The complexity of trauma response: a 4-year follow-up of adolescent Cambodian refugees

Child Abuse & Neglect 27 (2003) 1277–1290

The complexity of trauma response: a 4-year follow-up of adolescent Cambodian refugees夽 Cécile Rousseau a,b,∗ , Aline Drapeau a , Sadeq Rahimi a a

Department of Psychiatry, Montreal Children’s Hospital, 4018 Ste. Catherine Street West, Westmount, Que., Canada H3Z 1P2 b Department of Transcultural Psychiatry, McGill University, Montreal, Que., Canada

Received 5 November 2002; received in revised form 14 June 2003; accepted 2 July 2003

Abstract Objective: The objective of this study was to document the psychosocial adjustment of young refugees during their adolescence and its association with the war-related trauma experienced by their family before migration. Method: Data were collected on 57 young Khmer resettled in Montreal and followed from early to late adolescence. The associations between premigratory exposure to political violence and postmigratory mental health and social adjustment were estimated for early, mid-, and late adolescence. Results: The associations between premigratory exposure to political violence and postmigratory psychosocial adjustment fluctuated over the adolescence period. Overall, the adolescents whose families were more highly exposed to political violence tended to report a more positive social adjustment and less mental health symptoms than those less exposed. Conclusion: The high expectations of Cambodian parents towards their children and the preservation of traditional values despite the Khmer rouge attempts to eradicate them might contribute to explain the paradoxical association between the families’ exposure to political violence and the adolescents’ psychosocial adjustment in the host country. Although children and adult refugees seen in clinical setting are reminders of the negative effects of adversity, resilience should be more systematically explored in community samples to further our understanding of the long-term effects of trauma. © 2003 Elsevier Ltd. All rights reserved. Keywords: Trauma; Adolescents; Refugees; Resilience; Mental health

夽 This research was supported by grants from the Conseil Qu´eb´ecois de la Recherche en Sant´e and the National Health Research and Development Program of Canada (now known as the Canadian Institutes for Health Research). ∗ Corresponding author.

0145-2134/$ – see front matter © 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.chiabu.2003.07.001

1278

C. Rousseau et al. / Child Abuse & Neglect 27 (2003) 1277–1290

Introduction A number of studies have been conducted to understand better the long-term effect of past exposure to political violence on the mental health of children and adolescents who were forced to migrate as refugees to various host countries, with or without their parents. Posttraumatic stress disorder has been found to be very prevalent in Khmer children and adolescents who have survived the Pol Pot regime (Hubbard, Realmuto, Northwood, & Masten, 1995; Kinzie, Sack, Angell, Manson, & Ben, 1986; Kinzie, Sack, Angell, Clarke, & Ben, 1989; Mollica, Poole, Son, Murray, & Tor, 1997; Sack, 1999; Sack, Clarke, & Seeley, 1996; Sack et al., 1994; Savin, Sack, Clarke, Meas, & Richart, 1996) and in their parents (Mollica et al., 1993). A positive association was observed between children of war’s perception of their own efficacy and their self-confidence and self-esteem (Garbarino & Kostelny, 1996). Macksoud, Dyregrov, and Raundalen (1993) also noted that traumatized children tend to isolate themselves from their peers. Other studies have reported that children’s personal and social identity and moral development are affected when their world is disrupted by war (Macksoud et al., 1993; Martin-Baro, 1994; Richman, 1993). In parallel to the vast literature on the negative impact of political violence on mental health, some studies show that in spite of all their psychological symptoms, the majority of severely traumatized children manage to become well-adjusted adults (Dalianis-Karambatzakis, 1994; Lyons, 1991; Sigal, 1998). Macksoud and Aber (1996) observed that different experiences of trauma and loss led to a wide range of emotional and behavioral responses in Lebanese children, including such positive effects as an increase in prosocial and planful behavior. Traumatized children also have been reported to maintain or improve their academic performance in spite of their trauma (Terr, 1983). Finally, in a study of Bosnian adolescents, Ferren (1999) demonstrated that the self-efficacy of traumatized boys was higher than that of their nontraumatized peers. He hypothesizes that in the Bosnian context, surviving traumatic experiences may have a steeling effect that helps maintain high self-efficacy levels. In war, suffering occurs and is resolved in a social context, shaped by the meaning collectively and individually constructed around events (Summerfield, 1999). Exposure to political violence may lead to a wide array of trauma responses, going from building up a resiliency that may foster psychosocial adjustment to disrupting psycho-emotional balance for a number of years. Between 1975 and 1995, 16,818 Cambodian refugees resettled in Canada (United Nations High Commissioner for Refugees, 2000). They were either selected by Canadian immigration officers in refugee camps or were sponsored by their families or religious organizations. In either case, they landed in Canada as permanent residents, a status that entitled them to basic financial support, health and social services, and training in the mainstream language (i.e., French in Quebec, English in other Canadian provinces). Nearly all refugees who have resettled in Quebec are living in or close to Montreal where migrants make up 20% of the population. Cambodian refugees appear to be ill-equipped to face the challenges of living in an industrialized setting. Most had been peasants or small underground business people with little or no education and had no knowledge of either French or English on arrival. A considerable number landed in Canada with some or all of their children, most of whom were born in refugee camps or in Cambodia shortly before the family fled the country.

