Staff Perspective: Intergenerational Trauma: The Transgenerational Impact of PTSD on the (Military) Family
It was happening again. Following another humid South Carolina rain, I sat beside my 6-year old sister, Trinh, who was having a “spell” – what we now know was some type of re-experiencing or panic attack - likely related to her boat escape from Vietnam just 10 days following the fall of Saigon. At the time, I could only do what my 5-year old self thought was best. Hold her hand, get the dog, tell her everything was going to be alright and wait for the spell to pass. We were alone in our struggle to figure out what was going on, as these episodes only served to exasperate our parents, who either did not understand them or viewed them as the overdramatized reminder of events that they would have rather forgotten.
To help one put this memory into context, let me explain that my father was a Vietnam Vet; my mother was his war bride who fled with her family from rural Vietnam to the city to escape the ravages of war; her village was attacked during the Tet Offensive. My older sister, in the frantic, disorganized course of events that often accompanies war, was left behind and later reunited with our family stateside. While mother, father and sister had all directly experienced war-related traumas, the rest of the family had not and yet, we did not remain unaffected by the war. Significantly, much of this trauma seemed exponential on my mother’s side, given the disappearance of my grandfather, a Vietnamese soldier, and my maternal grandmother’s brushes with civil unrest and hostile occupation even before my mother was born. Apparently my mother inherited more than just grandmother’s feistiness and figure; it was almost as if she absorbed all of her own mother’s fears about a far too dangerous world. She remembers being perpetually unsafe, and then just numb, even as a young girl. Unknowingly, she would pass much of this heightened caution and fear onto us – her children - and we, in turn, would wonder if we would continue to inadvertently pass it on to our own broods.
We all wondered … would past events we had not even experienced (and, at times, had not even fully heard or known of) have the power to seep into our bones, our veins, and our collective unconscious or subconscious like some sort of “blood memory”? Would our children and grandchildren continue to feel the reverberations of a war two and three or more times removed from them? What about the younger generations of other families who have experienced war and/or mass trauma? Apparently this concern and phenomenon has a name: It is known as intergenerational or transgenerational trauma.
While many studies have discussed the direct detrimental effects of war-related trauma on veterans and 1st generation witnesses such as the one mentioned here (link to your older VV blog), less is known about the legacy that trauma might leave, i.e. posttraumatic affects, across generations. Here, let us briefly examine and discuss (1) the literature defining transgenerational trauma and its impact; (2) its proposed mechanisms of transmission and (3) potential mechanisms of healing.
What exactly is Transgenerational Trauma?
Transgenerational Trauma Defined. Clinically, we have long known that the consequences of trauma are not limited only to those individuals directly exposed to a traumatic event but rather, there is often a ripple effect that may impact the family and close significant others. Numerous terms have been used to describe this effect including vicarious traumatization, secondary traumatization, and traumatic countertransference (Dekel & Hadass, 2008). It is important to note that these terms specifically refer to trauma impacting someone in extended immediate contact with the trauma survivor.
The aforementioned phenomenon differs somewhat from what may be interchangeably known as historical trauma, intergenerational trauma or transgenerational trauma, in that the negative effects of a past trauma are believed to potentially remain and be passed down to the second and third generation onward. So those impacted may never have had any direct contact with the individual who was initially traumatized, yet may still manifest negative symptoms related to that original trauma which occurred in the distant past.
Inclusion Criteria. Following in line with the research on vicarious traumatization, the research is expanding and becoming more inclusive on this topic and looks at trauma, in a broader sense. Importantly, one must soberly consider the specific etiology and impact of intergenerational trauma to include not only “primary” PTSD being passed down to a secondary and tertiary source, but also the negative symptoms (included in but not necessarily meeting full criteria for a PTSD diagnosis) experienced by the trauma survivor which might then contribute to negative trauma-related effects passed down from generation to generation. One must note that, often, the primary survivors of the remote trauma may never have had the opportunity to seek out care following the trauma incident and; therefore, would not have a formal diagnosis of PTSD. By viewing transgenerational trauma in broad terms, we are better equipped to investigate the current questions posed about this type of trauma without risk of excluding any factors, which might be correlational or contributory.
