family trauma and its association with emotional and behavioral problems and social adjustment in...

PII S0145-2134(99)00100-3

FAMILY TRAUMA AND ITS ASSOCIATION WITHEMOTIONAL AND BEHAVIORAL PROBLEMS AND

SOCIAL ADJUSTMENT IN ADOLESCENTCAMBODIAN REFUGEES

CECILE ROUSSEAU

Department of Psychiatry, Montreal Children’s Hospital; Department of Transcultural Psychiatry, McGill University,Montreal, Quebec, Canada

ALINE DRAPEAU

Department of Psychiatry, Montreal Children’s Hospital, Montreal, Quebec, Canada

ROBERT PLATT

Research Institute, Montreal Children’s Hospital; Department of Epidemiology and Biostatistics, McGill University,Montreal, Quebec, Canada

ABSTRACT

Objective: The main aim of this study was to investigate the effect of war-related trauma on the subsequent socialadjustment and functioning of young Cambodian refugees.Method: This longitudinal study of 67 young Cambodian refugees in Montreal interviewed in the first year of high schooland then 2 years later examines a family’s exposure to war related premigration trauma and its association with anadolescent’s emotional and behavioral problems and social adjustment. Emotional and behavioral problems were assessedusing the Youth Self-Report and an inventory of risk behavior. Social adjustment was assessed in terms of academicachievement, peer relations, and feeling of competence.Results: The trauma a family suffered before leaving their homeland and prior to the teenager’s birth seems to play aprotective role at various times in adolescence with regard to externalized symptoms, risk behavior, and school failure inboys, and foster positive social adjustment in girls.Conclusions:These reactions may be understood as overcompensation by the children of the survivors of a massacre, towhom the implicit duty to succeed has been passed on. They suggest that a broader range of posttraumatic responses to warsituations should be investigated and that trauma’s dual nature as both burden and source of strength should be examinedmore closely. © 1999 Elsevier Science Ltd

Keywords—War trauma, Young refugees, Social adjustment, Strength.

DETERMINING THE EFFECT of war trauma on children and adolescents is a complex under-taking. Media attention focuses on the stark terror of war itself, but war is much more than that.

This research was supported by a grant from the Conseil que´becois de la recherche sociale.

Submitted for publication November 11, 1998; final revision received March 22, 1999; accepted March 28, 1999.

Requests for reprints should be sent to Ce´cile Rousseau, Department of Psychiatry, Montreal Children’s Hospital, 4018 Ste.Catherine Street West, Montreal, Quebec, Canada H3Z 1P2.

PergamonChild Abuse & Neglect, Vol. 23, No. 12, pp. 1263–1273, 1999

Copyright © 1999 Elsevier Science LtdPrinted in the USA. All rights reserved

0145-2134/99/$–see front matter

1263

It involves an entire reorganization of family and society around a long-lasting traumatic situation.Children are therefore not only directly exposed to uncommon sources of stress, but are also deeplyaffected by the transformation of the family, itself traumatized, and by changes in their society’sframe of reference. In most cases, the effects of direct and indirect traumatic war experiencescombine to accompany and modulate children’s entire development, but their long-term evolutionand exact impact on child development are still largely unknown. Time is a key criterion indifferentiating types of trauma in Western society (Terr, 1991) and it is also a central aspect ofsocial transformations caused by war, because not only does the sense of insecurity last for weeks,months, even years, but even after the war ends, its repercussions are felt for generations.

In this paper, we discuss family trauma and its association with emotional and behavioralproblems and social adjustment of young Cambodian refugees settled in Montreal. In an effort todetermine how the association might change in the course of adolescence, we interviewed theseteenagers and their families in their first year of high school and again 2 years later. Studies on thelong-term effects of war on children and adolescents have tended to focus either on the directimpact of war on children and their families or on the transgenerational transmission of trauma. Inexploring direct trauma, emphasis has been laid on psychiatric symptoms stemming from thetraumatic experience itself, known collectively as posttraumatic stress syndrome (PTSS). Kinzieand Sack’s longitudinal study (Kinzie, Sack, Angell, Manson, & Roth, 1986) of Khmer teenagersin the USA who had lived through the Pol Pot re´gime as preteens found that half the sampledisplayed PTSS that persisted 3 years later (Kinzie, Sack, Angell, Clarke, & Ben, 1989) and hadabated only slightly 6 years after the first interview (Sack et al., 1993). There was some fluctuationin at least a third of the sample, however: Some teenagers who initially had had no symptoms laterpresented with PTSS, while others became asymptomatic. In a study of another cohort ofadolescents, Sack and colleagues (1994) discovered a relationship between PTSS and age andhypothesized that his findings reflected more-indirect exposure to traumatic events, as the youngestchildren in the sample had been infants under Pol Pot. He also pointed out that like earlier studies(Kinzie et al., 1986) theirs had not found many behavioral problems and emphasized the need toreplicate these results with Khmer adolescents in other settlement locations.

