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Clinical practice guidelines, such as those focusing on traumatic stress treatment, can play an important role in promoting inclusion and equity. Based on a review of 14 international trauma treatment guidance documents that explicitly mentioned children, we reflect on two areas in which these guidelines can become more inclusive and equitable; a) representation of children's cultural background and b) children's opportunity to have their voice heard. While a few guidelines mentioned that treatment should be tailored to children's cultural needs, there was little guidance on how this could be done. Moreover, there still appears to be a strong white Western lens across all stages of producing and evaluating the international evidence base. The available documentation also suggested that no young people under the age of 18 had been consulted in the guideline development processes. To contribute to inclusion and equity, we suggest five elements for future national guideline development endeavours. Promoting research and guideline development with, by, and for currently under-represented communities should be a high priority for our field. Our national, regional and global professional associations are in an excellent position to (continue to) stimulate conversation and action in this domain.Las guías de práctica clínica, como las que se centran en el tratamiento del estrés traumático, pueden desempeñar un papel importante en la promoción de la inclusión y la equidad. Basados en una revisión de 14 documentos internacionales de orientación sobre el tratamiento del trauma que mencionaban explícitamente a los niños, reflexionamos sobre dos áreas en las que estas guías pueden ser más inclusivas y equitativas; a) representación de los antecedentes culturales de los niños y b) oportunidad de los niños para que se escuche su voz. Si bien en algunas pautas se mencionó que el tratamiento debería adaptarse a las necesidades culturales de los niños, hubo poca orientación sobre cómo hacerlo. Más aún, todavía parece haber una fuerte perspectiva occidental blanca en todas las etapas de producción y evaluación de la base de evidencia internacional. Las directrices disponibles también sugirieron que no se había consultado a ningún joven menor de 18 años en sus procesos de elaboración. Para contribuir a la inclusión y la equidad, sugerimos cinco elementos para futuros esfuerzos de desarrollo de directrices nacionales. Promover la investigación y el desarrollo de directrices con, por y para las comunidades actualmente subrepresentadas debe ser una alta prioridad para nuestro campo. Nuestras asociaciones profesionales nacionales, regionales y mundiales se encuentran en una excelente posición para (continuar) estimulando la conversación y la acción en este ámbito.临床实践指南, 如关注于创伤性应激治疗的指南, 可以在提升包容性和公平性方面发挥重要作用。在对14项明确提及儿童的国际创伤治疗指导文件综述的基础上, 我们对这些指南可以变得更具包容性和公平性的两个领域进行了反思; a) 儿童文化背景的体现, b) 儿童表达其声音的机会。尽管有几条准则提到应根据儿童的文化需求量身定制治疗方法, 但关于这一点如何实现的指导却很少。而且, 在产生和评估国际证据基础的各个阶段, 似乎仍然有强烈的西方白人眼光。现有指南还意味着在指南开发过程中未咨询18岁以下的青年。为了促进包容性和公平性, 我们建议了未来国家指南制定工作的五个要素。对于目前代表性不足的群体, 与其一同以及针对目前代表性不足的群体来促进研究和指南开发, 应该是我们领域的高度优先事项。我们国家, 地区和全球专业协会在 (继续) 促进这一领域的对话和行动方面处于优势地位。.

Background The wars in the Democratic Republic of Congo have left indelible marks on the mental health and functioning of the Congolese civilians that sought refuge in Uganda. Even though it is clear that civilians who are exposed to potentially traumatizing events in war and conflict areas develop trauma-related mental health problems, scholarly information on gender differences on exposure to different war-related traumatic events, their conditional risks to developing PTSD and whether the cumulative exposure to traumatic events affects men and women differently is still scanty. Methods In total, 325 (n = 143 males, n = 182 females) Congolese refugees who lived in Nakivale, a refugee settlement in the Southwestern part of Uganda were interviewed within a year after their arrival. Assessment included exposure to war-related traumatic events, and DSM-IV PTSD symptom severity. Results Our main findings were that refugees were highly exposed to war-related traumatic events with experiencing dangerous flight as the most common event for both men (97%) and women (97%). The overall high prevalence of PTSD differed among women (94%) and men (84%). The highest conditional prevalence of PTSD in women was associated with experiencing rape. The dose-response effect differed significantly between men and women with women showing higher PTSD symptom severity when experiencing low and moderate levels of potentially traumatizing event types. Conclusion In conflict areas, civilians are highly exposed to different types of war-related traumatic events that expose them to high levels of PTSD symptoms, particularly women. Interventions focused at reducing mental health problems resulting from war should take the context of gender into consideration.

In the past decade, millions of children and adolescents have been forced to flee from protracted or newly erupted violent conflicts. Forcibly displaced children are particularly vulnerable for developing mental health problems. However, a timely and systematic review of the current evidence is lacking. We conducted a systematic review of factors contributing to the mental health of refugee children across different socio-ecological levels (individual, family, community, sociocultural). We systematically searched the databases Medline, PsycINFO, Web of Science, and Cochrane for English studies published in peer-reviewed journals between August 2010 and May 2020. Of the 2413 identified studies, 63 were included in the analyses. Only 24 studies were considered to be of high quality. Pre-migration individual (risk: exposure to war-related trauma, female gender) and post-migration family factors (risk: parental mental health problems and impaired parenting, protective: family cohesion) currently have the best evidence base. Post-migration community (protective: school connectedness, support by peers) and sociocultural factors (risk: discrimination and acculturative stress, protective: integrative acculturation) have gained some support in high-income settings. Prevention and intervention approaches should integrate factors across different socio-ecological levels. More longitudinal studies and research in low- and middle-income countries are needed to advance our knowledge on causal mechanisms behind factors contributing to refugee youth's mental health.