Vertical vs. Horizontal Transmission. The research looks at two potential types of trauma transmission, noting that trauma may be “spread” in much the same way as a cold – vertically or horizontally. Within horizontal transmission, trauma is directly transmitted to individuals of the same generation or “cohort”. By comparison, vertical transmission is believed to occur with the spread of effects from generation to generation. The latter appears to refer to transgenerational trauma. By looking first at secondary trauma and then expanding our questioning and research, we may be able to learn more specifically about transgenerational effects.
Current Questions. While there is a paucity of current research about this specific type of trauma, there has been a growing interest into this phenomenon. Many have wondered “Can an individual or a community pass down a trauma from generation to generation?”, “If so, for how long?” or “Can a trauma register in the physical body or subconscious mind without one’s ever directly experiencing it?” Why are some families/groups impacted and not others? Can trauma be stored away and remain latent, but always present, in the collective unconscious of a community? What are the known effects of said trauma?
Understandably, it can be difficult to fully research these questions given the complexity of this type of psychological insult. Also, one might assume that the existence of transgenerational trauma can be simplified to being a series of secondary traumatizations occurring over and over again across time. And that it may be; however, research is needed to learn more about what exactly transgenerational trauma is, how it is transmitted, and how it may impact our families and communities.
Mechanisms of Transmission: The 3 “N’s” of Transgenerational Trauma Transmission
As I sought understanding about Transgenerational Trauma, my reading tended to fall into 3 categories with regards to mechanisms of transmission. I call them the 3 “N’s”, those being transmission via Nature, Nurture or Narrative means. Given the complexity of trauma, I do not mean to propose that one of the “N’s” is more powerful than the other. Instead, these factors may be impacted by a number of things, not limited to physical and psychological vulnerabilities or societal/cultural factors. Here I discuss each proposed mechanism of transmission separately:
Nature. It is imperative that one considers the holistic nature of trauma when looking at potential ways of transmission. Trauma affects the whole person – mind, body and psyche. When working with the traumatized, individual symptoms almost always manifest in the physical. Sleep, energy, body tension and increased illness or pain can be present. To date, numerous studies have been conducted in looking at stress/trauma impacts on the body. Studies have also looked at the potential etiology of factors contributing to heightened vulnerability. Epigenetics plays its part. Well known have been rat studies indicating the presence of higher cortisol levels in the progeny of rats exposed to various stressors. Again, if we think of the physical stressors related to PTSD or other trauma, we can see how these effects may generalize to other species. So commonly, when one thinks trauma one may think of elevated cortisol levels. However, newer studies are showing that individuals with lower cortisol levels may also be susceptible to PTSD or high trauma.
A 2016 interview (on Intergenerational transmission of stress and PTSD) with neuroscientist, Dr. Rachel Yehuda notes that newer studies are showing that lower cortisol levels may predispose one to the development of PTSD triggered by a later trauma. If we look only for elevated cortisol levels we may miss something. Instead Dr. Yehuda’s work emphasizes the importance of looking at variations in cortisol level over time, as well as the need to look at cortisol metabolism, the machinations of glucocorticoid receptors and the possibility that numerous other biomarkers related to cortisol may also be involved in the trauma transmission process (Jain, interview with Yehuda, 2016). All this is occurring within the context of maternal transmission, as expanding upon Dr. Yehuda’s 2005 research on women who were pregnant in the World Trade Center attack. All this points to the possible intergenerational transmission of trauma through ancestral pass down and body memory.
Nurture. Most of the studies looking at secondary trauma and intergenerational trauma speak to the socio-psychological impact of trauma on the children of survivors. When looking at nature as the main means of transmission, these discuss the learned behaviors and psychological symptoms of the survivor and how they impact loved ones. Understandably all look at secondary trauma with hypotheses about further trauma transmission. A summary of these studies point to the transmission of the following to the children of combat veterans in particular: stress, low self-esteem, impaired interpersonal functioning, heightened alertness, increased vulnerability to self-medication, emotional numbing and perceived overall impaired functioning of the family (Dekel & Goldblatt, 2008; Dinstein, Dekel, & Polliack, 2011; King & Smith, 2016; Mc Cormack & Sly, 2013; Souzzi & Motta, 2004) Mc Cormack & Sly’s writing on the subjective “lived” experiences of being the child of a Vietnam Vet was one that the author could identify with.
