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European Journal of Psychotraumatology logoLink to European Journal of Psychotraumatology
. 2024 Jul 31;15(1):2382554. doi: 10.1080/20008066.2024.2382554

Trauma-related mental health problems among mothers in Taiwan and their relationship with children’s emotional and behavioral problems

Problemas de salud mental relacionados con trauma entre madres en Taiwán y su relación con los problemas emocionales y de comportamiento de los niños

Hong Wang Fung a,*,CONTACT, Kunhua Lee b, Edward K S Wang c, Janet Yuen-Ha Wong a,✉
PMCID: PMC11293261  PMID: 39082192

ABSTRACT

Background: Trauma can give rise to mental health problems and emotional and interpersonal difficulties, which in turn can perpetuate the cycle of trauma and adversity for future generations. However, little is known about the prevalence and potential effects of trauma and trauma-related mental health problems among parents.

Objective: The primary goal of this study was to examine childhood and adulthood trauma and trauma-related symptoms among mothers of children aged between 6 and 18. We also conducted exploratory analyses of their potential relationship with children’s emotional and behavioural problems.

Method: A total of 817 mothers living with a child aged between 6 and 18 in Taiwan completed standardized self-report assessments of trauma exposure, trauma-related symptoms, and children’s emotional and behavioural problems. A subsample (n = 256) also provided follow-up data after six months.

Results: Most surveyed mothers reported at least one childhood traumatic event (74.79%) and one adulthood traumatic event (78.70%); 4.4% met the ICD-11 criteria for PTSD, and 12.1% for complex PTSD; 11.4% reported clinically significant dissociative symptoms. Mothers’ complex PTSD and dissociative symptoms were cross-sectionally correlated with children’s emotional and behavioural problem (rs = .186 to .239, p < .001). After controlling for possible confounding variables and baseline scores, mothers’ childhood non-betrayal trauma reported at baseline was found to be a predictor of children's emotional and behavioural problems reported at follow up.

Conclusion: This study is the first to provide data regarding childhood and adulthood trauma and trauma-related disorders, including ICD-11 complex PTSD, among mothers in the community. It calls for more studies to understand the potential effects of intergenerational trauma.

KEYWORDS: Intergenerational trauma, betrayal trauma, complex post-traumatic stress disorder (complex PTSD), dissociation, childhood trauma

HIGHLIGHTS

  • Trauma-related symptoms are common among mothers.

  • Mothers’ childhood non-betrayal trauma predicted children's problems.

  • Intergenerational trauma warrants recognition as a public health concern.

1. Introduction

Trauma, especially childhood trauma, has been increasingly recognized as an important aetiological risk factor for a variety of physical and mental health problems (The Childhood Adversity Narratives, 2015). Evidence from recent systematic reviews showed that trauma and stressful events during childhood (e.g. physical abuse, sexual abuse, family violence) could increase the risk of developing cancer (Holman et al., 2016), cardiovascular diseases (Godoy et al., 2021), as well as emotional and mental health problems (e.g. De Venter et al., 2013; Hughes et al., 2017; Petruccelli et al., 2019). A recent meta-analysis found that childhood maltreatment could account for 21% to 41% of common mental health problems (e.g. depression, suicide attempts) in Australia (Grummitt et al., 2024), highlighting the potentially significant effects of trauma and adversities. Previous studies have further indicated that interpersonal trauma, particularly betrayal trauma or violence committed by someone close to the victim (such as a family member), can have more severe consequences than non-interpersonal trauma (such as natural disasters or car accidents) (Chiu et al., 2017; López-Martínez et al., 2018). This may be due to the fact that betrayal trauma can be more enduring, as it often occurs within the context of the victim’s family or social network, and can shatter the trust and security of the victim’s attachment relationships (Freyd, 1996). Additionally, victims of betrayal trauma may experience more toxic stress due to the lack of social support and resources, as those who are supposed to be trustworthy are the ones who have caused them harm (Fung, Chien, et al., 2023; Fung, Lam, et al., 2022).

As highlighted in a recent Lancet systematic review (Hughes et al., 2017), childhood trauma and adversities not only increase the risk for various health problems, but can also lead to violence, mental disorders, and emotional and interpersonal difficulties, which can in turn become the trauma and adversities for the next generation (e.g. a traumatized person becomes an emotionally unstable parent for the children). Parents or caregivers with unresolved trauma may transmit the effects of trauma to their children through their problematic or maladaptive attachment, behaviours, and parenting styles, and this process is known as intergenerational trauma (Isobel et al., 2019).

Although the effects of trauma have gained more recognition in recent years, there are some major knowledge gaps regarding intergenerational trauma. Currently, there are limited studies on intergenerational trauma. Little is known about the prevalence of trauma and trauma-related mental health problems among parents and their potential impacts on parenting issues and children’s outcomes. While some studies have examined trauma and trauma-related disorders, such as post-traumatic stress disorder (PTSD) in parents, the majority of these studies focused on specific populations, such as parents of children undergoing medical procedures, experiencing illness, or following childbirth (e.g. Manne et al., 2002; Olde et al., 2005; Xiong et al., 2022). A few studies have also examined the effects of intergenerational trauma in survivors of genocides (Dashorst et al., 2019). Maternal childhood adversity and mental health problems were also found to predict children's internalizing problems (Roubinov et al., 2022). However, much less is known about the prevalence of various types of traumatic experiences as well as major trauma-related mental health problems (e.g. PTSD and dissociative symptoms) among parents. No study has reported the prevalence of complex PTSD (C-PTSD) in general caregivers of children. C-PTSD is a trauma disorder particularly related to prolonged or repetitive traumatic experiences, when compared to ‘classical’ or ‘simple’ PTSD, and C-PTSD has been recently listed as an official mental disorder in the ICD-11 (World Health Organization, 2019). Similarly, although dissociation (i.e. failures in the process of integrating one’s own psychophysiological experiences) is a common post-traumatic reaction (Fung, Chien, et al., 2023), little is known about the prevalence and correlates of dissociative symptoms among general parents. Furthermore, while some studies showed that parental trauma-related mental health problems may be associated with impairments in parenting (Christie et al., 2019), little is known about their relationship with children’s well-being or behavioural problems, especially in the Asian context. Understanding the prevalence and potential effects of trauma and trauma-related symptoms among parents is important from a public health perspective.