Not all studies agree on either the extent or the form of the consequences of direct trauma. Instudies of Latin American Ame´ricains (Allodi, 1989), and Guatemalan children (Miller, 1996), theauthors found no evidence of PTSS. They raise a number of hypotheses to explain this finding: Thechild’s age at the time of the trauma, protective factors related to family and communitymechanisms, and methodological issues such as assessment of trauma and PTSS. Several authors(Becker, Morales, & Aguilar, 1994; Kestenberg, 1993; Richman, 1993) argue that, despite theimportance attributed to it, PTSS is far from the only, or even the main, consequence of children’swar experience. War trauma, direct and indirect, also affects children’s overall moral developmentand this in turn has various repercussions on their behavior (Cairns & Dawes, 1996). The negativerepercussions of socialization in a climate of violence have received the most attention (Cairns &Dawes, 1996), but in an interesting paper, Macksoud and Aber (1996), raise the perhaps unex-pected possibility that some types of war trauma may be associated with “positive adaptationaloutcomes.” In a study of 224 Lebanese children aged 10 to 16, they observed that those who hadbeen separated from their parents or had witnessed acts of violence were more sensitive to altruisticissues and reported more prosocial behavior, while children who had lost a parent reported moreplanful behavior. These observations corroborate the findings of Ayalon (1982) and suggest thatsocial and personal involvement with the aim of avoiding a repetition of trauma may be a strategyfor coping with one’s own suffering.

This dual nature of the effects of traumatic experience can also be found in studies on thetransgenerational transmission of trauma, characteristic of indirect trauma, to which most childrenliving through war are also subjected. Although much has been written on the transmission ofsuffering and symptoms (Danieli, 1985), other authors prefer to underscore the recuperative powers

1264 C. Rousseau, A. Drapeau, and R. Platt

of the second generation (Sigal & Weinfeld, 1985). In a review of the literature on the subject,Solkoff (1992) suggests that research has overemphasized the negative effects of parental traumaand that it is time to look for evidence of possible positive effects.

It would seem logical that in most situations of war and armed conflict, direct and indirecttraumas interact continuously. Therefore, if we are to gain a better understanding of the complexityof traumatic phenomena, we should not be simply documenting psychiatric symptoms; we shouldalso be attempting to explore a wide range of possible effects on the social adjustment of childrenand adolescents over the medium and long term. In this process, adolescence, even if it is notnecessarily experienced as a crisis in non-Western societies, is certainly a pivotal time. Parents andcommunities that have been through war expect their children, when grown, to respect thecommitments of their parents without repeating their failures or experiencing the same traumas(Becker, Morales, & Aguilar, 1994). Processes of individuation and separation begin again inadolescence, and it is a time when expectations may crystallize. It may also trigger an anniversary-like reaction in parents.

This paper attempts to answer the following questions with regard to a group of adolescentCambodian refugees:

How does the association between traumatic experience and emotional and behavioral problemschange between the start of high school and 2 years later?

How does the association between traumatic experience and social adjustment change over thesame period?

Is there any difference between the impact of direct trauma (experienced by the family after thechild’s birth) and indirect trauma (experienced before the birth of the child)?

METHOD

The study population consisted of Cambodian teenagers born outside Canada and living inMontreal. At baseline (Time 1), in 1994, the sample numbered 76 Grade 7 and 8 students registeredat six multiethnic high schools. By 1996 (Time 2), the attrition rate was 12%. Students lost tofollow-up (n 5 9) tended to have been in Canada for a shorter time than those who were still inthe study at Time 2 (7.2 vs. 10.1 years); they also all belonged to families who had reported morethan one traumatic event sustained after the birth of the teenager compared to 44.8% (30/67) of thesubjects seen at Time 2. To verify that this selective loss to follow-up did not bias the results, westudied the associations observed at baseline between the teenagers’ mental health profile (inter-nalizing, externalizing, competence) and their length of stay in Canada (method: Pearson’scorrelation) or the trauma sustained by the family after the birth of the teenagers (method: meanscomparison); these associations were similar for the total sample (n 5 76) and for the subjects seenat baseline and T2 (n 5 67) thus suggesting that loss to follow-up was not a major source of bias.

Both parents and adolescents signed consent forms describing their participation and theobjectives of the study. Parents were interviewed in Khmer, whereas teenagers were interviewedmainly in French, although they could switch to Khmer whenever they wished. All interviews wereconducted in the parents’ homes by Cambodian interviewers.

In this paper, three categories of variables were considered: (1) Emotional and behavioralproblems: internalization, externalization, risk behavior; (2) Social adjustment: feeling of compe-tence, peer relationships, school performance; (3) War trauma: type and timing (before and afterthe subject’s birth). Data were analyzed by gender of subject and by time of study (baseline vs.Time 2).