Narrative. While the singular trauma survivor may not share all of his or her experience, even the unspoken may have an impact on future generations by way of oral pass down. This may be especially true when an entire group of people – think slavery, ethnic targeting, wars with mass casualties, genocide - experience the same trauma together. In such instances, even the unspoken may be powerful in intergenerational impact:
“At home, children are more often exposed not to their parents’ stories about the war, but to their behavior, body language, disabilities, and anxiety-loaded silence with regards to war-related situations. Children therefore re-construct their parents’ war experience with the help of their own imagination and dependent on their already internalized knowledge about wars, enemies, heroic death, or battlefields.” (Jordanova, 2012)
Perstein & Motta’s 2012 study looks at the potential transmission of Holocaust-related intergenerational trauma to the Third generation. The study found that the transfer of such trauma was less dependent on one’s being the grandchild of a Holocaust survivor and more dependent on a child’s being a member of an ultra-Orthodox Jewish community. The authors explained that this “latent” form of transgenerational trauma was inadvertently perpetuated through the community stories told and re-told in an effort to commemorate its victims and “guard against future danger”.
Words and stories can prove to be “dangerous” and, as such, may lead to the use of euphemism or indirect language to protect others in the re-telling. In spite of this, community and historical accounts may undoubtedly contribute to the transmitting of intergenerational trauma. Culturally sanctioned rules may play into the sharing of the narrative in order to contain or mitigate its negative impact.
Mechanisms of Healing. In looking at transgenerational trauma, we would be remiss to not look and hope for specific mechanisms to facilitate healing. As we learn more about transgenerational trauma, there is no doubt that various modes of healing will begin to be created and refined. In the meantime, I would posit that it is important that healing focus both on identifying risk and resiliency factors to help with treatment. Also, healing ought to be holistically focused given the holistic nature of trauma symptoms. Finally, in wide-spread and intergenerational trauma, awareness and a focus on collective post-traumatic growth utilizing culturally and spiritually congruent healing practices is needed.
For now. And time is helpful in the healing when we have a greater understanding of shared pain. My sister no longer has “spells” and we look back on that time as a time of bonding. Being grown and having a greater understanding of what was happening helps, as does the realization that many others have been through similar experiences and certainly understand.
For this blog, I would like to extend my dearest thanks to my sister Trinh for allowing me to share her story. Also, many thanks to my friend Dr. Celena Thompson, Head Psychologist of the Hampton VA PTSD Domiciliary Program, for encouraging me to share our story and more about transgenerational trauma with others who may have been impacted.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Kimberly Copeland, Psy.D., ia a Military Behavioral Health Psychologist s at the Cetner for Deployment Psychology at Uniformed Services University of the Health Sciences in Bethesda, MD.
References & Resources:
Perlstein, P. and Motta, R.W. (2012). An investigation of potential Holocaust-related secondary trauma in the third generation, Traumatology 19(2) 95-106
Dinshtein, Y., Dekel, R., Polliack, M. Secondary traumatization among adult children of PTSD veterans: The role of mother-child relationships Journal of family social work, 14:109-124, 2011 DOI: 10.1080/10522158.2011.544021
Jain, S. Cortisol, the intergenerational transmission of stress, and ptsd: An interview with Dr. Rache Yehuda (Obtained from the Internet on 6/08/2016)
Jordovana, Kalina. Transmission of traumatic experiences in the families of war survivors from Bosnia and Herzegovina. Obtained from the Internet: June 2018 https://hrcak.srce.hr/file/142812.
King, N., Smith A. Exploring the impact of parental post-traumatic stress disorder on military family children: A review of the literature, Nurse Education Today (2016), http://dx.doi.org/10.1016/j.nedt.2016.04018
McCormack, L. & Sly, R. (2013). Distress and growth: The subjective “lived” experiences of being the child of a Vietnam Veteran. Traumatology, 19 (4) 303-312. DOI:10.1177/1534765613481855
Dekel, R. & Goldblatt, H. (2008). Is there transmission of Trauma? The case of the combat veteran’s children. American Journal of Orthopsychiatry Vol. 78 (3), 281-289.
Souzzi, J.M. & Motta, R.W. (Mar 2004). The relationship between combat exposure and the transfer of trauma-like symptoms to offspring of veterans. Traumatology, Vol 10 (1) 17-27.
