for WIZARD KIM: Review Paper—Topic Proposal & Reference Page

Do Secondary Trauma Symptoms in Spouses of Combat-Exposed National Guard Soldiers Mediate Impacts of Soldiers’ Trauma Exposure on Their Children?

Joseph R. Herzog • R. Blaine Everson •

James D. Whitworth

Published online: 5 August 2011

� Springer Science+Business Media, LLC 2011

Abstract This exploratory study examines the associated effects of combat exposure on Soldiers assigned to a Midwestern Army National Guard unit. It also

explores the secondary and mediating effects of combat exposure on Soldier’s

spouses and children. The correlations of combat exposure with trauma symptoms,

substance abuse, domestic violence and secondary trauma symptoms among family

members are identified. Survey results suggest that immediate family members of

combat-exposed Soldiers with high levels of post traumatic stress disorder (PTSD)

are at risk for developing secondary traumatic stress. Secondary trauma symptoms

in these spouses are a risk-increasing mediating variable between trauma symptoms

in combat-exposed Soldiers and secondary trauma symptoms in their children.

Results from this investigation emphasize the need for further inquiry into this topic.

They further highlight the need for preventive and treatment efforts targeted toward

all family members and relationships in order to lessen the effects of combat

exposure.

Keywords Secondary trauma � National Guard � Military families � Mediating variable � PTSD � Military children

J. R. Herzog (&) � J. D. Whitworth The University of West Florida, 11000 University Parkway, Building 85 Room 143, Pensacola,

FL, USA

e-mail: [email protected]

J. D. Whitworth

e-mail: [email protected]

R. B. Everson

The Samaritan Counseling Center of Northeast Georgia, 455 N. Lumpkin Street, Athens,

GA 30603, USA

e-mail: [email protected]

123

Child Adolesc Soc Work J (2011) 28:459–473

DOI 10.1007/s10560-011-0243-z

Introduction

Serving in today’s military often includes dangerous duty (Tanielian et al. 2008;

Hoge et al. 2005), lengthy periods of separation, frequent geographic relocation, and

the possibility of death and dismemberment of the military member (Cozza et al.

2005). Military members, especially those serving in Army and Marine Corps

combat units, have regularly been exposed to traumatic events that can have a

lasting effect on themselves and their families (Herzog and Everson 2010). This

study seeks to identify the effects of combat exposure on a group of Army National

Guard Soldiers along with discovering any secondary and meditational impacts of

that exposure on their family members.

The experience of war deployment has led to the development of symptoms

associated with emotional trauma in some service members, especially those who

have experienced heavy combat. An estimated 15% or more of Soldiers deployed to

Iraq in 2007 had acute stress symptoms (the precursor to post traumatic stress

disorder or PTSD), 7% had depressive symptoms, and another 7% experienced

anxiety symptoms (Mental Health Advisory Team V 2008). Members engaged in

active combat in Afghanistan and Iraq have experienced traumatic brain injury at

rates up to 30% (Tanielian et al. 2008). Reintegration of combat service members

back into their families is often quite stressful (Doyle and Peterson 2005) and is

frequently complicated by the member’s trauma and traumatic brain injury

symptoms.

Family members of individuals exposed to traumatic events are vulnerable to

secondary impacts of that stress (Figley 1983). Among combat veterans and their

families, such ‘‘secondary traumatization’’ has been defined as ‘‘the relationship

between the fathers’ war experiences and subsequent stress disorder and their

children’s problems’’ (Rosenheck and Nathan 1985, p. 538). Having a parent with

PTSD theoretically negatively impacts not only other adult members, but their

children as well (Dirkzwager et al. 2005). Military spouses have higher rates of

somatic, psychiatric symptoms (Dirkzwager et al. 2005; Mikulincer et al. 1995;

Solomon et al. 1992) and emotional distress (Dekel et al. 2005). Spouses of soldiers

with PTSD frequently have limited social support, along with marital relation

problems (Dirkzwager et al. 2005) and marital adjustment (Dekel et al. 2005;

Solomon et al. 1992).