Background Teacher violence toward students is a common public health risk associated with various negative outcomes. Though previous studies examined the prevalence of teacher violence toward students and its association with negative outcomes, little is known about the association between teacher violence and school performance, and the mediating role of students’ emotional and behavioral problems, particularly in developing countries. Objective This study sought to investigate the prevalence of teacher violence toward students, its association with school performance, and the mediating role of emotional and behavioral problems. Participants and Setting Data were collected from 293 students (M = 12.59, SD = 1.07) and 205 teachers (M = 37.20, SD = 8.41) using a structured sampling approach. Methods Our cross-sectional study used a multi-informant approach: both teachers and students reported on violence by teachers. Students reported also on other types of violence, emotional and behavioral problems, and school performance. Results Of all students, 55 % reported that they were exposed to teacher violence at least once in the past month, while 83 % of teachers reported having used any type of violence against students. Path analysis indicated direct associations between teacher violence toward students and students’ behavioral and emotional problems (β = 0.21) and school performance (β = −0.15), and an indirect association between teacher violence and school performance (β = −0.05) via emotional and behavioral problems. Conclusions Teacher violence toward students was highly prevalent and associated with emotional and behavioral problems and lower school performance. Prevention programs and social policies aiming to reduce violence by teachers are urgently needed.

International concern over refugee militarization has grown greatly in recent years. Despite the growing prominence attached to this issue by scholars and international organizations alike, few have examined refugee recruitment from the perspective of the recruiter. Drawing on the signalling theory, we argue that recruiters will only approach those refugees who show willingness to get involved in militancy. Empirically, we focus on four attributes that might show this willingness: the role of ethnicity, economic deprivation, camp insecurity and the social network of the refugee. We examine the importance of these factors with the help of new data collected via interviews with more than 280 Congolese refugees. Our analyses show that recruiters especially approach those refugees who feel economically deprived, have combat experience and already know people that were successfully mobilized. Contrary to our expectations, ethnicity plays only a limited role.

Little is known about the prevalence of mental health problems among adolescents in Sub-Saharan Africa. Research consistently determined violence and maltreatment to be important risk factors. In this study, we examined the prevalence of mental health problems among adolescents in Tanzania, as well as the association with exposure to violence and maltreatment. We administered a set of questionnaires (e.g., strength and difficulties questionnaire; conflict tactic scale) to a nationally representative sample of 700 Tanzanian secondary school children (52% girls; age 14.92 years, SD = 1.02) and 333 parents or primary caregivers (53% females; age 43.47 years, SD = 9.02). 41% of the students reported an elevated level of mental health problems (emotional problems 40%, peer problems 63%, conduct problems 45%, hyperactivity 17%) in the past 6 months. Concordantly, 31% of parents reported observing an elevated level of mental health problems in their children (emotional problems 37%, peer problems 54%, conduct problems 35%, hyperactivity 17%). After controlling for other risk factors, we found significant associations between physical violence by parents and adolescent’s mental health problems reported by students (β = 0.15) and their parents (β = 0.33). Our findings suggest a high prevalence of mental health problems using screening tools among secondary school students in Tanzania as well as an association between physical violence by parents and adolescents’ mental health problems. Our findings emphasize the need to inform the population at large about the potentially adverse consequences associated with violence against children and adolescents.

Background The detrimental impact of child maltreatment on children and adolescents' academic achievement and later socioeconomic wellbeing is well known. However, it is still unclear (1) whether maltreatment is actually linked to youth's long- and short-term memory deficits and (2) whether potential impairments are due to maltreatment per se or related psychopathology. Objective Based on the Attentional Control Theory, we investigated a mediational model in which maltreatment would be related to psychopathology (internalizing symptoms, posttraumatic stress symptoms, posttraumatic cognitions), which would in turn be related to impaired memory functioning. Participants and setting We drew on a sample of 155 Burundian refugee youth (aged 11 to 15) currently living in refugee camps in Tanzania and at high risk of experiencing ongoing maltreatment by parents. Methods Youth reported on their experiences of maltreatment and psychopathology in structured clinical interviews and completed visuospatial memory tasks involving a short-term and a working memory component (Corsi Block Tapping Test) and delayed recall from long-term memory (Rey-Osterrieth Complex Figure). Results Structural equation modeling showed that psychopathology mediated the association between increased maltreatment and reduced working memory capacity (β = −0.07, p = .02), with a trend towards mediation for short-term memory (β = −0.05, p = .06). Higher levels of maltreatment, but not psychopathology, were directly linked to long-term memory deficits (β = −0.20, p = .02). Conclusions Preventive efforts targeting maltreatment and interventions focusing on related psychopathology are needed to counter memory deficits and their potential negative implications for academic and socioeconomic outcomes.

Posttraumatic stress (PTS) indicates a continuous stress response that persists though threats to life had been experienced in the past. However, threats to life are frequently ongoing. For these contexts, the concept of continuous traumatic stress (CTS) has been put forward. Based on structured clinical interviews with Congolese refugees ( N = 226), this study investigated the CTS concept and whether it can be distinguished from PTS. We found that current exposure to violence correlated positively with concerns about its recurrence in the CTS group ( r = .46). An ANCOVA indicated that higher intrusion symptom severity in the PTS group (no symptom reduction under safe conditions) was explained by higher lifetime trauma exposure (η2 = .125). In contexts of continuous trauma exposure, symptom-like responses may be regarded as appropriate responses to realistic danger. In these contexts, the possibility that symptom changes are a response to real threats should be considered to avoid overestimation of PTSD prevalences.