It was happening again. Following another humid South Carolina rain, I sat beside my 6-year old sister, Trinh, who was having a “spell” – what we now know was some type of re-experiencing or panic attack - likely related to her boat escape from Vietnam just 10 days following the fall of Saigon. At the time, I could only do what my 5-year old self thought was best. Hold her hand, get the dog, tell her everything was going to be alright and wait for the spell to pass. We were alone in our struggle to figure out what was going on, as these episodes only served to exasperate our parents, who either did not understand them or viewed them as the overdramatized reminder of events that they would have rather forgotten.
To help one put this memory into context, let me explain that my father was a Vietnam Vet; my mother was his war bride who fled with her family from rural Vietnam to the city to escape the ravages of war; her village was attacked during the Tet Offensive. My older sister, in the frantic, disorganized course of events that often accompanies war, was left behind and later reunited with our family stateside. While mother, father and sister had all directly experienced war-related traumas, the rest of the family had not and yet, we did not remain unaffected by the war. Significantly, much of this trauma seemed exponential on my mother’s side, given the disappearance of my grandfather, a Vietnamese soldier, and my maternal grandmother’s brushes with civil unrest and hostile occupation even before my mother was born. Apparently my mother inherited more than just grandmother’s feistiness and figure; it was almost as if she absorbed all of her own mother’s fears about a far too dangerous world. She remembers being perpetually unsafe, and then just numb, even as a young girl. Unknowingly, she would pass much of this heightened caution and fear onto us – her children - and we, in turn, would wonder if we would continue to inadvertently pass it on to our own broods.
We all wondered … would past events we had not even experienced (and, at times, had not even fully heard or known of) have the power to seep into our bones, our veins, and our collective unconscious or subconscious like some sort of “blood memory”? Would our children and grandchildren continue to feel the reverberations of a war two and three or more times removed from them? What about the younger generations of other families who have experienced war and/or mass trauma? Apparently this concern and phenomenon has a name: It is known as intergenerational or transgenerational trauma.
While many studies have discussed the direct detrimental effects of war-related trauma on veterans and 1st generation witnesses such as the one mentioned here (link to your older VV blog), less is known about the legacy that trauma might leave, i.e. posttraumatic affects, across generations. Here, let us briefly examine and discuss (1) the literature defining transgenerational trauma and its impact; (2) its proposed mechanisms of transmission and (3) potential mechanisms of healing.
What exactly is Transgenerational Trauma?
Transgenerational Trauma Defined. Clinically, we have long known that the consequences of trauma are not limited only to those individuals directly exposed to a traumatic event but rather, there is often a ripple effect that may impact the family and close significant others. Numerous terms have been used to describe this effect including vicarious traumatization, secondary traumatization, and traumatic countertransference (Dekel & Hadass, 2008). It is important to note that these terms specifically refer to trauma impacting someone in extended immediate contact with the trauma survivor.
The aforementioned phenomenon differs somewhat from what may be interchangeably known as historical trauma, intergenerational trauma or transgenerational trauma, in that the negative effects of a past trauma are believed to potentially remain and be passed down to the second and third generation onward. So those impacted may never have had any direct contact with the individual who was initially traumatized, yet may still manifest negative symptoms related to that original trauma which occurred in the distant past.
Inclusion Criteria. Following in line with the research on vicarious traumatization, the research is expanding and becoming more inclusive on this topic and looks at trauma, in a broader sense. Importantly, one must soberly consider the specific etiology and impact of intergenerational trauma to include not only “primary” PTSD being passed down to a secondary and tertiary source, but also the negative symptoms (included in but not necessarily meeting full criteria for a PTSD diagnosis) experienced by the trauma survivor which might then contribute to negative trauma-related effects passed down from generation to generation. One must note that, often, the primary survivors of the remote trauma may never have had the opportunity to seek out care following the trauma incident and; therefore, would not have a formal diagnosis of PTSD. By viewing transgenerational trauma in broad terms, we are better equipped to investigate the current questions posed about this type of trauma without risk of excluding any factors, which might be correlational or contributory.
