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Volume 19, 2018 - Issue 2

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Intergenerational transmission of
25 traumatization: Theoretical framework and
implications for prevention
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Ariel J. Lang  , PhD, MPH & Maria A. Gartstein , PhD

Pages 162-175 | Received 29 Nov 2016, Accepted 10 Mar 2017, Accepted author version posted online: 16 May 2017, Published online: 29 Jun
2017

 Download citation  https://doi.org/10.1080/15299732.2017.1329773

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ABSTRACT
In this article
Intergenerational transmission of traumatization (ITT) occurs when traumatized
People also read

ABSTRACT parents have offspring with increased risk for emotional and behavioral problems.
Although fetal exposure to the maternal biological milieu is known to be one factor in Article
PTSD and ITT
ITT, PTSD-driven parent–child interactions represent an additional important and Shifting the focus:
Nonpathologizing
Parent–child potentially modifiable contributor. The Perinatal Interactional Model of ITT presented
interactions and approaches to healing
ITT herein proposes that PTSD leads to social learning and suboptimal parent–child from betrayal trauma
interactions, which undermine child regulatory capacity and increase distress, largely through an emphasis
Perinatal
on relational care 
interactional model explaining poor social-emotional outcomes for offspring of parents with PTSD.
of ITT
Psychosocial intervention, particularly when delivered early in pregnancy, holds the
Jennifer M. Gómez et al.
Interrupting ITT possibility of disrupting ITT.
Journal of Trauma & Dissociation
Volume 17, 2016 - Issue 2
References KEYWORDS: Cognitive behavioral, intergenerational transmission of traumatization, perinatal mental
Published online: 13 Oct 2015

health, PTSD

Article
Exposure to trauma is an unfortunately common human experience. World wide over Symptoms of
70% of people are exposed to trauma, with approximately 30% reporting more than Trauma and
one such event (Benjet et al.,  2016). Intergenerational transmission of Traumatic Memory
Retrieval in Adult
traumatization (ITT) occurs when offspring of a traumatized individual display adverse
Survivors of
outcomes (Bowers & Yehuda,  2016). Currently, contextual factors provide the most
Childhood Sexual
likely path through which to prevent ITT. Abuse 

The objective of this article is to provide a framework describing posttraumatic stress

Cheryl Malmo PhD et al.
disorder-(PTSD-) related behavioral and cognitive factors that contribute to
Journal of Trauma & Dissociation
suboptimal parent–child interactions thereby supporting ITT. While caregiver trauma Volume 11, 2010 - Issue 1

Published online: 7 Jan 2010

exposure alone may contribute to ITT (e.g., through fetal exposure to stress 

hormones; Babenko, Kovalchuk, & Metz,  2015), PTSD increases the risk for
offspring dysfunction above and beyond trauma exposure (Marsanic, Margetic, Jukic,
Editorial
Matko, & Grgic,  2014; Tees et al.,  2010; Zerach, Kanat-Maymon, Aloni, &
Sexuality and
Solomon,  2016). Because this exacerbation of risk appears attributable to trauma:
psychopathology, we focus on parents with PTSD, articulating a parent–child Intersections
interaction-focused model and proposing strategies for prevention of ITT. between sexual
orientation, sexual
Although the nature of caregiver trauma and mechanisms responsible for symptom functioning, and
onset are likely relevant to child outcomes, such distinctions are beyond the scope of
sexual health and
traumatic events 
the proposed framework. If the model is supported, subsequent refinement based on
trauma type/symptom origin would be important. Similarly, ITT has been linked to
Alec M. Smidt et al.
epigenetic, neuroendocrine, and neuroanatomical changes (Bowers & Yehuda,
Journal of Trauma & Dissociation
 2016); these are understood as a context for our model but not the present focus. Volume 19, 2018 - Issue 4

Published online: 30 Mar 2018

Finally, we focus on “top-down” exposure, wherein only the parent experienced the 

traumatic event (Leen-Feldner et al.,  2013).