Abstract. Traumatic exposure is particularly devastating for those who, at a young age, have become combatants or experienced massive adversity after abduction by armed movements. We investigated the impact of traumatic stressors on psychopathology among war-affected young men of Northern Uganda, including former child soldiers. Adaptation to violent environments and coping with trauma-related symptoms often result in an increasing appetite for violence. We analyze implicit attitudes toward violence, assessed by an Implicit Association Test (IAT), among 64 male participants. Implicit attitudes varied as a function of the number of experienced traumatic event types and committed offense types. As the number of traumatic experiences and violence exposure increased, more appetitive aggression was reported, whereas the IAT indicated increasingly negative implicit attitudes toward aggression. The IAT was also the strongest predictor of cortisol levels. Diffusion-model analysis was the best way to demonstrate IAT validity. Implicit measures revealed the trauma-related changes of cognitive structures.

Das klassische Konzept der „sozialen Unterstutzung“ wird im Zusammenhang mit traumatisierten Patientengruppen und hier aktuell den traumatisierten Fluchtlingen und Migranten wieder besonders aktuell. Der Beitrag soll wichtige Ergebnisse der Soziale-Unterstutzungs-Forschung illustrieren, z. B. die Arten ihrer positiven Wirkung, Kontexte, Geschlechts- und kulturelle Aspekte. Alle diese Aspekte werden anhand vorhandener Untersuchungen dargestellt, die aus der angewandten Gesundheitsforschung stammen und die eine grose Bandbreite gesundheitlicher Wirkungen beschreiben: neben erhohtem Wohlbefinden und verringerter Depressivitat, verbesserte funktionelle Fahigkeiten, verbesserter Immunstatus und langere Uberlebenszeiten. Zwei neue traumaspezifische Differenzierungen des Konzepts werden eingefuhrt: Wertschatzung als Traumauberlebende und Offenlegung traumatischer Erfahrungen. Fur die Arbeit mit und die Versorgung von Fluchtlingen ergeben sich viele Anknupfungspunkte: Die Forderung von Selbstwirksamkeit und posttraumatischer Reifung sowie die Therapie psychischer Storungen profitieren entscheidend von der (Mit-)Orientierung auf soziale Unterstutzung. Zum Schluss wird auf die Moglichkeiten der digitalen Kommunikation als soziale Unterstutzung hingewiesen, die in diesem Kontext ebenfalls relevant sind.

It has been postulated that the violent behavior that characterizes armed conflict is reinforced by the possibility of receiving rewards. The present study examined the potential influence of two types of rewards in an ongoing setting of conflict: extrinsic and intrinsic rewards. Former combatants active in the Democratic Republic of the Congo (N = 198) were interviewed and questioned about the way they were recruited, the offenses they committed during combat, their level of perceived intrinsic rewards (i.e., appetitive perception of violence), and the number of received extrinsic rewards during their time in the armed group (e.g., money, extra food, alcohol, or drugs). A moderated multiple regression analysis showed that the number of received extrinsic rewards and the level of intrinsic rewards were significantly positively related to the number of different types of offenses committed. In contrast to our expectations and previous findings, the recruitment type (forced conscription vs. voluntary enlistment) did not moderate this relation. Our findings suggest that both types of rewards play a role in committing violence during combat. We suggest, therefore, that reintegration programs should not only consider the influence of extrinsic rewards, but also need to address the influence of intrinsic rewards to counter violent behavior among former combatants. Aggr. Behav. 43:241–250, 2017. © 2016 Wiley Periodicals, Inc.

BackgroundDespite global efforts to end violence against children in all settings, reports reveal that violence against children is still highly prevalent, especially in low-and middle- income countries. Violence in childhood is associated with a host of negative outcomes, and exposure in one setting can easily spill over to other contexts. For instance, exposure to family violence was not only related to mental health problems but also seems to be a risk factor for peer victimization.ObjectivesThe present study aimed to examine the prevalence of maltreatment within the family and adolescents’ mental health problems and their relation to peer victimization. We also aimed to gain new insights into the perceptions of adolescents concerning maltreatment within their families.MethodsData were collected from April to November 2017 in a representative sample of 702 students from 12 public secondary schools in Southwestern Uganda who responded to self-administered questionnaires.ResultsOverall, 95% of the students experienced at least one type of family violence in the past month. Students (81.3%) had endorsed some level of acceptance of violent discipline as a valid strategy in response to any misbehavior. Maltreatment within the family was related to peer victimization (β = .47) and this relation was mediated by mental health problems (0.002, 95%-CI: 0.001–0.004).ConclusionsThe results indicated a high prevalence of maltreatment within Ugandan families that was associated with peer victimization. This underscores the need to implement interventions aiming to reduce maltreatment and violence in order to protect children from potentially negative consequences. published

Background Globally, the use of violent discipline methods by teachers to manage child behavior is still highly prevalent despite enactment of laws that prohibit school violence. In the case of Uganda there is a dearth of accurate prevalence statistics on school violence and factors associated with the use of violence by teachers. Objectives Therefore, the current study examined the prevalence of and attitudes towards violence. The study also explored the association between teachers’ stress, positive attitudes towards violence and the use of violent discipline management methods. Methods A representative sample of 291 teachers and 702 students from 12 public secondary schools in southwestern Uganda responded to anonymous self-administered questionnaires. Data were collected from April to November 2017. Results Findings indicated that 86.5% of the teachers reported having used violent disciplinary methods on students in the past month while 91.5% of the students reported experiencing violence by teachers. Teachers (88.3%, n = 256) endorsed positive attitudes towards violent discipline. Teachers’ stress was related to higher levels of violent discipline (β = 0.20). This relation was mediated by positive attitudes towards violence (0.06, SE: 0.01, 95%-CI: 0.035–0.092). Conclusions Our findings indicate that teacher reported stress was associated with their use of violent behavior and positive attitudes and that positive attitudes reduced the association between teachers’ stress and violent behavior. Therefore, interventions aiming to reduce violence by teachers may need to integrate effective stress management skills, in addition to nonviolent discipline strategies, and fostering attitudinal change towards the use of violent methods.