To address these knowledge gaps, we conducted a survey study with both cross-sectional and longitudinal data. The primary goal of this study was to examine: How prevalent were trauma and trauma-related mental health symptoms in a sample of mothers in Taiwan? Additionally, we conducted exploratory analyses to examine whether mothers’ trauma and trauma-related mental health symptoms would be statistically associated with subsequent children’s emotional and behavioural problems, after controlling for the baseline severity and possible covariates. Since mothers are typically the primary caregivers of children in Chinese societies, we focused on mothers only in this study.

2. Methods

2.1. Participants

We analysed survey data from a project which investigated trauma exposure, mental health problems, and parenting issues among mothers in Taiwan. The project obtained ethical approval from institutional review board at the National Tsing Hua University, Taiwan. Potential participants were recruited using online advertising on social media platforms in July 2023. The methodology and part of the data unrelated to the present research questions have been reported elsewhere (Lee et al., 2023).

The inclusion criteria were as follows: (1) being aged 18 or above; (2) provided online written informed consent and agreed to participate in this survey study; (3) was a mother living with a child aged between 6 and 18 every day (because we only wanted to focus on mothers who had close interaction with their children); and (4) currently living in Taiwan. The exclusion criterion was having an official medical diagnosis of a reading disorder, an intellectual disability, or cognitive impairments.

Additionally, participants were invited to complete a follow-up survey after about six months through email.

2.2. Measures

At baseline, participants completed an online survey, which included self-report measures of trauma exposure and trauma-related symptoms. The survey also included questions about demographic backgrounds of the participants (the mothers) and their children, such as mother’s age, education level, employment status, and the child’s age, gender, disability status (see Table 1). The survey also included a measure of children’s emotional and behavioural problems. When answering questions related to the child, participants were instructed to consider the elder child only if there were more than one child aged between 6 and 18. At follow-up, they completed the measure of children’s emotional and behavioural problems again.

Table 1.

Sample characteristics, frequency of trauma and trauma-related symptoms, and correlates of children’s emotional and behavioural problems at baseline (N = 817) and follow up (N = 256).

  Sample characteristics (baseline) Pearson and point-biserial correlations with children’s emotional and behavioural problems
Variables Mean SD Percentage Baseline Follow up
Mother’s age 39.93 3.84   .008 −.045
Mother’s education level (undergraduate or above)     83.2% −.041 −.029
Mother’s marriage status (married)     89.5% −.007 −.060
Mother’s employment status (full-time employed)     63.3% −.088 −.033
Mother seeing a psychiatrist in the past 12 months     9.3% .074 .034
Number of children 1.98 0.73   .025 −.020
Age of the child 10.49 3.27   .016 −.036
Gender of the child (female)     45.2% −.012 −.025
Child having any disabilities     14.7% .206*** .174**
Mother’s childhood betrayal trauma 1.09 1.28   .162*** .161*
Mother’s childhood non-betrayal trauma 0.82 0.96   .126*** .152*
Mother’s adulthood betrayal trauma 0.89 1.08   .160*** .060
Mother’s adulthood non-betrayal trauma 0.68 0.92   .075* .138*
Mother’s PTSD symptoms 7.33 6.23   .201*** .109
Mother’s DSO symptoms 8.30 6.22   .239*** .267***
Mother’s dissociative symptoms 0.91 1.47   .186*** .179**
Children’s emotional and behavioural problem (baseline) 20.07 5.31   1 .738***
Children’s emotional and behavioural problem (follow up) 19.77 5.45   / 1/
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Trauma exposure of the mothers were assessed using the Brief Betrayal Trauma Survey (BBTS), which is a 24-item reliable questionnaire asking about 12 different types of traumatic events during childhood and adulthood (Goldberg & Freyd, 2006). The traumatic events can be further divided into betrayal and non-betrayal trauma. Betrayal trauma refers to trauma perpetrated by a close person, such as a parent, siblings, caretaker, or intimate partner. The items of the BBTS can be found in Table 2. The Chinese version of the BBTS had acceptable test-retest reliability (Fung, Chien, et al., 2022).

Table 2.

Trauma histories in a sample of mothers in Taiwan (N = 817).

Traumatic experiences reported on the Brief Betrayal Trauma Survey Before age 18 Age 18 or older
Trauma with Less Betrayal    
1. Major earthquake, fire, flood, hurricane, tornado 12.4% 11.3%
2. Major auto, plane, train, or industrial accident 12.1% 19.1%
4. Witnessed someone suicide, killed, or injured 1 14.6% 17.4%
7. Were yourself severely attacked 1 11.5% 6.0%
9. Made to have sexual contact 1 31.6% 14.6%
Trauma with More Betrayal    
3. Witnessed someone suicide, killed, or injured 2 18.1% 11.0%
5. Witnessed someone severely attack a family member 2 20.8% 9.9%
6. Were yourself severely attacked 2 16.2% 11.0%
8. Made to have sexual contact 2 13.0% 9.2%
10. Emotionally or psychologically mistreated 2 40.5% 48.1%
Others    
11. Death of one’s own child 1.2% 11.3%
12. Other seriously traumatic event 15.3% 26.6%
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Notes: 1 = ‘Someone not close to you’; 2 = ‘Someone close to you’.

PTSD symptoms of the mothers were measured using the International Trauma Questionnaire (ITQ), which has 18 items and is a widely used assessment tool for ICD-11 PTSD and C-PTSD symptoms (Cloitre et al., 2018; Cloitre et al., 2021). The ITQ had 6 items that assessed classical PTSD symptoms (possible range: 0–24) and 6 items for disturbances in self-organization (DSO) symptoms (possible range: 0–24). Additionally, a provisional diagnosis of PTSD/C-PTSD can be made using the ITQ based on the ICD-11 criteria, and this method was commonly used in previous studies on C-PTSD (Hyland et al., 2020; Jowett et al., 2022). The Chinese version of the ITQ has satisfactory reliability and validity (Ho et al., 2019).