Article

Trauma-Related
PTSD and ITT Altered States of
Consciousness:
Exploring the 4-D
Parental PTSD is associated with poorer lifetime offspring outcomes. Maternal PTSD
Model 
has been linked to infant internalizing, externalizing and dysregulation symptoms
(Bosquet Enlow et al.,  2011) as well as “difficult temperament” (Tees et al.,  2010).
Paul A. Frewen et al.
Caregiver PTSD also appears to translate into infant’s poor coping with stress,
Journal of Trauma & Dissociation
including greater distress when presented with novelty (Brand, Engel, Canfield, & Volume 15, 2014 - Issue 4

Published online: 20 Mar 2014

Yehuda,  2006) and slower recovery from distress, controlling for maternal 

depression and infant traumatization (Bosquet Enlow et al.,  2011; Enlow et al.,
 2009). During childhood, maternal avoidance symptoms related to interpersonal Article
violence were associated with child regulatory difficulties, and hyperarousal and re- Childhood Traumatic
experiencing symptoms were linked to child socio-emotional problems (Ahlfs-Dunn & Experiences and
Dissociative
Huth-Bocks,  2014). Similarly, maternal PTSD and depression related to the World
Phenomena in Eating
Trade Center attacks were associated with increased aggressive behavior, emotional Disorders: Level and
reactivity, and somatic symptoms for preschool-age children (Chemtob et al.,  2010; Association with the
Severity of Binge Eating
Nomura & Chemtob,  2009). Adolescent offspring of male Croatian war veterans Symptoms 
with PTSD, as opposed to those of veterans without PTSD, self-reported more
internalizing and externalizing symptoms as well as more total problems (Marsanic et Giovanni L. Palmisano et al.
al.,  2014). Journal of Trauma & Dissociation
Volume 19, 2018 - Issue 1

Published online: 5 Apr 2017

A series of studies with adult offspring of Holocaust survivors (e.g., Yehuda, Halligan, 

& Bierer,  2001) showed parental PTSD predicting offspring psychiatric problems.
Similarly, data from the National Comorbidity Survey—Replication demonstrated that
Introduction
parental PTSD was associated with offspring anxiety and depression, even after
Polyvictimization in
controlling for demographic factors and comorbidity (Leen-Feldner, Feldner, Bunaciu, childhood and its
& Blumenthal,  2011). adverse impacts
across the lifespan:
The Perinatal Interactional Model of ITT proposed herein focuses on infancy as a Introduction to the
critical window, prior to offspring symptom onset, when temperamental self- special issue 
regulation emerges and reactive tendencies consolidate. Disruptions as self-
regulation first “comes online” (Posner, Rothbart, Sheese, & Voelker,  2012) can Julian D. Ford et al.
Journal of Trauma & Dissociation
predispose children to a wide range of behavioral/emotional difficulties. According to Volume 19, 2018 - Issue 3

the psychobiological model of temperament, regulation that manifests as control over Published online: 16 Mar 2018

behavior and emotions is afforded by attentional skills, developing rapidly in early
childhood. Orienting attention in infancy provides the foundation for subsequent
flexible, volitionally controlled attention, a product of developing executive functions
and the maturation of frontal brain regions (Gartstein, Bridgett, Young, Panksepp &
Power,  2013). Attention-based regulation is relevant to a multitude of critical
outcomes across the lifespan (Gartstein, Putnam, Aaron & Rothbart,  2016); its early
disruption would account for the broad spectrum of difficulties identified in offspring
of parents with PTSD.

Parent–child interactions and ITT

Early parent–child interactions are critical to the development of self-regulation

(Conradt & Ablow,  2010; Gartstein, Crawford, & Robertson,  2008). Observational
studies suggest poorer quality of parent-child relations in the context of caregiver
PTSD; maternal depression and PTSD were prospectively linked to impaired bonding
(Seng et al.,  2013) and predicted child insecure attachment (Bosquet Enlow,
Egeland, Carlson, Blood, & Wright,  2014). We suggest that two processes, social
learning and impaired caregiving behavior, largely explain the diminished quality of
parent–child relationships observed for caregivers with PTSD.

Social learning

Social learning is the phenomenon, whereby emotional/behavioral reactions can be

learned by observation (Bandura,  1963). Parental negative affect is highly salient to
children (Carver & Vaccaro,  2007), increasing the odds of social learning of
emotional and behavioral patterns. In the case of parents with PTSD, children may
observe intense emotional reactions (e.g., fearfulness, anger, sadness), avoidance, or
withdrawal/dissociation.

