Influence of Maternal Traumatic Experiences on Their Children’s Mental Health Symptoms in Afghanistan

Abstract

Background:

Caregivers play an essential role in shaping their child’s mental health outcomes.

Aims:

This paper aimed to characterize the association between caregiver and child mental health among a highly traumatized population.

Methods:

A total of 813 pairs of children and their female caregiver (mostly mother) were included. The SDQ parent version measured child mental health problems, which were classified in four categories: internal only, external only, both and none. The LEC-5 and PCL-5 measured traumatic event exposure for the female caregiver and events were classified into meaningful categories based on type of event. Multiple logistic regressions were used to assess the four child mental problem categories.

Results:

Overall, 10.95% of the children had internal problems only, 27.55% had external problems only, 27.10% had both internal and external problems, and 8.25% were impaired by these problems in their daily life. Boys had more external problems than girls. There was an association between parental interpersonal violence exposure (RR = 1.97), collective violence (RR = 1.57), caused or witness harm (RR = 2.39), accidental injury (RR = 1.67) and their children combined internal and external problems. The number of events independently added to that risk (RR = 1.64). In gender stratified analyses, boys were at risk for combined problems for witnessing interpersonal violence (RR = 3.15) and girls for internal only problems for witnessing accidental injury (RR = 3.82).

Conclusion:

Children with caregivers who have high levels of trauma exposure have an increased risk of developing mental health problems. Preventive measures have been developed and positively evaluated in Afghanistan such as preventing family and school violence. Providing screening and assessment of mental health problems in youth in primary care or other medical contact is also an important part of strengthening the health of the Afghan population.

Keywords

Afghanistan trauma war or armed conflict child mental health

Background

Mental health is an integral part of overall child health and well-being. According to the World Health Organization (WHO), one in seven 10 to 19 year olds experience mental health disorders, accounting for 13% of the global disease burden for this age group (WHO, 2021). Many risk and protective factors affect child mental health, including exposure to adversity, pressure to conform with peers, exploration of identity, media influence, gender norms, quality of home life, relationship with peers, violence, harsh parenting and socio economic problems (WHO, 2021). While these factors have received increased attention in the global mental health literature, few studies systematically investigate associations between caregiver and child mental health in contexts affected by chronic poverty, conflict, and forced displacement (Panter-Brick et al., 2014; Scharpf et al., 2021). Afghanistan presents a unique context for examining the caregiver-child mental health relationship, as the population has experienced persistent exposure to poverty and conflict while maintaining strong family structures that are central to Afghan culture. Few studies have examined how caregiver trauma exposure impacts child outcomes in Afghanistan (Catani et al., 2008, 2009; Panter-Brick et al., 2009), but longitudinal research in Kabul and Peshawar during the 2010s found that caregiver PTSD increased children’s risk of experiencing potentially traumatic events (Najm et al., 2023; Panter-Brick et al., 2014).

Through their influence over childhood homes, caregivers directly impact family environment and shape child health outcomes (Rieder et al., 2019). Early childhood environments affect brain development, language, social skills, emotional regulation, self-control, mental and physical health, health risk behavior, and capacity to cope with major life events (Cecil et al., 2012; Odgers et al., 2012). Further, parental mental disorders are associated with a wide range of emotional and behavioral problems from infancy through childhood (Kingston et al., 2012; Kingston & Tough, 2014; Natsuaki et al., 2014; O’Connor et al., 2016; Verkuijl et al., 2014; Weissman, 2016) and into adulthood. The impact of maternal mental health on child mental health—be it through post-partum depression or other non-maternal-role-specific mental health conditions—has been studied in many contexts, with evidence of child anxiety, attention deficit hyperactivity disorders symptoms, and PTSD symptoms; however, documentation of the scale and mechanisms by which maternal mental health impacts child mental health is lacking (Eruyar et al., 2020; Karam et al., 2019; Meyer et al., 2017; Scharpf et al., 2021). In contexts affected by displacement and conflict, where individual, familial, and community protective factors may be limited (Scharpf et al., 2021), higher caregiver distress and psychopathology are associated with increased internalizing and externalizing disorders, as well as other emotional and behavioral problems in children (Betancourt et al., 2012; Eruyar et al., 2018; Scharpf et al., 2021).