(1) Background: Teachers’ personal and strenuous working conditions reflect the realities of the teaching vocation that may result in increased stress levels and associated negative consequences, such as negative emotions. It is also well-known that teacher stress contributes to more violence against students. However, little is known about personal and school context factors that contribute to teachers’ stress. The current study examined whether, in addition to school-related factors, job perceptions, including the feeling of pressure at work and perceived school climate and teaching difficulties, contribute to teachers’ stress.(2) Methods: A representative sample of 291 teachers from 12 public secondary schools in southwestern Uganda responded to self-administered questionnaires.(3) Results: Teaching difficulties and feelings of pressure at work contributed to teachers’ stress. Furthermore, stress did not vary with teachers’ sociodemographic variables.(4) Conclusions: Teachers’ perceptions of their working conditions were associated with teacher stress levels. Therefore, more efforts need to be geared towards improving the working conditions of teachers as a way of reducing stress. published

Background Sexual violence against minors is a global phenomenon with wide-ranging negative consequences. Global reports suggest that it is a particularly serious issue in East African countries, although research on prevalence and characteristics of violence in these countries is scarce. Objective The aim of this study was to assess sexual violence and its circumstances among Tanzanian and Ugandan adolescents. Participants and setting Two representative samples of secondary school students aged 12–17 from Tanzania and Uganda (N = 1402) were included in this study. Methods Data assessed using standardized questionnaires were analyzed to determine prevalence, characteristics, and contributing factors of sexual violence among youth. Results We found high levels of sexual violence (27.2 %) exceeding global average estimates of under 20 %. Significantly more sexual violence experiences were reported by boys (29.9 %) than girls (24.6 %) and by older compared to younger adolescents (30.2 % vs. 19.6 %). Peers were the most frequent perpetrator group, named by 47.6 % of those reporting abuse. Several potential contributing factors for victimization were identified, such as rural living area, external financial support, and being in a romantic relationship. Conclusions Sexual violence is a relevant issue among East African adolescents that occurs in a variety of settings but appears to be most prevalent between peers. Comprehensive sexual education approaches may help to improve the protection of adolescents and to enhance autonomous sexual development.

BACKGROUND: Depending on the exposure to traumatic stressors and combat, 20% to 50% of ex-combatants present with trauma-related disorders, and more than half of the members of armed groups have a proclivity to violence. Therefore, psychotherapeutic assistance should address both, trauma-related suffering and the lowered threshold for aggressive behaviour. OBJECTIVE: Supporting the demobilization process of ex-combatants in the eastern DR-Congo, we implemented a version of Narrative Exposure Therapy adapted for Forensic Offender Rehabilitation (FORNET). METHOD: In two successive dissemination stages (DS), local counsellors conducted FORNET. In DS1, they were trained by clinical experts, and in DS2, the by then experienced counsellors trained and supervised a second group of local counsellors (DS2). The training consisted of a 3-week workshop covering theoretical concepts and practical therapeutic skills. In DS1 and DS2, a total of 98 demobilizing combatants received an intervention; treatment-as-usual served as the control condition. Posttraumatic stress disorder, appetitive aggression, depression severity and drug dependence were assessed prior to the intervention and 6 and 12 months later; additionally, we assessed reintegration success. RESULTS: Six months post-intervention, FORNET significantly reduced Posttraumatic stress disorder symptoms but had less effect on the trait of appetitive aggression; moreover, beneficial effects were found for depression severity and drug dependence as well as for reintegration indices. Treatment gains were retained at 12 months. CONCLUSIONS: Individuals without previous training in psychotherapy can learn to effectively apply the brief intervention FORNET and support the demobilization process in ongoing conflicts. The study suggests that it is possible to pass down psychotherapeutic techniques over generations of counsellors. © 2015 The Authors. Clinical Psychology & Psychotherapy published by John Wiley & Sons Ltd. KEY PRACTITIONER MESSAGE: Posttraumatic stress symptoms, depression and clinically relevant levels of drug dependence can effectively be reduced with a version of Narrative Exposure Therapy (NET) adapted for Forensic Offender Rehabilitation (FORNET). The intervention is effective in the context of ongoing conflict. Individuals without previous training in psychotherapy can learn to effectively apply the brief intervention FORNET. It is possible to pass down psychotherapeutic techniques like FORNET over generations of counsellors. Psychotherapeutic interventions like FORNET may facilitate the transition to peace in war-torn regions. Language: en

Zusammenfassung: Traumata werden definiert als Ereignisse von außergewöhnlicher Bedrohung, die nahezu bei jedem tiefgreifende Verzweiflung auslösen würde. Die "klassische" posttraumatische Belastungsstörung (PTBS) ist gekennzeichnet durch Intrusionen, Vermeidung und Hyperarousal. Die komplexe posttraumatische Belastungsstörung (KPTBS) wird als eigenständige Diagnose in die ICD-11 aufgenommen und tritt als Folge von sich wiederholenden oder lang andauernden traumatischen Ereignissen auf. Die KPTBS ist neben den Symptomen der PTBS durch Affektregulationsstörungen, negative Selbstwahrnehmung und Beziehungsstörungen gekennzeichnet. Aktuelle empirische Studien lieferten Hinweise für die Validität dieser Diagnose. Die Exposition in sensu mit dem traumatischen Ereignis steht im Mittelpunkt der als erfolgreich evaluierten Psychotherapien von PTBS und KPTBS. Zur differenziellen Wirkung einzelner traumafokussierter Verfahren bei KPTBS können jedoch noch keine eindeutigen Empfehlungen ausgesprochen werden.