C. Rousseau et al. / Child Abuse & Neglect 27 (2003) 1277–1290

1279

The study reported here was designed to investigate the evolution of the effects of the family’s premigration exposure to political violence on the psychosocial adjustment of young Cambodian refugees from early to late adolescence. Analyses carried out at baseline and 2 years later suggest that premigration trauma experienced by a family prior to a child’s birth plays a steeling role at various times in the child’s adolescence. For boys, this translates in externalizing symptoms and risk behavior, and for girls, in social adjustment (Rousseau, Drapeau, & Platt, 1999). These reactions were interpreted as overcompensation on the part of the children of Pol Pot survivors, to whom the implicit duty of succeeding has been passed on. In this paper, we report on analyses that were carried out, first, to verify whether the steeling effect of exposure to political violence on some dimensions of the psychosocial adjustment of young Cambodian showed up in early, mid-, and late adolescence of those who took part in the three phases of the study and, second, to explore the associations between exposure and how adolescents view themselves and others as they enter adulthood.

Method Study sample The study population consisted of Cambodian teenagers born outside of Canada and living in Montreal. A sample of 57 young Cambodians were followed from early to late adolescence and were interviewed three times during that period (in 1994, 1996, 1998). Data reported here cover the three phases of the study and pertain to these 57 adolescents. At baseline, in 1994, the sample numbered 76 Grade 7 and Grade 8 students registered at six multiethnic high schools. By 1998 (Time 3), the loss to follow-up was 25%. The baseline sociodemographic profile was similar for Time 3 participants (n = 57) and nonparticipants (n = 19), but the pattern of family premigration exposure to political violence differed. The parents of those lost to follow-up were more likely than the parents of those who remained in the study to report more than one premigration trauma experienced after the birth of the adolescents under study (74% vs. 44%), and the mean number of traumas experienced before the children’s birth was lower in nonparticipants than participants (3.1 vs. 5.2). However, both the initial sample (n = 76) and the final sample (n = 57) showed a higher level of emotional problems in young Cambodians born into families with a higher versus a lower level of exposure to political violence. So, although the loss to follow-up was selective, it was probably not a major source of bias, as it did not alter the conclusion drawn at baseline. The Ethical Review Board of the Montreal Children’s Hospital approved the study and both parents and adolescents signed consent forms describing their participation and the objectives of the study and ensuring confidentiality. Parents were interviewed in Khmer, whereas teenagers were interviewed in French. The mainstream language in Quebec is French and, in order to preserve this cultural heritage, all immigrant and refugee children are required by law to attend French schools. Thus the young Cambodians who participated in the study had been studying in French since their first year of schooling in Quebec and were flu-

1280

C. Rousseau et al. / Child Abuse & Neglect 27 (2003) 1277–1290

ent in that language. All interviews were conducted in the parents’ homes by Cambodian interviewers.

Measures Premigratory exposure to political violence At baseline, a series of questions presented in a checklist format were used to ask parents about the family’s traumatic experiences. This checklist enumerated 19 types of trauma that, according to Cambodian key informants, may have been experienced by the family or by the child during the political repression in Cambodia (e.g., threats, harassment, torture, execution, forced labor, disappearance, imprisonment). Parents were asked whether they or a member of their family had experienced each type of trauma and, if so, the age of the child under study at that time. Two indices of premigratory exposure to political violence were investigated: the number of traumatic experiences suffered by the family before the child’s birth was used as a proxy for the child’s indirect exposure, whereas the number experienced after the child’s birth was used as a proxy for more direct exposure. The number of traumatic experiences suffered before the child’s birth was normally distributed so this first index was analyzed as a continuous variable. The distribution of the number of traumatic experiences sustained after the child’s birth was highly skewed: 32 of the 57 parents reported only one trauma, most commonly a stay in a refugee camp, whereas other parents reported more than one traumatic experience. Thus, this second index was dichotomized: one trauma reported versus more than one. Because premigration trauma may affect various dimensions of the psychosocial adjustment of young refugees, three categories of outcome variables were considered: (1) emotional and behavioral problems, such as internalization, externalization, and risk behavior; (2) social adjustment, such as the feeling of competence and peer relationships; (3) perception of self and others, such as self-esteem, collective self-esteem, and experience of racism. Emotional and behavioral problems The Youth Self-Report (YSR) developed by Achenbach and his team (1991) is one of the most widely used scales in studies of adolescents. The YSR assesses behavioral and emotional symptoms rather than psychiatric diagnosis, and it has shown a high level of crosscultural generalizability (Bird, 1996; Crijnen, Achenbach, & Verhulst, 1997, 1999; De Groot, Koot, & Verhulst, 1996; Verhulst & Achenbach, 1995). We used the French version of the YSR, provided by Achenbach’s team, to assess levels of internalizing symptoms (29 items) and externalizing symptoms (30 items). Reliability of the Internalizing and Externalizing indices for the sample of young Cambodians was high, with Cronbach’s alpha ranging from .77 to .87 for the whole study. A questionnaire developed by Sylvestre et al. (1992) to measure common risk behaviors in North American teenagers was used to derive a dichotomous variable indicating whether or not the adolescent had engaged in risk behavior—such as using drugs or alcohol regularly,

