Children of Veterans and Adults with PTSD

Introduction

Researchers have recently examined the impact of veterans' posttraumatic stress disorder (PTSD) symptoms on family relationships, and on children of veterans in particular. Family members of individuals with PTSD may experience numerous difficulties. This fact sheet explains the common problems that children of veterans experience and provides recommendations for how to cope with these difficulties. Although much of the research described here has been conducted with children of Vietnam veterans, it is likely that much of the information applies to children of combat veterans of other conflicts.

How might a veteran's PTSD symptoms affect his or her children?

Re-experiencing symptoms
Individuals who have PTSD often 're-experience' traumatic events through vivid daytime memories or dreams. Re-experiencing can occur suddenly and without intention, and it is typically accompanied by intense emotions, such as grief, guilt, fear, or anger. Sometimes these intrusions can be so strong or vivid that the individual believes the trauma is reoccurring.
These symptoms can be frightening not only for the individual experiencing them but also for children who witness them. Children may not understand what is happening or why it is happening, and they may start to worry about their parent's well-being. Children may also worry that their parent cannot properly care for them.

Avoidance and numbing symptoms
Because the re-experiencing symptoms characteristic of PTSD are so uncomfortable, people who have been traumatized tend to try to avoid thinking about the traumatic event. They may also attempt to avoid places and experiences that could trigger upsetting memories. As a result, veterans may not want to do things or go places, such as to the store, to the movies, or out to dinner. Children may feel that their parent does not care about them when really it is that the parent is avoiding places that are just too frightening. In addition to these active avoidance strategies, traumatized individuals often struggle with experiencing positive emotions and may feel 'cut off' from other people, including family members. These avoidance and numbing symptoms can have a direct impact on children. For example, when a parent with PTSD withdraws from family members and has trouble feeling positive emotions, children can inaccurately interpret this as the parent not being interested in them or loving them, even though the parent may try to indicate otherwise

Hyperarousal symptoms
Individuals with PTSD tend to have a high level of anxiety and arousal, which shows up as difficulty sleeping, impaired concentration, and being easily startled. They tend to have a high level of irritability and may experience an exaggerated concern for their own safety and the safety of their loved ones. It is easy to see how these hyperarousal symptoms can influence family members. For instance, irritability and low frustration tolerance can make a parent seem hostile or distant, again making children question the parent's love for them. This perception is simply a misunderstanding of the reasons behind the symptoms.

What are the typical patterns of how children respond to a parent with PTSD?

Researchers have observed a direct relationship between each of the parent's PTSD symptoms and the children's responses. Researchers also have noticed patterns in the ways children respond to the parent's overall presentation of PTSD. Harkness (1991) described three typical ways these children respond: (1) the over-identified child: the child experiences secondary traumatization and comes to experience many of the symptoms the parent with PTSD is having; (2) the rescuer: the child takes on parental roles and responsibilities to compensate for the parent’s difficulties; and (3) the emotionally uninvolved child: this child receives little emotional support, which results in problems at school, depression and anxiety, and relational problems later in life.

These theories certainly do not represent every possible reaction children may have to parents with combat-related PTSD, but they offer some useful ways of understanding how symptoms might develop for these children.

What are the common problems children of veterans with PTSD face?

Social & behavioral problems
Research has shown that there is significantly more violence in families of Vietnam veterans with PTSD than in families of veterans without PTSD, including increased violent behavior of the child. 1 Several studies have examined the effect that fathers' combat-related PTSD and violent behaviors have on their children. 2, 3, 4 Results have generally revealed that children of veterans with PTSD are at higher risk for behavioral, academic, and interpersonal problems. Their parents tend to view them as more depressed, anxious, aggressive, hyperactive, and delinquent compared to children of non-combat Vietnam era veterans (who do not have PTSD). In addition, the children are perceived as having difficulty establishing and maintaining friendships. Chaotic family experiences can make it difficult to establish positive attachments to parents, which can make it difficult for children to create healthy relationships outside the family too. There is also research showing that children may have particular behavioral disturbances if their parent veteran participated in abusive violence (i.e., atrocities) during combat service. 5

Emotional problems and secondary traumatization
Results have also shown that children of veterans with PTSD are at higher risk for being depressed and anxious than non-combat Vietnam era veteran's children. Children may start to experience the parent's PTSD symptoms (e.g., start having nightmares about the parent's trauma) or have PTSD symptoms related to witnessing their parent's symptoms (e.g., having difficulty concentrating at school because they're thinking about the parent's difficulties). Some researchers describe the impact that a parents PTSD symptoms have on a child as secondary traumatization. 2 However, because of the increased likelihood that violence occurs in the home of a veteran with PTSD, it is also possible that children develop PTSD symptoms of their own. Having a seemingly unsupportive parent can compound these symptoms.

Problems may continue into adolescence
Adolescent children of veterans with PTSD may also be affected by their parent's symptoms. Compared to adolescent children of non-veteran fathers, adolescent children of Vietnam combat veteran fathers show poorer attitudes toward school, more negative attitudes toward their fathers, and higher levels of depression and anxiety. They also receive lower scores on creativity 6 . Adolescent children of Vietnam combat veterans may also have more problematic behaviors as rated by their mothers, although their behavior at school does not show evidence of disturbance. In spite of these differences, the two groups of adolescents were actually quite similar on a range of other measures of social and personality adjustment. One of the potential reasons for the limited impact on this group of adolescents is that the fathers in this study experienced combat but were not actually diagnosed with PTSD. It seems that children of combat veterans may struggle with some psychological and behavioral difficulties, but higher levels of impairment are much more likely when the veteran is struggling with mental health issues of his/her own, such as PTSD.