Dissociative symptoms of the mothers were assessed using the Dissociative Features Section of the Self-Report Dissociative Disorders Interview Schedule (SR-DDIS-DF). The DDIS is a well-validated structured interview for DSM dissociative disorders (Ross et al., 1987; 2002). As a self-report measure, the SR-DDIS was also reliable and valid (Ross & Browning, 2017). There is a 16-item section (i.e. the Dissociative Features section) that can be particularly used to assess psychoform dissociative symptoms (possible range: 0–16). The Chinese version of the SR-DDIS was found to be a valid screening tool; a cutoff score of 3 on the SR-DDIS-DF had a sensitivity of 100% and a specificity of 85.19% in detecting dissociative disorders (Fung et al., 2018).

Emotional and behavioural problems of the child were assessed using the Child Behavior Checklist (CBCL), which is originally a comprehensive measure of child’s behavioural problems as reported by the parent (Achenbach & Ruffle, 2000). The abbreviated CBSL has 13 items and can assess child internalizing and externalizing symptoms as rated by the parents (possible range: 13–39). The abbreviated CBSL had good reliability and validity in the Chinese context (Chan, Leung, et al., 2023; Chan, Wang, et al., 2022).

The surveys also included attention checking items (e.g. 3 + 4 = ?) to ensure the validity of the responses.

2.3. Data analysis

SPSS 22.0 was used for statistical analysis. To answer the first research question, we conducted descriptive analysis to report the prevalence of trauma and trauma-related mental health problems among the surveyed mothers at baseline. To answer the second research question (i.e. the exploratory analyses), hierarchical multiple regression analyses were conducted to examine whether mother’s trauma exposure (the BBTS results) and trauma-related symptoms (the ITQ and SR-DDIS-DF scores) (which were reported at baseline) would be potentially associated with children’s emotional and behavioural problems (the abbreviated CBSL) at follow up, after controlling for it severity at baseline as well as possible covariates (see Table 1). Instead of putting all trauma types and trauma-related symptoms in the same model, we repeated the regression analyses to reveal their unique effects separately. In each hierarchical multiple regression analysis, we first entered the potential covariates and baseline CBSL score in Step 1, and then entered the variables of interest in Step 2.

3. Results

3.1. Sample characteristics

A total of 867 participants met all inclusion criteria and provided valid responses to our survey, but 50 of them were excluded from analysis because they did not meet their child every day.

Of the 817 participants included in this study, 89.5% were married or in a common-law relationship. Their ages ranged from 27 to 56. As mentioned, if the mother had more than one child who was aged between 6 and 18, they were asked to focus on the elder child when answering the questions related to the child. Around half of the children were female (45.2%); 14.7% of the children were reported to have some kinds of officially diagnosed disabilities. The sample characteristics are summarized in Table 1.

A total of 256 participants completed the follow-up survey after about six months (average number of days = 194.5; SD = 7.46). Considering that 30 participants did not provide a valid email address for follow up, the retention rate was 31.3%. Independent sample t test and chi-square analyses showed that mothers who participated in the follow-up survey (n = 256) and those who did not (n = 561) did not differ in most major variables at baseline, except for the following. Mothers who participated in the follow-up survey were more likely to have an undergraduate degree (89.8% vs 80.2%, χ2 = 11.680, p < .001), be full-time employed (69.1% vs 60.6%, χ2 = 5.510, p = .019). Additionally, for mothers who participated in the follow-up survey, the age of their children was slightly younger (M = 10.06; SD = 3.12 vs M = 10.69; SD = 3.32), t = 3.974, p = .009.

3.2. Prevalence of trauma and trauma-related symptoms among the mothers

On the BBTS, 88.37% of the mothers reported at least one-lifetime traumatic experience – 74.79% had at least one childhood traumatic event, and 78.70% had at least one adulthood traumatic event. Out of 24 different traumatic events, they reported an average of 4.03 different types of traumatic events (SD = 3.30). The most common types of trauma were adulthood (48.1%) and childhood (40.5%) emotional maltreatment. Exposure to family violence (20.8%), physical (16.2%) and sexual (13.0%) abuse perpetrated by a close person during childhood were quite common. The figures are reported in Table 2.

Of all participants, 4.4% met the criteria for PTSD, and 12.1% for C-PTSD, according to the BBTS and the ITQ screening results. Additionally, 11.4% reported clinically significant levels of dissociative symptoms (i.e. DDIS-FS ≥ 3).

Lifetime trauma exposure was positively correlated with PTSD (r = .412, p < .001), DSO (r = .400, p < .001), and dissociative symptoms (r = .325, p < .001) at baseline.

3.3. Potential relationships with children’s emotional and behavioural problems

We conducted hierarchical multiple regression to examine whether trauma exposure and trauma-related symptoms reported at baseline would be associated with subsequent children’s emotional and behavioural problems at follow up, after controlling for potential confounding variables. The analysis was conducted in the subsample who provided follow-up data.

For this purpose, we conducted a series of hierarchical regression analyses to reveal the potential unique predictive role of trauma types, complex PTSD symptoms, and dissociative symptoms, separately (see Tables 3–8).

Table 3.

Hierarchical multiple regression predicting children’s emotional and behavioural problems at follow up from mothers’ childhood betrayal trauma (N = 256).

  Children’s emotional and behavioural problems at follow up
Variables B S.E. 95% CI for B (lower bound) 95% CI for B (upper bound) β p F ΔR2 ΔF p
Step 1             30.794*** .557 30.794 <.001
Mother’s age .005 .071 −.135 .145 .003 .945        
Mother’s education level (undergraduate or above) −.771 .808 −2.363 .821 −.043 .341        
Mother’s marriage status (married) −.792 .806 −2.379 .796 −.044 .327        
Mother’s employment status (full-time employed) .464 .511 −.542 1.471 .039 .364        
Mother seeing a psychiatrist in the past 12 months .524 .755 −.963 2.011 .031 .488        
Number of children .024 .375 −.715 .763 .003 .949        
Age of the child −.047 .094 −.233 .139 −.027 .618        
Gender of the child (female) .436 .480 −.509 1.380 .040 .364        
Child having any disabilities .883 .675 −.445 2.212 .060 .192        
Children’s emotional and behavioural problems at baseline .776 .046 .686 .866 .736 .000        
Step 2             27.916*** .557 0.172 .679
Mother’s age .000 .073 −.143 .143 .000 .995        
Mother’s education level (undergraduate or above) −.766 .810 −2.361 .829 −.043 .345        
Mother’s marriage status (married) −.814 .809 −2.408 .780 −.045 .315        
Mother’s employment status (full-time employed) .452 .513 −.558 1.461 .038 .379        
Mother seeing a psychiatrist in the past 12 months .614 .786 −.935 2.162 .036 .436        
Number of children .004 .379 −.742 .750 .000 .992        
Age of the child −.040 .096 −.229 .149 −.023 .678        
Gender of the child (female) .450 .482 −.499 1.398 .041 .351        
Child having any disabilities .881 .676 −.450 2.212 .059 .193        
Children’s emotional and behavioural problems at baseline .780 .047 .688 .873 .740 .000        
Mother’s childhood betrayal trauma −.085 .204 −.487 .317 −.019 .679        
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Note: *p < .05, **p < .01, ***p < .001.