C. Rousseau et al. / Child Abuse & Neglect 27 (2003) 1277–1290

1281

stealing, engaging in physical violence, or belonging to a street gang—in the year preceding the interview. The questionnaire was well received by teenagers in earlier studies conducted in multiethnic high schools (Rousseau, Drapeau, & Platt, 2000; Sylvestre et al., 1992). Social adjustment The YSR was used to assess feelings of social competence (15 items). Reliability was good, with Cronbach’s alpha ranging from .71 to .79 over the three phases of the study. As is often the case in longitudinal studies, some scales were added over the course of the study to investigate specific topics that became meaningful to adolescents as they grew up. The Adolescent Friendship Inventory (AFI) developed by Rubenstein, Heeren, Housman, Rubin, and Stechler (1989) was administered at Time 2 and Time 3 to gather additional information on peer relationships and on the support that they may provide. This scale is made up of 30 statements regarding social comfort and satisfaction (e.g., I find it hard to make friends), emotional support (e.g.,“ I feel better when I talk things over with my friends”), family support for peer relationships (e.g., “My friends like being at my house”), loyalty and trust (e.g., “I feel I can trust my friends”) and ambivalence and conflict (e.g., “My friends and I argue a lot”). The choice of answers for each statement is a five point Likert scale (i.e., false, somewhat false, not sure, somewhat true or true). The maximum score is 150 and the higher this score, the higher the feeling of satisfaction with peer relationships. The AFI’s reliability was high in this study, with a Cronbach’s alpha of .80 at Time 2 and .88 at Time 3. Perception of self and others At Time 3, the last phase of the study, three scales were added to assess the teenagers’ perception of themselves and of the Cambodian community. Rosenberg’s 10-item Self-Esteem Scale (SES) (1965) was used to assess personal self-esteem. The SES has been used in a transcultural setting by Luhtanen and Crocker (1992) and Cronbach’s alpha for the SES reached .83 in our sample. Luthanen and Crocker introduced a scale measuring collective self-esteem (CSES) based on 16 items. The term “collective self-esteem” was proposed as an indicator of an individual’s positive evaluation of his or her sense of identity to his reference group. In the present study, the group of reference was defined as the Cambodian community. The CSES measures four dimensions of collective self-esteem: personal worth as a member of a group, worth of the group in one’s own eyes, how worthy one perceives one’s group to be in other people’s eyes, and how important group membership is to one’s self-identity. Cronbach’s alpha for the CSES was .81 in our sample. Beiser, Dion, Gotowiec, Hyman, and Vu (1995) argue that forging an identity in exile is a particular challenge for adolescents, especially when larger social forces like racism complicate the struggle. The racism experience scale (Noh, Beiser, Hou, & Kaspar, 1999; Noh, Beiser, Kaspar, Hou, & Rummens, 1999) was used to assess the racism perceived by young Cambodians. This scale describes eight types of racist acts and asks whether the teen had been a victim of such acts never, once, sometimes, often, or constantly. The racism experience scale exhibited a Cronbach’s alpha of. 77 in our sample.

1282

C. Rousseau et al. / Child Abuse & Neglect 27 (2003) 1277–1290

Analysis To test the evolution of continuous measures of psychosocial adjustment, generalized linear model analyses for repeated measures were carried out separately for each gender. To study the relationships between war-related trauma experienced by their families before or after the teenagers were born and the outcome variables, and to investigate the evolution of these relationships from Time 1 to Time 3, we performed three types of statistical analysis, depending on the scale used to measure the variables. For trauma sustained before the birth of the child and continuous outcome variables, Spearman correlation coefficients were used. For the dichotomous variable opposing one trauma sustained after the child’s birth to more than one trauma, the mean level of continuous outcome variables was compared for these two categories. Mean comparisons were also used to study the distribution of trauma experienced before the child’s birth across categories of dichotomous outcome variables. Finally, odds ratios served to estimate the association between trauma sustained after the birth of the teenagers and risk behavior, a dichotomous outcome. Confidence intervals at the .95 level were used to determine the precision and statistical significance of all measures of association or mean differences, which were calculated separately for girls and boys, and for the whole sample.

