Violent childhood experiences - Consequences on mental health and approaches to intervention

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In order to develop in a healthy manner, a child requires a secure environment and a steady bond with a close caregiver (Johnson, Browne, & Hamilton-Giachritsis, 2006). However, experiences of violence may interfere with this process of healthy development. The present thesis examined the consequences of exposure to family, institutional and organized violence on the mental health of children in Sub-Saharan Africa, living either in institutional care or being associated with armed forces. Subsequently, intervention approaches to reduce psychological suffering and to prevent children from further exposure to violence were developed and evaluated.


Children in Sub-Saharan Africa are exposed to high rates of corporal punishment within their families and schools (UNICEF, 2010, 2011). Studies from other settings have found that family violence is strongly related to mental health problems, including trauma spectrum disorders as well as internalizing and externalizing psychological problems (e.g. Catani, Jacob, Schauer, Kohila, & Neuner, 2008; Elbert et al., 2009; Gámez-Guadix, Straus, Carrobles, Muñoz-Rivas, & Almendros, 2010). In Sub-Saharan Africa, institutional care is part of the support system for orphans and vulnerable children (McCall, 2013; Wolff & Fesseha, 1998). The few existing studies investigating these contexts have indicated that the quality of caregiving in such institutions is poor and that the caregivers are often undereducated and overburdened (e.g. Espié et al., 2011; Levin & Haines, 2007; Wolff & Fesseha, 1999). To date, little is known about the occurrence of violence toward children in institutional care in Sub-Saharan Africa. Interventions in institutional care worldwide have successfully improved the quality of caregiving (e.g. Levin & Haines, 2007; St. Petersburg-USA Orphanage Research Team, 2008; Wolff & Fesseha, 1999), yet none of them specifically targeted violence in institutional care. In regions of war and conflict, children are exposed to additional stressors in form of organized violence. This is especially true if they are recruited as child soldiers, during which time they experience and perpetrate massive amounts of violence (Schauer & Elbert, 2010) and suffer heavily from the consequences resulting in trauma spectrum disorders and aggressive behavior (Maclure & Denov, 2006; Schauer & Elbert, 2010; Stott, 2009). These mental health problems can pose challenges to the reintegration process (Betancourt et al., 2010; Boyden, 2003). It is therefore important to support the reintegration process by addressing individual psychological suffering (Stott, 2009).


The present thesis focused on family and institutional violence in Tanzania and on organized violence in the Democratic Republic of the Congo (DRC). The first article investigated corporal punishment and its consequences on Tanzanian primary school children and found alarmingly high rates: More than 95% of the children reported experiencing corporal punishment in the family and at school. More than half of the children reported incidents of corporal punishment in the family within the last year. Experiences of corporal punishment were related to externalizing problems, such as aggression and hyperactivity. The findings were in line with reports from UNICEF (2011) and research from other countries (Ani & Grantham-McGregor, 1998; Schilling, Aseltine, & Gore, 2007). The second and the third article revealed that corporal punishment and violence were equally common in institutional care. Experiences of violence in institutional care were more strongly related to mental health problems than were experiences in the family of origin. The most affected children were institutionalized at a very young age. Thus, adverse experiences in institutional care compounded with adverse experiences in the family of origin and distant and unresponsive caregiving in institutional care (Johnson et al., 2006; McCall, 2013). Subsequently, a two-component intervention was developed in the third article that addressed individual psychological suffering as well as prevention from further exposure to violence. Children suffering from traumatic stress were treated with KIDNET (Ruf et al., 2007). To reduce further exposure to violence and to improve caregiving all caregivers were trained in parenting skills and nonviolent discipline strategies. A six-month follow-up demonstrated this intervention’s feasibility and showed initial positive outcomes. Traumatic stress and experiences of violence in institutional care substantially decreased post treatment.