Table 4.

Hierarchical multiple regression predicting children’s emotional and behavioural problems at follow up from mothers’ childhood non-betrayal trauma (N = 256).

  Children’s emotional and behavioural problems at follow up
Variables B S.E. 95% CI for B (lower bound) 95% CI for B (upper bound) β p F ΔR2 ΔF p
Step 2             28.738*** .007 4.178 .042
Mother’s age .016 .071 −.124 .156 .011 .821        
Mother’s education level (undergraduate or above) −.700 .804 −2.284 .883 −.039 .384        
Mother’s marriage status (married) −.802 .801 −2.380 .775 −.045 .317        
Mother’s employment status (full-time employed) .521 .508 −.480 1.522 .044 .307        
Mother seeing a psychiatrist in the past 12 months .371 .754 −1.113 1.856 .022 .623        
Number of children .094 .374 −.643 .831 .012 .802        
Age of the child −.074 .095 −.260 .112 −.042 .434        
Gender of the child (female) .441 .477 −.498 1.379 .040 .356        
Child having any disabilities .998 .673 −.327 2.323 .067 .139        
Children’s emotional and behavioural problems at baseline .766 .046 .676 .856 .727 .000        
Mother’s childhood non-betrayal trauma .548 .268 .020 1.075 .089 .042        
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Note: *p < .05, **p < .01, ***p < .001.

The controlled variables in Step 1 are the same as those reported in Table 3. Therefore, only Step 2 (including the variable of interest) is reported here.

Table 5.

Hierarchical multiple regression predicting children’s emotional and behavioural problems at follow up from mothers’ adulthood betrayal trauma (N = 256).

  Children’s emotional and behavioural problems at follow up
Variables B S.E. 95% CI for B (lower bound) 95% CI for B (upper bound) β p F ΔR2 ΔF p
Step 2             28.727*** .007 4.127 .043
Mother’s age −.008 .071 −.149 .132 −.006 .905        
Mother’s education level (undergraduate or above) −.937 .807 −2.527 .653 −.052 .247        
Mother’s marriage status (married) −1.137 .819 −2.750 .475 −.063 .166        
Mother’s employment status (full-time employed) .307 .513 −.704 1.318 .026 .550        
Mother seeing a psychiatrist in the past 12 months .971 .782 −.569 2.510 .057 .215        
Number of children −.004 .373 −.739 .730 −.001 .991        
Age of the child −.017 .095 −.204 .169 −.010 .854        
Gender of the child (female) .488 .477 −.453 1.428 .044 .308        
Child having any disabilities .966 .671 −.356 2.289 .065 .151        
Children’s emotional and behavioural problems at baseline .790 .046 .699 .880 .749 .000        
Mother’s adulthood betrayal trauma −.499 .246 −.983 −.015 −.097 .043        
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Note: *p < .05, **p < .01, ***p < .001.

The controlled variables in Step 1 are the same as those reported in Table 3. Therefore, only Step 2 (including the variable of interest) is reported here.

Table 6.

Hierarchical multiple regression predicting children’s emotional and behavioural problems at follow up from mothers’ adulthood non-betrayal trauma (N = 256).

  Children’s emotional and behavioural problems at follow up
Variables B S.E. 95% CI for B (lower bound) 95% CI for B (upper bound) β p F ΔR2 ΔF p
Step 2             27.944*** .001 0.307 .580
Mother’s age .002 .072 −.139 .143 .001 .980        
Mother’s education level (undergraduate or above) −.681 .826 −2.307 .945 −.038 .411        
Mother’s marriage status (married) −.766 .808 −2.358 .827 −.043 .345        
Mother’s employment status (full-time employed) .442 .513 −.568 1.453 .038 .389        
Mother seeing a psychiatrist in the past 12 months .490 .758 −1.004 1.984 .029 .519        
Number of children .029 .376 −.711 .769 .004 .938        
Age of the child −.047 .094 −.233 .139 −.027 .620        
Gender of the child (female) .430 .480 −.516 1.376 .039 .372        
Child having any disabilities .864 .676 −.468 2.196 .058 .203        
Children’s emotional and behavioural problems at baseline .772 .046 .681 .863 .733 .000        
Mother’s adulthood non-betrayal trauma .156 .281 −.398 .709 .025 .580        
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Note: *p < .05, **p < .01, ***p < .001.

The controlled variables in Step 1 are the same as those reported in Table 3. Therefore, only Step 2 (including the variable of interest) is reported here.

Table 7.

Hierarchical multiple regression predicting children’s emotional and behavioural problems at follow up from mothers’ complex PTSD symptoms (N = 256).

  Children’s emotional and behavioural problems at follow up
Variables B S.E. 95% CI for B (lower bound) 95% CI for B (upper bound) β p F ΔR2 ΔF p
Step 2             26.081*** .006 1.672 .190
Mother’s age −.015 .072 −.157 .126 −.011 .832        
Mother’s education level (undergraduate or above) −.932 .812 −2.531 .667 −.052 .252        
Mother’s marriage status (married) −.714 .807 −2.303 .874 −.040 .377        
Mother’s employment status (full-time employed) .545 .511 −.462 1.552 .046 .288        
Mother seeing a psychiatrist in the past 12 months .582 .784 −.962 2.126 .034 .459        
Number of children −.053 .377 −.796 .690 −.007 .889        
Age of the child −.042 .094 −.227 .143 −.024 .657        
Gender of the child (female) .465 .479 −.479 1.409 .042 .333        
Child having any disabilities .801 .677 −.531 2.134 .054 .237        
Children’s emotional and behavioural problems at baseline .773 .048 .678 .868 .733 .000        
Mother’s PTSD symptoms −.083 .046 −.173 .008 −.099 .072        
Mother’s DSO symptoms .066 .052 −.037 .169 .072 .209        
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Note: *p < .05, **p < .01, ***p < .001.