Results At baseline, the mean age of the teenagers was 13.6 years, and they had been living in Canada for a mean of 9.9 years. The teenagers’ households changed little over the study period. At Time 3, 63.2% of respondents were living with both parents with the mean number of people per household equaling 5. The majority of parents (77.2%) felt that their annual income was low and 66.7% of all households were headed by unemployed parents. Indeed, the parents, most of whom peasants or fishermen in Cambodia, would often have been ill-equipped to work in an industrialized setting like Montreal as 47.4% had only a primary education or had never been to school. Premigratory exposure to political violence The mean number of traumas experienced by the family before the birth of the child was 5.2, and 43.9% of parents reported experiencing more than one trauma after (Table 1). The types of trauma sustained before the child’s birth were different from those which occurred after (Table 2). Those most frequently experienced by the family before the birth of the child were forced labor, execution and threats, whereas those sustained after consisted mainly of staying in a refugee camp and of traumas sustained while fleeing from Cambodia. Emotional and behavioral problems The evolution of emotional symptoms during adolescence varied across mental health measures and sometimes across gender (Table 3). Internalizing scores changed significantly during the adolescence. The lowest mean level was found at mid-adolescence for both boys and girls.

C. Rousseau et al. / Child Abuse & Neglect 27 (2003) 1277–1290

1283

Table 1 Mean number of war traumas experienced by family before child’s birth and percentage of parents reporting more than one trauma experienced after child’s birth Gender of child

Before child’s birth

Total (N = 57) Girls (n = 24) Boys (n = 33) a

After child’s birth

Mean

CIa

%

CI

5.2 5.6 4.9

4.3 to 6.0 4.2 to 7.0 3.8 to 6.0

43.9 29.2 54.5

30.7 to 57.6 12.6 to 51.1 36.4 to 71.9

Confidence level is .95.

Table 2 Type and timing of main war traumas reported by parents (N = 57) Type of trauma

Before child’s birth (%)

After child’s birth (%)

Harassment Threats Imprisonment Execution Torture Disappearance Forced labor Refugee camp Youth eyewitness Migration trauma

10.5 36.8 3.5 38.6 5.3 19.3 78.9 – – –

3.5 5.3 – 3.5 – 3.5 8.8 100.0 8.8 33.3

Table 3 Mean level of psychosocial adjustment measures by gender Time 1a

Time 2b

Time 3c

Fd

p value

Internalizing Girlse Boysf

18.2 17.0

15.3 16.0

17.1 18.8

3.98 3.63

.034 .038

Externalizing Girls Boys

14.8 15.7

12.1 15.8

13.3 15.9

3.18 .008

.061 .992

Competence Girls Boys

22.3 23.8

22.4 24.3

23.3 24.3

.699 .344

.508 .711

Peer relationship Girls Boys

n/a n/a

118.9 115.7

119.4 115.6

.041 .006

.841 .938

a

In 1994. In 1996. c In 1998. d F statistic for the multivariate test of generalized linear model for repeated measures. e 24 girls. f 33 boys. b

1284

C. Rousseau et al. / Child Abuse & Neglect 27 (2003) 1277–1290

However, the highest mean level of internalizing symptoms was observed in early adolescence for the girls and in late adolescence for the boys. Externalizing scores remained constant during the adolescence period for the boys whereas it followed a pattern similar to that of internalizing scores for the girls, nearly reaching statistical significance (p = .061). Risk behavior decreased from 25 (43%) adolescents providing positive reports at baseline to 16 (28%) at both Time 2 and Time 3, and a higher percentage of boys than girls reported one or more types of risk behavior at each phase of the study. Social adjustment The mean feeling of competence slightly increased during the adolescence for both boys and girls but it was far from statistical significance in both genders (Table 3). The mean level of satisfaction with peer relationships appeared to be similar across time and gender (Table 3). Table 4 Spearman correlations between adolescent psychosocial profile and exposure to political violence before child’s birth Psychosocial profile

Girls (n = 24)

Boys (n = 33)