High levels of intrusive thoughts and avoidance symptoms in members with

PTSD have been associated with lower levels of cohesion, expressiveness, and

marital satisfaction (Hendrix et al. 1995). Of particular concern are conflict oriented

and rigid-moral families of veterans with PTSD whose wives themselves are at

increased risk of developing psychopathology and behavioral problems (Waysman

et al. 1993). Given that the literature and associated research suggest that combat-

exposed military members are at great risk for experienced stress and even

psychopathology, and that their spouse and children in turn are at risk for increased

secondary stress, the present study sought to explore three specific questions: (1)

whether Soldiers deployed to combat from a Midwestern Army National Guard unit

experience increased levels of traumatic stress symptoms, (2) whether the Soldiers’

traumatic stress symptoms are correlated with secondary stress experienced by their

460 J. R. Herzog et al.

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spouse and children, and (3) whether secondary spousal stress symptoms mediate

the secondary stress experienced by their children.

Method

Sample

Introductory letters, sealed surveys, and reminder cards were provided to the

participating National Guard Brigade Combat Team family program that then sent

these materials to 1,011 households containing their married Guard members. The

introductory letter described the study and addressed possible risks and benefits

from participation in the project. The survey mail-out was followed by 3 reminder

cards sent over a 7-week period. Not all of the households that received surveys

actually contained eligible participants. To be eligible for inclusion in the study, the

household must have had an Army National Guard Soldier, a spouse or partner

residing with them, and had at least one child in the home between the ages of 2 and

18. Surveys were mailed directly from the subjects to the office of principal

investigator. At no time did the National Guard family program have access to

individual survey results. The National Guard family program did not have a

breakdown of how many of the households had eligible participants. So determining

an exact response rate was not possible. Eighty-seven households returned surveys.

Of these 87, 54 contained complete surveys of participants eligible for the study,

while 33 only had data from the National Guard member, their spouse, or had no

minor children residing in the household. The study was approved by the University

of South Carolina Institutional Review Board.

Design, Data Collection and Measures

The study employed a non-experimental observational single cohort design that

included a one-time survey given to a group of Soldiers and their spouses or

partners. The principal investigator organized a pencil and paper survey instrument

that included the following items: (a) demographic questions on the age, race and

gender of each Soldier, spouse, and child, the socio-economic status of the family,

as well as the length and frequency of deployment(s), (b) the PTSD checklist,

Military Version (PCL-M) (Weathers et al. 1993) (c), the secondary trauma scale

(STS) (Motta et al. 2001), (d) the hurt-insult-threaten-scream (HITS) (Sherin et al.

1998), (e) the relax-alone-friends-family-trouble (RAFFT) (Bastiaens et al. 2002),

(f) and the child behavior checklist (CBCL) (Achenbach and Rescorla 2001). The

PCL-M portion was only completed by the soldier and the STS portions were only

done by the spouse or partner. All other sections of the survey were given to both

the member and their spouse/partner.

The PCL is a 17-item scale used to measure PTSD symptoms on a 5 point scale.

This scale, particularly the military version (PCL-M), was chosen for its ability to

measure post-trauma symptoms in military service personnel. The PCL-M asks

about symptoms in response to a ‘‘stressful military experience’’ versus a ‘‘stress

Impacts of Soldiers’ Trauma Exposure 461

123

experience’’ as requested in the PCL. Weathers et al. (1993) suggest a cut-off score

of 50 as highly predictive of a PTSD diagnosis. The PCL has been highly correlated

(.92) with the clinician administered PTSD scale in a civilian sample of motor

vehicle accident and sexual assault survivors (Blanchard et al. 1996). The PCL has

also been highly correlated (r [ .75) with the well known Impact of Event Scale and Mississippi Scale for PTSD—Civilian version (Ruggiero et al. 2003). Ruggiero

et al. (2003) also reported the test–retest correlations to be .92 for immediate re-

testers, .88 at 1 week, and .68 at 2 weeks while Weathers et al. report .96 at

2–3 days. Internal consistency for the PCL has been reported with Cronbach’s as of .97 (Weathers et al. 1993), .94 (Ruggiero et al. 2003) and .92 (Shapinsky et al.

