Posttraumatic Stress Disorder in Infants and Young ... · Results: PTSD was diagnosed in 37.8% of...

NEW RESEARCH

Posttraumatic Stress Disorderin Infants and Young Children

Exposed to War-Related TraumaRuth Feldman, Ph.D., AND Adva Vengrober, M.A.

Objective: Although millions of the world’s children are growing up amidst armed conflict,little research has described the specific symptom manifestations and relational behavior inyoung children exposed to wartime trauma or assessed factors that chart pathways of risk andresilience. Method: Participants included 232 Israeli children 1.5 to 5 years of age, 148 livingnear the Gaza Strip and exposed to daily war-related trauma and 84 controls. Children’ssymptoms were diagnosed, maternal and child attachment-related behaviors observed duringthe evocation of traumatic memories, and maternal psychological symptoms and socialsupport were self-reported. Results: PTSD was diagnosed in 37.8% of war-exposed children(n � 56). Children with PTSD exhibited multiple posttraumatic symptoms and substantialdevelopmental regression. Symptoms observed in more than 60% of diagnosed children includednonverbal representation of trauma in play; frequent crying, night waking, and mood shifts; andsocial withdrawal and object focus. Mothers of children with PTSD reported the highestdepression, anxiety, and posttraumatic symptoms and the lowest social support, and displayed theleast sensitivity during trauma evocation. Attachment behavior of children in the Exposed-No-PTSD group was characterized by use of secure-base behavior, whereas children with PTSDshowed increased behavioral avoidance. Mother’s, but not child’s, degree of trauma exposure andmaternal PTSD correlated with child avoidance. Conclusions: Large proportions of youngchildren exposed to repeated wartime trauma exhibit a severe posttraumatic profile that placestheir future adaptation at significant risk. Although more resilient children actively seekmaternal support, avoidance signals high risk. Maternal well-being, sensitive behavior, andsupport networks serve as resilience factors and should be the focus of interventions for familiesof war-exposed infants and children. J. Am. Acad. Child Adolesc. Psychiatry, 2011;50(7):645–658. Key words: PTSD, war-related trauma, toddlers, preschoolers, attachment theory

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T he understanding that repeated exposure towar-related trauma can carry a lasting im-pact on infants and young children is, sur-

prisingly, a relatively recent phenomenon. Untilrecently, clinicians and researchers have gener-ally held that young children are resilient tosevere traumatic experiences and lack the cogni-tive mechanisms to both understand the gravityof such events or hold them in memory.1 Theformal diagnosis of posttraumatic stress disorder

This article is discussed in an editorial by Dr. Alicia Lieberman onpage 640.

An interview with the author is available by podcast at
www.jaacap.org.
JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY

VOLUME 50 NUMBER 7 JULY 2011

PTSD) in nonverbal or minimally verbal chil-ren has similarly posed a range of difficulties.oung children often provide incoherent ac-ounts of their experiences, do not have theinguistic capacities to contain and detail over-

helming events, and the specific manifestationsf re-experiencing, dissociation, and hyper-rousal symptoms in young children differ ineaningful ways from those observed in older

hildren and adults.2,3 As to the specific effects ofarmed conflict, very little research has systemat-ically addressed the effects of daily exposure towar and terrorism on the development, preva-lence, and symptom formation of PTSD in infantsand young children.

Several studies examined PTSD in young chil-
dren after traumatic experiences, such as Hurri-
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FELDMAN AND VENGROBER

cane Katrina,4 the September 11th terroristattack,5 natural disasters,6,7 motor vehicle acci-dents,8 or exposure to domestic violence,9-11 tak-ing into account the developmental sensitivities,assessment difficulties, and specific symptommanifestations at this age group.12 All studiesdemonstrated a distinct and detectable PTSDconstellation in young children after traumaticexperiences that involve a real threat to thephysical integrity of the self or significant oth-ers.13,14 Research on children exposed repeatedlyto war, typically assessing older children or ad-olescents, has similarly underscored the long-term effects of wartime experiences on children’swell-being, emotional reactivity, and mental andphysical health.15-17 It has been further empha-sized that the assessment of PTSD in youngchildren should be accompanied by direct obser-vations of the child’s emotional reactions to theevocation of traumatic memories in addition tomaternal reports, in particular, the increase insecure base behaviors or signs of withdrawal andnumbing, which mark the child’s nonverbal dis-tress to trauma reminders. However, we areaware of no study that included formal obser-vations of young children’s behavior duringthe evocation of traumatic memories as codedby individuals blind to the child’s psychiatricdiagnosis.

Theoretical models of childhood PTSD positthat the study of risk and resilience after traumashould be viewed from a perspective that takesinto account multiple levels of the child’s ecol-ogy, including the mother’s mental health andemotional resources, the nature of the mother–child relationship, and the family’s broader socialsupport networks.2,18-22 In particular, the studyof resilience, defined as positive outcome despitesignificant adversity,23 may benefit from researchon the correlates of war-related childhood PTSD.Among the central controversies in the study ofresilience is uncertainty in the measurement ofrisk. Not only is it impossible to ascertain theaccuracy of young children’s reports, but envi-ronments marked by chronic early stress differsubstantially from one another, underscoring thequestion of whether resilient children are thosewho experienced less adversity.24 War exposureoffers a ”natural experiment” in which all chil-dren are exposed to the same or highly similartraumatic experiences over a lengthy period; yet,individual differences in the child’s biological
and social provisions may chart specific path-
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ays to the development of the disorder in somehildren but not in others. Consistent with theiew that resilience is a process reflecting naturaluman adaptation,25 war exposure may offer a

context to describe child and family factors thatfunction to enhance positive adaptation in theface of chronic stress.26

Since the early work of Anna Freud and Dor-othy Burlingham on young children duringWorld War II,27 it has been suggested that the

other’s emotional adaptation serves as a ”de-ensive wall” against the effects of war on thehild and plays an important role in the devel-pment of the child’s disorder and in its symp-om severity and trajectory over time. Studiesssessing children’s traumatic responses to warnd terrorism across the globe, following the/11 terrorist attack,28 the war in Lebanon,29

military violence in Gaza,30 SCUD missilesin Israel,20 the wars in Kosovo31 and Bosnia-Hercegovina,17 or the Oklahoma City bombing,32

demonstrate that the mother’s posttraumaticsymptoms, depression, and anxiety meaningfullyincrease the risk of childhood PTSD. Similarly,the family’s support networks serve as a bufferagainst maternal psychopathology and increasethe mother’s ability to contain her own and thechild’s distress.