The fourth article shifted the focus from family violence to organized violence in the DRC and examined the experiences of violence and mental health of former child soldiers. Results revealed that child soldiers experienced and perpetrated higher amounts of violence compared to adult combatants. Additionally, they suffered more from the consequences of being both victim and perpetrator, resulting in higher rates of traumatic stress and aggression. In accordance with the literature (Betancourt et al., 2010), aggressive behavior was linked to failed integration attempts. Based on these findings, the fifth article described the development and evaluation of a two-component intervention, addressing mental health problems as well as aiming to reduce exposure to further violence by supporting the integration of former child soldiers into civil society. The intervention was embedded within a reintegration program offering vocational training and social support and was tested in a randomized-controlled trial against treatment as usual. An advanced version of NET (Schauer, Neuner, & Elbert, 2011) focusing on traumatic experiences as well as perpetrated violence was implemented. Individual sessions were followed by a group session, which dealt with the role change from combatant to civilian. A six-month follow-up confirmed feasibility and found initial positive outcomes. Traumatic stress decreased substantially in the treatment group, whereas aggression decreased in both groups. Closeness to combatants was used as an inverse index of integration and this index showed a specific decline as a result of the intervention.


The present thesis showed that exposure to violence, namely violence in families and institutions as well as organized and perpetrated violence in armed conflict, has detrimental consequences for children’s mental health. Consequently, the present thesis developed and successfully tested two interventions designed to reduce the children’s psychological suffering as well as to protect them from further exposure to violence. The interventions targeted children in institutional care and former child soldiers in reintegration programs. Thus, the present thesis showed that intervention approaches focusing on both individual psychological support and prevention of further exposure to violence promise to support affected children in overcoming their psychological suffering, providing them the opportunity to grow up in a secure and supportive environment.

Zusammenfassung in einer weiteren Sprache

Für eine gesunde Entwicklung benötigt ein Kind ein sicheres Umfeld und eine stabile Beziehung zu einer engen Bezugsperson (Johnson et al., 2006). Gewalterfahrungen können eine gesunde Entwicklung jedoch gefährden. Die vorliegende Arbeit untersuchte die Folgen von Gewalterfahrungen in der Familie oder in Fürsorgeeinrichtungen sowie von organisierter Gewalt auf die psychische Gesundheit von Kindern in Sub-Sahara Afrika, die entweder in Fürsorgeeinrichtungen lebten oder in bewaffneten Gruppen aufwuchsen. Im Anschluss wurden Interventionsansätze zur Verringerung von psychischem Leiden und zur Prävention von weiteren Gewalterfahrungen entwickelt und getestet.


In Sub-Sahara Afrika sind Kinder hohen Raten von körperlicher Bestrafung in Familien und Schulen ausgesetzt (UNICEF, 2010, 2011). Studien aus anderen Kontexten haben gezeigt, dass familiäre Gewalt eng mit psychischen Problemen, wie Störungen aus dem Traumaspektrum oder auch mit anderen internalisierenden und externalisierenden psychischen Problemen, zusammenhängt (z.B. Catani, Jacob, Schauer, Kohila, & Neuner, 2008; Elbert et al., 2009; Gámez-Guadix, Straus, Carrobles, Muñoz-Rivas, & Almendros, 2010). In Sub-Sahara Afrika sind Fürsorgeeinrichtungen ein Teil des Unterstützungssystems für Waisen und vulnerable Kinder (McCall, 2013; Wolff & Fesseha, 1998). Die wenigen existierenden Studien aus diesem Kontext weisen darauf hin, dass die Betreuungsqualität in diesen Einrichtungen gering ist und Betreuer häufig schlecht ausgebildet und überfordert sind (z.B. Espié et al., 2011; Levin & Haines, 2007; Wolff & Fesseha, 1999). Bisher ist wenig über die Verbreitung von Gewalt gegenüber Kindern in Fürsorgeeinrichtungen in Sub-Sahara Afrika bekannt. Interventionen in Fürsorgeeinrichtungen weltweit verbesserten die Betreuungsqualität erfolgreich (z.B. Levin & Haines, 2007; St. Petersburg-USA Orphanage Research Team, 2008; Wolff & Fesseha, 1999), doch zielte keine Intervention spezifisch auf die Reduzierung von Gewalt in Fürsorgeeinrichtungen ab.