Total sample (N = 57)

ra

Cib

r

CI

r

CI

Internalizing Time 1c Time 2d Time 3e

−.25 −.17 −.11

−.59 to .17 −.54 to .25 −.49 to .31

−.01 −.35 −.10

−.35 to .33 −.62 to −.01 −.43 to .25

−.11 −.22 −.13

−.36 to .16 −.45 to .04 −.38 to .14

Externalizing Time 1 Time 2 Time 3

−.22 −.003 .03

−.57 to .20 −.41 to .40 −.38 to .43

−.01 −.38 .05

−.35 to .33 −.64 to −.04 −.30 to .39

−.12 −.21 .02

−.37 to .15 −.45 to .05 −.24 to .28

Competence Time 1 Time 2 Time 3

.51 .39 .30

.13 to .76 −.02 to .69 −.12 to .63

.02 −.43 .1 X7

−.33 to .36 −.67 to −.10 −.18 to .49

.19 −.07 .21

−.07 to .43 −.32 to .19 −.05 to .45

Peer relations Time 2 Time 3

.60 .34

.26 to .81 −.07 to .65

.11 .04

−.24 to .44 −.31 to .38

.34 .22

.09 to .55 −.04 to .45

.28

−.14 to .61

.40

.07 to .65

.34

.09 to .55

.38

−.03 to .68

.24

−.11 to .54

.28

.02 to .50

−.15

−.52 to .27

−.35

−.25

−.48 to .01

Self-esteem (T3)f Collective self−esteem (T3) Racism (T3) a

f

f

Spearman correlation coefficient. Confidence level is .95. c In 1994. d In 1996. e In 1998. f Assessed at Time 3 only. b

−.62 to −.01

Girls (n = 24) Presencea Risk behavior Time 1d 4.8 Time 2e 5.0 Time 3f 4.0 a

Boys (n = 33) Absenceb

CIc

Presence

Absence

CI

Presence

Absence

6.0 5.8 5.8

−1.8 to 4.3 −1.5 to 3.0 −2.6 to 6.2

4.5 3.5 3.6

5.3 5.5 5.6

−1.4 to 3.1 −.4 to 4.3 −.3 to 4.3

4.6 4.1 3.6

5.7 5.6 5.8

Mean number of traumas for subjects with a positive report of risk behavior. Mean number of traumas for subjects with no report of risk behavior. c Confidence level for mean difference is .95. d In 1994. e In 1996. f In 1998. b

Total (N = 57) CI −.6 to 2.8 −.08 to 3.2 .09 to 4.0

C. Rousseau et al. / Child Abuse & Neglect 27 (2003) 1277–1290

Table 5 Mean number of exposure to political violence before child’s birth, by presence or absence of risk behavior

1285

1286

C. Rousseau et al. / Child Abuse & Neglect 27 (2003) 1277–1290

Association between family trauma and adolescents’ psychosocial adjustment No significant pattern of association was detected between trauma experienced after the birth of the adolescents and their psychosocial adjustment. Thus, we will focus our report on the associations of the latter with family trauma suffered before the birth of the teenagers. In short, these associations tended to differ slightly across time and gender (Tables 4 and 5). Overall, for the girls, the relationship between trauma experienced by their family before their birth and their personal psychosocial adjustment seemed stronger at baseline than at Time 2 or Time 3, although this pattern was not significant (Table 4). Correlations with exposure were particularly high for feelings of competence, relationship with peers, and collective and personal self-esteem (Table 4). For the boys, the associations between the trauma experienced by their families before their birth and their psychosocial adjustment were stronger at mid-adolescence than at baseline or Time 3 (Table 4). They were also apparently contradictory. On the one hand, trauma was negatively associated at Time 2 with internalizing and externalizing symptoms, which suggests that greater family exposure to trauma before the child’s birth gave rise to fewer symptoms in mid-adolescence. On the other hand, a negative association between trauma and psychosocial adjustment was observed at Time 2 for the boys’ feeling of competence, suggesting that greater exposure may engender a lower feeling of competence, contrary to the girls, for whom this association was positive and rather strong throughout adolescence, especially at baseline (Table 4). Trauma experienced by the family before the birth of the child was positively associated with the boys’ self-esteem and negatively associated with their experience of racism.

Discussion Traumatic family experiences linked to the Pol Pot regime may still influence the lives of young Khmer refugees as they enter into adulthood. The results of this longitudinal study suggest that family trauma experienced before the birth of a child may have a steeling effect, which can be observed in early and mid-adolescence and persists over time, although in altered form. The associations between trauma and emotional and behavioral symptoms fade, whereas adolescents reporting involvement in risk behavior tend to be from a less exposed family than those reporting no such behavior. Positive social adjustment thus persists, and may reflect a kind of overcompensation linked in the adolescents’ minds to the debt they feel towards their parents (Rousseau et al., 1999). Family exposure to political violence after the teen’s birth does not appear to show a significantly persistent association with Cambodian adolescents psychosocial adjustment in the host country. The very young age of most of our subjects during the Pol Pot era or their birth in refugee camps might explain why they have fewer symptoms in the long run than their older counterparts interviewed in other studies (Mollica et al., 1990; Sack, Seidler, & Thomas, 1976). The fact that the trauma experienced by the family before and after the adolescent birth are not of the same type might also be a reason for the observed difference. Nonetheless, even studies reporting long-term persistence (up to 12 years) of PTSD have found rather good social adjustment in spite of symptoms observed (Sack, Seeley, & Clarke, 1997).