Although little research has focused on ob-served mother–child interactions, war exposuremay provide a unique vantage point to study theattachment system and its ability to function as a”secure base”33 during periods of continuousstress. Conditions of stress and uncertainty acti-vate the attachment system and have tradition-ally been used to assess individual variability inits parameters.34 Children experiencing consis-ent maternal sensitivity tend to increase the usef secure base behaviors during moments ofistress, such as proximity seeking or heightened

ocus on mother, which reciprocally elicit moreensitive caregiving.35 In fact, Bowlby’s seminalormulations on the attachment system and itshree phases of attachment, separation, andoss36-38 were based on observations of young

children’s reactions to repeated wartime traumaand the role of secure base behaviors and themother’s sensitive response in repairing momen-tary disruptions to the attachment relationship.Such mechanisms were thought to protectagainst the avoidance and numbing associatedwith the loss of attachment bonds, which results
from the mother’s prolonged inability to function
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WAR-RELATED PTSD IN EARLY CHILDHOOD

as a secure base. In support, animal and humanstudies have demonstrated that maternal prox-imity and sensitive caregiving provide ”externalregulators” that buffer against the hyperarousal,anxiety, and bio-behavioral disorganizationcaused by maternal separation, whereas pro-longed separation and the decompensation of themother’s regulatory functions results in hypoac-tivity and biological and behavioral withdraw-al.39-41 It can thus be expected that sensitivemothering and children’s increased use of securebase behaviors would chart a resilience pathwayand may buffer against the development ofPTSD. On the other hand, the avoidant behav-ioral response typical of loss would mark a riskpathway and correlate with greater posttrau-matic symptomatology in young children.Avoidance as a signal of more pathological reac-tion to war-related trauma has similarly beenreported in older children30 and adults.42

In light of the above, the current study exam-ined the development of PTSD in infants andyoung children 1.5 to 5 years of age exposed towar-related trauma over a lengthy period. Alarge cohort of Israeli children living at the bor-der of the Gaza Strip and exposed to dailyrockets and terrorist attacks were observed withtheir mothers and compared with nonexposedmatched controls. Two major goals guided thestudy: (1) to describe the PTSD constellation ininfants and young children following war-related trauma in terms of specific symptoms,developmental regression, and observed attach-ment-related behavior, including secure base andavoidant behavior during the evocation of trau-matic memories, and (2) to assess maternal cor-relates of childhood PTSD related to both ob-served maternal sensitivity and mental healthfactors. We sought to chart maternal and childrisk and resilience pathways to the developmentof PTSD and thus, a special focus were thedifferences between war-exposed children whodeveloped PTSD and those exposed to the samewartime trauma who did not develop the disor-der (Exposed-No-PTSD children).

Our specific hypotheses were: (1) a subgroupof war-exposed children would develop the earlychildhood PTSD syndrome and exhibit the typi-cal symptoms in the re-experiencing, avoidance,and hyperarousal domains. (2) With regard tochild risk and resilience factors, we hypothesizedthat children with PTSD would show greater
developmental regression in the cognitive, social, s


and daily living domains, and would exhibitmore behavioral avoidance during the evocationof traumatic memories, whereas Exposed-No-PTSD children would display more secure basebehaviors during trauma evocation. (3) Regard-ing maternal risk and resilience factors, we ex-pected that mothers of PTSD children wouldreport higher depression, anxiety, and posttrau-matic symptoms and lower social support ascompared with mothers of Exposed-No-PTSDchildren, whereas mothers of Exposed-No-PTSDchildren would display greater sensitivity duringtrauma evocation. Finally, (4) attachment-relatedmaternal and child behavior during the evoca-tion of traumatic memories—maternal sensitiv-ity, child secure base behavior, and childavoidant behavior—would each be indepen-dently predicted by components of the child’secology, including maternal, child, and contex-tual factors.

METHODParticipantsParticipants included 232 children 1.5 to 5 years of age(mean age � 33.08 months, SD � 10.89 months) andheir mothers (mean age � 31.27 years, SD � 5.55ears, range � 22.3–47.4 years). Of the children, 47.6%ere male and 47.1% were firstborn. Maternal andaternal education averaged 3.88 (SD � 1.44) and 3.51

SD � 1.49) respectively on a scale of 1 (elementarychool) to 4 (college education). Among mothers,1.6% worked full-time and 42.6% worked part-time,nd 11% were single mothers.

A total of 148 families comprised the war-exposedroup. These included children living in the sameeighborhoods in the town of Sderot, located 10 kmrom the Gaza border. Citizens of Sderot were exposedepeatedly to rocket attacks over a period of severalears, had only 15 seconds to enter protected spacesfter hearing the alert sirens, and were exposed torequent mortar shelling to which no alert signals wererovided. Testing was conducted during a period ofepeated rocket and missile attacks (January 2006–ctober 2008). During this period rocket attacks on

derot occurred unpredictably and continuously sev-ral times a month, and all children were seen at leastmonth after the period these attacks began. Visitsere not conducted during the day of the attack orithin the next 2 to 3 days.Recruitment was conducted through clinicians liv-

ng in Sderot or in neighboring cities who were famil-ar with the clinical and childcare services for this age;nce recruitment had begun, participants helped iden-ify eligible friends and neighbors. Advertisements for
tudy participation were posted in all childcare loca-
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tions across Sderot, and the great majority of familiesapproached (�90%) agreed to participate. It can thusbe acssumed that the majority of young childrengrowing up in these frontline neighborhoods partici-pated in the study and exclusion criteria included onlythose who were physically or mentally handicapped(e.g., severe autism, mental retardation). Family re-ceived $80 in vouchers for their participation.