Social learning of fear has been demonstrated in both animal (e.g., Debiec & Sullivan,
 2014) and human experiments, albeit not specifically in the context of PTSD. Infants
who observed a brief socially anxious mother–stranger interaction demonstrated
more fear and avoidance with a stranger than did those who observed an interaction
with a stranger during a neutral/pleasant condition (De Rosnay, Cooper, Tsigaras, &
Murray,  2006). Infants of socially anxious or nonanxious parents observed their
mother interact with a stranger and then interacted with that same stranger. Children
of socially anxious mothers were more behaviorally inhibited with the stranger, and
maternal expressed anxiety predicted infant avoidance (Murray et al.,  2008).
Anxious/fearful mothers approach situations with uncertainty/hesitation in the
presence of their infants, leading to an exacerbation of the children’s fearful reactions
(Muris, Steerneman, Merckelbach, & Meesters,  1996).

Social learning is also relevant to learning other types of responses (Boccia & Campos,
 1989). For example, learning to manipulating an object to make a sound (Paulus,
Hunnius, & Bekkering,  2013), pacing of movement (Scola, Bourjade, & Jover,
 2015), and food preferences (Hamlin & Wynn,  2012) have been linked to social
learning. The most extensive evidence supports social transmission of fear in infancy;
this could be a function of extant research, the evolutionary salience of fear reactions,
or the timing of this domain of temperament, which develops rapidly starting around
6 months of age (Gartstein et al.,  2010). Extrapolating from these studies, other
forms of parental emotional responding and intrusive/aggressive behavior (Elwood,
Williams, Olatunji, & Lohr,  2007) are hypothesized to shape children’s reactions as
well and may become more critical beyond infancy.

Caregiving behavior

Caregiving behavior is an essential component of parent–child interactions,

contributing to bonding and offspring resilience. Seminal studies demonstrated that
maternal care during the first 10 days of life was related to the stress response of
adult offspring of rats (e.g., Caldji, Diorio, & Meaney,  2000). For humans, sensitive–
responsive mother–infant interactions offer protective effects with respect to infant
stress reactivity and regulatory capacity/orienting (Gartstein, Crawford, & Robertson,
 2008; Landry, Smith, & Swank,  2006; Thompson & Trevathan,  2008).
Importantly, maternal sensitivity buffered against effects of maternal antenatal
psychiatric diagnoses on infant cortisol (Kaplan, Evans, & Monk,  2008). Maternal
insensitivity, on the other hand, was associated with greater sympathetic activation
and cortisol output when infants were confronted with a stressor (Bosquet Enlow et
al.,  2014). Factors that contribute to a dysregulated stress response in the offspring
are important, as the latter has been linked with a variety of problematic outcomes,
for example, disrupting attentional functioning critical to self-regulation (Lengua,
Zalewski, Fisherb, & Moran,  2013). More generally, unsupportive maternal behavior
was prospectively linked to child mental health problems into adulthood (Fan et al.,
 2014).

Parental PTSD appears to interfere with caregiving behavior. Women with PTSD report
more hostility (Davies, Slade, Wright, & Stewart,  2008) and psychological and
physical aggression (Chemtob, Gudino, & Laraque,  2013) toward their infants.
Families in which a parent has PTSD have been characterized by more conflictual
exchanges (Westerink & Giarratano,  1999), and higher rates of child maltreatment
(Yehuda, Blair, Labinsky, & Bierer,  2007; Yehuda, Halligan, & Grossman,  2001),
punitiveness, psychological aggression, and physical discipline (Cohen, Hien, &
Batchelder,  2008). In a refugee sample, intrusion and avoidance explained
individual differences in extremely insensitive parenting, which had direct negative
effects on children’s attachment organization (Van Ee, Kleber, Jongmans, Mooren, &
Out,  2016).

PTSD can directly interfere with parenting. Symptoms such as irritability, anxiety, or
dissociation negatively affect the child, particularly in the case of infants with their
considerable dependence and constant need for care. Exposure to maternal negative
affect may enhance the expression of neuronal groups associated with withdrawal
behavior and negativity in the infant brain (Nelson & Bosquet,  2000). Further,
infants’ physiology closely matches maternal stress responses (Waters, West, &
Mendes,  2014), so would be adversely affected by maternal
reactivity/dysregulation. In addition, numbing and dissociation are exhibited as
unavailability, inconsistent with sensitivity necessary for more optimal exchanges with
the infant, facilitating attachment security and other important outcomes (e.g., De
Wolff & Van Ijzendoom,  1997; Gartstein, Crawford, & Robertson,  2008).
Consistent with this pattern of results, “unresolved trauma” was described as
precipitating parental behaviors experienced as frightening by the infant (e.g., sudden
retreat from the infant, treatment of the infant as a potentially dangerous object;
Schuengel, Bakermans-Kranenburg, & Van Ijzendoorn,  1999).