In Kriegs- und Konfliktregionen sind Kinder zusätzlich organisierter Gewalt ausgesetzt. Besonders wenn sie als Kindersoldaten rekrutiert werden, erleben und üben sie regelmäßig extreme Formen von Gewalt aus (Schauer & Elbert, 2010) und leiden oftmals sehr unter den Konsequenzen der Gewalterfahrungen. Dies führt oft zu Störungen des Traumaspektrums und zu aggressivem Verhalten (Maclure & Denov, 2006; Schauer & Elbert, 2010; Stott, 2009). Diese psychischen Probleme können wiederum den Reintegrationsprozess erschweren (Betancourt et al., 2010; Boyden, 2003), weshalb es wichtig ist diesen durch individuelle psychologische Hilfe zu unterstützen (Stott, 2009).


Die vorliegende Arbeit konzentrierte sich auf Gewalt in der Familie und in Fürsorgeeinrichtungen in Tansania und auf organisierte Gewalt in der Demokratischen Republik (DR) Kongo. Der erste Artikel untersuchte körperliche Bestrafung und deren Folgen bei tansanischen Grundschulkindern und fand alarmierend hohe Raten: Mehr als 95% der Kinder berichteten körperliche Bestrafung in der Familie und in der Schule. Über die Hälfte der Kinder berichteten Erlebnisse von körperlicher Bestrafung in der Familie im letzten Jahr. Erfahrungen von körperlicher Bestrafung hingen mit externalisierenden psychischen Problemen, wie Aggression und Hyperaktivität, zusammen. Die Befunde stimmen mit Berichten von UNICEF (2011) und Studien aus anderen Ländern überein (Ani & Grantham-McGregor, 1998; Schilling et al., 2007). Der zweite und dritte Artikel zeigten, dass körperliche Bestrafung und Gewalt ebenfalls in Fürsorgeeinrichtungen verbreitet sind. Gewalterfahrungen in Fürsorgeeinrichtungen waren stärker mit den psychischen Problemen der Kinder assoziiert als Gewalterfahrungen in der Ursprungsfamilie. Die am stärksten belasteten Kinder waren sehr früh institutionalisiert worden. Folglich addieren sich die schädigenden Erfahrungen in Fürsorgeeinrichtungen zu den schlechten Erfahrungen in der Ursprungsfamilie und dem distanzierten und teilnahmslosen Erziehungsstil in Fürsorgeeinrichtungen (Johnson et al., 2006; McCall, 2013). Im Anschluss wurde im dritten Artikel eine Zwei-Komponenten Intervention entwickelt, die sowohl das individuelle psychische Leiden als auch die Prävention weiterer Gewalterfahrungen umfasste. Kinder, die unter traumatischem Stress litten, wurden mit KIDNET (Ruf et al., 2007) behandelt. Um weitere Gewalterfahrungen zu verhindern und die Betreuungsqualität zu verbessern, wurden alle Betreuer in Erziehungsfertigkeiten und gewaltfreien Disziplinierungsstrategien trainiert. Eine Folgeuntersuchung nach sechs Monaten bestätigte die Umsetzbarkeit dieser Intervention und präsentierte erste positive Effekte. Der traumatische Stress der Kinder und die Gewalterfahrungen in der Fürsorgeeinrichtung verringerten sich substantiell.


Der vierte Artikel verschob den Fokus von familiärer auf organisierte Gewalt in der DR Kongo und untersuchte die Gewalterfahrungen und die psychische Gesundheit von ehemaligen Kindersoldaten. Die Ergebnisse zeigten, dass Kindersoldaten mehr Gewalt erlebten und ausübten als erwachsene Soldaten. Zusätzlich litten sie ebenfalls stärker darunter sowohl Opfer als auch Täter zu sein, was in höheren Raten von traumatischem Stress und Aggression resultierte. Übereinstimmend mit der Literatur (Betancourt et al., 2010) hing aggressives Verhalten mit gescheiterten Integrationsversuchen zusammen. Basierend auf diesen Erkenntnissen beschrieb der fünfte Artikel die Entwicklung und Evaluation einer Zwei-Komponenten Intervention, welche sowohl auf die Behandlung von individuellen psychischen Problemen als auch auf die Reduktion weiterer Gewalterfahrungen abzielte, indem die Integration ehemaliger Kindersoldaten in die zivile Gesellschaft unterstützt wurde. Die Intervention wurde in ein Reintegrationsprogramm eingebettet, das berufliches Training und soziale Unterstützung anbot. Die Intervention wurde in einer randomisierten Kontrollgruppenstudie im Vergleich zum üblichen Reintegrationsprogramm getestet. Eine erweiterte Version von NET (Schauer, Neuner, & Elbert, 2011) wurde eingesetzt, welche traumatische Erfahrungen und ausgeübte Gewalt miteinschließt. Eine Gruppensitzung, welche den Rollenwechsel vom Kombattanten zum Zivilisten unterstützte, schloss sich an die Einzelsitzungen an. Eine Folgeuntersuchung nach sechs Monaten bestätigte die Durchführbarkeit und zeigte erste positive Effekte. Traumatischer Stress verringerte sich substantiell in der Interventionsgruppe, während Aggression sich in beiden Gruppen reduzierte. Die Nähe zu Kombattanten wurde als invertierter Integrationsindex eingesetzt und zeigte einen interventionsspezifischen Rückgang des Kontakts zu Kombattanten.