A total of 84 nonexposed children were recruited ascontrols from towns within the greater Tel-Aviv area(e.g., Or Yehuda, Pardes Katz) that were equivalent tothe town of Sderot in terms of population size, socio-economic composition, and housing and employmentopportunities. These areas were not exposed to war-related trauma during the study period, and controlswere matched to the exposed group in age, gender,birth order (firstborn/later born), maternal and pater-nal age and education, and maternal employment andmarital status. Before home visits, control familieswere screened by phone for major traumatic events inthe child’s life (e.g., terror exposure, motor vehicleaccidents, physical or sexual abuse), and those report-ing such trauma were excluded. The study was ap-proved by the University’s Institutional Review Board,and all mothers signed informed consent.

ProcedureChild PTSD. Trained clinicians with a background inearly childhood development and psychopathologyvisited families at home and diagnosed the child’sPTSD using the Diagnostic Classification: Zero-to-Three Revised (DC:0-3R).43 Clinicians received exten-sive training on the clinical features of PTSD at this ageand its specific behavioral manifestations; how tointerview mothers and elicit information on youngchildren’s emotional state; the specific symptom man-ifestations at this age; how to approach mothers andchildren living under continuous war-related trauma;the specific DC 0-3R criteria for diagnosing earlychildhood PTSD and the information that should becollected on the nature and proximity to the traumaticevent, child emotional reaction, specific symptoms inthe various symptom clusters; and how to provide adevelopmentally sensitive evaluation of the child’sdevelopmental regression. Clinicians were supervisedby a senior clinical child psychologist and a childpsychiatrist, and cases were conferred every fewweeks.

The home visit was intended to diagnose the childin his/her natural ecology and to enable the observa-tion of maternal and child behavior during the evoca-tion of traumatic memories. Such observations havebeen advocated as central for the diagnosis of PTSD inyoung children.2, 3 Information was collected duringone afternoon visit that lasted approximately 3.5 to 4hours (with breaks). A second visit was scheduled tocollect questionnaires and additional information if
data were missing.
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Home visits began with the clinician interviewinghe mother and collecting detailed information for theiagnosis of PTSD, including the specifics of the

rauma exposure, the child’s and family members’egree of exposure, and the child’s emotional reaction

o specific events, including description of incidencesf exposure, the child’s proximity to the explosion,hether the child or family members were injured and

ow severely, and the child’s behavioral expression ofear, horror, and other emotions in response to eachraumatic exposure (criterion A). The clinicians thenlicited the mother’s detailed description of the child’specific posttraumatic symptoms. The re-experiencingomain (criterion B) is typically observed in younghildren through the expression of trauma remindersn words or gestures during play or daily activities,ompulsive or repetitive play that re-creates elementsf the traumatic events, or repeated thoughts, flash-acks, or freezing in response to trauma reminders.he avoidance domain (criterion C) is often observedt this age through a set of behaviors indicatingisengagement, such as social withdrawal, constric-

ion of affective range, lack of interest in daily activi-ies, or avoidance of people or places that remind thehild of the trauma. Based on previous research at thisge,3,8 only one symptom in the avoidance category isequired to diagnose PTSD in young children. Theyperarousal category refers to behavioral and physi-logical agitation expressed in difficulties in fallingsleep or remaining asleep, concentration problems,xaggerated startle, hypervigilance, tantrums or unex-lained anger outbursts, or quick mood shifts; twoymptoms are required in this category for the diag-osis of PTSD at this age. Information on a fourthategory of symptoms, fears and aggression, was col-ected, as suggested by the DC 0-3R criteria but is notequired for the diagnosis of PTSD. Similarly, as perhe guidelines, detailed information was collected onhe child’s developmental regression, defined as akill the child had mastered but lost after an intense periodf trauma exposure, and mothers were asked about devel-pmental regression in the various domains.

After the clinical interview, mothers were asked toate the child’s symptoms on a list of 58 posttraumaticymptoms that were compiled after a year of pilottudy in Israeli and Palestinian war-exposed locations.he pilot included extensive interviews conductedith parents, caregivers, and therapists living in war

ones on the typical symptoms young children exhibitfter repeated exposure to war-related violence.44 The

final list of 58 symptoms included symptoms detailedby the DC 0-3R as typical of young children aftertrauma and additional symptoms described by parentsand clinicians during the pilot. For each symptom,each mother rated if she had not noticed the symptomin her child (score � 0) and if she did, whether thechild exhibited the symptom infrequently (1 � once a
week or less) or frequently (2 � daily or every 2–3


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days). Scores were then summarized into the ”re-experiencing” (7 items), ”avoidance” (13 items), ”hy-perarousal” (11 items), ”fears and aggression” (13items), and ”developmental regression” (14 items).Possible score ranges were as follows: re-experiencing,0 to 14; avoidance, 0 to 26, hyperarousal, 0 to 22; andfears and aggression, 0 to 26.