A recent nationwide population-based study from which this current study is based documented child outcomes in Afghanistan using the Strengths and Difficulties Questionnaire (SDQ). This study found that 39.19% of children had emotional problems, 51.98% had conduct disorder, 15.37% had hyperactivity/inattention problems and 12.38% of school aged children (aged 7–15) had problems impacting daily life (Kovess-Masfety et al., 2023) indicating poor functioning among Afghan children. Level of terrorist threat was also associated with mental health problems, where youth in regions with high levels of terrorist threat were more likely to have problems than youth in regions with low or medium levels of danger, independent of region and ethnicity.

While the link between caregiver trauma and child outcomes is broadly acknowledged, research examining these dynamics within populations experiencing prolonged conflict remains limited. The present study addresses this gap using a large dataset of mother/child dyads in Afghanistan from 2017 to evaluate maternal experience of trauma with child mental health. We examined the burden of Afghan child mental health problems and their correlates including gender and age. We also assessed the association of child mental health problem with maternal trauma exposure. Given Afghanistan’s ongoing humanitarian crisis, these findings are essential for understanding the complex, intergenerational transmission of trauma and may assist with developing culturally informed interventions.

Methods

Sample

A cross-sectional household survey was implemented from April to October 2017 in each of the eight regions of Afghanistan. A multi-stage stratified cluster sampling method was applied and two provinces were randomly selected in each region. A random sampling of clusters within each province were selected using maps of 320 clusters provided by the Central Statistical Organization. Within each cluster, 14 households were randomly selected, and eligibility criteria was assessed. In the household, adult respondents were randomly selected using Kish selection before starting the interview. Eligibility criteria included Afghan males and females at least 15 years old and caregivers who were residents of the household and those who had given consent to participate in the study. One child aged 4 to 15 years in the household was also selected randomly. A consent form was read aloud and accepted for each selected person prior to the interview; those who did not give consent were excluded. Consent for child participation was obtained from the caregiver prior to participation. The study received the institutional review board approval by the December 31, 2016. A team of one female and one male was responsible to collect data from each household. Data collection was supervised by provincial supervisors, and regular monitoring visits were conducted by monitoring officers.

Information was collected on 4,480 households, consisting of 4,364 adults and 3,784 children aged 4 to 15. Details of the study design and methodology can be found elsewhere (Kovess-Masfety, Keyes, et al., 2021). For the current study we paired each child caregiver of the randomized child with their corresponding individual questionnaire. To create the mother/child dyads, we dropped the largest families (10 members or more) since these households grouped more than 1 parent/child unit and we kept the age of the individual questionnaire between 17 to 65. This corresponded to 62.32% of the households. Within the same household, we paired on gender and age the randomized individual with the corresponding caregiver’s questionnaire. This resulted in 1,027 child/adult pairs. To increase the homogeneity of the sample, we excluded male respondents (N = 207), resulting in 820 female caregiver respondents. In addition to having too few responses for gender-based comparisons, male respondents were excluded to adhere to the Afghan cultural context. In Afghanistan, gender roles are highly patriarchal and rigidly defined, where men are viewed as the main income earners and women are seen as the homemakers and caregivers (Evason, 2019; Hossain et al., 2005; Kiram, 2025; Wood, 2024). Following these adjustments, the final sample included 813 pairs of child/female caregiver dyads.