2005).

The STS was chosen for its ability to measure secondary trauma symptoms in

family members of trauma victims. This scale counting 18 items relevant to

secondary trauma was given to the spouses or partners residing with military service

member. Previous reliability for this scale has ranged from .82 (Motta et al. 2001) to

.89 (Motta et al. 2004). Motta et al. (2004) further developed the STS by providing

cut-off scores suggesting that a score of 45 or higher be of concern to clinicians. The

HITS scale was chosen to control for domestic violence. It is a 4-item scale

designed to detect domestic violence victims in medical settings, such as emergency

rooms and domestic violence shelters (Sherin et al. 1998). Cronbach’s a for the HITS scale range from .80 and higher. The RAFFT is a 5-item scale designed to

screen for substance use disorders (Bastiaens et al. 2002). The CBCL was selected

for its ability to measure emotional and behavioral characteristics indicative of

secondary trauma symptoms in children (Achenbach and Rescorla 2001). Respon-

dents were asked to evaluate the oldest child between the ages of 6 and 18 in the

family.

Results

A total of 141 Soldiers and their spouse/partners responded to the survey. Of these

141 respondents, 7 individuals returned surveys unaccompanied by their spouse

survey and 26 individuals (13 couples) returned surveys without completing the

CBCL. The final sample for this study included 108 individuals who comprised 54

couples that completed all sections of the survey All of the Soldiers who comprised

the final sample were male who ranged in age from 28 to 53 years. All spouses who

responded to the survey were female and ranged in age from 25 to 53 years, with

their children ranging in age from 2 to 17 years Demographic data for the entire

sample has been presented in Table 1.

Association of Combat Exposure and Soldier’s Self-Reported Levels

of Traumatic Stress Symptoms

Soldier scores on the PCL-M ranged from 17 to 78 (M = 31.57; SD = 14.10). The cut-off score for the PCL has previously been established at 50 (Weathers et al.

1993). Of the 54 Soldiers, five (10.8%) scored in the diagnostic range on the PCL.

462 J. R. Herzog et al.

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Table 1 Descriptive Statistics for the Sample

Variable n or Mean

Soldier’s age 37.8 (SD = 5.9)

Soldier’s ethnicity

Black 0

Hispanic 2

Caucasian 51

Other 1

Soldier gender

Female 0

Male 54

Soldier’s rank

Enlisted 38

Officer 16

Soldier years of service 17.3 (SD = 6.01)

Soldier frequency of deployments

One 26

Two or more 28

Soldier months deployed (since 2003) 24.4 (SD = 6.31)

Soldier educational level

GED only 1

High school graduate 6

Some college 46

Spouse gender

Female 54

Male 0

Spouse age 37 (SD = 6.27)

Spouse educational level

GED only 1

High school graduate 6

Some college 47

Years married to soldier 12.4 (SD = 5.14)

Spouse ethnicity

Black 0

Hispanic 1

Caucasian 52

Other 0

Age of oldest minor child in household 9.38 (SD = 4.54)

Gender of oldest minor child in household

Female 31

Male 23

Ethnicity of oldest minor child in household

Black 0

Hispanic 2

Caucasian 52

Other 1

Impacts of Soldiers’ Trauma Exposure 463

123

Two other soldiers scored close to the clinical range at 48 and 49. There was a gap

in scores with 42 being the next highest score. Cronbach’s a for the PCL-M for the current sample was .95 indicating a high-level of internal consistency. A recent

investigation concluded that PCL-M cut off scores of 30–34 could be used to

diagnose PTSD among military members deployed to Iraq or Afghanistan (Bliese

et al. 2008).