In terms of developmental regression, mothers firstrated the child’s overall regression on a scale of 1 to 10and then rated specific symptoms of developmentalregressions in the social (e.g., staying alone at afriend’s house, four items), emotional (e.g., intense fearwhen put to sleep, five items), and daily-living (e.g.,toilet training, five items) domains, which weresummed for each category. Control mothers wereinterviewed in the same manner. Mothers were askedto describe events the child experienced as ”traumatic”or emotionally difficult during the past few monthsand both interview and symptom list followed thesame procedure as the exposed group. Mothers de-scribed mildly ”traumatic” events in the child’s life,such as loss of a grandparent, illness in the family, ormoving to a new neighborhood.Maternal Psychopathology. Mothers’ depression wasassessed with the Beck Depression Inventory,45 mater-nal anxiety with the State-Trait Anxiety,46 and mater-nal PTSD symptoms with the Post-traumatic Diagnos-tic Scale.47 Mothers also completed the Social SupportScale.48

Maternal and Child’s Behavior During the Evocationof Traumatic Memories. During the maternal PTSDinterview, which lasted approximately 1 hour, chil-dren were present in the room and a trained assistantfollowed the child and videotaped the mother andchild’s behavior throughout the interview. Tapes werelater coded for maternal and child behavior duringtrauma evocation. Maternal behavior, emotional state,narrative coherence, and awareness of the child’s dis-tress, and the child’s emotions and behaviors totrauma reminders were coded offline by raters blindedto maternal and child psychiatric information along 35scales (20 for mother and 15 for child) each rated from1 (low) to 5 (high). The instrument was based on theCoding Interactive Behavior,49 a well-validated codingsystem for adult and child behavior during interac-tions. The system has shown good psychometric prop-erties and sensitivity to adult and child interactivebehavior related to age, culture, biological and social-emotional risk conditions, and the effects of interven-tion.50-53 The maternal sensitivity construct of the CIBhas been associated with the child’s attachment behav-ior, including secure base and avoidant behavior,during a separation–reunion episode.41 Interrater reli-ability was conducted for 46 (20%) interactions andreliability averaged 93%, intraclass r � 0.91.

Three composites were created on the basis ofprevious research. Maternal sensitivity (� � 0.82) in-
cluded the following items: consistency of the mater-


nal style, appropriate range of affect, reflective abilityon the child’s state and behavior, coherence of narra-tive, awareness of the child’s distress, and maternalsupportive presence. Child secure base behavior includ-ed: regressive behavior (e.g., thumb-sucking), childreliance on mother (e.g., ”Get me this..”), child focuson mother and increased vigilance, proximity-seekingbehaviors, whine/cry/call to mother, and child cud-dling on mother (� � 0.84). Child avoidant behaviorincluded child gaze aversion, emotional withdrawal,moving away from mother’s arms’ reach, and in-creased and inappropriate preoccupation with objects(� � 0.81).

Statistical AnalysisMultivariate analysis of variance (MANOVA) withgroup (PTSD, Exposed-No-PTSD, and control) andchild gender as the between-subject factors examineddifferences in three clusters, i.e., child PTSD symp-toms, maternal psychological symptoms, and maternaland child interactive behavior. Post hoc comparisonswith Scheffé tests followed significant main effects.Three hierarchical regression equations predicted ma-ternal and child attachment-related behavior (maternalsensitivity, child secure base behavior, and childavoidant behavior) from maternal, child, and contex-tual factors, and Pearson’s correlations assessed asso-ciations between the predictor variables. The sampleprovides sufficient power to detect small effect sizes.54

RESULTSPTSD Syndrome in Young ChildrenOf the 148 children exposed to repeated war-relatedtrauma, 56 were diagnosed with PTSD (37.8%)and 92 were classified as Exposed-No-PTSD. Nochild in the control group was diagnosed withPTSD, �2 � 262.4, p �.000. No differences in

emographic factors emerged between childrenho did or did not develop PTSD apart from

hild age: PTSD children were older (mean �6.22 months, SD � 10.36 months) than Exposed-o-PTSD children (mean � 31.50 months, SD �

0.18 months), F (df � 1, 147) � 6.97, p � .009. Wehus measured differences in the prevalence ofTSD in toddlers versus preschoolers. Among

he 92 exposed toddlers (1.5–3 years), 24 wereiagnosed with PTSD (26.08%). However, among

he 56 exposed preschoolers (3–5 years), 25 re-eived a diagnosis of PTSD (44.6%), �2 � 5.81,

p � .016. These findings indicate a significantlygreater risk for developing PTSD in exposedpreschoolers as compared with toddlers.

Children presented a range of posttraumatic
symptoms unique to this age group. MANOVA
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assessing children’s symptoms in the threesymptom clusters (re-experiencing, avoidance,hyperarousal) with group (PTSD, Exposed-No-PTSD, control) and child gender as the between-subject factors showed an overall main effect forgroup, Wilks F (df � 6, 441) � 7.86, p �.000, effectsize (ES) � 0.11. Univariate analyses with posthoc comparisons show that PTSD children pre-sented the most symptoms in all symptom clus-ters as compared with Exposed-No-PTSD chil-dren, who showed significantly more symptomsin all clusters than controls (Table 1). No childgender effects were found.

Figure 1 presents the most prevalent symp-toms in each symptom cluster that were observedin more than 60% of children diagnosed withPTSD (23% of exposed children). As seen, mostPTSD children re-created the trauma in play,speech, and gestures; showed social withdrawal,

TABLE 1 Posttraumatic Symptoms, Developmental RegreExposed Children With Posttraumatic Stress Disorder (PTS(Exposed-No-PTSD), and Controls

PTSD (a)

M SD

Posttraumatic symptomsRe-experiencing 7.52 3.20Avoidance 15.61 3.47Hyperarousal 17.89 5.73Developmental regressionOverall regression 7.78 2.92Emotional 4.87 3.14Social 4.94 2.88Daily living 3.65 2.60

Maternal psychological symptomsDepressiona 8.10 7.81Anxietyb 40.18 10.73Posttraumatic symptomsc 6.82 11.80

Maternal and child behaviorduring trauma evocation

Mother sensitivityd 3.02 0.64Child secure base behaviord 2.54 0.83Child avoidant behaviora 2.18 0.75

Note: Information on child PTSD symptoms and developmental regressidescribed by the Diagnostic Classification of Mental Health and Devecompiled in war-exposed Israeli and Palestinian locations. M � mean

aMeasured with the Beck Depression Inventory.45

bMeasured with the State-Trait Anxiety Inventory.46

cMeasured with the Posttraumatic Diagnostic Scale.dCoded on a scale of 1 (low) to 5 (high) using the Coding Interactive Be*p � .05, **p � .01, ***p � .001.

increased interest in objects, and constriction of

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social life; and had difficulties in sleep, moodregulation, and self-quieting.