Instruments

Two questionnaires—an “adult” questionnaire and a “parent” questionnaire—were merged for analyses. The adult questionnaire collected pertinent sociodemographic information. Traumatic event exposure and post-traumatic stress disorder were assessed using the Life Event Checklist 5 (LEC-5) together with PTSD Check-List 5 (PCL-5) (Blevins et al., 2015; Weathers et al., 2013) using the DSM-5 algorithm. We categorized traumatic events in six groups: collective violence, sexual violence, accidental injury, caused/witnessed harm, interpersonal violence, and any traumatic events. Collective violence included those who experienced or witnessed (1) fire or explosion; (2) assault with a weapon (e.g. being shot, stabbed, threatened with a knife, gun, bomb); (3) combat or exposure to a warzone (in the military or as a civilian); and (4) captivity (e.g. being kidnapped, abducted, held hostage, prisoner of war). Sexual violence included having experienced or witnessed (1) sexual assault (rape, attempted rape, made to perform any type of sexual act through force or threat of harm); and (2) other unwanted or uncomfortable sexual experience (for example, sex during menstruation, sex without your permission with your partner). Accidental injury exposure included (1) natural disaster (e.g. food, earthquake); (2) transportation accident (e.g. car accident, plane crash); (3) serious accident at work, home, or during any activity; (4) exposure to toxic substance (e.g. mercury, benzene); and (5) life-threatening illness or injury; and sudden accidental death (only witnessed). Caused/witnessed harm included (1) sudden violent death (e.g. homicide, suicide) and (2) sudden accidental death. Interpersonal violence included physical assault (e.g. being attacked, hit, slapped, kicked, beaten up). Lastly, any traumatic event represented a respondent having experienced or witnessed any previously listed event. This classification was previously used by other authors (Karam et al., 2014; Kessler et al., 2017). Each traumatic event type was categorized into three categories: total, experienced and witnessed. The number of traumatic events were also classified into three groups: no traumatic events, one to three events and more than three events (Karam et al., 2014).

Child psychopathology was assessed using the parent version of the SDQ, a 25-item questionnaire completed by the child’s parent. The SDQ has been used in Bangladesh, Pakistan, and Gaza where parents experienced increased stress and trauma. Its usage outside Europe has been documented and validated against clinical instruments in multiple languages (Husky et al., 2020; Mullick & Goodman, 2001; Samad et al., 2005; Thabet et al., 2000; Woerner et al., 2004). Thus, the SDQ has been validated in different cultures and settings including potentially traumatized parents. This does not imply that parent pathology does not influence child symptoms, but rather the parent’s psychopathology potentially mediates the child’s symptoms which contributes to the challenges in pursuing this research. At any rate, we remain confident that the instrument measurements support our findings on parental trauma affecting child mental health. Each item was scored as “not true,” “somewhat true” or “certainly true” in reference to the past 6 months. The questionnaire was divided into five subscales of five items each: hyperactivity/inattention, emotional problems, conduct problems, peer problems and prosocial behaviors. Additional questions were presented in the SDQ to measure the functional impairment experienced by the child, such as distress and interference in everyday life activities. For each of these scales, cut off points were provided by the author (www.sdqinfo.org) (Goodman, 1997) and consisted of “unlikely,” “possible” or “probable” problems, including presence of impairment. A present/absent category was created by using “probable” versus “unlikely” or “possible.” In addition, presence of ADHD and conduct problems were merged into an “externalized” problems variable, while emotional problems were merged to create an “internalized” variable. Both types of problems could be present together, demonstrating an element of severity. Lastly, the problems were classified into four mutually exclusive categories: internal only, external only, both and none. The SDQ had been translated and validated in Dari and Pashtu languages and have been previously used in Afghanistan (Panter-Brick et al., 2009). Moreover, in the present sample, the instrument yielded a Cronbach’s alpha of .84 for the total scale, while the subscales yielded 0.70 for the emotional scale, 0.54 for conduct scale 0.60 for hyperactivity/inattention, 0.42 for peer relations, and 0.65 for prosocial. As expected, the total difficulties scores were correlated with each subscale (0.78, 0.68, 0.73, 0.55, respectively), except for the prosocial scale, which does not assess mental health problems. This pattern was quite similar to what was obtained by other studies (Maurice-Stam et al., 2018; Mieloo et al., 2014).

Data Management and Analysis

All data were entered twice into the Census and Survey Processing System (CS-Pro), and both datasets were verified for consistency. If inconsistencies were found, the original questionnaire was re-checked to validate the response, and corrective measures were taken. The clean dataset was integrated into STATA and further cleaning processes were conducted by a statistician and analyst. Analyses were completed using STATA 18, and all analyses incorporated sampling weights. Our analyses first assessed frequencies and prevalence estimates for all study variables, including outcome variables. Second, the outcome variables were cross tabulated by independent variables to assess any bivariate relationships using Pearson chi-square tests. Finally, both non-adjusted and adjusted multinomial logistic regressions were conducted to determine the strength of association, controlling for child age, caregiver education, marital status, economic status, ethnicity, place of residence, and number of traumatic events. These covariates were selected based on our previous research with this dataset and sample population (Kovess-Masfety, Keyes, et al., 2021; Sabawoon et al., 2022, 2025).