Levels of internalizing and externalizing symptoms were assessed by means of the YouthSelf-Report (YSR) (Achenbach, 1991), a scale that has been widely used with children and

Family trauma and adolescent refugees 1265

adolescents in transcultural settings adolescents (Bird, 1996; Crijnen, Achenbach, & Verhulst,1997; Verhulst & Achenbach, 1995). The French version was provided by Achenbach’s team.Reliability, as measured by Cronbach’s alpha, of the Internalizing and Externalizing scores for thesample was high:a 5 .86 anda 5 .77, respectively, at baseline anda 5 .83 anda 5 .80 at Time2. The Internalizing grouping consists of 29 items and the Externalizing grouping of 30 (Cross-Informants Syndrome Constructs). The 15-item YSR Competence subscale was used to assess oneaspect of social adjustment. This score showed good reliability, witha 5 .76 at baseline anda 5.78 at Time 2.

From a questionnaire developed by Sylvestre and colleagues (1992) to measure common riskbehaviors in North American youth, we derived a dichotomous variable indicating whether or notthe youth has engaged in risk behavior—such as using drugs or alcohol regularly, committingburglary, engaging in physical violence, and belonging to a street gang—in the last year. Whenused in previous studies conducted in multiethnic high schools, this questionnaire was wellreceived by the teenagers. At baseline, 9 of the 27 (33%) Cambodian girls and half of the 40Cambodian boys reported at least one risk behavior; at Time 2, the count was 8 (30%) girls and 15(38%) boys. The percentages observed at Time 2 are lower than those observed in Quebecois girls(52%) and boys (66%) of the same age group living in Montreal. The odds of reporting riskbehavior at Time 2 given that such behavior had been reported at baseline were not significant: .6for the girls and 1.2 for the boys.

Peer relationships were measured with the 30-item Adolescent Friendship Inventory (AFI)developed by Rubenstein, Heeren, Housman, Rubin, and Stechler (1989). Respondents indicatewhether they feel each statement is false, somewhat false, somewhat true or true as applied tothemselves. (They can also answer “not sure.”) The higher the total score, the higher the feeling ofsatisfaction with peer relationships. We added the AFI at Time 2 because we felt that we did nothave sufficient information on peer relationships and the support they may provide. The inventoryproved quite reliable (a 5 .78) in our sample.

We rated school performance in terms of two indicators of failure: (1) failing any of the threecompulsory high-school courses (French, English, or math) and (2) dropping out between baselineand Time 2. We looked at these indicators rather than grades because at Time 2, some teens hadmoved to schools that did not necessarily apply the same grading criteria. Academic records wereprovided by the schools. At baseline, 21 girls and 23 boys had passed all three compulsory coursesin the current school year, compared with 17 girls and 25 boys at Time 2.

We asked the parents about war trauma experienced by their families. Using a scale based on theBreslau and Davis model (1987) and developed in the course of earlier research (Rousseau, Corin,& Renaud, 1989; Rousseau, Drapeau, & Corin, 1998), we built two scores as proxies for indirectand direct exposure: the number of traumatic experiences sustained by the family before the child’sbirth and the number sustained after the child’s birth. The scale lists 19 types of trauma that mighthave been experienced prior or after the child’s birth (e.g., torture, execution, disappearance,imprisonment) and additional possible traumas the child might have suffered directly such as livingin a refugee camp and witnessing war-related violence. The number of traumatic experiencessustained before the birth of the teenagers was normally distributed, contrary to the number oftraumatic experiences after their birth. For the latter, 37 of the 67 subjects reported only one trauma,most commonly a stay in a refugee camp.

ANALYSIS

Ideally, the effect of war-related trauma on the mental health of young Cambodians should bestudied through a comparison of exposed and unexposed teenagers of the same ethnic origin whowent through the same migration process. Given the recent Cambodian history, such an unexposedgroup does not exist and thus the comparison has to be based on the level of exposure.


To study the relationship between war trauma experienced before or after the teenagers wereborn and their emotional or behavioral problems and social adjustment, and to investigate theevolution of these relationships between Time 1 and Time 2, we performed three types of statisticalanalysis, depending on the scales used to measure the variables and their distribution. For thenormally distributed traumas sustained before the birth of the teenagers, Spearman correlationcoefficients were used. Because of the strong asymmetry observed in the distribution of traumassustained after the birth of the teenagers, that variable was dichotomized between those whoreported only one trauma and those who reported more than one trauma, and the mean level ofemotional and behavioral problems and social adjustment was compared for these two categories.We used odds ratios to calculate the association between trauma sustained after the birth of theteenagers and risk behavior. Statistical significance was assessed using .95 confidence intervals forall measures of association or differences of means calculated separately for girls and boys, atbaseline and at Time 2.