Vertical vs. Horizontal Transmission. The research looks at two potential types of trauma transmission, noting that trauma may be “spread” in much the same way as a cold – vertically or horizontally. Within horizontal transmission, trauma is directly transmitted to individuals of the same generation or “cohort”. By comparison, vertical transmission is believed to occur with the spread of effects from generation to generation. The latter appears to refer to transgenerational trauma. By looking first at secondary trauma and then expanding our questioning and research, we may be able to learn more specifically about transgenerational effects.
Current Questions. While there is a paucity of current research about this specific type of trauma, there has been a growing interest into this phenomenon. Many have wondered “Can an individual or a community pass down a trauma from generation to generation?”, “If so, for how long?” or “Can a trauma register in the physical body or subconscious mind without one’s ever directly experiencing it?” Why are some families/groups impacted and not others? Can trauma be stored away and remain latent, but always present, in the collective unconscious of a community? What are the known effects of said trauma?
Understandably, it can be difficult to fully research these questions given the complexity of this type of psychological insult. Also, one might assume that the existence of transgenerational trauma can be simplified to being a series of secondary traumatizations occurring over and over again across time. And that it may be; however, research is needed to learn more about what exactly transgenerational trauma is, how it is transmitted, and how it may impact our families and communities.
Mechanisms of Transmission: The 3 “N’s” of Transgenerational Trauma Transmission
As I sought understanding about Transgenerational Trauma, my reading tended to fall into 3 categories with regards to mechanisms of transmission. I call them the 3 “N’s”, those being transmission via Nature, Nurture or Narrative means. Given the complexity of trauma, I do not mean to propose that one of the “N’s” is more powerful than the other. Instead, these factors may be impacted by a number of things, not limited to physical and psychological vulnerabilities or societal/cultural factors. Here I discuss each proposed mechanism of transmission separately:
Nature. It is imperative that one considers the holistic nature of trauma when looking at potential ways of transmission. Trauma affects the whole person – mind, body and psyche. When working with the traumatized, individual symptoms almost always manifest in the physical. Sleep, energy, body tension and increased illness or pain can be present. To date, numerous studies have been conducted in looking at stress/trauma impacts on the body. Studies have also looked at the potential etiology of factors contributing to heightened vulnerability. Epigenetics plays its part. Well known have been rat studies indicating the presence of higher cortisol levels in the progeny of rats exposed to various stressors. Again, if we think of the physical stressors related to PTSD or other trauma, we can see how these effects may generalize to other species. So commonly, when one thinks trauma one may think of elevated cortisol levels. However, newer studies are showing that individuals with lower cortisol levels may also be susceptible to PTSD or high trauma.
A 2016 interview (on Intergenerational transmission of stress and PTSD) with neuroscientist, Dr. Rachel Yehuda notes that newer studies are showing that lower cortisol levels may predispose one to the development of PTSD triggered by a later trauma. If we look only for elevated cortisol levels we may miss something. Instead Dr. Yehuda’s work emphasizes the importance of looking at variations in cortisol level over time, as well as the need to look at cortisol metabolism, the machinations of glucocorticoid receptors and the possibility that numerous other biomarkers related to cortisol may also be involved in the trauma transmission process (Jain, interview with Yehuda, 2016). All this is occurring within the context of maternal transmission, as expanding upon Dr. Yehuda’s 2005 research on women who were pregnant in the World Trade Center attack. All this points to the possible intergenerational transmission of trauma through ancestral pass down and body memory.
Nurture. Most of the studies looking at secondary trauma and intergenerational trauma speak to the socio-psychological impact of trauma on the children of survivors. When looking at nature as the main means of transmission, these discuss the learned behaviors and psychological symptoms of the survivor and how they impact loved ones. Understandably all look at secondary trauma with hypotheses about further trauma transmission. A summary of these studies point to the transmission of the following to the children of combat veterans in particular: stress, low self-esteem, impaired interpersonal functioning, heightened alertness, increased vulnerability to self-medication, emotional numbing and perceived overall impaired functioning of the family (Dekel & Goldblatt, 2008; Dinstein, Dekel, & Polliack, 2011; King & Smith, 2016; Mc Cormack & Sly, 2013; Souzzi & Motta, 2004) Mc Cormack & Sly’s writing on the subjective “lived” experiences of being the child of a Vietnam Vet was one that the author could identify with.