Although all children experienced the sametraumatic events, the degree of direct exposurediffered (e.g., some homes were hit while mothersor child were present). Child proximity to thetraumatic event correlated with the number ofchild avoidance symptoms, r � 0.29, p �. 01, butnot with other types of symptoms. Similarly, themother’s proximity to the event correlated with thechild’s avoidance symptoms, r � 0.31, p �. 01. Chil-dren in the PTSD and Exposed-No-PTSD groups didnot differ in the degree of proximity to the trauma.However, mothers of PTSD children reported greaterproximity to the traumatic event (mean � 3.87, SD �1.24) than mothers of Exposed-No-PTSD children(mean � 2.78, SD � 2.21), F (df �1,147) � 4.37, p � .05.No correlations were found between the number ofchild symptoms or PTSD diagnosis and the number

, Maternal Symptoms, and Observed Behavior in War-xposed Children Without Posttraumatic Stress Disorder

osed-No-PTSD(b) Controls (c)

Univariate FSD M SD

.62 1.34 1.73 0.80 22.04***a�b�c

.27 4.56 1.86 1.10 34.16***a�b�c

.83 4.66 6.36 3.22 23.52***a�b�c

.55 1.62 1.32 0.90 18.54** a�b�c

.66 1.87 1.24 1.03 10.39***a�b�c

.59 2.20 1.78 1.44 11.76***a�b�c

.29 2.03 1.73 1.30 12.68***a�b�c

.31 5.84 3.71 2.91 10.54***a�b�c

.68 9.56 33.79 7.92 8.79***a�b�c

.64 7.47 0.58 3.01 11.36***a�b�c

.28 0.55 3.53 0.56 7.19** c�b�a

.93 0.98 2.23 0.86 5.23* b�a�c

.54 0.79 1.13 0.52 10.62***a�b�c

re based on a maternal questionnaire of 58 items including symptomsntal Disorders of Infancy and Early Childhood (DC 0-3R) and symptoms

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Finally, because of differences in the defini-tion of preschool PTSD between the DC:0-3Rand the alternative criteria,11 according towhich there is no need for expressing intensefear and horror during the traumatic event(A2), the re-experiencing expressed in repeti-tive play is not necessarily trauma related(criterion B), and only one hyperarousal symp-tom is required for diagnosis (criterion D), weexamined the prevalence of PTSD according tothe alternative criteria. This resulted in theinclusion of 14 additional children in the PTSDgroup, leading to a total of 70 children diag-nosed with PTSD (47% of exposed group).

Child Risk and Resilience FactorsMANOVA assessing the child’s developmentalregression in the three domains (emotional, so-cial, daily living) with group and child gender asthe between-subject factors showed an overallmain effect for group, Wilks F (df � 6, 441) �

FIGURE 1 Percentages of children diagnosed with warprevalent symptoms in the re-experiencing, avoidance, an

4.27, p �.001, ES � 0.08. Univariate analysis with



post hoc comparisons indicated that PTSD chil-dren showed greater developmental regressionin all domains compared with Exposed-No-PTSDchildren, who showed significantly more regres-sion than controls who displayed little or noregression (Table 1). Analysis of variance(ANOVA) assessing the child’s overall regressionrevealed that PTSD children showed significantlygreater regression than Exposed-No-PTSD chil-dren, who showed greater regression than con-trols (Table 1).

MANOVA assessing the three attachment-related behavior scores (i.e., maternal sensitivity,child secure base behavior, and child avoidantbehavior) showed an overall main effect forgroup, Wilks F (df � 6, 441) � 3.98, p �.001, ES �0.08. With regard to child factors, univariate tests(Table 1, Figure 2) with post hoc comparisonsshowed that Exposed-No-PTSD children showedthe highest levels of secure base behavior, controlchildren scored lower, and PTSD children exhib-

ted posttraumatic stress disorder (PTSD) exhibitingperarousal categories.

-relad hy

ited the least amount of secure-base behaviors.

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However, PTSD children displayed the highestlevel of avoidant behavior, Exposed-No-PTSDchildren showed less, and controls exhibited littleor no avoidant behavior.

Maternal Risk and Resilience Factors.MANOVA assessing maternal psychologicalsymptoms (depression, anxiety, PTSD) withgroup and child gender as the between-subjectfactors showed an overall main effect for group,Wilks F (df � 6, 441) � 5.22, p �.000, ES � 0.07.Univarite tests (Table 1) with post hoc compari-sons showed that mothers of PTSD childrenscored the highest on symptoms of depression,anxiety, and PTSD, mothers of Exposed-No-PTSD children scored lower, and mothers ofcontrols scored the lowest (Figure 3). ANOVAwith post hoc comparisons indicated that moth-ers of PTSD children had lower social support(mean � 17.96, SD � 10.79) than mothers ofExposed-No-PTSD children (mean � 19.84, SD �10.99), whose social support did not differ fromcontrols (mean � 22.42, SD � 9.62), F (df � 1, 231) �3.83, p � .023. Finally, we examined correlationsbetween maternal PTSD symptoms with the

FIGURE 2 Child behavior during the evocation of traumaticInteractive Behavior Manual49 from observations during the evodisorder. *p �.05, **p �.01.

child’s overall symptoms and the number of

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symptom in each symptom-cluster. MaternalPTSD correlated with the child’s overall post-traumatic symptoms, r � 0.25, p �.01, and withthe number of the child’s avoidance symptoms,r � 0.33, p �.001.