To enhance our interpretation of the data, we performed a qualitative analysis of discussions heldin focus groups with young Cambodians having a social profile similar to those in the study.

RESULTS

Description of the Sample

At baseline, the mean age of the teenagers was 13.7 years and they had been in Canada a meanof 10.1 years. The characteristics of most of the households changed little over the study period.At baseline, a minority (28.4%) of the teens were living in a one-parent household; in 61.2% ofcases, both parents were unemployed; and 82.1% of parents interviewed felt their annual incomewas low. At Time 2, the percentage of one-parent households was the same, but four of them werenewly separated or divorced, whereas four of the households that had been headed by a singleparent at baseline were reconstructed two-parent households at Time 2; 35 of the 41 householdswith unemployed parents at baseline were in the same situation at Time 2 and four households wereheaded by newly unemployed parents at Time 2; the percentage of parents who perceived theirannual income as low rose from 82.1% at baseline to 89.6% at Time 2.

Trauma Sustained Before and after the Birth of the Child

The mean number of traumas sustained before the birth of the child was 4.8 and 44.8% of parentsreported more than one trauma sustained after the birth of the child (Table 1). The types of traumareported as having occurred before the child’s birth were different from those reported as havingoccurred after (Table 2). The types of trauma most frequently experienced by families before the

Table 1. Mean Number of War Traumas Sustained by the FamilyBefore theTeenager’s Birth and Percent of Parents Reporting More Than One Trauma Sus-

tained After Teenager’s Birth

Gender of Adolescent

BeforeTeenager’s Birth After Teenager’s Birth

Mean CIa % CI

Total (N 5 67) 4.82 4.03 to 5.61 44.8 32.6 to 57.4Girls (n 5 27) 5.48 4.17 to 6.80 33.3 16.5 to 54.0Boys (n 5 40) 4.38 3.37 to 5.38 52.5 36.1 to 68.5

a Confidence level is 0.95.


birth of the child were threats, execution and forced labor, whereas those sustained after consistedmainly of staying in a refugee camp and of traumas sustained while fleeing from Cambodia.

Psychosocial Profile of Girls and Boys

The girls’ mean Externalizing score decreased from 14.8 at baseline to 12.6 at Time 2 (theconfidence interval for the mean difference was .1 to 4.3) whereas their mean scores on theInternalizing (18.0 vs. 16.2) and Competence groupings (22.4 both times) were stable. For the boys,these three scores remained stable between baseline and Time 2: Externalizing scores wererespectively 16.0 and 16.2, Internalizing 17.2 and 15.5, and Competence 23.4 and 24.0. The meanlevel of satisfaction with peer relationships at Time 2 was similar for boys (115.5) and girls (118.9).

Association of Trauma Sustained Before the Birth of the Teenagers with Their PsychosocialProfile

The number of traumatic experiences before the birth of the teenagers was positively associatedwith the girls’ feeling of competence at baseline (r 5 .43) and negatively associated with the boys’level of externalizing symptoms (r 5 2 .35) at Time 2 (Table 3). The pattern of associationbetween trauma sustained before the birth of the teenagers and emotional profile did not differ

Table 2. Type and Timing of Main War Traumas Reported by Parents (N 5 67)

Type of Trauma BeforeTeenager’s Birth (%) After Teenager’s Birth (%)

Harassment 10.5 6.6Threats 34.2 10.5Imprisonment 2.6 —Execution 32.9 3.9Torture 3.9 1.3Disappearance 15.8 2.6Forced Labor 77.6 10.5Refugee Camp — 98.7Youth

Eyewitness — 9.0Migratory

Trauma — 34.3

Table 3. Spearman Correlations Between Adolescent Emotional Profile Scores and War TraumasSustained by FamilyBefore Teenager’s Birth

Emotional profile

Girls (n 5 27) Boys (n 5 40)

ra CIb r CI

InternalizingTime 1c 20.10 20.46 to 0.29 0.01 20.30 to 0.32Time 2d 20.14 20.50 to 0.25 20.28 20.54 to 0.03

ExternalizingTime 1 20.12 20.48 to 0.27 20.11 20.41 to 0.20Time 2 0.01 20.37 to 0.39 20.35 20.60 to20.04

CompetenceTime 1 0.43 0.06 to 0.69 0.11 20.20 to 0.41Time 2 0.25 20.14 to 0.58 20.24 20.51 to 0.08

a Spearman correlation coefficient.b Confidence level is 0.95.c Baseline data gathered in 1994.d Time 2 data gathered in 1996.


significantly between baseline and Time 2 for either gender. For the girls, there was a positiveassociation between trauma sustained before they were born and their level of satisfaction withfriendship (r 5 .49, CI .14 to .74); this association was not significant for the boys (r 5 .10, CI2.22 to .40). At Time 2, the mean number of traumas sustained before the birth of the teenagers waslower for boys reporting one or more risk behaviors compared with those reporting no risk behavior(2.9 vs. 5.2).