Die vorliegende Arbeit zeigte, dass Gewalterfahrungen, und zwar Erfahrungen sowohl von familiärer und institutioneller Gewalt als auch von organisierter und selbst ausgeübter Gewalt in bewaffneten Konflikten, schädliche Folgen für die psychische Gesundheit von Kindern haben. Daraus folgend entwickelte und testete die vorliegende Arbeit erfolgreich zwei Interventionen, mit dem Ziel das psychische Leiden der Kinder zu reduzieren und sie vor weiteren Gewalterfahrungen zu schützen. Die Zielgruppen der Interventionen waren Kinder in Fürsorgeeinrichtungen und ehemalige Kindersoldaten in Reintegrationsprogrammen. Dadurch zeigte die vorliegende Arbeit, dass Interventionsansätze, die sich auf die individuelle psychologische Unterstützung und die Prävention weiterer Gewalterfahrungen konzentrieren, vielversprechend sind, um betroffenen Kinder bei der Bewältigung ihres psychischen Leidens zu unterstützen und ihnen eine Chance zu geben in einem sicheren und unterstützenden Umfeld aufzuwachsen.

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ISO 690HERMENAU, Katharin, 2014. Violent childhood experiences - Consequences on mental health and approaches to intervention [Dissertation]. Konstanz: University of Konstanz
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@phdthesis{Hermenau2014Viole-28896,
  year={2014},
  title={Violent childhood experiences - Consequences on mental health and approaches to intervention},
  author={Hermenau, Katharin},
  address={Konstanz},
  school={Universität Konstanz}
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    <dcterms:abstract xml:lang="eng">In order to develop in a healthy manner, a child requires a secure environment and a steady bond with a close caregiver (Johnson, Browne, &amp; Hamilton-Giachritsis, 2006). However, experiences of violence may interfere with this process of healthy development. The present thesis examined the consequences of exposure to family, institutional and organized violence on the mental health of children in Sub-Saharan Africa, living either in institutional care or being associated with armed forces. Subsequently, intervention approaches to reduce psychological suffering and to prevent children from further exposure to violence were developed and evaluated.&lt;br /&gt;&lt;br /&gt;&lt;br /&gt;Children in Sub-Saharan Africa are exposed to high rates of corporal punishment within their families and schools (UNICEF, 2010, 2011). Studies from other settings have found that family violence is strongly related to mental health problems, including trauma spectrum disorders as well as internalizing and externalizing psychological problems (e.g. Catani, Jacob, Schauer, Kohila, &amp; Neuner, 2008; Elbert et al., 2009; Gámez-Guadix, Straus, Carrobles, Muñoz-Rivas, &amp; Almendros, 2010). In Sub-Saharan Africa, institutional care is part of the support system for orphans and vulnerable children (McCall, 2013; Wolff &amp; Fesseha, 1998). The few existing studies investigating these contexts have indicated that the quality of caregiving in such institutions is poor and that the caregivers are often undereducated and overburdened (e.g. Espié et al., 2011; Levin &amp; Haines, 2007; Wolff &amp; Fesseha, 1999). To date, little is known about the occurrence of violence toward children in institutional care in Sub-Saharan Africa. Interventions in institutional care worldwide have successfully improved the quality of caregiving (e.g. Levin &amp; Haines, 2007; St. Petersburg-USA Orphanage Research Team, 2008; Wolff &amp; Fesseha, 1999), yet none of them specifically targeted violence in institutional care. In regions of war and conflict, children are exposed to additional stressors in form of organized violence. This is especially true if they are recruited as child soldiers, during which time they experience and perpetrate massive amounts of violence (Schauer &amp; Elbert, 2010) and suffer heavily from the consequences resulting in trauma spectrum disorders and aggressive behavior (Maclure &amp; Denov, 2006; Schauer &amp; Elbert, 2010; Stott, 2009). These mental health problems can pose challenges to the reintegration process (Betancourt et al., 2010; Boyden, 2003). It is therefore important to support the reintegration process by addressing individual psychological suffering (Stott, 2009).