In terms of observed maternal behavior, moth-ers of control children showed the highest levelsof sensitivity, mothers of Exposed-No-PTSD chil-dren showed lower, and mothers of PTSD chil-dren exhibited significantly lower sensitivitythan mothers of Exposed-No-PTSD children(Table 1).

Predicting Maternal and Child Attachment-RelatedBehaviorsThree regression equations were computed pre-dicting maternal sensitivity, child secure basebehaviors, and child avoidance behavior. Predic-tors included maternal, child, and contextualfactors for a full ecological model, were the samein each regression, and were entered in fiveblocks. In the first block, demographic factorswere entered, including child age (in months),maternal age, and maternal education, to partialout variance related to demographic conditions.

ories. Note: Coded on a scale of 1 to 5 using the Codingn of traumatic memories. PTSD � posttraumatic stress

memcatio

In the second block, the mother’s mental health




factors were entered: depression, anxiety, andPTSD. In the third block, the family social sup-port was entered. In the fourth block, the childoverall developmental regression was entered. Inthe fifth block, the child’s PTSD diagnosis wasentered to examine whether child psychiatric

TABLE 2 Predicting Maternal Sensitive Containment and

Criterion Maternal Sensitivity C

Predictors Change Beta R2 Change F Change Be

Child age �0.06Mother age 0.09Mother education �0.24§ 0.06 5.37** 0.1Mother depression �0.18§

Mother anxiety �0.27Mother posttraumatic

symptoms�0.33§ 0.10 7.42** �0.2

Social support 0.19§ 0.03 3.82§ 0.3Child developmental

regression�0.25§ 0.04 4.31§ �0.2

Child PTSD �0.16 0.01 2.43 �0.3

Note: R2 total 0.25, F 9, 218 � 7.86, p � .001. 0.28, F9, 216 � 8.36, p

FIGURE 3 Maternal depression, anxiety, and posttraumexposed children with PTSD, war-exposed children withouMaternal anxiety was assessed with the State-Trait AnxietInventory,45 and maternal PTSD with the Posttraumatic Di

§p �.04; **p �.01.



diagnosis predicted additional variance aboveand beyond all factors in the model.

Before computing the regressions, correlationswere examined between the predictor variablesand significant correlations are reported. Mater-nal education correlated with greater social sup-

d Avoidance Behavior During the Evocation of Trauma

ecure Base Behavior Child Avoidant Behavior

R2 Change F Change Beta R2 Change F Change

�0.24§ 0.22§

0.07 �0.050.05 4.18§ 0.03 0.04 3.86§

�0.22§ 0.27**�0.18 �0.22

0.08 5.58§ 0.36** 0.11 6.93**

0.06 4.82§ �0.12 0.02 2.850.03 3.88§ 0.23 0.03 3.98§

0.06 5.83§ 0.29§ 0.03 4.02§

1 0.23, F9, 216 � 7.11, p � .001. PTSD � posttraumatic stress disorder.

stress disorder (PTSD) symptoms in mothers of war-D, and controls. Note: Numbers represent z scores.

entory,46 maternal depression with the Beck Depressionstic Scale.47 *p �.05, **p �.01.

Chil

hild S

ta

0

6§

0**2

2**

� .00

atict PTSy Invagno

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port (r � 0.27, p �.001) and less maternal depres-sion (r � �0.21, p �.01) anxiety (r � �0.32,p �.001), and posttraumatic symptoms (r ��0.19, p �.05). Maternal age correlated with lessanxiety (r � �0.22, p �.01). Maternal depressioncorrelated with anxiety (r � 0.62, p �.001) andmaternal PTSD symptoms (r � 0.32, p �.001),and maternal anxiety and PTSD were interre-lated (r � 0.25, p �.001). Social support wasassociated with lower depression (r � �0.40,p �.001) and maternal PTSD symptoms (r ��0.26, p �.001). Finally, child developmentalregression correlated with greater maternalPTSD symptoms (r � 0.24, p �.01). The threebehavior scores were interrelated: Maternal sen-sitivity correlated with more secure base behav-ior (r � 0.27, p �.001) and less avoidance (r ��0.26, p �.001), and children’s secure base be-havior correlated with less avoidant behavior(r � �0.33, p �.001).

Results of the three regressions (Table 2) indi-cate that all models were significant and thepredictor variables tested here cumulatively ex-plained 25%, 28%, and 23% of the variance inmother sensitivity, child secure base behavior,and child avoidant behavior respectively. Inde-pendent predictors of maternal sensitivity in-cluded maternal education, less maternal depres-sion and PTSD, greater social support, and lesschild developmental regression. Independentpredictors of child secure base behavior includedlower child age, less maternal depression andPTSD, greater social support, and no PTSD diag-nosis. Independent predictors of child avoidantbehavior included higher child age, maternaldepression, maternal PTSD, and child PTSD di-agnosis.

DISCUSSIONAlthough the numbers of young children aroundthe world growing up amidst armed conflictappear to increase each decade, very little isknown about the psychological growth, posttrau-matic symptoms, and observed behavioral man-ifestations of infants and young children exposedto war-related trauma over a lengthy period. Thisstudy is among the first to provide a detailedaccount of the early childhood PTSD constella-tion in a large cohort of children exposed to warand terror in terms of specific symptoms, devel-opmental regression, and attachment-related ma-
ternal and child behavior during the evocation of
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traumatic memories. Child diagnosis was exam-ined from an ecological perspective and in-cluded, in addition to maternal reports, struc-tured observations of behavior. Theoretically,war exposure was viewed as a ”natural experi-ment” that enabled a unique context to examinerisk and resilience pathways differentiating chil-dren who developed the full-blown disorderfrom those exposed to the same trauma whowere more resilient. The present results may thuscontribute to the general discussion on resilienceand shed light on the functioning of the attach-ment system under conditions of chronic stressand uncertainty.