C. Rousseau et al. / Child Abuse & Neglect 27 (2003) 1277–1290

1287

The addition at Time 3 of variables assessing perception of the self and of others throws some light on the seemingly paradoxical positive association between trauma and psychosocial adjustment. Our data indicate that the intensity of family trauma sustained before the birth of the teen, which represents the trauma indirectly experienced by the teen, is positively associated with self-esteem in Cambodian adolescents. In focus groups that we conducted sometime ago, Khmer teens did report feeling that their parents would give anything for them and that they owe them a great deal (Rousseau et al., 1999). Perhaps the parents’ high investment in them endows the teenagers with a feeling of purpose, which, although it can be a burden, also enhances their resilience. Dalianis-Karambatzakis (1994), in a unique longitudinal follow-up of young Greek adults who were jailed with their mothers as toddlers, observed that the incarcerated children developed a protective attitude towards their mothers that enhanced their self-esteem. Although in Dalianis-Karambtzakis study the trauma happened after the birth of the child, her results also highlight how certain aspects of the traumatic experience can be appropriated by the children and improve their perception of themselves. Our finding that mean collective self-esteem is higher in teenagers whose families were more traumatized before their birth is noteworthy. Luhtanen and Crocker (1992), as well as Robins and Foster (1994) have shown that collective self-esteem correlates closely with specific styles of confrontation selected in response to threats to collective identity, similar to the ways personal self-esteem scores have been found repeatedly to predict responses to perceptions of threat to personal identity. Verkuyten and Masson (1995) further observed that minority group members who scored higher on the collective self-esteem scale also displayed lower rates of perception of ethnic prejudice. Martin-Baro (1994) asserts that children are faced with difficult identity choices during armed conflict. They either internalize an identity that dehumanizes human relations but provides them with the relative safety of power or they adopt a socially stigmatized identity, with the need to resort often to social lies in order to survive. The Pol Pot regime organized a special assault against the Khmer and Buddhist identity and culture by killing educated people, including Buddhist monks, and by forbidding traditional rituals. After the war, these events determined the aspects of their collective identity that Cambodians valued even more highly than they had before. The relationship between collective self-esteem and trauma that we have observed may reflect some of the resistance and reconstruction strategies used by families who had been particularly affected by the war. Perhaps by placing high value on the collective identity that the Khmer Rouge wanted to destroy, the survivors of the Pol-Pot regime may ultimately defeat them. Finally, the association observed between boys’ decreased perception of racism with trauma sustained before their birth is also of interest. Here again, the earlier literature would support the reverse relationship: distrust is one of the very well recognized consequences of war. However, given the effect of family trauma on personal and collective self-esteem in our sample, this finding may reflect the beneficial influence of a positive group identity that is a source of pride, thus decreasing the perception of the threat that can come from outside of the community. As mentioned earlier, original studies done in the Netherlands by Verkuyten and Masson (1995) have demonstrated that immigrant adolescents with higher collective self-esteem tend to exhibit less ethnic prejudice than those with lower collective self-esteem. According to the authors, low collective self-esteem can result in a negative view of the outsiders in an effort to enhance one’s own self-esteem. Rahimi (2000) has also demonstrated a negative relationship

1288

C. Rousseau et al. / Child Abuse & Neglect 27 (2003) 1277–1290

between collective self-esteem and perception of racism. He reported that subjects with higher collective self-esteem tend to perceive lower degrees of racism in an ambiguous situation than do those with lower collective self-esteem. The inverse relationship between trauma before birth and lower perception of racism may thus be explained as the outcome of a higher collective self-esteem developed by the Khmer population in reaction to the Pol Pot and Khmer Rouge atrocities that targeted their collective identity. Some caution must be exercised in interpreting the results of this study, which should be viewed as exploratory for a number of reasons. First, the relatively small sample size produces wide confidence intervals and thus imprecise results, especially in some gender-specific analyses. Second, though the loss to follow-up was rather small considering that this study was carried out on teenagers from early to late adolescence, it was somewhat selective, as those who completed the study had, on average, been less exposed to premigration political violence. Finally, the scales used in this study were selected, in part, for their demonstrated transcultural validity. Nevertheless, some of the social adjustment and self-perception measures used here, such as self-esteem and feelings of competence, may be more in keeping with North American values rather than with the Khmer conception of adjustment. The data presented here should not be understood as minimizing the individual and collective suffering provoked by organized violence. Children seen in clinical setting are reminders of the multiple consequences of adversity (Howard & Hodes, 2000). However, the results do underline what Sack (1999) calls “the mystery of resiliency” and provide some insight into the complex articulation between individual and collective responses to trauma. As one reviewer of this paper pointed out, it also raises important questions such as: How will these teenagers do over the long haul? What role will the earlier experiences continue to play? And, above all, what price does the person pay for her/his resilience? Political violence appropriates the private sphere and through this appropriation hurts the community (Vinar, 1993). In the same way, reconstruction processes borrow from collective representations to structure the individual experience. The appraisal of the central but very delicate interrelationships between the subject in a community and culture, genealogy and history may become the key to a more comprehensive understanding of the phenomenon of resiliency.