At baseline, boys who had passed all three compulsory courses belonged to families that hadsustained a significantly higher mean number of traumas before their birth (5.2 vs. 3.2; CI of thedifference .0 to 3.9); for girls, the difference was as high (6.0 vs. 3.8, CI of the difference2 .8 to5.4), but was not statistically significant because of the smaller sample (n 5 27). At Time 2, therewas no significant difference in the mean number of traumas sustained before the birth of theteenagers in boys or girls who were successful in school compared with those who had failed oneor more compulsory courses or who had dropped out of school.

Association of Trauma Sustained Before the Birth of the Teenagers with Their PsychosocialProfile

The association observed between psychosocial symptoms and war-related trauma differedsomewhat for trauma sustained after the birth of the child. Caution must be exercised in assessingthis difference, however, because traumas that occurred before the birth of the child are describedby a continuous variable whereas traumas that occurred after the birth of the child are dichoto-mized. Girls whose parents reported more than one trauma after their birth showed a higher meanInternalizing score than those whose parents reported only one such trauma (Table 4). The meanlevel of satisfaction with friendship was similar for youths whose families had reported only onetrauma sustained after their birth compared with those whose families had reported more than onetrauma; it was also similar in boys and girls for each level of exposure to trauma. None of the oddsratios for risk behavior or school failure were statistically significant although some were consid-erable. The odds ratio between trauma after the child’s birth and risk behavior ranged from .16(girls c.i. .02 to 1.52) and .54 (boys c.i. .16 to 1.91) at baseline to 2.80 (girls c.i. .50 to 15.66) and1.06 (boys c.i. .29 to 3.80) at Time 2. At baseline, the odds ratios of school failure were 1.03 (c.i.29 to 3.62) for boys and 6.40 (c.i. .89 to 45.99) for girls from families that had been exposed to

Table 4. Mean Adolescent Emotional Profile Scores, by Type of War Traumas Sustained by FamilyAfter Child’sBirth

Emotional Profile

Girls Boys

Refugee Campa

(n 5 18)More Traumab

(n 5 9) CIcRefugee Camp

(n 5 19)More Trauma

(n 5 21) CI

InternalizingT1d 16.7 20.6 210.1 to 2.4 16.6 17.8 26.2 to 3.9T2e 14.1 20.3 212.6 to 0.0 15.5 15.5 23.9 to 4.0

ExternalizingT1 14.8 14.8 24.7 to 4.8 15.2 16.7 25.4 to 2.4T2 11.6 14.6 28.0 to 2.1 15.3 17.0 25.6 to 2.3

CompetenceT1 23.2 20.8 20.3 to 5.2 23.2 23.5 23.0 to 2.3T2 22.8 21.7 22.4 to 4.8 22.9 24.9 24.2 to 0.1

a Parents reported only one trauma, most commonly residing in a refugee camp.b Parents reported more than one trauma.c Confidence level for the mean difference is 0.95.d Baseline data gathered in 1994.e Time 2 data gathered in 1996.


multiple trauma after their birth; at Time 2, these odds were .92 (.23 to 3.66) for the boys and .26(c.i. .03 to 2.66) for the girls.

DISCUSSION

Overall, our results show that responses to trauma are extremely complex and depend in part onthe trauma timing and on developmental factors that is, whether it was experienced before or afterthe birth of the subject. The second type applies particularly to adolescent refugees, who areinfluenced by the ever-changing cultural constructs of the kind of men and women that they areexpected to become. Before discussing the characteristics of the associations observed, we shouldpoint out the particular characteristics of our sample as compared with other populations describedin the literature.

The teenagers we interviewed differ from those studied by Sack and Kinzie’s team (Sack,Richard, Kinzie, & Roth-Ber, 1986; Kinzie et al., 1989; Sack et al., 1994) in several respects. Theywere almost all born around 1979, and so were very young when they left Cambodia; some of themwere born in refugee camps. Their relatively low level of direct exposure to the Pol Pot re´gime maywell explain, at least in part, the difference between the level of symptoms associated with directwar trauma in other studies and in ours. Traumas experienced after the child’s birth are associatedonly with anxiety and depression, reported by teenagers at Time 2. This association could havesomething to do with the extreme closeness between Cambodian girls and their parents. “Mymother often talks about the Pol Pot war. I don’t like it. Every time she starts talking, she cries, andit makes me upset inside, too” (16-year-old girl). An anniversary-like reaction may also beinvolved: Girls’ puberty may reactivate the memory of collective violence that specifically targetedwomen and that tarnished the honor of the community through them (Atlani, 1997; Rousseau et al.,1998).

