behavior.

Although the concept of salutogenesis as formulated by Antonovsky was not used in this study, the results of the psychological and physical components of the ITIA sub-scales were not significant despite their encompassing what Antonovsky denoted as the biological domain of salutogenesis. On the other hand, the results obtained on the SDQ sub-scales emotionality and prosocial behavior also qualified as personality attributes similar to what has been termed the psychological domain in salutogenesis [38, 39]. The term salutogenesis [40–42] highlights the aspects of wellbeing rather than of pathogenesis. Antonovsky observed that some Holocaust survivors had fared relatively well despite their overwhelming negative experiences. He proposed that the core factor in salutogenesis is the individual's possession of a high sense of coherence (SOC). SOC is defined as 'a global orientation that expresses the extent to which one has a pervasive, enduring and dynamic feeling of confidence; that one's internal and external environments are predictable and that there is a high probability that things will work out as well as can be reasonably expected' [8]. SOC, which is comprised of comprehensibility, manageability, and meaningfulness, is an essential component of the individual's sense of wellbeing.

Antonovsky's interpersonal domain may be operationalised as the ITIA sub-scale relation to family (p < 0.06) and the SDQ's sub-scale peer problems (p < 0.001), as studied among children of traumatized parents. If so, the findings indicate that having a supportive family and adequate relations to others are main factors in understanding both protective factors and salutogenesis. To reiterate, further research is needed to explore the complexities of the salutogenic framework of those children in the present study who, although their parents were traumatized, did not develop PTSD-related symptoms.

The children in the non-traumatized parents group had significantly higher scores on the WISC-III with respect to VIQ, PIQ and FSIQ compared with the children in the traumatized parents group. As there was some difference referring to the educational level of the two parental groups, and as no IQ-tests were performed when investigating the parents, this result is not surprising. Although the children from the traumatized parents not showing PTSD-related symptoms showed relatively higher values on the VIQ, our results did not support the hypothesis that IQ was a factor involved in understanding resilience in this study.

Children in the traumatized parents group displayed behavioral and cognitive impairments manifested mainly as PTSD-related symptoms [1]. However, not all the children in the traumatized parents group displayed such impairments; instead, they showed resilience. Most probably their resiliency was strengthened by the perception that their family was supportive despite the parents' impairments, and because they had good relations to their peers. The findings of the present study point at the importance of a supportive environment for enhancing refugee children's wellbeing. Further study is needed, however, to determine what assertive efforts could be made in the school environment and during the children's leisure-time to promote the development of resilience. These issues are essential in healthcare planning, especially in a preventive perspective.