Association of Soldiers’ Traumatic Stress Symptoms and Stress Experienced

by Spouse and Children

Scores on the STS among Soldier’s spouse in our sample ranged from 18 to 78

(M = 32.30; SD = 11.89. The cut-off score for the STS was established at 45 (Motta et al. 2004). Of the 54 spouses in the final sample, eight (14.8%) scored in

the clinical range of 45 or higher on the STS while two others scored close to the

clinical range at 44. Cronbach’s a, for the STS scale with the current sample was .89 reflecting strong internal consistency.

The combined total mean on the CBCL for spouse and Soldier scores was 45.98

with a standard deviation of 38.63. The combined total scores ranged from four to

244. The mean for Soldier total CBCL scores was 20.27. The mean for spouse total

CBCL scores was 25.7 and the standard deviation was 15.5. The average CBCL

total problems score for Soldier—spouse couples was lower for Soldiers than for

spouses. The mean difference between the spouses was -5.42. There was not a

significant difference between Soldier and spouse CBCL total problems score on an

independent samples t test. All mean comparisons and parameter estimates were tested at a minimum significance of p \ .05.

The combined internalizing problems mean for Soldiers and spouses on the

CBCL was 9.34. The soldier internalizing problems mean on the CBCL was 5.44

and the scores ranged from 0 to 38. The spouse internalizing problems mean on the

CBCL was 7.79 and the scores ranged from 0 to 39. The mean difference between

the Soldier and the spouses was -2.35 reflecting a significant difference

(independent samples t test: t = -1.697, df = 107, p \ .093). The combined externalizing problems mean for Soldiers and spouses on the CBCL was 10.05 and

the scores ranged from 0 to 57. The Soldier externalizing problems mean on the

CBCL was 6.38 and the scores ranged from 0 to 34. The spouse externalizing

problems mean on the CBCL was 7.33 and the scores ranged from 0 to 35. There

was not a significant difference between Soldier and spouse CBCL externalizing

problems score on an independent samples t test. The correlational coefficients between CBCL scores and PCL scores or CBCL

scores and STS scores are reported in Table 2. There was a significant relationship

between combined Soldier-spouse perceptions of total problem scores on the CBCL

and PCL scores (r = .470, N = 54, p \ .000) as well as between combined soldier- spouse perceptions of total problem scores on the CBCL and STS scores (r = .441, N = 54, p = .001). Since the CBCL is composed of internalizing and externalizing subscales, further analysis was conducted between the subscales and the PCL and

the STS as is shown in Table 3 and is described below. There was a significant

positive correlation between Soldier perceptions of child total problems on the

464 J. R. Herzog et al.

123

CBCL and the PCL (r = .405, N = 54, p = .002). The correlation was moderate in strength. A moderate correlation was also found Soldier for perceptions of child

internalizing problems on the CBCL and the PCL (r = .355, N = 54, p = .008). The correlation was not significant for soldier perceptions of child externalizing

problems on the CBCL and the PCL (r = .231, N = 54, p = .093). Soldier perceptions of child total problems on the CBCL was positively

correlated with STS scores (r = .351, N = 54, p = .009). A moderate significant correlation was also found for Soldier perceptions of child internalizing problems on

the CBCL and the STS (r = .391, N = 54, p = .003). The correlation was not significant for Soldier perceptions of child externalizing problems on the CBCL and

the STS (r = .176, N = 54, p = .202).