The controlled variables in Step 1 are the same as those reported in Table 3. Therefore, only Step 2 (including the variable of interest) is reported here.

Table 8.

Hierarchical multiple regression predicting children’s emotional and behavioural problems at follow up from mothers’ dissociative symptoms (N = 256).

  Children’s emotional and behavioural problems at follow up
Variables B S.E. 95% CI for B (lower bound) 95% CI for B (upper bound) β p F ΔR2 ΔF p
Step 2             26.377*** .004 2.421 .121
Mother’s age .026 .072 −.117 .168 .018 .721        
Mother’s education level (undergraduate or above) −.723 .806 −2.312 .865 −.040 .371        
Mother’s marriage status (married) −.681 .807 −2.270 .908 −.038 .400        
Mother’s employment status (full-time employed) .452 .509 −.551 1.456 .038 .375        
Mother seeing a psychiatrist in the past 12 months .374 .759 −1.121 1.868 .022 .623        
Number of children .061 .375 −.677 .800 .008 .870        
Age of the child −.046 .094 −.231 .139 −.026 .625        
Gender of the child (female) .402 .479 −.541 1.345 .037 .402        
Child having any disabilities .873 .673 −.452 2.198 .059 .195        
Children’s emotional and behavioural problems at baseline .767 .046 .676 .857 .727 .000        
Mother’s dissociative symptoms .271 .174 −.072 .615 .069 .121        
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Note: *p < .05, **p < .01, ***p < .001.

The controlled variables in Step 1 are the same as those reported in Table 3. Therefore, only Step 2 (including the variable of interest) is reported here.

As reported in Table 4, after controlling for potential confounding variables and baseline severity of children’s emotional and behavioural problems, mother’s childhood non-betrayal trauma positively at baseline predicted children’s emotional and behavioural problems at follow up (β = .089, p = .042); however, we also observed that mother’s adulthood betrayal trauma had a negative association with this variable (β = −.097, p = .043) (see Table 5).

After controlling for the possible confounding variables and baseline severity of children’s emotional and behavioural problems, mother’s PTSD (p = .072) and DSO (p = .209) symptoms (see Table 7) and dissociative symptoms (p = .121) (see Table 8) were not statistically significantly associated with children’s emotional and behavioural problems at follow up.

4. Discussion

While the impacts of trauma on one’s physical and mental health problems have been increasingly recognized, much less is known about intergenerational trauma. This study provides up-to-date data regarding the prevalence of trauma and trauma-related symptoms in a reasonably sized sample of mothers in Taiwan who had daily contact with their children. The primary finding is that lifetime trauma (88.37%) was common in this sample. C-PTSD, which is a newly recognized trauma disorder, was also prevalent (12.1%). Childhood betrayal trauma was also common: for example, 13.0% experienced sexual abuse by a close person during childhood. Additionally, our exploratory analyses also found that mothers’ childhood non-betrayal trauma (β = .089, p = .042) reported at baseline positively predicted children’s emotional and behavioural problems at follow up, after controlling for baseline severity and possible covariates. The findings of this study suggest that further research on the prevalence and potential effects of trauma among parents is needed. There might be significant public health implications of recognizing intergenerational trauma, although more studies are required.

First, this study provides updated data regarding the prevalence of different types of traumatic experiences and trauma-related symptoms among mothers. We found that trauma and trauma-related symptoms are not uncommon in our sample, although the figures are similar to those reported in other non-psychiatric samples – for example, using the same assessment methods, previous studies reported that 11.2% of surveyed high school students experienced dissociative symptoms (Fung, Geng, et al., 2023) and the prevalence rates of C-PTSD ranged from 3.8% to 18.4% in community settings (Fung, Wong, et al., 2023; Hyland et al., 2021). As mentioned, trauma could increase the risk of developing a wide range of health problems (Hughes et al., 2017). The relatively high prevalence of trauma observed in our sample of mothers implies that many mothers may be affected by these adverse experiences. Additionally, we found that complex PTSD was more common than ‘simple’ PTSD, and this finding is consistent with those observed in previous studies which also used the ITQ to assess probable PTSD and complex PTSD. For example, many clinical and general population studies have reported that complex PTSD was actually more common than PTSD (e.g. Cloitre et al., 2019; Ho et al., 2024; Howard et al., 2021; Hyland et al., 2021).

Furthermore, our exploratory analyses showed that mother’s childhood non-betrayal trauma had a statistically significant, positive association with children's emotional and behavioural problems at follow-up. As such exploratory results are preliminary, and there are some methodological concerns which will be further discussed below, further studies are needed to examine whether the trauma and trauma-related symptoms of mothers would affect parenting styles and children’s physical and psychosocial outcomes. In fact, attachment problems and emotional dysregulation are common consequences of trauma (Cloitre et al., 2020), which could in turn result in parenting difficulties (e.g. over-reactivity). Furthermore, parental emotional problems could create an emotionally unstable and insecure developmental environment for children. When parents struggle to regulate their own emotions, they may inadvertently expose their children to stress and emotional dysregulation, which can negatively impact their children's emotional and social development. Nevertheless, our preliminary results did not show a statistically significant effects of mother’s trauma-related symptoms, which may be due to our methodological limitations. Therefore, further studies are needed to understand the potential effects of trauma among parents in order to better acknowledge and prevent intergenerational trauma.

Our results have some potential implications for research, policy and practice. First, given the high prevalence of trauma-related symptoms among mothers and their potential effects on their children, the public health importance of preventing trauma should be recognized. Second, more research on the longitudinal effects of parental trauma on the next generation is needed. Third, given that mothers are commonly exposed to trauma and that the effects of trauma could be long-lasting, it is important to consider regular trauma screening as part of family planning and family support services.