Results

Table 1 describes the general characteristics and traumatic events. In our sample, more than half were girls (52.24%) and aged 4 to 9 years of age (59.01%). Most caregivers did not attend any school (77.78%), were married and living with their spouse (85.31%), reported belonging to middle and rich economic status (62.41%), and lived in rural areas (72.47%) (Table 1). The Pushtun ethnic group was most common (43.61%) (Table 1). We found that 17.59% of caregivers were exposed to war zones, 7 out of 10 caregivers had experienced any traumatic event and 3 out of 10 were exposed to more than 3 traumatic events. Accidental injury (62.74%), collective violence (39.54%), interpersonal violence (29.47%) and cause/witnessed harm (9.76%) were the most common types of traumatic events, while sexual violence (4.76%) was less commonly reported (Table 1).

Table 1.

Description of Sample’s General Characteristics.

Variables	Unweighted		Weighted*
Variables	Number**	%	Number	%
Children
Child gender
Boys	392	48.76	291.14	47.76
Girls	412	51.24	318.43	52.24
Child age (years)
4 to 9	461	56.84	363.52	59.01
10 to 14	350	43.16	252.5	40.99
Caregivers
Caregiver education
Never attend school	663	81.95	477.92	77.78
Attend any kind of school	146	18.05	136.53	22.22
Marital status
Not married and DSW	87	10.77	90.09	14.69
Married living with spouse	721	89.23	523.11	85.31
Self-reported economic status
Poor	315	39.42	227.56	37.59
Middle and rich	484	60.58	377.78	62.41
Ethnicity
Tajik	228	28.04	179.51	29.09
Pashtun	370	45.51	269.15	43.61
Hazara	105	12.92	82.13	13.31
Uzbek	52	6.4	39.74	6.44
Other	58	7.13	46.63	7.56
Place of residence
Urban	226	27.8	169.91	27.53
Rural	587	72.2	447.25	72.47
Collective violence total
No	481	59.31	372.44	60.46
Yes	330	40.69	243.58	39.54
Collective violence experienced
No	694	85.68	532.98	86.72
Yes	116	14.32	81.61	13.28
Collective violence witnessed
No	511	63.01	394.31	64.01
Yes	300	36.99	221.71	35.99
Caused/witnessed harm total
No	726	89.63	554.47	90.24
Yes	84	10.37	59.94	9.76
Caused harm
No	811	99.88	615.66	99.88
Yes	1	0.12	0.75	0.12
Harm witnessed
No	727	89.75	555.22	90.37
Yes	83	10.25	59.19	9.63
Interpersonal violence total
No	560	69.14	433.86	70.53
Yes	250	30.86	181.32	29.47
Interpersonal violence experienced
No	649	80.12	501.6	81.54
Yes	161	19.88	113.58	18.46
Interpersonal violence witnessed
No	638	78.77	487.02	79.17
Yes	172	21.23	128.16	20.83
Sexual violence total
No	769	94.82	585.69	95.24
Yes	42	5.18	29.29	4.76
Sexual violence experienced
No	791	97.53	600.62	97.66
Yes	20	2.47	14.36	2.34
Sexual violence witnessed
No	784	96.67	596.75	97.04
Yes	27	3.33	18.23	2.96
Accidental injury total
No	291	35.97	228.69	37.26
Yes	518	64.03	385.15	62.74
Accidental injury experienced
No	525	65.06	401.46	65.63
Yes	282	34.94	210.2	34.37
Accidental injury witnessed
No	366	45.24	286.14	46.61
Yes	443	54.76	327.7	53.39
Any event total
No	228	28.22	181.36	29.61
Yes	580	71.78	431.05	70.39
Any event experienced
No	434	54.05	338.02	55.58
Yes	369	45.95	270.14	44.42
Any event witnessed
No	301	37.34	235.48	38.54
Yes	505	62.66	375.59	61.46
Numbers of traumatic events
No traumatic event	233	28.66	186.11	30.16
1 to 3 events	323	39.73	243.22	39.41
4 and more events	257	31.61	187.83	30.43
Exposure to war zone
No exposure	660	81.18	508.59	82.41
Experienced or witnessed	153	18.82	108.57	17.59

Note. DSW = Divorced, separated, or widowed.