Despite the different resettlement context (Canada rather than the United States), our data on therelatively low levels of behavioral problems coincide with what Sack and colleagues (1994)observed in Oregon, which could be interpreted as reflecting the internalization of Buddhiststandards of conduct (Rousseau et al., 1998). Nevertheless, our results also suggest that this patternis not independent of the trauma history and that the traumatic experiences of the family before thechild’s birth may play a protective role at various times in adolescence with regard to externalizingsymptoms, risk behavior, and academic failure in boys, and foster positive social adjustment (interms of friendship and competence) in girls. This pattern of association could be understood asovercompensation on the part of the children and grandchildren of the survivors of a massacre, whoinherit the implicit obligation to succeed for the sake of those no longer among the living. In aseries of studies of Cambodian women who lived through the Pol Pot re´gime, Campbell (1992)notes that these women see themselves as powerless to recover from their losses and unable torestore the family honor. They place the burden on their children, who they hope will succeed atany price, and so restore the dignity lost by the family and appease the spirits of relatives who diedwithout a proper burial (the Khmer Rouge outlawed traditional Buddhist rituals to honor the deadand allow them to rest in peace). The focus group conducted with Cambodian teens confirmed thatthey felt indebted to their parents and their community because of the trauma they had beenthrough, and that they were quite aware of bearing the weight of their families’ great expectations.“They (our parents) always think of us before thinking of their own lives. . . . Whatwill becomeof their child? They always think of their child before . . .They will do anything for their child.I would do anything for her (my mother), you know, anything she asked” (17-year-old boy).

It is interesting to note that these expectations affect boys differently than they do girls.Culturally, boys have direct, explicit control over their surroundings (Kulig, 1994) and are chieflyexpected to observe the traditional codes of conduct better. Girls, on the other hand, are expected


to “hold their culture” (Kulig, 1994) and maintain harmony in family relationships (Frye &D’Avanzo, 1994) by avoiding confrontation and resorting to much less direct methods of control.Krulfeld (1994) underscores how changes in gender roles among Cambodians are influenced bymicroprocesses triggered by interaction with the host society. She points out that in the refugeesettlement process gender identity is usually recreated, reinvented and renegotiated to fit the newsetting. Our data suggest that this identity is also a reflection, or even an embodiment, of the historyof the family and the community. This observation is similar to the findings of Puna¨maki (1996),who, examining the meaning adolescents attribute to war and to peace, shows how expectationsdiffer depending on gender, because the role of each gender in the community determines in partone’s understanding of history.

Our data on the potentially protective effect of some forms of war trauma also corroborate theobservations of Macksoud and Aber (1996), who, without minimizing the suffering associated withwar trauma, argues that traumatic experiences may also have positive effects and suggestsinvestigating a broader range of responses to war trauma, far beyond just posttraumatic symptoms.

The complexity of responses to war trauma may be linked to the network of meanings theyevoke. In an essay comparing symptomatology profile and in particular the presence or absence ofdissociation in Holocaust survivors and victims of child abuse in North America, Kirmayer (1996)suggests that the collective meaning attributed to these events shapes the construction of memoriesaround them. The collective meaning built in war or armed conflict situations could structure notonly the way in which the pain will be expressed but also the different avenues that will permitpersonal and collective reconstruction.

If the contradictory effects of war trauma, which are often observed clinically, are really to betaken into account, then we should rethink more fundamentally the theory that trauma is essentiallya handicap. Nathan (1988) proposes considering trauma as a metamorphosis, which could be abetter way of conceptualizing the processes involved in both individual and group responses totrauma. This new perspective would have a direct impact on approaches to therapy, because itwould no longer be a matter of simply eliminating symptoms, but just as important, of acknowl-edging and fostering the resilience that is born of suffering, however extreme.

Repeating the Buddhist teachings of her family and talking about the strength that she and herfamily discovered through their ordeals during the Pol Pot re´gime, Mom, a 16-year-old girl, said,“I am hopeful. There is always a way out. That’s what my mother always tells me. She gives meadvice. She says, ‘You mustn’t give up when you have a problem, or it will get worse, it will justget worse and worse.’. . . when I am in a situation, sometimes I cry, I start crying, but thenafterwards, I gather my strength. I don’t run away when I have a problem.”

REFERENCES

Achenbach, T. M. (1991).Manual for the Youth Self-Report and 1991 Profile. Burlington, VT: University of Vermont,Department of Psychiatry.

Allodi, F. (1989). The children of victims of political persecution and torture: A psychological study of a Latin Americanrefugee community.International Journal of Mental Health, 18, 3–15.

Atlani, L. (1997). Assistance aux victimes de violence sexuelle dans les camps de re´fugies. Lecture ethnologique desrecommandations des agences internationales de soutien psychosocial.Psychopathologie Africaine, 28, 25–53.