This study has the strengths of using well-validated measures, employing a relatively large sample of mothers in the community, and including both cross-sectional and longitudinal data. The findings contribute to the limited body of knowledge on intergenerational trauma. However, this study also has some major limitations. First, although online methods are commonly used to recruit participants for epidemiological and social studies and although online assessments are found to be valid (Amon et al., 2014; Chan et al., 2017; Fung et al., 2020), there may be self-selection bias in online surveys. It is important to acknowledge that our sample is not representative of all mothers in Taiwan. Second, while the CBSL is a well-validated measure of children’s problems as rated by caregivers, the data were provided by mothers and there may be reporting bias. The levels of children's problems were solely perceived and reported by the mothers themselves. Future studies can make use of data reported by both parents and children, or even structured clinical interviews to assess children’s outcomes. Third, the retention rate of the subsample who provided follow-up data was relatively low, which may be due to the lack of incentives. Yet, it is important to highlight that very few differences were observed between those who provided follow-up data and those who did not. In our exploratory analyses, the limitation of having a high attrition rate should be acknowledged. It has been revealed that even with imputation and weighting techniques, attrition bias may not be fully corrected when attrition is non-random (Kristman et al., 2005). Therefore, future studies should make greater efforts during the design phrase to minimize the attrition rate in longitudinal surveys (Rioux et al., 2020). Our findings, while preliminary, call for more studies on intergenerational trauma. Future studies should employ a representative sample and collect data from a variety of sources (e.g. parents, children, teachers, medical record) so as to further investigate the prevalence and impacts of parental trauma.

5. Concluding remarks

This study provides evidence that trauma and trauma-related mental health problems are prevalent among mothers in Taiwan and some of them might be positively associated with subsequent children’s emotional and behavioural problems, although further studies are required to reveal their causal relationships. The results underscore the potential importance of preventing, recognizing, and managing the mental health consequences of trauma in parents who are responsible for the care of children. We call for more studies and efforts to understand and prevent the intergenerational effects of trauma.

Acknowledgements

The first author, HWF, received The RGC Postdoctoral Fellowship Scheme 2022/2023 from the Research Grants Council (RGC), Hong Kong.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Availability of data and material

The dataset generated and analysed during the current study is available from the corresponding author (HWF) on reasonable request.

Consent to participate

Online written informed consent was obtained from all participants before study participation.

Ethics approval

The project obtained ethical approval from the institutional review board at the National Tsing Hua University, Taiwan. All participants provided online written informed consent before they completed the survey.

Author contributorship

HWF contributed to the conceptualization and study design. HWF and KL collected the data, conducted data analysis, and prepared the first draft, and shared the first authorship. EKSW and JYHW provided supervision and overall guidance regarding the interpretation of the findings. All authors provided critical comments regarding the first draft and contributed to the revision of the manuscript. All authors read and approved the final manuscript.