Weighted estimation are used to compensate for the over or under sampling of targeted samples.

The number of frequencies are not consistent for different covariates because of missing values.

Tabel 2 depicts the prevalence of probable common mental health problems and diagnoses disaggregated by child gender and age. Internalizing (emotional) only problems were reported for 10.95% of children, while 27.55% had only externalizing (conduct and hyperactivity) problems and 27.10% had both internalizing and externalizing problems. The prevalence of any impairment due to these problems was found to be much lower (8.25%) and 6.53% of children were found to have any mental health diagnosis including impairment. The current study found a statistical difference between child gender and presence of both internalizing and externalizing mental health symptoms: 30.61% of boys had both internalizing and externalizing symptoms compared to 23.30% for girls (p = .002) (Table 2). A significant association was also found between any impairment due to mental health problems and child age: 6.07% of children younger than 10 years of age reported impairment versus 11.17% for those 10 years or older (p = .009).

Table 2.

Outcome Description by Child Gender and Age.

Variables	Mental health problems							Any impairment due to MHP			Any psychiatric diagnosis
	n	Only internal*		Only external^†		Internal and external		n	%	95% CI	n	%	95% CI
	n	%	95% CI	%	95% CI	%	95% CI	n	%	95% CI	n	%	95% CI
Overall Prevalence^§	813	10.95	[8.88, 13.30]	27.55	[24.51, 30.76]	27.1	[24.03, 30.26]	812	8.25	[6.45, 10.36]	812	6.53	[4.92, 8.45]
Gender
Boys	392	11.22	[8.28, 14.77]	30.36	[25.84, 35.17]	30.61	[26.09, 35.44]	392	8.16	[5.65, 11.33]	392	6.89	[4.59, 9.86]
Girls	412	10.92	[8.08, 14.34]	25.24	[21.11, 29.73]	23.30	[19.30, 27.69]	411	8.27	[5.80, 11.37]	411	6.08	[3.97, 8.85]
Child age
4 to 9 years	461	12.15	[9.31, 15.48]	27.55	[23.52, 31.87]	26.68	[22.70, 30.97]	461	6.07	[4.07, 8.66]	461	5.42	[3.54, 7.90]
10 to 14 years	350	9.14	[6.34, 12.66]	27.43	[22.82, 32.42]	27.71	[23.09, 32.72]	349	11.17	[8.07, 14.96]	349	8.02	[5.40, 11.39]

Note. MHP = mental health problems. CI = confidence interval. Values in bold indicate statistically significant difference p ⩽ .05.

Internal = emotional symptoms.

†

External = conduct disorder and hyperactivity symptoms.

The total prevalence of internal prevalence was 38.01%, 95% CI [34.66, 41.44] and the total prevalence of external symptoms was 54.61%, 95% CI [51.11, 58.07].

Table 3 presents the unadjusted logistic regression of child mental health problems disaggregated by child sex and age along with caregivers’ general characteristics and traumatic events. Boys compared to girls were more likely to have externalizing mental health problems and concurrent emotional, conduct and hyperactivity symptoms (RR = 1.71; 95% CI [1.17, 2.51] and RR = 2.06; 95% CI [1.41, 3.02], respectively). Children with poor economic status were more likely to have concurrent emotional, conduct and hyperactivity problems compared to those with middle and rich economic status (RR = 1.76; 95% CI [1.20, 2.58]). Collective violence, cause/witness harm, interpersonal violence, and accidental injury were also found to increase the risk of concurrent emotional, conduct and hyperactivity problems in children.

Table 3.

Unadjusted Multinomial Logistic Regression of Children with Mental Health Symptoms by Child Gender and Age, and Mothers’ General Characteristics and Traumatic Events.