Maternal cognitions

Mothers with PTSD have been observed to characterize their babies as less warm,
more invasive, and more difficult than mothers without the diagnosis (Davies et al.,
 2008). One possible explanation for this finding is that the PTSD-related cognitive
biases that lead individuals to view others negatively extend to beliefs about the child.
This hypothesis was examined by Schechter and colleagues ( 2005), who found that
greater maternal PTSD severity was associated with unrealistic expectations of the
child and attributions of malevolent intention to child behavior. Similarly, Daggett and
colleagues ( 2000) reported unrealistic expectations about offspring developmental
progress for mothers who experienced childhood adverse events, developing
“negative attitudes about life” and the child. Thus, we suggest that PTSD influences
mothers’ appraisals of their offspring thereby eroding the quality of parent–child
interactions.

Summary

Suboptimal parenting renders children less able to tolerate and/or recover from
stress (e.g., Zalewski, Lengua, Kiff & Fisher,  2012). Over time, the parent and child
develop a dysfunctional interactional system. The child’s distress is directed toward a
parent who, in turn, exhibits inadequate tolerance of the child’s distress and limited
coping resources. Mothers with PTSD reported greater psychological stress and, in
line with the latter pathway, showed more limbic and less frontocortical activity
relative to healthy controls when observing children being separated from a caregiver
(Schechter et al.,  2012).

Perinatal interactional model of ITT

This literature can be summarized in the Perinatal Interactional Model of ITT (Figure
1), referred to as such because of our emphasis on parent–child interaction (i.e.,
maladaptive parenting and social learning) mechanisms. This focus is supported by
the existing literature and further justified because these components are modifiable
through treatment, expected to be most effective if delivered prior to the child’s birth.
The current model represents a theory synthesis effort, which followed prescribed
steps: (1) specifying focal concepts; (2) reviewing the literature to discern variables
related to focal concepts and the nature of their relationships; and (3) organizing
concepts/statements into an integrated model that represents the phenomenon of
interest (Olszewski-Walker & Avant,  2011). The goal of this effort was to stimulate
model-testing efforts along with clinical applications. Only studies deemed to possess
high levels of internal validity (either relying on an experimental paradigm, or
implementing proper statistical control in quasi-experimental and correlational
studies) provided the basis for the model. Some potentially relevant elements were
necessarily excluded during this initial theory synthesis effort, as, for example, our
model does not address the cause of maternal of PTSD, or type of trauma. Empirical
tests of the proposed model will be used as a guide in determining the next set of
relationships/concepts to synthesize.

Figure 1. Perinatal interactional model of ITT.

Display full size

PTSD leads to biological changes in offspring (“fetal programming”; Figure 1, path a)

that affect the child’s regulatory capacity (path b, Bowers & Yehuda,  2016;
Danielson, Hankin, & Badanes,  2015). After birth, PTSD symptoms, including
emotional dysregulation and trauma-related beliefs, drive maladaptive parenting
behavior (path c, Berlin, Dodge, & Reznick,  2013; Elwood et al.,  2007) and
contribute to social learning, for example through displays of emotionally charged
behavior (path d). Suboptimal parenting behavior has been shown to impede the
development of the child’s regulatory capacity (path e, Pat-Horenczyk et al.,  2015).
Maternal modeling and insensitivity to distress lead children to minimize, mask, or
over-regulate negative emotions, instead of expressing or modulating these more
adaptively (Cassidy,  1994), contributing to behavioral problems and lower social
competence (Leerkes, Blankson, & O’Brien,  2009). Maladaptive parenting and social
learning via caregiver emotional behavior also directly contribute to child reactivity
and distress (path f, Calkins,  1994; path g, De Rosnay et al.,  2006). Further, the
child and his/her distress may be viewed as a threat or as exceeding the parent’s
coping resources, thus exacerbating parental distress (path h, Davies et al.,  2008;
Schechter et al.,  2015). The self-perpetuating nature of this cycle culminates in
greater adversity for the offspring in the long term, without strategic intervention
efforts.