References Achenbach, T. M. (1991). Manual for the Youth Self-Report and 1991 profile. Burlington, VT: Department of Psychiatry, University of Vermont. Beiser, M., Dion, R., Gotowiec, A., Hyman, I., & Vu, N. (1995). Immigrant and refugee children in Canada. Canadian Journal of Psychiatry, 40, 67–72. Bird, H. (1996). Epidemiology of childhood disorders in a cross-cultural context. Journal of Child Psychology and Psychiatry, 37, 35–49. Crijnen, A. A., Achenbach, T. M., & Verhulst, F. C. (1997). Comparisons of problems reported by parents of children in 12 cultures: Total problems, externalizing, and internalizing. Journal of American Academy of Child and Adolescent Psychiatry, 36, 1269–1277. Crijnen, A. A., Achenback, T. M., & Verhulst, F. C. (1999). Problems reported by parents of children in multiple cultures: The Child Behavior Checklist syndrome constructs. American Journal of Psychiatry, 156, 569– 574.

C. Rousseau et al. / Child Abuse & Neglect 27 (2003) 1277–1290

1289

Dalianis-Karambatzakis, A. M. (1994). Children in turmoil during the Greek Civil War 1946–49: Today’s adults. A longitudinal study on children confined with their mothers in prison. Stockholm: Child and Adolescent Psychiatric Unit, Department of Woman and Child Health, Karolinska Institutet. De Groot, A., Koot, H. M., & Verhulst, F. C. (1996). Cross-cultural generalizability of the Youth Self-Report and teacher’s report form cross-informant syndromes. Journal of Abnormal Child Psychology, 24, 651–664. Ferren, P. M. (1999). Comparing perceived self-efficacy among adolescent Bosnian and Croatian refugees with and without posttraumatic stress disorder. Journal of Traumatic Stress, 12, 405–420. Garbarino, J., & Kostelny, K. (1996). What do we need to know to understand children in war and community violence? In R. J. Apfel & B. Simon (Eds.), Minefields in their hearts: The mental health of children in war and communal violence (pp. 33–51). New Haven, CT: Yale University Press. Howard, M., & Hodes, M. (2000). Psychopathology, adversity, and service utilization of young refugees. Journal of the American Academy of Child & Adolescent Psychiatry, 39, 368–377. Hubbard, J., Realmuto, G., Northwood, A. K., & Masten, A. S. (1995). Comorbidity of psychiatric diagnoses with posttraumatic stress disorder in survivors of childhood trauma. Journal of American Academy Child & Adolescent Psychiatry, 34, 1167–1173. Kinzie, J. D., Sack, W. H., Angell, R. H., Clarke, G., & Ben, R. (1989). A three-year follow-up of Cambodian young people traumatized as children. Journal of the American Academy of Child and Adolescent Psychiatry, 28, 501–504. Kinzie, J. D., Sack, W. H., Angell, R. H., Manson, S., & Ben, R. (1986). The psychiatric effects of massive trauma on Cambodian children: 1. The children. Journal of the American Academy of Child and Adolescent Psychiatry, 25, 370–376. Luhtanen, R., & Crocker, J. (1992). A collective self-esteem scale: Self-evaluation of one’s social identity. Personality and Social Psychology Bulletin, 18, 302–318. Lyons, J. A. (1991). Strategies for assessing the potential for positive adjustment following trauma. Journal of Traumatic Stress, 4, 93–111. Macksoud, M. S., & Aber, J. L. (1996). The war experiences and psychosocial development of children in Lebanon. Child Development, 67, 70–88. Macksoud, M. S., Dyregrov, A., & Raundalen, M. (1993). Traumatic war experiences and their effects on children. In J. P. Wilson & B. Raphael (Eds.), International handbook of traumatic stress syndromes (pp. 625–633). New York: Plenum Press. Martin-Baro, I. (1994). War and the psychosocial trauma of Salvadoran children. In A. Aron & S. Corne (Eds.), Writings for a liberation psychology (p. 242). Cambridge: Harvard University Press. Mollica, R. F., Donelan, K., Tor, S., Lavelle, J., Elias, C., Frankel, M., & Blendon, R. J. (1993). The effect of trauma and confinement on functional health and mental health status of Cambodians living in Thailand-Cambodia border camps. Journal of the American Medical Association, 270, 581–586. Mollica, R. F., Poole, C., Son, L., Murray, C. C., & Tor, S. (1997). Effects of war trauma on Cambodian refugee adolescents’ functional health and mental health status. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 1098–1106. Mollica, R. F., Wyshak, G., Lavelle, J., Truong, T., Tor, S., & Yang, T. (1990). Assessing symptom change in Southeast Asian refugee survivors of mass violence and torture. American Journal of Psychiatry, 147, 83–88. Noh, S., Beiser, M., Hou, F., & Kaspar, V. (1999). Experiences of racism among Southeast Asian refugees in Canada. In R. Roth (Ed.), Psychologists facing the challenge of a global culture and human rights and mental health (pp. 505–515). Lengerich, Germany: Pabst Science Publishers. Noh, S., Beiser, M., Kaspar, V., Hou, F., & Rummens, E. (1999). Perceived discrimination, depression, and coping: A study of Southeast Asian refugees in Canada. Journal of Health and Social Behavior, 40, 195–207. Rahimi, S. (2000). Psychosocial correlates of collective self-esteem: A comparative study. Unpublished Master Thesis, McGill University, Montreal. Richman, N. (1993). Annotation: Children in situations of political violence. Journal of Child Psychology and Psychiatry, 34, 1286–1302. Robins, E. M., & Foster, D. (1994). Social identity versus personal identity: An investigation into the interaction of group and personal status with collective self-esteem on ingroup favouritism. South African Journal of Psychology, 24, 115–121.