Variables	Only internal			Only external			Internal and external
	95% CI			95% CI			95% CI
	RRR	LL	UL	RRR	LL	UL	RRR	LL	UL
Children
Boys vs. Girls	1.67	1.00	2.78	1.71 **	1.17	2.51	2.06 ***	1.41	3.02
10 to 14 vs. 4 to 9 years	0.75	0.44	1.27	0.91	0.62	1.32	0.99	0.68	1.44
Caregivers
Attend any kind of school vs. never attending	0.56	0.27	1.19	1.18	0.73	1.89	0.87	0.53	1.42
Not married and DSW vs. Married and living with spouse	1.73	0.81	3.70	1.12	0.59	2.13	1.16	0.64	2.13
Poor vs. middle and rich	0.93	0.54	1.57	1.17	0.79	1.73	1.76 **	1.20	2.58
Ethnicity
Tajik	Ref.
Pashtun	1.57	0.85	2.90	1.10	0.70	1.73	1.12	0.72	1.76
Hazara	0.98	0.36	2.67	1.71	0.92	3.15	1.23	0.65	2.30
Uzbek	0.44	0.12	1.66	1.06	0.48	2.36	0.85	0.38	1.88
Other	1.01	0.36	2.84	1.01	0.47	2.18	0.51	0.22	1.17
Rural vs. Urban	0.92	0.52	1.63	0.77	0.51	1.17	0.89	0.58	1.37
Traumatic events
Collective violence total	0.93	0.55	1.58	1.23	0.84	1.81	1.57 *	1.07	2.30
Collective violence experienced	0.48	0.20	1.14	0.97	0.57	1.67	1.39	0.83	2.32
Collective violence witnessed	1.05	0.61	1.79	1.31	0.89	1.95	1.65 *	1.12	2.43
Caused/witnessed harm total	0.81	0.31	2.11	1.95 *	1.03	3.66	2.39 **	1.29	4.41
Harm witnessed^†	0.81	0.31	2.11	1.95 *	1.03	3.66	2.30 **	1.23	4.26
Interpersonal violence total	1.26	0.72	2.21	1.33	0.88	2.02	1.99 ***	1.32	2.98
Interpersonal violence experienced	1.11	0.57	2.15	1.37	0.85	2.22	1.68 *	1.06	2.68
Interpersonal violence witnessed	0.96	0.50	1.85	1.21	0.75	1.94	1.97 **	1.25	3.11
Sexual violence total^§	0.41	0.09	1.90	0.86	0.36	2.01	1.58	0.73	3.44
Accidental injury total	0.88	0.52	1.48	1.19	0.81	1.76	1.64 *	1.10	2.44
Accidental injury experienced	1.34	0.79	2.29	1.15	0.77	1.73	1.67 *	1.13	2.48
Accidental injury witnessed	0.80	0.48	1.32	0.96	0.66	1.40	1.64 *	1.12	2.41
Number of traumatic events vs. no traumatic events
1 to 3 events	1.01	0.56	1.85	1.17	0.74	1.85	1.20	0.75	1.92
4 and more events	0.92	0.47	1.83	1.31	0.80	2.13	1.87 *	1.16	3.03
Exposure to war zone vs. no exposure to war zone
Experienced or witnessed	0.56	0.26	1.21	0.93	0.57	1.52	1.44	0.91	2.25

Note. CI = Confidence interval; RRR = Relative risk ratio; LL = Lower limit; UL = Upper limit; DSW = Divorced, separated, widowed. Values in bold indicate statistically significant results.

.05 ⩾ p > .01. **.01 ⩾ p > .001. ***p ⩽ .001.

†

There is only one respondent who caused harm to others, therefore not reported.

There are few respondents who experienced sexual violence or witnessed sexual violence, therefore, only total sexual violence was reported.

Children whose caregivers witnessed collective violence and witnessed harm were more likely to have concurrent emotional, conduct and hyperactivity problems compared to their counterparts (RR = 1.57; 95% CI [1.07, 2.30] and RR = 2.30; 95% CI [1.23, 4.26], respectively). Furthermore, children whose caregivers experienced interpersonal violence and accidental injury were more likely to have concurrent emotional, conduct and hyperactivity problems compared to children whose caregivers did not experience interpersonal violence and accidental injury (RR = 1.68; 95% CI [1.06, 2.68] and RR = 1.67; 95% CI [1.13, 2.48], respectively). Finally, children whose caregiver had four or more traumatic events were more likely to have concurrent emotional, conduct and hyperactivity problems compared to children whose caregiver did not have any traumatic event exposure (RR = 1.87; 95% CI [1.16, 3.03]; Table 3).