War-related trauma exposure has been linked to aggression and enhanced levels of community and family violence, suggesting a cycle of violence. Reactive aggression--an aggressive reaction to a perceived threat--has been associated with posttraumatic stress disorder (PTSD). In contrast, appetitive aggression--a hedonic, intrinsically motivated form of aggression--seems to be negatively related to PTSD in offender and military populations. This study examined the associations between exposure to violence, trauma-related symptoms and aggression in a civilian population. In semistructured interviews, 290 Congolese refugees were questioned about trauma exposure, PTSD symptoms, and aggression. War-related trauma exposure correlated positively with exposure to family and community violence in the past month (r = .31, p < .001), and appetitive (r = .18, p = .002) and reactive aggression (r = .29, p < .001). The relationship between war-related trauma exposure and reactive aggressive behavior was mediated by PTSD symptoms and appetitive aggression. In a multiple sequential regression analysis, trauma exposure (β = .43, p < .001) and reactive aggression (β = .36, p < .001) were positively associated with PTSD symptoms, whereas appetitive aggression was negatively associated (β = -.13, p = .007) with PTSD symptoms. Our findings were congruent with the cycle of violence hypothesis and indicate a differential relation between distinct subtypes of aggression and PTSD.

Child maltreatment is known to engender negative emotional and behavioral consequences. Although neglect is the most frequent form of maltreatment, it has thus far only received little attention, especially when looking at low-resource countries. The current study investigated possible associations between neglect and internalizing and externalizing problems. As neglect and abuse often co-occur, the latter was controlled for. In total, 409 Tanzanian primary school students (52% boys, M = 10.5 years, range = 6–15) participated in the cross-sectional study. Structured clinical interviews were conducted assessing maltreatment, internalizing problems, and externalizing problems. Overall, 31% (n = 128) of the children reported at least one type of physical neglect and 31% (n = 127) of emotional neglect. Using structural equation modeling, we found a significant association between neglect and internalizing (β = 0.59, p < .01) and externalizing problems (β = 0.35, p < .05). However, these associations could only be detected in younger children (ages 6–9), whereas in older children (ages 10–15), mental health problems were significantly related to violence and abuse. Our findings suggest that the current age may influence the association between maltreatment type and the development of internalizing and/or externalizing problems.

Prevalence rates are still lacking for posttraumatic stress disorder (PTSD) and complex PTSD (CPTSD) diagnoses based on the new ICD-11 criteria. In a nationwide representative German sample (N = 2524; 14-99 years), exposure to traumatic events and symptoms of PTSD or CPTSD were assessed with the International Trauma Questionnaire. A clinical variant of CPTSD with a lower threshold for core PTSD symptoms was also calculated, in addition to conditional prevalence rates dependent on trauma type and differential predictors. One-month prevalence rates were as follows: PTSD, 1.5%; CPTSD, 0.5%; and CPTSD variant, 0.7%. For PTSD, the highest conditional prevalence was associated with kidnapping or rape, and the highest CPTSD rates were associated with sexual childhood abuse or rape. PTSD and CPTSD were best differentiated by sexual violence. Combined PTSD and CPTSD (ICD-11) rates were in the range of previously reported prevalences for unified PTSD (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; ICD-10). Evidence on differential predictors of PTSD and CPTSD is still preliminary.

Though the Sustainable Development Goals of the United Nations aim to end all forms of violence against minors, child maltreatment remains a globally prevalent phenomenon. Despite the fact that parents in numerous countries apply violent discipline methods to control children’s behavior, little is known about the prevalence of maltreatment and violent discipline in Sub-Saharan Africa. In this study, we examined the prevalence of maltreatment and violent discipline from both the adolescents’ and parents’ perspectives. In addition, we explored risk factors that could be associated with violent discipline by parents. We administered questionnaires to a nationally representative sample of 700 Tanzanian secondary school students (52% girls, mean age: 14.92 years, SD = 1.02, range: 12–17) and 333 parents or primary guardians (53% females; mean age: of 43.47 years, SD = 9.02, range: 19–71). More than 90% of all students reported exposure to violent discipline by a parent within the past year. Concurrently, more than 80% of parents acknowledged using violent discipline techniques. Using a path model, we found that violent discipline by parents was associated with parental stress. Other risk factors contributed to a higher stress level but were not directly linked to maltreatment. Our findings indicate high levels of violent discipline in Tanzanian families. There is a pressing need to design and implement interventions that prevent children from experiencing violence at home. Reducing parents’ stress levels may be a starting point for intervention. Yet, due to the high levels of violent discipline, societal beliefs also need to be considered.

Violent forms of discipline in schools continue to be widespread across the globe despite their damaging effects. Since little is known about factors influencing the extent of violence applied by teachers, this study aimed to investigate the influence of teachers' stress, work satisfaction, and personal characteristics on their disciplining style. Using structural equation modeling, associations between violent discipline, burnout symptoms, and job perceptions (pressure and difficulties in class) reported by 222 teachers from 11 secondary schools in Tanzania in 2015 were analyzed. Results indicated a direct association between perceived stress and emotional violent discipline (β=.18, p

Background: Differentiated and economical diagnostic methods are in ever greater demand in the treatment of soldiers traumatised by war. In the context of cognitive-behavioural approaches, the Posttraumatic Cognitions Inventory (PTCI) serves to identify dysfunctional cognitions that play a key role in the development and persistence of trauma-related disorders such as posttraumatic stress disorder (PTSD). Objectives: The aim of this study is develop and validate an efficient shortened version of the PTCI for soldiers traumatised on deployment in order to provide an improved and practical instrument for use in everyday clinical practice. Methodology: A total of 352 Bundeswehr soldiers diagnosed with deployment-related mental health problems were examined using the PTCI, with the number of items covered by the original instrument being reduced from 33 to 12. The resulting military version of the PTCI (PTCI –Short Version / PTCI-SV) was then validated using a sample of 109 personnel with deployment-related PTSD. Results: The overall scale of the PTCI-SV showed good internal consistency with α=0.86. (Subscales: “negative cognitions about the self” α=0.89; “negative cognitions about the world” α=0.86; “self-blame” α=0.61). Discussion: The possibility of improving trauma therapy for soldiers with deployment-related mental health issues by further developing existing screening instruments is discussed.