It is of interest that some of the major devel-opmental theories that shaped clinical thoughtwere based on the observations of young chil-dren exposed to war-related trauma duringWorld War II. These include Anna Freud’s con-ceptualizations on ego development and de-fenses,27 Bowbly’s seminal formulations on at-achment security and disorganization,33 andpitz’s descriptions of early regressive states andhildren’s anaclitic depression and nonorganicailure to thrive.55 Combined with the early ani-

mal research of Hofer on maternal proximity asproviding a set of bio-behavioral hidden regula-tors39 and current neurobiological perspectives

n childhood trauma,56 it is clear that continuouswar not only exerts a profound effect on chil-dren’s biology and behavior but that such settingmay provide a unique context to study resilienceas a process reflecting natural human adapta-tion.25 Unlike conditions of early adversity suchas poverty or maltreatment, the cohort of chil-dren living in frontline neighborhoods and ex-posed to the same or similar wartime stressorsrepresents a variety of family adaptation, fromexcellent to very poor, and a range of attachmenthistories. As such, differentiating the symptomsthat spell risk from those that mark a moreresilient course and charting the maternal, child,contextual, and attachment-related correlates ofresilience may be of theoretical and clinical im-portance.

Overall, the data indicate that a large propor-tion of young children (37.8%) growing up in warzones and exposed to daily shooting, rockets, ormissile attacks are likely to develop PTSD, withfrequent symptoms of inconsolability and agita-tion, repeated expression of trauma reminders indaily life, and substantial constriction of social
life. Such children also tend to present a marked


entmNstdcptas

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developmental regression in the social, emo-tional, and daily living domains. Specific post-traumatic symptoms observed in more than 60%of the diagnosed children included nonverbalre-experiencing of trauma in words and gestures;frequent crying, night waking, and mood shifts;and symptoms of social withdrawal, such aspreference for solitary functional play and in-creased interest in objects combined with de-creased interest in people. These findings maysuggest that more than a third of the world’syoung children exposed to armed conflict over alengthy period are likely to present a severeenough psychiatric profile that places their futureadaptation at significant risk and requires intenseintervention. Between the ages of 1.5 and 5 years,substantial maturation occurs in environment-dependent brain systems implicated in executivecontrol and stress modulation; children enter thesocial world; and marked strides are noted in thedomains of language, symbol formation, empa-thy, and behavior regulation.57-58 The disruptionsto the maturation of these skills caused by expo-sure to repeated war trauma place the futureadjustment of such infants at great risk.

Several factors differentiated war-exposedchildren who did or did not develop PTSD: childage, maternal psychopathology, family socialsupport, and maternal and child attachment-related behaviors. With regard to child age, ex-posed preschoolers were nearly twice as likely todevelop PTSD compared with exposed toddlers.Although these findings require much furtherresearch, it is possible that the preschool yearsmark an especially vulnerable period for youngchildren exposed to chronic stress or trauma. Atthis stage, children gain linguistic, symbolic, andexecutive skills that enable them to project to thefuture, thereby markedly increasing the child’sanxiety, and improve their ability to express fearsin words, play, and actions.57-58 Similarly, by thepreschool years the child has already masteredimportant milestones and the developmental re-gression may thus be more notable. On the otherhand, as compared with school-age children,preschoolers have not yet developed the formaloperative thought, the more refined self-regula-tory repertoire, or the focus on social life and theability to draw comfort from the peer group,placing preschool children 3 to 5 years of age atespecially high risk.

Mothers of PTSD children reported more symp-
toms of depression, anxiety, and PTSD than moth-


ers of exposed children without PTSD, indicatingthat the mother’s resilience in the face of traumashapes the child’s psychiatric condition. Moreover,results indicate that the degree of maternal prox-imity to the traumatic event, not the child’s prox-imity, differentiated war-exposed children withand without PTSD, highlighting the critical impactof the mother’s posttraumatic state on the child’sdisorder, as has long been suggested by AnnaFreud.27 The cross-generation associations betweenmaternal and child’s posttraumatic symptoms fur-ther point to the close links between maternalposttraumatic psychopathology and the develop-ment of childhood PTSD. These findings are inaccordance with much previous research in olderchildren and adolescents on the effects of maternalpsychopathology on the child’s reaction to war,natural disasters, or severe accidents.17,59,60 Theffect of maternal symptoms on the child’s prone-ess to psychopathology is likely transmitted

hrough both genetic vulnerabilities and concreteaternal behavior. As seen, mothers of Exposed-o-PTSD children were able to provide more sen-

itive containment to the child’s distress duringrauma evocation, expressed in consistent and pre-ictable style, appropriate range of affect, reflectiveapacity, awareness of the child’s distress, and therovision of supportive and calming presence to

he child’s fears and anxieties. Maternal sensitivityt moments of distress is considered the corner-tone of attachment theory36 and is thought to

provide a regulatory framework for the develop-ment of bio-behavioral stress-management sys-tems.35 Consistent with much research in the at-achment tradition,35 less maternal depression andosttraumatic symptomatology each accounted fornique variance in maternal sensitivity, underscor-

ng the links between maternal emotional state andensitive behavior. In addition to mental health,others of exposed children without PTSD re-

orted greater social support and their supportetworks did not differ from those reported byontrols. Models on childhood PTSD18 consider

social support as an important ecological assetthat increases the family’s resilience during peri-ods of extended trauma. At the same time, it isalso possible that more resilient mothers arebetter able to recruit a larger system of support toprovide a holding environment for themselvesand their children.