Ayalon, O. (1982). Children as hostages.Practitioner, 226, 1773–1781.Becker, D., Morales, G., & Aguilar, M. I. (Ed.). (1994).Trauma psicosocial y adolescentes Latinoamericanos: Formas de

Accion Grupal. Santiago, Chile: Instituto Latino Americano de Salud Mental y Derechos Humanos.Bird, H. (1996). Epidemiology of childhood disorders in a cross-cultural context.Journal of Child Psychology and

Psychiatry, 37, 35–49.Breslau, N., & Davis, G. C. (1987). Post-traumatic stress disorder: The etiologic specificity of wartime stressors.American

Journal of Psychiatry, 144, 578–583.Cairns, E., & Dawes, A. (1996). Children: Ethnic and political violence—a commentary.Child Development, 67, 129–139.Campbell, H. L. (1992).Southeast Asian refugee psychotherapy: Progression of dreams a clinical study. Narini, Italy: SPC.Crijnen, A., Achenbach, T., & Verhulst, F. C. (1997). Comparisons of problems reported by parents of children in 12


cultures: Total problems, externalizing, and internalizing.Journal of American Academy of Child and AdolescentPsychiatry, 36, 1269–1277.

Danieli, Y. (1985). The treatment and prevention of long-term effects and intergenerational transmission of victimization:A lesson from Holocaust survivors and their children. In C. R. Figley (Ed.),Trauma and its wake(pp. 295–313). NewYork: Brunner/Mazel.

Frye, B. A., & D’Avanzo, C. D. (1994). Cultural themes in family stress and violence among Cambodian refugee womenin the inner city.Advances in Nursing Science, 16, 64–77.

Kestenberg, J. S. (1993).The diversity of child survivors of the Holocaust. Children, war, and persecution. Hamburg,Germany.

Kinzie, D., Sack, H. W., Angell, H. R., Manson, S., & Roth, B. (1986). The psychiatric effects of massive trauma onCambodian children: 1. The children.Journal of the American Academy of Child and Adolescent Psychiatry, 25,370–376.

Kinzie, J. D., Sack, W., Angell, R., Clarke, G., & Ben, R. (1989). A three-year follow-up of Cambodian young peopletraumatized as children.Journal of the American Academy of Child and Adolescent Psychiatry, 28, 501–504.

Kirmayer, L. J. (1996). Landscapes of memory. Trauma, narrative and dissociation. In P. A. Antze & M. Lambek (Eds.),Tense past cultural essays in trauma and memory(pp. 173–198). New York: Routledge.

Krulfeld, R. M. (1994). Buddhism, maintenance, and change: Reinterpreting gender in a Lao refugee community. In L. A.Camino & R. M. Krulfeld (Eds.),Reconstructing lives, recapturing meaning. Refugee identity, gender, and culturechange(pp. 97–127). Washington, DC: Gordon and Breach Publishers.

Kulig, J. C. (1994). Old traditions in a new world: Changing gender relations among Cambodian refugees. In L. A. Camino& R. M. Krulfeld (Eds.),Reconstructing lives, recapturing meaning, refugee identity, gender, and culture change(pp.129–146). Washington, DC: Gordon and Breach Publishers.

Macksoud, M. S., & Aber, J. L. (1996). The war experiences and psychosocial development of children in Lebanon.ChildDevelopment, 67, 70–88.

Miller, K. E. (1996). The effects of state terrorism and exile on indigenous Guatemalan refugee children: A mental healthassessment and an analysis of children’s narratives.Child Development, 67, 89–106.

Nathan, T. (1988). La migration des aˆmes.Nouvelle Revue d’Ethnopsychiatrie, 11, 25–42.Punama¨ki, R.-L. (1996). Can ideological commitment protect children’s psychosocial well-being in situations of political

violence?Child Development, 67, 55–69.Richman, N. (1993). Annotation: Children in situations of political violence.Journal of Child Psychology and Psychiatry,

34, 1286–1302.Rousseau, C., Corin, E., & Renaud, C. (1989). Conflit arme´ et trauma: une e´tude clinique chez des enfants re´fugies

latino-americains.Canadian Journal of Psychiatry, 34, 376–385.Rousseau, C., Drapeau, A., & Corin, E. (1998). Risk and protective factors in central American and Southeast Asian refugee

children.Journal of Refugee Studies, 11, 20–37.Rubenstein, J. L., Heeren, T., Housman, D., Rubin, C., & Stechler, G. (1989). Suicidal behavior in “normal” adolescents:

Risk and protective factors.American Journal of Orthopsychiatry, 59, 59–71.Sack, W. H., Clarke, G., Him, C., Dickason, D., Goff, B., Lanham, K., & Kinzie, D. (1993). A 6-year follow-up study of

Cambodian refugee adolescents traumatized as children.Journal of the American Academy of Child and AdolescentPsychiatry, 32, 431–437.