Table 4 illustrates the adjusted model of children with mental health symptoms by caregivers’ traumatic event exposure. The model revealed that children whose caregiver witnessed interpersonal violence were more likely to have concurrent emotional, conduct and hyperactivity symptoms compared to those whose caregiver did not witness interpersonal violence (RR = 1.81; 95% CI [1.04, 3.16]). Children whose caregivers had any type of traumatic event exposure were more likely to have concurrent emotional, conduct and hyperactivity symptoms compared to those whose caregiver did not have any traumatic event exposure (RR = 1.86; 95% CI [1.11, 3.11]). Finally, children whose caregiver had more than three traumatic events were more likely to have concurrent emotional, conduct and hyperactivity symptoms (RR = 1.75; 95% CI [1.05, 2.91]; Table 4).

Table 4.

Adjusted Multinomial Logistic Regression of Children Mental Health Problems by Female Care Givers’ Type of Traumatic Events.

Variables	Only internal			Only external			Internal and external
	95% CI			95% CI			95% CI
	RRR	LL	UL	RRR	LL	UL	RRR	LL	UL
Traumatic Events
Collective violence total	1.09	0.51	2.34	0.90	0.49	1.65	1.04	0.56	1.93
Collective violence experienced	0.55	0.21	1.45	0.79	0.42	1.47	0.93	0.51	1.70
Collective violence witnessed	1.36	0.63	2.92	1.11	0.60	2.03	1.16	0.64	2.11
Caused/witnessed harm total	0.81	0.27	2.37	1.70	0.82	3.55	1.76	0.87	3.55
Harm witnessed	0.81	0.27	2.37	1.71	0.82	3.55	1.70	0.84	3.43
Interpersonal violence total	1.74	0.83	3.63	1.20	0.67	2.13	1.64	0.97	2.79
Interpersonal violence experienced	1.27	0.56	2.84	1.22	0.68	2.19	1.13	0.66	1.93
Interpersonal violence witnessed	1.10	0.47	2.55	1.05	0.58	1.91	1.81 *	1.04	3.16
Sexual violence total	0.45	0.10	2.14	1.06	0.42	2.70	1.34	0.58	3.09
Accidental injury total	0.90	0.35	2.36	1.03	0.49	2.17	1.87	0.81	4.34
Accidental injury experienced	1.72	0.88	3.36	0.88	0.54	1.44	1.34	0.82	2.18
Accidental injury witnessed	0.72	0.33	1.55	0.72	0.40	1.32	1.56	0.81	2.99
Any event total	0.84	0.43	1.66	1.24	0.74	2.08	1.86 *	1.11	3.11
Any event experienced	1.24	0.62	2.48	0.92	0.55	1.54	1.05	0.62	1.78
Any event witnessed	0.86	0.34	2.22	0.93	0.46	1.88	2.16	0.91	5.14
Number of traumatic events vs. no traumatic events
1 to 3 events	1.07	0.58	1.97	1.08	0.67	1.75	1.16	0.70	1.91
4 and more events	0.83	0.42	1.63	1.17	0.70	1.95	1.75 *	1.05	2.91
Exposure to war zone vs. no exposure to war zone
Experienced or witnessed	0.60	0.24	1.49	0.75	0.41	1.36	1.00	0.56	1.79

Note. CI = Confidence interval; RRR = Relative risk ratio; LL = Lower limit; UL = Upper limit. The adjusted model controlled for child age, caregiver education, marital status, economic status, ethnicity, place of residence, and number of traumatic events. Values in bold indicate statistically significant results.

p ⩽ .05.

Table 5 presents the adjusted logistic model stratified by child gender assessing the strength of association of caregivers’ traumatic events. Boys whose caregivers were married and lived with their spouses were less likely to have only emotional symptoms compared to boys whose caregivers were unmarried, divorced or widowed (RR = 0.30; 95% CI [0.10, 0.94]). Boys whose caregivers belong to middle and rich economic group were less likely to have concurrent emotional, conduct and hyperactivity symptoms comparing to those boys whose caregivers belonged to poor economic group (RR = 0.54; 95% CI [0.29, 0.99]). Boys whose caregiver witnessed interpersonal violence were more likely to have concurrent emotional, conduct and hyperactivity symptoms (RR = 3.15; 95% CI [1.33, 7.43]; Table 5). Girls whose caregivers experienced accidental injury were more likely to have only emotional symptom compared to girls whose caregivers had no experience of accidental injuries (RR = 3.82; 95% CI [1.41, 10.32]; Table 5).