In Sub-Saharan Africa, poverty and the HIV/AIDS pandemic have led to constantly rising numbers of orphans over the last decades. In many African countries, childcare institutions constitute the most frequently utilized form of providing formal care for children without parents. In addition to parental loss and possible maltreatment in the family of origin, orphans are burdened with further experiences of maltreatment in childcare institutions, which may have detrimental consequences for mental health and development. Additionally, the often unresponsive and distant caregiving in institutional care may result in neglect. Thus, prevention of abuse and neglect is highly important in institutional care settings. With Interaction Competencies with Children – for Caregivers (ICC-C), we present a preventative intervention approach that aims to improve care quality and to prevent maltreatment in institutional care, particularly in Sub-Saharan Africa. ICC-C proved its feasibility and showed first promising results in a study with caregivers in Tanzanian orphanages. As maltreatment occurs in all alternative care settings, we emphasize that improving care quality may be more important than the type of care. Although basic nutrition, sanitation, and medical care are essential, interactions with responsive nonviolent caregivers are crucial to the children’s physical and behavioral development. Therefore, we advocate for focusing on the prevention of maltreatment and violence in institutional care and other care settings in Sub-Saharan Africa.

Research has shown the harmful potential of institutional care on young children; however, little is known about the consequences of institutional care on infants in Sub-Saharan Africa. We compared 35 Tanzanian children who were institutionalized at birth to 4 years of age with a matched group of 35 children who were institutionalized at 5 to 14 years of age. We examined adverse childhood experiences over the course of their entire lives, in their family of origin and in institutional care, and mental health problems at primary school age, such as depressive symptoms, aggressive behavior, and internalizing and externalizing problems. Results showed that early institutionalized children reported more adverse experiences during their time in institutional care and a greater variety of mental health problems than did late institutionalized children. Moreover, maltreatment in institutional care was positively related to mental health problems only in early institutionalized children. We conclude that adverse experiences in institutional care play an important role for early institutionalized children who need special care from adequately educated caregivers. Therefore, training concepts focusing on the needs of the youngest children have to be developed, tested, and established. Countries such as Tanzania need policies that apply to all orphanages to ensure an adequate standard of quality in childcare.

As a consequence of the ongoing conflict in the Democratic Republic of the Congo (DRC), combatants are constantly involved in various forms of violence. Findings concerning the impact of perpetrating violence on mental health are contradictory, ranging from increasing to buffering the risk for mental ill health. The present study investigated the impact of perpetrating violence on mental health. In total, 204 forcibly recruited and voluntary male combatants (mean age = 24.61 years) from different armed groups in the eastern DRC took part in the study. In a semistructured interview, respondents were questioned about appetitive aggression and posttraumatic stress disorder (PTSD) as well as self-experienced violence and self-perpetrated violent offending. A multivariate analysis of variance (η(2) = .23) revealed that voluntary combatants perpetrated more violent acts (η(2) = .06) and showed higher appetitive aggression η(2) = .03). A moderated multiple regression analysis (R(2) = .20) showed that perpetrating violence was positively related to PTSD in forcibly recruited combatants, but not in voluntary combatants. Thus, perpetrating violence may not necessarily qualify as a traumatic stressor. Further studies might consider assessing the combatant's perception of committing violent acts. Language: en

Quality of child care has been shown to have a crucial impact on children’s development and psychological adjustment, particularly for orphans with a history of maltreatment and trauma. However, adequate care for orphans is often impacted by unfavorable caregiver–child ratios and poorly trained, overburdened personnel, especially in institutional care in countries with limited resources and large numbers of orphans. This systematic review investigated the effects of structural interventions and caregiver trainings on child development in institutional environments. The 24 intervention studies included in this systematic review reported beneficial effects on the children’s emotional, social, and cognitive development. Yet, few studies focused on effects of interventions on the child–caregiver relationship or the general institutional environment. Moreover, our review revealed that interventions aimed at improving institutional care settings have largely neglected violence and abuse prevention. Unfortunately, our findings are partially limited by constraints of study design and methodology. In sum, this systematic review sheds light on obstacles and possibilities for the improvement in institutional care. There must be greater efforts at preventing violence, abuse, and neglect of children living in institutional care. Therefore, we advocate for combining attachment theory-based models with maltreatment prevention approaches and then testing them using rigorous scientific standards. By using approaches grounded in the evidence, it could be possible to enable more children to grow up in supportive and nonviolent environments.

Objective Spirit possession is a phenomenon frequently occurring in war-torn countries. It has been shown to be an idiom of distress entailing dissociative symptoms. However, its association with trauma exposure and trauma-related disorders remains unclear. This study aimed to explore subjective disease models and the relationship between pathological spirit possession and trauma-related disorders in the Eastern Democratic Republic of the Congo. Method Seventy-three (formerly) possessed persons (74% female, mean age = 34 years), referred by traditional and spiritual healers, were interviewed about their experiences of pathological spirit possession, trauma exposure, posttraumatic stress disorder (PTSD) symptoms, depressive symptoms, shame and guilt, psychotic symptoms, somatic complaints, and the impairment of psychosocial functioning. Results The most common disease model for pathological spirit possession was another person having sent the spirit, mostly a family member or a neighbor, out of jealousy or conflict over resources. Significant correlations were found between spirit possession over lifetime and PTSD symptom severity, feelings of shame and guilt, depressive symptoms, somatic complaints, and psychotic symptoms. Spirit possession during the preceding 4 weeks was associated with PTSD symptom severity, impairment of psychosocial functioning, and psychotic symptom severity. Conclusions The results of this study indicate that pathological spirit possession is a broad explanatory framework for various subjectively unexplainable mental and physical health problems, including but not limited to trauma-related disorders. Understanding pathological spirit possession as a subjective disease model for various mental and physical health problems may help researchers and clinicians to develop culturally sensitive treatment approaches for affected individuals. (PsycINFO Database Record