Table 2 Correlation of CBCL, with PCL, and STS

Variable (N = 54) PCL (N = 54) STS (N = 54)

Child total combined .470* .441**

Child internalized—soldier .355**** .391*****

Child externalized—soldier .231 .176

Child total—soldier .405*** .351****

Child internalized—spouse .410*** .532*

Child externalized—spouse .240 .233

Child total—spouse .466* .461*

Significance (2-tailed) * p \ .000; ** p = .001; *** p = .002; **** p = .008; ***** p = .003

Table 3 Mediation analysis steps

Variable Step 1 Step 2 Step 3

PCL STS

Combined total

b .533 .470 .328 .266

p Value .000 .000 .024 .066

Soldier total

b .533 .405 .305 .189

p Value .000 .002 .024 .210

Soldier internalizing

b .533 .355 .205 .281

p Value .000 .008 .177 .066

Spouse total

b .533 .470 .328 .266

p Value .000 .000 .024 .066

Spouse internalizing

b .533 .410 .177 .438

p Value .000 .002 .206 .003

Impacts of Soldiers’ Trauma Exposure 465

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A moderate positive correlation between spouse perceptions of child total

problems on the CBCL and the PCL was identified (r = .466, N = 54, p \ .000). A moderate significant correlation was also found for spouse perceptions of child

internalizing problems on the CBCL and the PCL (r = .410, N = 54, p = .002). The correlation did not however hold for spouse perceptions of child externalizing

problems on the CBCL and the PCL. The correlation was weak and not significant

(r = .240, N = 54, p = .08). There was a significant moderate positive correlation between spouse perceptions

of child total problems on the CBCL and the STS (r = .461, N = 54, p \ .000). A moderate correlation was also for found spouse perceptions of child internalizing

problems on the CBCL and the STS. The correlation was significant (r = .532, N = 54, p \ .000). The correlation was not however significant for spouse perceptions of child externalizing problems on the CBCL and the STS (r = .240, N = 54, p = .08).

To analyze if children of combat Soldiers with high levels of post-trauma

symptoms will have more emotional and behavioral symptoms when compared to

published norms, those cases with a PCL score of 48 or higher were selected. In

examining the PCL data, there was a gap in scores from 42 to 48. It appeared that

the individuals who scored 48 and 49 on the PCL were closer to the group of

individuals who had high levels (scores over 50) of post trauma symptoms than

those who did not. The addition of these cases resulted in seven cases identified with

elevated levels of post-trauma symptoms. Spousal scores on the CBCL were utilized

to determine secondary trauma symptom level in children.

Children with fathers who scored in the high level range on the PCL averaged at

the 76.7 percentile on total problems scale on the CBCL when compared to norms.

These children averaged at the 72.8 percentile on internalizing problems scale and

69 percentile on externalizing problems scale on the CBCL when compared to

norms. Two of these children scored in the clinical range and one in the borderline

range for total problems. Three of these children scored in the clinical range for

internalizing problems and one scored in the clinical range for externalizing

problems.

The Mediating Effects of Secondary Spousal Stress Symptoms and Children’s

Secondary Stress Symptoms

The suggestions made by Baron and Kenny (1986) were utilized in testing if Post-

trauma symptoms in combat veterans were related to emotional and behavioral

symptoms in their children and if this relationship was greatly reduced by

accounting for secondary trauma symptoms in spouses (see Table 3).

In the first step, STS scores (the mediator) were regressed on PCL scores (the

independent variable). In the second step, CBCL scores were regressed on PCL

scores. CBCL scores were finally regressed on PCL and STS scores. These steps

were used to analyze Soldier-spouse combined perceptions of child total problems

scores on the CBCL. Soldier perceptions of child externalizing problem scores on

the CBCL and spouse perceptions of child externalizing problems scores on the

CBCL were not utilized as the dependent variable because of the lack of correlation

466 J. R. Herzog et al.

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between these scores and PCL and STS scores as indicated in Table 2. Non-

significant results were found for the mediator when Soldier-spouse combined

perceptions of child total problems scores on the CBCL. Soldier perceptions of child

total problems scores on the CBCL, Soldier perceptions of child internalizing

problem scores on the CBCL, spouse perceptions of child total problems scores on

the CBCL were used as the dependent variable. However, using the stepwise

method, a significant model emerged: F = 20.66, p \ .000 when spouse percep- tions of child internalizing problem scores on the CBCL was used as the dependent

variable. Spouse secondary trauma symptoms were found to be a mediating variable

between PTSD symptoms in soldiers and spouse perceptions of child internalizing

problem scores on the CBCL. In fact, the PCL became non-significant in step 3, just

as Barron and Kenny suggest (1986).