References

  1. Achenbach, T. M., & Ruffle, T. M. (2000). The Child Behavior Checklist and related forms for assessing behavioral/emotional problems and competencies. Pediatrics in Review, 21(8), 265–271. 10.1542/pir.21.8.265 [DOI] [PubMed] [Google Scholar]
  2. Amon, K. L., Campbell, A. J., Hawke, C., & Steinbeck, K. (2014). Facebook as a recruitment tool for adolescent health research: A systematic review. Academic Pediatrics, 14(5), 439–447.e4. e434. 10.1016/j.acap.2014.05.049 [DOI] [PubMed] [Google Scholar]
  3. Chan, C., Fung, H. W., Choi, T. M., & Ross, C. A. (2017). Using online methods to develop and examine the Hong Kong Chinese translation of the Dissociative Experiences Scale. Journal of Evidence-Informed Social Work, 14(2), 70–85. 10.1080/23761407.2017.1298073 [DOI] [PubMed] [Google Scholar]
  4. Chan, K. K. S., Leung, D. C. K., & Fung, W. T. W. (2023). Longitudinal impact of parents’ discrimination experiences on children’s internalizing and externalizing symptoms: A 2-year study of families of autistic children. Autism, 27(2, 296–308. 10.1177/13623613221093110 [DOI] [PubMed] [Google Scholar]
  5. Chan, K. K. S., Wang, Z., & Li, H. (2022). Longitudinal impact of mindful parenting on internalizing and externalizing symptoms among children with autism spectrum disorder. Mindfulness, 13(8), 1984–1993. 10.1007/s12671-022-01933-4 [DOI] [Google Scholar]
  6. Chiu, C.-D., Lee, M.-H., Chen, W.-C., Ho, H. L., & Wu, H.-C. (2017). Childhood trauma perpetrated by close others, psychiatric dysfunction, and urological symptoms in patients with interstitial cystitis/bladder pain syndrome. Journal of Psychosomatic Research, 93, 90–95. 10.1016/j.jpsychores.2016.12.014 [DOI] [PubMed] [Google Scholar]
  7. Christie, H., Hamilton-Giachritsis, C., Alves-Costa, F., Tomlinson, M., & Halligan, S. L. (2019). The impact of parental posttraumatic stress disorder on parenting: A systematic review. European Journal of Psychotraumatology, 10(1), 1550345. 10.1080/20008198.2018.1550345 [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Cloitre, M., Cohen, L. R., Ortigo, K. M., Jackson, C., & Koenen, K. C. (2020). Treating survivors of childhood abuse and interpersonal trauma: STAIR Narrative Therapy (2nd ed.). The Guilford Press. [Google Scholar]
  9. Cloitre, M., Hyland, P., Bisson, J. I., Brewin, C. R., Roberts, N. P., Karatzias, T., & Shevlin, M. (2019). ICD-11 Posttraumatic stress disorder and complex posttraumatic stress disorder in the United States: A population-based study. Journal of Traumatic Stress, 32(6), 833–842. 10.1002/jts.22454 [DOI] [PubMed] [Google Scholar]
  10. Cloitre, M., Hyland, P., Prins, A., & Shevlin, M. (2021). The International Trauma Questionnaire (ITQ) measures reliable and clinically significant treatment-related change in PTSD and complex PTSD. European Journal of Psychotraumatology, 12(1), 1930961. 10.1080/20008198.2021.1930961 [DOI] [PMC free article] [PubMed] [Google Scholar]
  11. Cloitre, M., Shevlin, M., Brewin, C. R., Bisson, J. I., Roberts, N. P., Maercker, A., Karatzias, T., & Hyland, P. (2018). The International Trauma Questionnaire: Development of a self-report measure of ICD-11 PTSD and complex PTSD. Acta Psychiatrica Scandinavica, 138(6), 536–546. 10.1111/acps.12956 [DOI] [PubMed] [Google Scholar]
  12. Dashorst, P., Mooren, T. M., Kleber, R. J., de Jong, P. J., & Huntjens, R. J. (2019). Intergenerational consequences of the Holocaust on offspring mental health: A systematic review of associated factors and mechanisms. European Journal of Psychotraumatology, 10(1), 1654065. 10.1080/20008198.2019.1654065 [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. De Venter, M., Demyttenaere, K., & Bruffaerts, R. (2013). The relationship between adverse childhood experiences and mental health in adulthood. A systematic literature review [PAPER]. Tijdschrift Voor Psychiatrie, 55(4), 259–268. [PubMed] [Google Scholar]
  14. Freyd, J. J. (1996). Betrayal trauma: The logic of forgetting childhood abuse. Harvard University Press. [Google Scholar]
  15. Fung, H. W., Chan, C., Lee, C. Y., Yau, C. K. M., Chung, H. M., & Ross, C. A. (2020). Validity of a web-based measure of borderline personality disorder: A preliminary study. Journal of Evidence-Based Social Work, 17(4), 443–456. 10.1080/26408066.2020.1760162 [DOI] [PubMed] [Google Scholar]
  16. Fung, H. W., Chien, W. T., Chan, C., & Ross, C. A. (2023). A cross-cultural investigation of the association between betrayal trauma and dissociative features. Journal of Interpersonal Violence, 38(1-2), 1630–1653. 10.1177/08862605221090568 [DOI] [PubMed] [Google Scholar]
  17. Fung, H. W., Chien, W. T., Ling, H. W. H., Ross, C. A., & Lam, S. K. K. (2022). The mediating role of post-traumatic stress disorder symptoms in the relationship between childhood adversities and depressive symptoms in two samples. Child Abuse & Neglect, 131, 105707. 10.1016/j.chiabu.2022.105707 [DOI] [PubMed] [Google Scholar]
  18. Fung, H. W., Choi, T. M., Chan, C., & Ross, C. A. (2018). Psychometric properties of the pathological dissociation measures among Chinese – a pilot study using online methods. Journal of Evidence-Informed Social Work, 15(4), 371–384. 10.1080/23761407.2018.1456995 [DOI] [PubMed] [Google Scholar]
  19. Fung, H. W., Geng, F., Yuan, D., Zhan, N., & Lee, V. W. P. (2023). Childhood experiences and dissociation among high school students in China: Theoretical reexamination and clinical implications. International Journal of Social Psychiatry, 69, 8. 10.1177/00207640231181528 [DOI] [PubMed] [Google Scholar]
  20. Fung, H. W., Lam, S. K. K., Chien, W. T., Hung, S. L., Ling, H. W. H., Lee, V. W. P., & Wang, E. K. S. (2022). Interpersonal stress mediates the relationship between childhood trauma and depressive symptoms: Findings from two culturally different samples. Australian & New Zealand Journal of Psychiatry, 57(7). 10.1177/00048674221138501 [DOI] [PubMed] [Google Scholar]
  21. Fung, H. W., Wong, E. N. M., Lam, S. K. K., Chien, W. T., Hung, S. L., Ross, C. A., & Cloitre, M. (2023). Prevalence and sociocultural correlates of post-traumatic stress disorder and complex PTSD among Chinese community health service users in Hong Kong. International Journal of Social Psychiatry, 69(4). 10.1177/00207640221141018 [DOI] [PubMed] [Google Scholar]
  22. Godoy, L. C., Frankfurter, C., Cooper, M., Lay, C., Maunder, R., & Farkouh, M. E. (2021). Association of adverse childhood experiences with cardiovascular disease later in life. JAMA Cardiology, 6(2), 228–235. 10.1001/jamacardio.2020.6050 [DOI] [PubMed] [Google Scholar]
  23. Goldberg, L. R., & Freyd, J. J. (2006). Self-reports of potentially traumatic experiences in an adult community sample: Gender differences and test-retest stabilities of the items in a brief betrayal-trauma survey. Journal of Trauma & Dissociation, 7(3), 39–63. 10.1300/J229v07n03_04 [DOI] [PubMed] [Google Scholar]