Interrupting ITT

The Perinatal Interactional Model of ITT highlights the role of postpartum parental
behavior in ITT. To the extent that parental behavior is modifiable, maladaptive
trajectories and long-term risk associated with ITT can be altered. Because of the
potential teratogenic effects of typically recommended medications for PTSD (Gentile,
 2015), evidence-based psychotherapy offers considerable advantages for perinatal
PTSD. Psychotherapy appears to be well tolerated during pregnancy (Arch, Dimidjian,
& Chessick,  2012).

Psychotherapy is known to be effective in modifying symptomatology and

maladaptive beliefs (Zalta,  2015). Although the malleability of beliefs specific to
parenting/children has not been examined in the context of PTSD treatment, such
beliefs appear to be modifiable. Schechter and colleagues ( 2006) delivered a
“videofeedback exposure session” to mothers with PTSD, wherein each caregiver
viewed videotaped interactions with her child, discussing positive and negative
aspects of the interactions with a clinician. This brief intervention led to less negative
maternal attributions about the child—a finding that was replicated in a second study
of this procedure, showing that mothers with PTSD had more negative attributions
than control mothers before the intervention, but did not differ from controls after
treatment (Schechter et al.,  2015). These results seem promising, yet the probability
such maladaptive cognitions will return high unless the psychopathology underlying
these beliefs (i.e., PTSD) is addressed. Social learning that occurs as a child observes
signs and symptoms of maternal PTSD was also beyond the scope of this approach.
Treatment efforts not specific to PTSD indicate that mothers participating in an
intervention challenging parental attributions about the child responded with lower
levels of harsh parenting, relative to those in a control conditions (Bugental et al.,
 2002), and there is evidence that changing parental attributions translates into
altered behavior with children (Wilson & White,  2006). Thus, psychotherapy
designed to treat PTSD and associated symptoms, particularly with modifications
specific to the perinatal period and focused on parenting, likely can address these
problems, alleviating parental symptoms and benefiting parent–child interactions in
turn.

The malleability of PTSD suggests the possibility of preventing ITT in the perinatal
period. As presented in Figure 2, providing pregnant women relief for PTSD can be
expected to provide postpartum benefits, as decreased symptom frequency/severity
results in improved parent–child interactions (path c’) and reduced socially learned
emotionally driven behavior (path d’). Fewer distressing mother–child exchanges
would allow child regulatory capacity to “come online” without disruptions (path e’)
and reduce child distress (paths f’ and g’), which diminishes this stressor for the
mother (path h’). Importantly, effective PTSD treatment during pregnancy also can be
expected to prevent/minimize fetal programming related to prenatal trauma-related
exposure (path a’; Yehuda et al.,  2013).

Figure 2. Mechanisms of preventive intervention.

Display full size

As we have learned from treatment of postpartum depression, modifying maternal

psychopathology ultimately may not be sufficient to address mother–child
interactions and child outcomes (Murray, Cooper, Wilson, & Romaniuk,  2003). A
recent study showed that treatment of postpartum depression reduced parenting
stress but did not impact maternal responsivity or negative views about the infant
(Forman et al.,  2007). Thus, a more robust program, combining PTSD treatment
tailored for this population with post-partum boosters and parent–child interaction
training, may be required to disrupt ITT.

In conclusion, ITT is a well-described phenomenon understood in terms of

interactions between biological and environmental pathways. Currently, the most
viable strategy for preventing ITT begins with addressing maternal psychopathology,
ideally during pregnancy. Symptom alleviation is expected to reduce social learning of
emotional behavior and the impact of maladaptive parenting, improving parent–child
interactions. Importantly, the focus on parenting is expected to improve caregiving
and child outcomes. Such efforts are critical from the standpoint of public health,
given the tremendous personal and social cost associated with ITT (Anda et al.,
 2006). Although ITT appears to be more substantial in relation to maternal, relative
to paternal, PTSD (Yehuda, Bell, Bierer, & Schmeidler,  2008), PTSD in either parent
will impact the family system, and paternal PTSD should be studied more closely in
the future. Paternal PTSD appears to put offspring at greater risk for developing their
own PTSD following trauma (Zerach et al.,  2016) and was associated with less
caregiving behavior in both parents (Marsanic et al.,  2014). Thus, future work aimed
at understanding the impact of PTSD on the total family system is critical as well.

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