Secondary traumatic stress was correlated with several variables. As suggested in

the first step in the test for moderation, there was a significant positive correlation

between the PCL and the STS (r = . 533, N = 54, p \ .000). Secondary traumatic stress was also positively correlated with spousal reports of verbal abuse

(component 2 of the HITS) (r = .451, N = 54, p = .001). The correlation was moderate in strength. Secondary traumatic stress is negatively correlated with

spouse (r = -.368, N = 54, p = .006) and soldier (r = -.450, N = 54, p = .001) education as well as soldier rank (r = -.364, N = 54, p = .001).

The PCL, spouse verbal abuse, spouse education, soldier education, and soldier

rank were entered into a regression equation. A significant model emerged using the

stepwise method: F = 14.097, p \ .000. The PCL and spouse verbal abuse explained 33% (adjusted R2 = .331) in the variance in spouse secondary traumatic stress. Spouse physical abuse, spouse substance abuse, and soldier rank were

excluded in this model.

Spousal reports of externalizing behaviors in children were significantly correlated

with the spousal HITS (r = -.320, N = 54, p = .018). Spousal reports of child exter- nalizing behaviors were also correlated with spousal results of the two components of

the HITS, physical (r = .455, N = 54, p = .001) and verbal (r = -.323, N = 54, p = .017) abuse.

Domestic Violence and Substance Abuse among Surveyed Soldiers and Their

Families

The cut-off score for the HITS, previously developed to indicate clinical levels of

domestic violence, has been established at 11 (Shakil et al. 2005). Only two of the

54 spouses in the final sample reported scores that were in the domestic violence

victim range and none of the Soldiers reported scores in the victim range. The mean

score for spouses was 6.09 and the mean score for soldiers was 5.5. There was a

significant positive correlation between spouse and Soldier scores on the HITS

(r = .367, N = 54, p = .006). The internal consistency of the HITS was low. Cronbach’s a for the HITS was .69.

The internal consistency for the RAFFT for both Soldiers and spouses was very

low. Cronbach’s a for spousal RAFFT data was .55 and for the soldier RAFFT data it was .56. A score of 3 was used as a cut-off score for substance abuse. Of the

Impacts of Soldiers’ Trauma Exposure 467

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spouses, 10 (18.5%) scored in the substance abuse range while 15 soldiers (27%)

scored in the substance abuse range. The mean score for spouses was 1.3 with a

standard deviation of 1.29 while the mean score for soldiers was 1.5 with a standard

deviation of 1.31.

Discussion

Findings from the present study are consistent with the literature on secondary

traumatic stress that spouses of Soldiers with posttraumatic stress are at increased

risk of secondary traumatic stress symptoms (Dirkzwager et al. 2005; Dekel et al.

2005; Arzi et al. 2000). Secondary trauma symptoms in spouses in the current study

were in fact found to be significantly correlated with posttraumatic stress in

Soldiers. This study suggests that spouses of Iraqi war Soldiers, much like spouses

of Vietnam veterans and Dutch peacekeepers, are at increased risk for secondary

trauma stress. This research also lends support to conclusions from prior studies that

secondary trauma symptoms closely resemble PTSD symptoms. Symptoms include

the avoidance of thoughts, behaviors, and emotions and the intrusion of unwanted

cognitions and images that reminded the spouses of negative experiences of their

Iraqi war deployed Soldier.

Higher STS has been found to be strongly correlated with depression (Motta et al.

2004). Depression may in fact be an outcome of secondary traumatic stress. Several

spouses noted depression in the open-ended section of the current survey as being

the major symptom they were experiencing. Emotional distress including depressive

symptoms in spouses of Veterans with PTSD has previously been found in the

secondary trauma literature (Dekel et al. 2005; Arzi et al. 2000). Depression and

anxiety were the most common symptoms that military spouses requested treatment

for in this sample and in prior investigations. (Mansfield et al. 2010). The present

study therefore provides some evidence to support a broader definition of secondary

trauma that includes depressive features.