Narrative. While the singular trauma survivor may not share all of his or her experience, even the unspoken may have an impact on future generations by way of oral pass down. This may be especially true when an entire group of people – think slavery, ethnic targeting, wars with mass casualties, genocide - experience the same trauma together. In such instances, even the unspoken may be powerful in intergenerational impact:
“At home, children are more often exposed not to their parents’ stories about the war, but to their behavior, body language, disabilities, and anxiety-loaded silence with regards to war-related situations. Children therefore re-construct their parents’ war experience with the help of their own imagination and dependent on their already internalized knowledge about wars, enemies, heroic death, or battlefields.” (Jordanova, 2012)
Perstein & Motta’s 2012 study looks at the potential transmission of Holocaust-related intergenerational trauma to the Third generation. The study found that the transfer of such trauma was less dependent on one’s being the grandchild of a Holocaust survivor and more dependent on a child’s being a member of an ultra-Orthodox Jewish community. The authors explained that this “latent” form of transgenerational trauma was inadvertently perpetuated through the community stories told and re-told in an effort to commemorate its victims and “guard against future danger”.
Words and stories can prove to be “dangerous” and, as such, may lead to the use of euphemism or indirect language to protect others in the re-telling. In spite of this, community and historical accounts may undoubtedly contribute to the transmitting of intergenerational trauma. Culturally sanctioned rules may play into the sharing of the narrative in order to contain or mitigate its negative impact.
Mechanisms of Healing. In looking at transgenerational trauma, we would be remiss to not look and hope for specific mechanisms to facilitate healing. As we learn more about transgenerational trauma, there is no doubt that various modes of healing will begin to be created and refined. In the meantime, I would posit that it is important that healing focus both on identifying risk and resiliency factors to help with treatment. Also, healing ought to be holistically focused given the holistic nature of trauma symptoms. Finally, in wide-spread and intergenerational trauma, awareness and a focus on collective post-traumatic growth utilizing culturally and spiritually congruent healing practices is needed.
For now. And time is helpful in the healing when we have a greater understanding of shared pain. My sister no longer has “spells” and we look back on that time as a time of bonding. Being grown and having a greater understanding of what was happening helps, as does the realization that many others have been through similar experiences and certainly understand.
For this blog, I would like to extend my dearest thanks to my sister Trinh for allowing me to share her story. Also, many thanks to my friend Dr. Celena Thompson, Head Psychologist of the Hampton VA PTSD Domiciliary Program, for encouraging me to share our story and more about transgenerational trauma with others who may have been impacted.
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Kimberly Copeland, Psy.D., ia a Military Behavioral Health Psychologist s at the Cetner for Deployment Psychology at Uniformed Services University of the Health Sciences in Bethesda, MD.
References & Resources:
Perlstein, P. and Motta, R.W. (2012). An investigation of potential Holocaust-related secondary trauma in the third generation, Traumatology 19(2) 95-106
Dinshtein, Y., Dekel, R., Polliack, M. Secondary traumatization among adult children of PTSD veterans: The role of mother-child relationships Journal of family social work, 14:109-124, 2011 DOI: 10.1080/10522158.2011.544021
Jain, S. Cortisol, the intergenerational transmission of stress, and ptsd: An interview with Dr. Rache Yehuda (Obtained from the Internet on 6/08/2016)
Jordovana, Kalina. Transmission of traumatic experiences in the families of war survivors from Bosnia and Herzegovina. Obtained from the Internet: June 2018 https://hrcak.srce.hr/file/142812.
King, N., Smith A. Exploring the impact of parental post-traumatic stress disorder on military family children: A review of the literature, Nurse Education Today (2016), http://dx.doi.org/10.1016/j.nedt.2016.04018
McCormack, L. & Sly, R. (2013). Distress and growth: The subjective “lived” experiences of being the child of a Vietnam Veteran. Traumatology, 19 (4) 303-312. DOI:10.1177/1534765613481855
Dekel, R. & Goldblatt, H. (2008). Is there transmission of Trauma? The case of the combat veteran’s children. American Journal of Orthopsychiatry Vol. 78 (3), 281-289.
Souzzi, J.M. & Motta, R.W. (Mar 2004). The relationship between combat exposure and the transfer of trauma-like symptoms to offspring of veterans. Traumatology, Vol 10 (1) 17-27.