Posttraumatic stress disorder (PTSD) is one of the very few mental disorders that requires by definition an environmental context—a traumatic event or events—as a precondition for diagnosis. Both trauma sequelae and recovery always occur in the context of social–interpersonal contexts, for example, in interaction with a partner, family, the community, and the society. The present paper elaborates and extends the social–interpersonal framework model of PTSD. This was developed to complement other intrapersonally focused models of PTSD, which emphasize alterations in an individual’s memory, cognitions, or neurobiology. Four primary reasons for broadening the perspective from the individual to the interpersonal–societal contexts are discussed. The three layers of the model (social affects, close relationships, and culture and society) are outlined. We further discuss additional insights and benefits of the social–interpersonal perspective for the growing field of research regarding resilience after traumatic experiences. The paper closes with an outlook on therapy approaches and interventions considering this broader social–interpersonal perspective on PTSD.Keywords: Post-traumatic stress disorder; interpersonal processes; social context; disclosure; social sharing(Published: 18 March 2016)Responsible Editor: Marit Sijbrandij, VU University, Netherlands.This paper is part of the Special Issue: Trauma occurs in social contexts. More papers from this issue can be found at www.ejpt.netFor the abstract or full text in other languages, please see Supplementary files in the column to the right (under ‘Article Tools’)Citation: European Journal of Psychotraumatology 2016, 7: 29303 - http://dx.doi.org/10.3402/ejpt.v7.29303Citation: European Journal of Psychotraumatology 2016, 7: 29303 - http://dx.doi.org/10.3402/ejpt.v7.29303Copyright: © 2016 Andreas Maercker and Tobias Hecker. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License, allowing third parties to copy and redistribute the material in any medium or format, and to remix, transform, and build upon the material, for any purpose, even commercially, under the condition that appropriate credit is given, that a link to the license is provided, and that you indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.Received: 30 July 2015; Revised: 29 October 2015; Accepted: 13 November 2015; Published: 18 March 2016Competing interests and funding: The authors declare that they have no competing interests.*Correspondence to: Andreas Maercker, Division of Psychopathology and Clinical Intervention, Department of Psychology, University of Zurich, Binzmuehlestr, 14/17, CH-8050 Zurich, Switzerland, Email: maercker@psychologie.uzh.chThis paper is part of the Special Issue: Trauma occurs in social contexts. More papers from this issue can be found at www.ejpt.netFor the abstract or full text in other languages, please see Supplementary files under ‘Article Tools’

Child abuse is associated with a number of emotional and behavioral problems. Nevertheless, it has been argued that these adverse consequences may not hold for societies in which many of the specific acts of abuse are culturally normed. Epigenetic modifications in the genes of the hypothalamus–pituitary–adrenal axis may provide a potential mechanism translating abuse into altered gene expression, which subsequently results in behavioral changes. Our investigation took place in Tanzania, a society in which many forms of abuse are commonly employed as disciplinary methods. We included 35 children with high exposure and compared them to 25 children with low exposure. Extreme group comparisons revealed that children with high exposure reported more mental health problems. Child abuse was associated with differential methylation in the proopiomelanocortin gene (POMC), measured both in saliva and in blood. Hierarchical clustering based on the methylation of the POMC gene found two distinct clusters. These corresponded with children's self-reported abuse, with two-thirds of the children allocated into their respective group. Our results emphasize the consequences of child abuse based on both molecular and behavioral grounds, providing further evidence that acts of abuse affect children, even when culturally acceptable. Furthermore, on a molecular level, our findings strengthen the credibility of children's self-reports.

This paper addresses consequences of exposure to violence and trauma. Traumata are defined as events with an extraordinary threat or catastrophic extent. Beside Posttraumatic Stress Disorder (PTSD), affected people may develop Complex PTSD, Prolonged Grief Disorder or Adjustment Disorder as direct consequences of exposure with extreme stress. Indirect trauma-related disorders are amongst others Major Depression, Substance Dependency and Personality Disorders. These disorders develop often comorbid to PTSD. The likelihood to develop a PTSD at one point during the life course is 1-4% in Germany. A PTSD is diagnosed if for any length of time the traumatic situation is re-experienced (e.g. in pictures or nightmares), potential triggers are avoided, emotional reactivity is numb and a permanent hyperarousal is experienced. The intensity, the duration and the frequency of traumatic experiences as well as the lack of social support after the trauma are important risk factors for the development of a PTSD. In the last two decades successful treatment approaches for PTSD have been developed. The main focus of all evidence-based treatment approaches is the exposure in sensu of the traumatic experiences. Behavioral therapy approaches have shown to be most effective in the treatment of PTSD. A better understanding of the consequences of exposure to violence and trauma may help us to identify people at risk for developing trauma-related disorders already at an early stage.

This study explores the reasons behind sexual violence. In doing so, we focus on structured information given by 224 former combatants from different Congolese armed groups. Unlike other studies on sexual violence, we have controlled for the combatant’s experience with sexual violence: we have self-reports on whether they have witnessed, experienced, or perpetrated sexual assault themselves. Ultimately, by asking the former combatants themselves to react on particular statements on the reasons behind sexual violence, we can glimpse the logic behind this phenomenon. The results of the comparative analysis show that perpetrators differ from nonperpetrators by emphasizing that sexual violence occurs out of frustration or as revenge. Victims, however, emphasize the lack of punishment and the fact that perpetrators want to prove their strength. All in all, we found high levels of agreement surrounding the opportunity argument behind sexual violence during warfare, i.e. it occurs because war provides the perpetrator with an opportunity for this kind of behavior.