Sack, W. H., McSharry, S., Clarke, G. N., Kinney, R., Seeley, J., & Lewinsohn, P. (1994). The Khmer adolescent project:I. Epidemiologic findings in two generations of Cambodian refugees.Journal of Nervous and Mental Disease, 182,387–395.

Sack, W, Richard, H. A., Kinzie, H., Roth-Ber, D.J. (1986). The psychiatric effects of massive trauma on Cambodianchildren: II. The family, the home and the school.Journal of the American Academy of Child and Adolescent Psychiatry,25, 377–383.

Sigal, J. J., & Weinfeld, M. (1985). Control of aggression in adult children of survivors of the Nazi persecution.Journalof Abnormal Psychology, 94, 556–564.

Solkoff, N. (1992). Children of survivors of the Nazi Holocaust: A critical review of the literature.American Journal ofOrthopsychiatry, 62, 342–358.

Sylvestre, R., Frappier, J. Y., Doucet, H., Charbonneau, L., Lambert, J., Malus, M., & Saucier, J. F. (1992).Adaptation a`L’Adolescence et Appartenance Culturelle.Congress of the Canadian Anthropology Association, Montreal, Canada.

Terr, L. C. (1991). Chilhood traumas: An outline and overview.American Journal of Psychiatry, 148, 10–21.Verhulst, F. C., & Achenbach, T. M. (1995). Empirically based assessment and taxonomy of psychopathology: Cross-

cultural applications.European Child and Adolescent Psychiatry, 4, 61–76.

RESUME

Objectif: Le but principal de cette e´tude fut d’examiner les effets des traumatismes de guerre sur l’adaptation sociale et lefonctionnement de jeunes re´fugies cambodgiens.Methode: L’etude longitudinale portrait sur 67 jeunes re´fugies cambodgiens vivant a` Montreal, qui ont ete interviewesdurant la premie`re anneé du second cycle, et deux ans plus tard, afin d’examiner le veću de leurs familles durant la guerre.On s’est penche´ sur les traumatismes qui auraient prećede leur migration et les liens avec leur adaptation sociale et leursproblemes emotionnels et du comprotement. Ces proble`mes ont e´te evalues en se servant du Youth Self-Report et d’un


inventaire de comportements a` risque. L’ajustement social fut mesure´ en utilisant come indices le rendement scolaire, lesrelations avec ses pairs et le sens de la compe´tence personnelle.Resultats: Le traumatisme qu’aura e´prouvela famille avant de quitter sa patrie et avant la naissance de l’adolescent sembleavoir un effet protecteur durant diverses phases de l’adolescence, et ceci par rapport aux symptoˆmes exte´riorises, aucomportement a` risque et aux ećhecs scolaires des garçons; et il predispose les adolescentes a` jouir d’une adaptation socialefavorable.Conclusions:On conclut que ces reáctions seraient une sur-compensation de la part des enfants ne´s dans des familles quiont survecu les massacres et a` qui on a trainsmis la responsabilite´ de reussir dans la vie. On est porte´ a conclure que la vastegamme de reáctions post-traumatiques suite aux situations de guerre devraient eˆtre etudiees, autant a` titre d’epreuve que desource de vigueur.

RESUMEN

Objectivo: El principal objetivo de este estudio fue investigar el efecto del trauma relacionado con la guerra sobre el ajustesocial posterior y el funcionamiento de refugiados jo´venes de Cambodia.Metodo: Este estudio longitudinal de 67 jo´venes de Cambodia refugiados en Montreal entrevistados en el primer anõ desecundaria y entonces, dos anõs despue´s, examina la exposiciooń de la familia al trauma de premigracioń relacionado conla querra y su asociacioń con los problemas emocionales y conductuales de los adolescentes y su ajuste social. Losproblemas emocionales y conductuales fueron evaluados utilizando el “Youth Self-Report” y un inventario de conductas deriesgo. El ajuste social fue evaluado en te´rminos de aprovechamiento escolar, relaciones con sus compan˜eros y sentido decompetencia.Resultados:El trauma que una familia sufre antes de dejar su patria y antes del nacimiento del adolescente parece jugarun papel protector en varios momentos en la adolescencia en relacioń a sıńtomas externalizados, conducta de riesgo, yfracaso escolar en los varones, y promueven ajuste social postivo en las muchachas.Conclusion: Estas reacciones pueden entenderse como sobre-compensacioń de los que sobreviven una masacre, a quienesse les ha transmitido el deber implıćito de tener e´xito. Ellos sugieren que deben investigarse una variedad ma´s amplia derespuestas post-trauma´ticas a las situaciones de guerra y que debe ser examinada con ma´s cuidado la doble naturaleza deltrauma como carga y fuente de fortaleza.


family trauma and its association with emotional and behavioral problems and social adjustment in...

Documents