STS may affect people in the same manner that post traumatic stress effects

combat-exposed Soldiers. Some of these Soldiers who develop posttraumatic stress

symptoms have also been found to have higher rates of depression and anxiety

symptoms. It may be that some people exposed to secondary traumatic stress will

develop symptoms similar to PTSD while others will develop depression, anxiety,

or a combination of symptoms.

Consistent with past findings, this research also found evidence of a relationship

between posttraumatic stress in Soldiers and secondary trauma symptoms in

children. Children of parents who have PTSD have been previously shown to have

higher levels of anxiety, depression, and PTSD-type symptoms (Del Valle and

Avelo 1996).

Internalizing problems were found to be symptomatic of secondary trauma stress

in children in this study. This finding is consistent with the literature on child

secondary trauma stress. Past research has found internalizing behaviors to be

symptomatic of war-separated children (Medway et al. 1995). Specifically,

depression, anxiety, and somatization have been found to be symptomatic of

468 J. R. Herzog et al.

123

secondary trauma (Dansby and Marinelli 1999; Daud et al. 2005). Internalizing

problems on the CBCL are composed of anxious/depressed, withdrawn/depressed,

and somatic complaints subscales. The correlation between spouse reported child

internalizing problems and PTSD symptoms in Soldiers was moderate in strength.

This study supports the literature that finds internalizing problems to be

symptomatic of secondary traumatic stress.

Externalizing symptoms were not found to be symptomatic of secondary trauma

in children in the current research. This finding was inconsistent with past research.

PTSD symptoms have been found to account for as much as 34% of the variance in

externalizing behaviors in children of Vietnam veterans (Caselli and Motta 1995).

The current investigation did not examine the possible relationship between child

abuse, PTSD in Soldiers, and secondary trauma in children. A relationship has been

found in the past between child abuse and externalizing behaviors (Jouriles and

Norwood 1995), with boys at particular risk. High levels of conflict have been found

to be characteristic of Australian Vietnam veterans (Westerink and Giaratano 1999).

It may be the case that there is a relationship between PTSD symptoms, child abuse,

and externalizing behaviors. However, it may also be difficult to differentiate

between trauma symptoms in children as the result of child abuse rather than

secondary trauma stress. The challenge then is how to separate symptoms due to

child abuse from those due to secondary traumatic stress.

The central finding of this research was the support for the mediating model (see

Fig. 1). Within this model, a key relationship was identified which expands the

literature on secondary trauma. As a component of this relationship, it was

hypothesized that spouse secondary trauma stress symptoms would serve as a

mediating variable between soldier posttraumatic stress symptoms and child

secondary traumatic stress symptoms. This relationship has not been previously

examined in the secondary trauma literature. While not necessarily generalizable

from these data, the results of this study provide initial support for the mediating

model. This model expands the secondary trauma literature to include spousal

mediating effects on children.

Trauma

Symptoms

in Soldiers

Secondary

Trauma

Symptoms

Secondary

Trauma

Symptoms

in Spouses

Fig. 1 Secondary trauma mediating model

Impacts of Soldiers’ Trauma Exposure 469

123

Study Limitations

The present investigation was limited by a relatively small sample size, which may

have been a result partly due to a design that required both the spouse and the

Soldier to complete all surveys. The small sample size also likely resulted in a

reduced number of Soldiers who reported high levels of PTSD. Seven families were

identified with high levels of Soldier PTSD. As part of the analysis, children of

Soldiers with high levels of posttraumatic stress were compared to norms. It is

difficult to draw inferences from a sample with only seven soldiers with high levels

of PTSD. The inability to obtain a large number of Soldiers with PTSD in this

sample was a liability of conducting research with a non-clinical population.

National Guard units in several states declined to participate in the research project.