1290

C. Rousseau et al. / Child Abuse & Neglect 27 (2003) 1277–1290

Rosenberg, M. (1965). Society and the adolescent self-image. Princeton: Princeton University Press. Rousseau, C., Drapeau, A., & Platt, R. (1999). Family trauma and its association with emotional and behavioral problems and social adjustment in adolescent Cambodian refugees. Child Abuse & Neglect, 23, 1263–1273. Rousseau, C., Drapeau, A., & Platt, R. (2000). Living conditions and emotional profiles of young Cambodians, Central Americans and Quebecois. Canadian Journal of Psychiatry, 45, 905–911. Rubenstein, J. L., Heeren, T., Housman, D., Rubin, C., & Stechler, G. (1989). Suicidal behavior in “normal” adolescents: Risk and protective factors. American Journal of Orthopsychiatry, 59, 59–71. Sack, W. H. (1999). Twelve-year follow-up study of Khmer youths who suffered massive war trauma as children. Journal of the American Academy of Child & Adolescent Psychiatry, 38, 1173–1179. Sack, W. H., Clarke, G. N., & Seeley, J. R. (1996). Multiple forms of stress in Cambodian adolescent refugees. Child Development, 67, 107–116. Sack, W. H., McSharry, S., Clarke, G. N., Kinney, R., Seeley, J., & Lewinsohn, P. (1994). The Khmer Adolescent Project: I. Epidemiologic findings in two generations of Cambodian refugees. Journal of Nervous and Mental Disease, 182, 387–395. Sack, W. H., Seeley, J. R., & Clarke, G. N. (1997). Does PTSD transcend cultural barriers? A study from the Khmer adolescent refugee project. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 49–54. Sack, W. H., Seidler, J., & Thomas, S. (1976). The children of imprisoned parents: A psychosocial exploration. American Journal of Orthopsychiatry, 46, 618–628. Savin, D., Sack, W. H., Clarke, G. N., Meas, N., & Richart, I. (1996). The Khmer Adolescent Project: III. A study of trauma from Thailand’s site II refugee camp. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 384–391. Sigal, J. J. (1998). Long-term effects of the holocaust: Empirical evidence for resilience in the first, second, and third generation. Psychoanalytic Review, 85, 579–585. Summerfield, D. (1999). A critique of seven assumptions behind psychological trauma programmes in war-affected areas, Social Science. Social Science & Medicine, 48, 1449–1462. Sylvestre, R., Frappier, J. Y., Doucet, H., Charbonneau, L., Lambert, J., Malus, M., & Saucier, J. F. (1992). Adaptation à l’adolescence et appartenance culturelle. Paper Presented at the Meeting of the Canadian Anthropology Association, Montreal, Quebec, Canada. Terr, L. (1983). Chowchilla revisited: The effects of psychic trauma four years after a school bus kidnapping. American Journal of Psychiatry, 140, 1543–1550. United Nations High Commissioner for Refugees. (2000). The state of the world’s refugees: Fifty years of humanitarian action. Oxford: Oxford University Press. Verhulst, F. C., & Achenbach, T. M. (1995). Empirically based assessment and taxonomy of psychopathology: Cross-cultural applications. European Child and Adolescent Psychiatry, 4, 61–76. Verkuyten, M., & Masson, K. (1995). “New racism, ” self-esteem, and ethnic relations among minority and majority youth in the Netherlands. Social Behaviour and Personality, 23, 137–154. Vinar, M. U. (1993). Children affected by organized violence in South America. Paper Presented at the Conference on Children: War and Persecution, Hamburg, Germany.

Résumé/Resumen French- and Spanish-language abstracts not available at time of publication.