&lt;br /&gt;&lt;br /&gt;&lt;br /&gt;The present thesis focused on family and institutional violence in Tanzania and on organized violence in the Democratic Republic of the Congo (DRC). The first article investigated corporal punishment and its consequences on Tanzanian primary school children and found alarmingly high rates: More than 95% of the children reported experiencing corporal punishment in the family and at school. More than half of the children reported incidents of corporal punishment in the family within the last year. Experiences of corporal punishment were related to externalizing problems, such as aggression and hyperactivity. The findings were in line with reports from UNICEF (2011) and research from other countries (Ani &amp; Grantham-McGregor, 1998; Schilling, Aseltine, &amp; Gore, 2007). The second and the third article revealed that corporal punishment and violence were equally common in institutional care. Experiences of violence in institutional care were more strongly related to mental health problems than were experiences in the family of origin. The most affected children were institutionalized at a very young age. Thus, adverse experiences in institutional care compounded with adverse experiences in the family of origin and distant and unresponsive caregiving in institutional care (Johnson et al., 2006; McCall, 2013). Subsequently, a two-component intervention was developed in the third article that addressed individual psychological suffering as well as prevention from further exposure to violence. Children suffering from traumatic stress were treated with KIDNET (Ruf et al., 2007). To reduce further exposure to violence and to improve caregiving all caregivers were trained in parenting skills and nonviolent discipline strategies. A six-month follow-up demonstrated this intervention’s feasibility and showed initial positive outcomes. Traumatic stress and experiences of violence in institutional care substantially decreased post treatment.&lt;br /&gt;&lt;br /&gt;&lt;br /&gt;The fourth article shifted the focus from family violence to organized violence in the DRC and examined the experiences of violence and mental health of former child soldiers. Results revealed that child soldiers experienced and perpetrated higher amounts of violence compared to adult combatants. Additionally, they suffered more from the consequences of being both victim and perpetrator, resulting in higher rates of traumatic stress and aggression. In accordance with the literature (Betancourt et al., 2010), aggressive behavior was linked to failed integration attempts. Based on these findings, the fifth article described the development and evaluation of a two-component intervention, addressing mental health problems as well as aiming to reduce exposure to further violence by supporting the integration of former child soldiers into civil society. The intervention was embedded within a reintegration program offering vocational training and social support and was tested in a randomized-controlled trial against treatment as usual. An advanced version of NET (Schauer, Neuner, &amp; Elbert, 2011) focusing on traumatic experiences as well as perpetrated violence was implemented. Individual sessions were followed by a group session, which dealt with the role change from combatant to civilian. A six-month follow-up confirmed feasibility and found initial positive outcomes. Traumatic stress decreased substantially in the treatment group, whereas aggression decreased in both groups. Closeness to combatants was used as an inverse index of integration and this index showed a specific decline as a result of the intervention.&lt;br /&gt;&lt;br /&gt;&lt;br /&gt;The present thesis showed that exposure to violence, namely violence in families and institutions as well as organized and perpetrated violence in armed conflict, has detrimental consequences for children’s mental health. Consequently, the present thesis developed and successfully tested two interventions designed to reduce the children’s psychological suffering as well as to protect them from further exposure to violence. The interventions targeted children in institutional care and former child soldiers in reintegration programs. 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