Of interest were the differences in children’sattachment behavior during trauma evocation,
which may chart attachment-based mechanisms
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for the development of PTSD in young children.Although the more resilient Exposed-No-PTSDchildren increased their secure base behavior dur-ing the evocation of traumatic memories, PTSDchildren exhibited high levels of avoidant behavior.According to Bowbly,36-38 during moments of dis-tress children with a history of sensitive caregivingincrease their secure base behavior, including prox-imity seeking, heightened vigilance, crying formother’s attention, and regressive behavior. Thesehigh-arousal approach behaviors aim to elicitgreater maternal sensitivity, which, in turn, helps tore-establish the child’s physiological and behav-ioral equilibrium. It thus appears that the child’shigh arousal and regressive behavior mark a resil-ient, rather than risk pathway, which may seemcounter-intuitive to mothers and caregivers. Inter-vention programs for war-exposed families shouldthus assist mothers in perceiving the child’s regres-sive needs as a sign of strength and coping andlearn to respond to the child’s increased arousalwith more sensitive containment.

Child avoidance, on the other hand, emergedas the most notable risk pathway in trauma-exposed young children. During the evocation oftraumatic memories PTSD children increasedtheir avoidant behavior, including gaze aversion,emotional withdrawal, increased preoccupationwith objects, and physical distancing from themother, and such children also exhibited thehighest level of avoidance symptoms. Consistentwith Bowbly’s formulation on loss,38 avoidancemay indicate that the attachment system has notbeen able to contain the child’s anxieties, thatinitial attempts to recruit the maternal supportivepresence have failed, and that the child has shutdown biologically and behaviorally. The linkbetween a more severe course of the mother’sposttraumatic condition and the child’s avoid-ance is repeatedly seen in the data. Maternalproximity to the traumatic event and the moth-er’s PTSD symptoms correlated with the child’savoidance symptoms, not with other types ofsymptoms, and maternal depression and PTSDpredicted the child’s avoidant behavior. Twopotential mechanisms may thus be suggested onthe links between maternal posttrauma and childavoidance. First, mothers who were more trau-matized and depressed exhibited less sensitivecontainment of the child’s distress, anxiety, andregressive needs and these children may havelearned to internalize and ignore their anger,
fear, or dependency rather than use more adap- f
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ive approach behavior for the processing ofrauma. Second, the cross-generation associa-ions between maternal PTSD and the child’svoidance symptoms point to mechanisms ofodeling and social learning. Mothers of PTSD

hildren, who themselves avoided the active re-orking of the trauma, modeled the use of

voidant defenses to the child’s traumatic expe-iences.21 Similar findings are reported for Pales-

tinian children exposed to repeated military actsin Gaza, which indicated that children whosemothers suffered posttraumatic symptoms andexperienced the highest levels of exposure tomilitary aggression presented the highest levelsof avoidance symptoms.61 These data highlighthild avoidance—expressed in both daily symp-oms and concrete behavior in response to traumaeminders—as an indictor of high risk and areonsistent with the adult PTSD literature, whichndicates that symptoms of avoidance and numb-ng are markers of a more severe manifestation ofhe disorder and chart a worse prognosis.62,63

Maternal and child attachment-related behav-iors were independently predicted by compo-nents of the child’s ecology, including maternal,child, and contextual factors, thus supportingecological models of childhood PTSD.18 Mothers

ho were less educated, more traumatized andepressed, had lower social support, and hadhildren who displayed greater developmentalegression were less sensitive during traumavocation, and such diminished sensitivity mayave further exacerbated the child’s symptoms.ounger children whose mothers were less de-ressed, had fewer posttraumatic symptoms, andeceived more social support were able to ex-ress more secure base behavior. Finally,voidant behavior was more prevalent amongreschoolers as compared with toddlers, wasredicted by maternal depression and PTSD, andas related to the child’s PTSD diagnosis. Thesendings highlight the mother’s depression, post-

raumatic symptoms, and social support net-orks as central to the formation of her own and

he child’s attachment-related behavior duringxtended periods of stress and emphasize theeed to provide interventions to address themotional needs of mothers raising young chil-ren in areas exposed to war-related trauma.

It is important to note that because of the lackf longitudinal data, it is not possible to concludehat maternal psychopathology had a causal ef-
ect on the development of the child’s PTSD.



Similarly, because mother and child’s attachmentbehaviors were assessed after a lengthy exposureto trauma and during the evocation of traumaticmemories, it is not possible to determine thechild’s attachment classification before traumaonset. These limitations should thus be consid-ered in the interpretation of the findings. Futureintervention and longitudinal studies are neededto provide further insights on the effects oftrauma on the functioning of the attachmentsystem.

Further research is required to detail the ef-fects of continuous war, terror, and armed con-flict on young children’s mental health, behaviorregulation, and developmental trajectories. Fu-ture research may explore genetic, hormonal, and
temperamental risk and resilience pathways in
infancy and early childhood. J Am Acad Child Adolesc Psychia-try. 1995;34:191-200.



the face of daily trauma, and may assess theinterplay between the parenting envelope andthe child’s biology in shaping the distinct symp-tom constellation defined as posttraumatic stressdisorder of infancy and early childhood. &

Accepted March 2, 2011

Dr. Feldman and Ms. Vegrober are with Bar-Ilan University, Ramat-Gan, Israel.

This study was supported by a National Alliance for Research onSchizophrenia and Depression independent investigator award (R.F.).

Disclosure: Dr. Feldman and Ms. Vengrober report no biomedicalfinancial interests or potential conflicts of interest.

Correspondence to Dr. Ruth Feldman, Department of Psychologyand the Gonda Brain Sciences Center, Bar-Ilan University, Ramat-Gan, Israel 52900; e-mail: [email protected]

0890-8567/$36.00/©2011 American Academy of Child andAdolescent Psychiatry

DOI: 10.1016/j.jaac.2011.03.001

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