This paper addresses consequences of exposure to violence and trauma. Traumata are defined as events with an extraordinary threat or catastrophic extent. Beside Posttraumatic Stress Disorder (PTSD), affected people may develop Complex PTSD, Prolonged Grief Disorder or Adjustment Disorder as direct consequences of exposure with extreme stress. Indirect trauma-related disorders are amongst others Major Depression, Substance Dependency and Personality Disorders. These disorders develop often comorbid to PTSD. The likelihood to develop a PTSD at one point during the life course is 1-4% in Germany. A PTSD is diagnosed if for any length of time the traumatic situation is re-experienced (e.g. in pictures or nightmares), potential triggers are avoided, emotional reactivity is numb and a permanent hyperarousal is experienced. The intensity, the duration and the frequency of traumatic experiences as well as the lack of social support after the trauma are important risk factors for the development of a PTSD. In the last two decades successful treatment approaches for PTSD have been developed. The main focus of all evidence-based treatment approaches is the exposure in sensu of the traumatic experiences. Behavioral therapy approaches have shown to be most effective in the treatment of PTSD. A better understanding of the consequences of exposure to violence and trauma may help us to identify people at risk for developing trauma-related disorders already at an early stage.

Zusammenfassung: E-Mental-Health als innovative Form der psychotherapeutischen Versorgung findet in den letzten Jahren zunehmend Beachtung. Im Bereich der posttraumatischen Belastungsstörung (PTBS) und verwandter Belastungsfolgestörungen sind internetbasierte und andere E-Mental-Health-Angebote in großer Vielfalt entwickelt worden. Die niedrigschwelligsten Angebote in einem gestuften Versorgungssystem ("stepped-care") sind die reinen webbasierten Selbsthilfeprogramme. Auf der anderen Seite des Spektrums stehen Online-Psychotherapien und Virtual-Reality-Programme; während die Angebote im Bereich der M(obile)-Mental-Health die Palette neuer technologischer Möglichkeiten in der Psychotherapie ergänzen. Die vorliegenden Wirksamkeitsstudien belegen für alle vorgestellten Angebote klinische Wirksamkeit, auch wenn einige der Angebote noch nicht in Studien analog zu Phase-III-Studien der Psychopharmakologie untersucht wurden. E-Mental-Health-Angebote werden in Zukunft international mehr und mehr das Gesicht unseres Faches prägen.

Many studies have emphasized the role of natural resources in the onset and duration of armed conflict. Due to its characteristics, narcotics are considered to be one of the most influential resources. However, the dynamics of how this particular commodity is linked to conflict is still not well understood. Most scholars have focused on the revenue aspects of narcotics and only a few have mentioned the micro-level aspect, i.e., the effect of drug intake and alcohol consumption on combatants' behavior during conflict. With the help of a dataset based on 224 interviews held with former combatants in the Democratic Republic of the Congo, we examined this latter dynamic. Our analyses show, after controlling for armed group-level and individual-level variables, that drug intake and alcohol consumption boost the number of violent actions perpetrated by combatants.

The adverse effect of harsh corporal punishment on mental health and psychosocial func- tioning in children has been repeatedly suggested by studies in industrialized countries. Nevertheless, corporal punishment has remained common practice not only in many homes, but is also regularly practiced in schools, particularly in low-income countries, as a measure to maintain discipline. Proponents of corporal punishment have argued that the differences in culture and industrial development might also be reflected in a positive rela- tionship between the use of corporal punishment and improving behavioral problems in low-income nations. In the present study we assessed the occurrence of corporal punish- ment at home and in school in Tanzanian primary school students. We also examined the association between corporal punishment and externalizing problems. The 409 children (52% boys) from grade 2 to 7 had a mean age of 10.49 (SD = 1.89) years. Nearly all children had experienced corporal punishment at some point during their lifetime both in family and school contexts. Half of the respondents reported having experienced corporal punish- ment within the last year from a family member. A multiple sequential regression analysis revealed that corporal punishment by parents or by caregivers was positively related to children’s externalizing problems. The present study provides evidence that Tanzanian children of primary school age are frequently exposed to extreme levels of corporal punish- ment, with detrimental consequences for externalizing behavior. Our findings emphasize the need to inform parents, teachers and governmental organizations, especially in low- income countries, about the adverse consequences of using corporal punishment be it at home or at school.

Committing violent acts can be appealing, fascinating, exciting, and addictive (i.e., appetitive). Cultural settings that accept vio- lence as a means to power and success promote this appetitive form of aggression. Former child soldiers of Uganda with military rank reported committing a greater variety of violent acts compared to those without rank. They experienced aggressive behavior as more positive than both those without rank and controls who had never been involved in armed groups. The relation between the number of individually committed offense types and appetitive aggression is weaker in former child soldiers without rank compared to those with rank. This indicates that the potential for rapid development of appetitive aggression is rewarded with higher social status in war-afflicted communities.

Soldiers and combatants often report that committing violence can be appealing, fascinating and exciting (Elbert, Weierstall, & Schauer, 2010). This appetite for aggression was investigated in a sample of 224 former combatants from different armed groups and forces in eastern DRC. In a semistructured interview they were questioned about their military history, exposure to violence and perpetrated violence. Appetitive aggression was assessed with a 15-item-scale (Weierstall & Elbert, 2011), which was successfully implemented in comparable samples (Weierstall, Schalinski, Crombach, Hecker, & Elbert, submitted for publication). A sequential multiple regression was conducted to determine possible predictors of appetitive aggression. Perpetrated violence types, recruitment type, and joining as a child were significant predictors and explained 26% of the variability in appetitive aggression. Duration or military rank within the armed group and exposure to violence did not play a significant role. Thus, combatants reporting high levels of appetitive aggression are characterized by perpetrating a high number of violent acts, joining armed groups on their own accord and as children. Joining an armed group on one's own accord indicates pre-existing appetitive aggression. However, joining young and perpetrating violence on a regular basis seem to intensify the appetite for aggression.