Can children get PTSD from their parents?

It is possible for children to display symptoms of PTSD because they are upset by their parent's symptoms (secondary traumatization). Some researchers have also investigated the notion that trauma and the symptoms associated with it can be passed from one generation to the next. Researchers describe this phenomenon as intergenerational transmission of trauma. Much research has been conducted with victims of the Holocaust and their families (see Kellerman 7 for review), and some studies have expanded on these ideas to include families of combat veterans with PTSD.

Ancharoff, Munroe, and Fisher 8 described several ways to understand the mechanisms of intergenerational transmission of trauma. These mechanisms are silence, overdisclosure, identification, and reenactment.

• When a family silences a child, or teaches him/her to avoid discussions of events, situations, thoughts, or emotions, the child's anxiety tends to increase. He or she may start to worry about provoking the parent's symptoms. Without understanding the reasons for their parent's symptoms, children may create their own ideas about what the parent experienced, which can be even more horrifying than what actually occurred.

• Overdisclosure can be just as problematic. When children are exposed to graphic details about their parent's traumatic experiences, they can start to experience their own set of PTSD symptoms in response to the horrific images generated.

• Similarly, children who live with a traumatized parent may start to identify with the parent such that they begin to share in his or her symptoms as a way to connect with the parent.

• Children may also be pulled to reenact some aspect of the traumatic experience because the traumatized parent has difficulty separating past experiences from present.

What should I do if I feel my or my partner's PTSD is affecting my children?

Parents can help children by using the information provided in this fact sheet and in the resources identified below. Preventive interventions can be helpful and include explaining to family members the possible impact of intergenerational transmission of trauma, before it happens. Education about the potential impact on children can also be a useful reactive response, when a child is already being affected by his or her parent's trauma history.

An excellent first step in helping children cope with a parent's PTSD is to explain the reasons for the traumatized parent's difficulties, without burdening the child with graphic details. It is important to help children see that the symptoms are not related to them; children need to know they are not to blame. How much a parent says should be influenced by the child's age and maturity level. Some parents may prefer to have help with what they say to their children, and seeking assistance through therapy or written materials can be helpful. The National Center for PTSD's fact sheet below on "Children and disasters" can help parents talk to children about trauma. This fact sheet also describes how children may react differently, depending on the child's age.

In addition to this basic first step, there are multiple treatment options available for affected families. Treatment can include individual treatment for the veteran (symptom improvement for the person suffering from PTSD would indirectly benefit the family) and family therapy (to support the parent who is struggling with symptoms and teach family members how to get their own needs met). Family therapy is typically more effective if the veteran with PTSD has first received some type of trauma therapy such that he or she is better able to focus on helping the children during family sessions 9 . Children may benefit from individual therapy as well, with variations based on the child's age (e.g., art or play therapy for younger children, supportive talk therapy for older children and adolescents). Each family is unique, and decisions about what kind of treatment to seek, if any, can be complicated. The most important thing is to help each member of the family, including the children, have a voice in expressing what he or she needs. In light of the recent research showing the negative impact PTSD can have on families, Veterans Affairs PTSD programs ( http://www.va.gov) and Vet Centers ( http://www.va.gov/rcs/) across the country are beginning to offer group, couples, and individual programs for families of veterans.

References
1. Jordan, B. K., Marmar, C. B., Fairbank, J. A., Schlenger, W. E., Kulka, R. A., Hough, R. L., et al. (1992). Problems in families of male Vietnam veterans with posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 60, 916-926.

2. Cosgrove, L., Brady, M. E., & Peck, P. (1995). PTSD and the family: Secondary traumatization. In D. K. Rhoades, M. R. Leaveck, & J. C. Hudson (Eds.), The legacy of Vietnam veterans and their families: Survivors of war: catalysts for change (pp. 38-49). Washington: Agent Orange Class Assistance Program.

3. Harkness, L. (1993). Transgenerational transmission of war-related trauma. In J. P. Wilson & B. Raphael (Eds.), International handbook of traumatic stress syndromes (pp. 635-643). New York: Plenum Press.

4. Parsons, J., Kehle, T. J., & Owen, S. V. (1990). Incidence of behavior problems among children of Vietnam War veterans. School Psychology International, 11, 253-259.

5. Rosenheck, R., & Fontana, A. (1998). Transgenerational effects of abusive violence on the children of Vietnam combat veterans. Journal of Traumatic Stress, 11, 731-742.

6. Dansby, V. S., & Marinelli, R. P. (1999). Adolescent children of Vietnam combat veteran fathers: A population at risk. Journal of Adolescence, 22, 329-340.

7. Kellerman, N. (2001). Psychopathology in children of Holocaust survivors: A review of the research literature. Israel Journal of Psychiatry and Related Sciences, 38, 36-46.

8. Ancharoff, M. R., Munroe, J. F., & Fisher, L. M. (1998). The legacy of combat trauma: Clinical implications of intergenerational transmission. In Y. Danieli (Ed.), International handbook of multigenerational legacies of trauma (pp. 257-275). New York: Plenum Press.

9. Harkness, L. (1991). The effect of combat-related PTSD on children. National Center for PTSD Clinical Quarterly, 2(1).