  24. Grummitt, L., Baldwin, J. R., Lafoa’i, J., Keyes, K. M., & Barrett, E. L. (2024). Burden of mental disorders and suicide attributable to childhood maltreatment. JAMA Psychiatry. 10.1001/jamapsychiatry.2024.0804 [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Ho, G. W. K., Chan, K. L., Karatzias, T., Hyland, P., Fung, H. W., & Shevlin, M. (2024). Prevalence and validity of ICD-11 posttraumatic stress disorder (PTSD) and complex PTSD: A population-based survey of Hong Kong adults. Asian Journal of Psychiatry, 96, 104045. 10.1016/j.ajp.2024.104045 [DOI] [PubMed] [Google Scholar]
  26. Ho, G. W., Karatzias, T., Cloitre, M., Chan, A. C., Bressington, D., Chien, W. T., Hyland, P., & Shevlin, M. (2019). Translation and validation of the Chinese ICD-11 International Trauma Questionnaire (ITQ) for the Assessment of Posttraumatic Stress Disorder (PTSD) and Complex PTSD (CPTSD). European Journal of Psychotraumatology, 10(1), 1608718. 10.1080/20008198.2019.1608718 [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Holman, D. M., Ports, K. A., Buchanan, N. D., Hawkins, N. A., Merrick, M. T., Metzler, M., & Trivers, K. F. (2016). The association between adverse childhood experiences and risk of cancer in adulthood: A systematic review of the literature. Pediatrics, 138(Supplement_1), S81–S91. 10.1542/peds.2015-4268L [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Howard, A., Agathos, J. A., Phelps, A., Cowlishaw, S., Terhaag, S., Arjmand, H.-A., Armstrong, R., Berle, D., Steel, Z., & Brewer, D. (2021). Prevalence and treatment implications of ICD-11 complex PTSD in Australian treatment-seeking current and ex-serving military members. European Journal of Psychotraumatology, 12(1), 1844441. 10.1080/20008198.2020.1844441 [DOI] [PMC free article] [PubMed] [Google Scholar]
  29. Hughes, K., Bellis, M. A., Hardcastle, K. A., Sethi, D., Butchart, A., Mikton, C., Jones, L., & Dunne, M. P. (2017). The effect of multiple adverse childhood experiences on health: A systematic review and meta-analysis. The Lancet Public Health, 2(8), e356–e366. 10.1016/S2468-2667(17)30118-4 [DOI] [PubMed] [Google Scholar]
  30. Hyland, P., Shevlin, M., Fyvie, C., Cloitre, M., & Karatzias, T. (2020). The relationship between ICD-11 PTSD, complex PTSD and dissociative experiences. Journal of Trauma & Dissociation, 21(1), 62–72. 10.1080/15299732.2019.1675113 [DOI] [PubMed] [Google Scholar]
  31. Hyland, P., Vallières, F., Cloitre, M., Ben-Ezra, M., Karatzias, T., Olff, M., Murphy, J., & Shevlin, M. (2021). Trauma, PTSD, and complex PTSD in the Republic of Ireland: Prevalence, service use, comorbidity, and risk factors. Social Psychiatry and Psychiatric Epidemiology, 56(4), 649–658. 10.1007/s00127-020-01912-x [DOI] [PubMed] [Google Scholar]
  32. Isobel, S., Goodyear, M., Furness, T., & Foster, K. (2019). Preventing intergenerational trauma transmission: A critical interpretive synthesis. Journal of Clinical Nursing, 28(7-8), 1100–1113. 10.1111/jocn.14735 [DOI] [PubMed] [Google Scholar]
  33. Jowett, S., Karatzias, T., Shevlin, M., & Hyland, P. (2022). Psychological trauma at different developmental stages and ICD-11 CPTSD: The role of dissociation. Journal of Trauma & Dissociation, 23(1), 52–67. 10.1080/15299732.2021.1934936 [DOI] [PubMed] [Google Scholar]
  34. Kristman, V. L., Manno, M., & Côté, P. (2005). Methods to account for attrition in longitudinal data: do they work? A simulation study. European Journal of Epidemiology, 20(8), 657–662. 10.1007/s10654-005-7919-7 [DOI] [PubMed] [Google Scholar]
  35. Lee, K., Lam, S. K. K., Hung, S. L., & Fung, H. W. (2023). Substance abuse among mothers in Taiwan: Investigating its prevalence and testing the trauma model. Asian Journal of Psychiatry, 90, 103805. 10.1016/j.ajp.2023.103805 [DOI] [PubMed] [Google Scholar]
  36. López-Martínez, A. E., Serrano-Ibáñez, E. R., Ruiz-Párraga, G. T., Gómez-Pérez, L., Ramírez-Maestre, C., & Esteve, R. (2018). Physical health consequences of interpersonal trauma: A systematic review of the role of psychological variables. Trauma, Violence, & Abuse, 19(3), 305–322. 10.1177/1524838016659488 [DOI] [PubMed] [Google Scholar]
  37. Manne, S., DuHamel, K., Nereo, N., Ostroff, J., Parsons, S., Martini, R., Williams, S., Mee, L., Sexson, S., & Wu, L. (2002). Predictors of PTSD in mothers of children undergoing bone marrow transplantation: The role of cognitive and social processes. Journal of Pediatric Psychology, 27(7), 607–617. 10.1093/jpepsy/27.7.607 [DOI] [PubMed] [Google Scholar]
  38. Olde, E., van der Hart, O., Kleber, R. J., van Son, M. J., Wijnen, H. A., & Pop, V. J. (2005). Peritraumatic dissociation and emotions as predictors of PTSD symptoms following childbirth. Journal of Trauma & Dissociation, 6(3), 125–142. 10.1300/J229v06n03_06 [DOI] [PubMed] [Google Scholar]
  39. Petruccelli, K., Davis, J., & Berman, T. (2019). Adverse childhood experiences and associated health outcomes: A systematic review and meta-analysis. Child Abuse & Neglect, 97, 104127. 10.1016/j.chiabu.2019.104127 [DOI] [PubMed] [Google Scholar]
  40. Rioux, C., Lewin, A., Odejimi, O. A., & Little, T. D. (2020). Reflection on modern methods: planned missing data designs for epidemiological research. International Journal of Epidemiology, 49(5), 1702–1711. 10.1093/ije/dyaa042 [DOI] [PubMed] [Google Scholar]
  41. Ross, C. A., & Browning, E. (2017). The Self-Report Dissociative Disorders Interview Schedule: A preliminary report. Journal of Trauma & Dissociation, 18(1), 31–37. 10.1080/15299732.2016.1172538 [DOI] [PubMed] [Google Scholar]
  42. Ross, C. A., Duffy, C. M., & Ellason, J. W. (2002). Prevalence, reliability and validity of dissociative disorders in an inpatient setting. Journal of Trauma & Dissociation, 3(1), 7–17. 10.1300/J229v03n01_02 [DOI] [Google Scholar]
  43. Ross, C. A., Heber, S., Norton, G. R., Anderson, D., Anderson, G., & Barchet, P. (1987). PsycEXTRA Dataset. Dissociation, 2(3), 169–189. 10.1037/e609942012-089 [DOI] [Google Scholar]
  44. Roubinov, D., Browne, D., LeWinn, K. Z., Lisha, N., Mason, W. A., & Bush, N. R. (2022). Intergenerational transmission of maternal childhood adversity and depression on children's internalizing problems. Journal of Affective Disorders, 308, 205–212. 10.1016/j.jad.2022.04.030 [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. The Childhood Adversity Narratives . (2015). Opportunities to change the outcomes of traumatized children [BOOK]. http://static1.squarespace.com/static/552ec6c7e4b0b098cbafba75/t/56915f539cadb61a0a0d94a2/1452367700722/ CAN_Narrative_1-5-16-v4L.pdf.
  46. World Health Organization . (2019). The ICD-11 classification of mental and behavioral disorders. Clinical description and diagnostic guidelines. Author.
  47. Xiong, T., McGrath, P. J., Stewart, S. H., Bagnell, A., & Kaltenbach, E. (2022). Risk and protective factors for posttraumatic stress and posttraumatic growth in parents of children with intellectual and developmental disorders. European Journal of Psychotraumatology, 13(1), 2087979. 10.1080/20008198.2022.2087979 [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The dataset generated and analysed during the current study is available from the corresponding author (HWF) on reasonable request.

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