The participating National Guard unit has been commended for their innovative

reunion programming. There may be biased results obtained from this sample as

indicated by their innovative programming and willingness to participate in the

research project. We also cannot be sure of the extent to which the program’s

effectiveness reduced the amount of family problems observed as result of the

recent deployment and reunification.

The sample for this study was composed primarily of well-educated, high

ranking Soldiers and their spouses, which is somewhat different than samples of

typically younger and less educated active duty Soldiers. Soldier rank has been

thought of as an estimate of socioeconomic status (Cozza et al. 2005). Rank and

education, however, were not significantly related to child secondary traumatic

stress symptoms. Additionally, the National Guard unit was very active in its family

programming with a special focus on reunion integration. These protective factors

may have made for a healthier sample than was expected. Missing from this

research are the junior enlisted families, many of which have had difficulty

negotiating military family life.

Implications

This research supports the findings of prior investigations that family members of

Soldiers with high levels of PTSD symptoms are at risk for developing secondary

trauma symptoms. Social workers should be aware of the clinical presentation of

these family members. Spouses may present clinically with secondary traumatic

stress symptoms that mimic PTSD symptoms. These spouses may also present with

depressive or other anxiety symptoms as a result of secondary traumatic stress.

Social workers treating spouses with secondary traumatic stress symptoms should

be familiar with therapeutic techniques aimed at reducing these symptoms Children

may present clinically with internalizing problems as the product of secondary

traumatic stress. Internalizing problems in children include anxiety-related behav-

iors, depressed mood, withdrawal, and somatic symptoms. Social workers treating

children with secondary traumatic stress symptoms may wish to employ therapeutic

techniques aimed at reducing anxious and depressive symptoms, such as trauma

focused cognitive behavior therapy (TF-CBT), play therapy targeting secondary

470 J. R. Herzog et al.

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trauma symptoms, or utilize a family empowerment model with the entire family

(Deblinger et al. 2011; Herzog and Everson 2007, 2010). They should also consider

systemic interventions aimed at the possible mediating effects of spousal secondary

trauma symptoms on children of PTSD positive Soldiers. Everson and Figley (2010)

present systemic approaches for treating military families in multiple branches of

the uniformed services. Future investigations should also seek to identify and assess

interventions specifically developed to treat combat-exposed Soldiers and their

families.

Summary and Conclusions

This research has added to the growing literature on secondary trauma and military

family experiences. Results from this investigation are consistent with past findings

of a relationship between post-traumatic stress symptoms in Soldiers and secondary

trauma symptoms in family members. The model introduced in the current study

suggested that secondary trauma symptoms in spouses are a risk-increasing

mediating variable between post trauma symptoms in Soldiers and secondary

trauma symptoms in children. Secondary traumatic stress symptoms in children

were characterized by internalizing rather than externalizing problems. The present

results should be interpreted cautiously due to a low response rate and small sample

size. Nonetheless, this research suggests that clinicians working with this population

be cognizant of the relationship between posttraumatic stress symptoms in Soldiers

and secondary trauma symptoms in family members. Clinicians should further be

aware of the possible risk increasing role secondary trauma symptoms in spouses

has on the post traumatic stress in Soldiers and secondary trauma symptoms in

children relationship. This study should be replicated with the goal of increasing the

response rate and sample size in order to increase generalizability and to test the

revised model. The literature on secondary trauma would also benefit from a

longitudinal study aimed at examining the etiology of secondary trauma.

Secondary trauma symptoms in children of war veterans are an important topic of

study as the wars in Iraq and Afghanistan continue. These families bear the stress of

having a member with combat related injuries such as PTSD, depression, and

anxiety. Spouses and children of combat veterans with posttraumatic stress

symptoms suffer the unseen injury to themselves. These injuries take the form of

secondary traumatic stress symptoms. Military families have made tremendous

sacrifices and deserve the best mental health care available. It is incumbent upon the

society that sends Soldiers off to war to provide the best care possible to them and

their family members when they return.

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