Table 5.

Adjusted Multinomial Logistic Regression of Children Mental Health Problems by Female Care Givers’ Traumatic Events Stratified by Children Gender.

Variables	Boys									Girls
	Only internal			Only external			Internal and external			Only internal			Only external			Internal and external
	95% CI			95% CI			95% CI			95% CI			95% CI			95% CI
	RRR	LL	UL	RRR	LL	UL	RRR	LL	UL	RRR	LL	UL	RRR	LL	UL	RRR	LL	UL
Traumatic events
Collective violence total	1.63	0.48	5.47	0.68	0.29	1.62	0.87	0.37	2.07	0.78	0.29	2.12	1.11	0.48	2.53	1.26	0.55	2.87
Collective violence experienced	0.37	0.08	1.69	1.05	0.42	2.63	1.04	0.42	2.56	0.90	0.27	2.97	0.57	0.23	1.42	0.83	0.36	1.93
Collective violence witnessed	2.10	0.65	6.82	0.90	0.37	2.17	1.08	0.46	2.53	0.94	0.31	2.79	1.33	0.58	3.06	1.35	0.60	3.06
Caused/witnessed harm total	0.54	0.11	2.80	1.52	0.51	4.56	2.46	0.87	6.96	1.45	0.34	6.15	1.98	0.73	5.40	1.17	0.38	3.59
Harm witnessed	0.54	0.11	2.76	1.52	0.51	4.53	2.30	0.82	6.47	1.45	0.34	6.15	1.98	0.73	5.40	1.17	0.38	3.59
Interpersonal violence total	1.43	0.51	4.01	0.95	0.39	2.31	2.05	0.92	4.58	2.15	0.69	6.64	1.46	0.66	3.26	1.21	0.59	2.48
Interpersonal violence experienced	0.62	0.18	2.11	0.95	0.39	2.35	1.01	0.45	2.26	2.59	0.83	8.05	1.39	0.63	3.07	1.17	0.56	2.48
Interpersonal violence witnessed	1.75	0.53	5.80	1.37	0.54	3.44	3.15 **	1.33	7.43	0.78	0.21	2.95	0.98	0.42	2.33	1.07	0.49	2.36
Sexual violence total	0.87	0.15	5.04	0.76	0.19	3.08	1.24	0.37	4.23	0.00	0.00	0.00	1.34	0.41	4.35	1.42	0.44	4.56
Accidental injury total	0.78	0.20	2.96	1.23	0.45	3.36	1.56	0.53	4.62	1.12	0.27	4.64	0.87	0.29	2.58	2.62	0.70	9.81
Accidental injury experienced	0.88	0.33	2.34	0.56	0.27	1.16	1.21	0.60	2.43	3.82 **	1.41	10.32	1.28	0.64	2.57	1.41	0.71	2.80
Accidental injury witnessed	0.96	0.32	2.87	1.01	0.44	2.35	2.23	0.89	5.59	0.59	0.19	1.78	0.52	0.22	1.23	1.04	0.43	2.54
Any event total	1.43	0.52	3.93	1.58	0.71	3.47	1.82	0.85	3.89	0.53	0.19	1.44	0.94	0.45	1.96	2.13	0.96	4.73
Any event experienced	0.68	0.25	1.83	0.68	0.32	1.42	0.90	0.42	1.92	2.55	0.87	7.46	1.13	0.54	2.35	1.17	0.56	2.46
Any event witnessed	0.96	0.22	4.11	0.99	0.35	2.80	2.13	0.61	7.43	0.91	0.26	3.24	0.87	0.33	2.27	2.28	0.73	7.18
Number of traumatic events vs. no traumatic events
1 to 3 events	0.82	0.32	2.10	0.95	0.46	1.95	0.80	0.39	1.65	1.49	0.68	3.28	1.00	0.51	1.97	1.72	0.80	3.69
4 and more events	1.43	0.52	3.95	1.49	0.67	3.27	1.74	0.81	3.75	0.51	0.19	1.38	0.87	0.42	1.80	1.90	0.87	4.12
Exposure to war zone vs. no exposure to war zone
Experienced or witnessed	0.65	0.20	2.14	0.69	0.30	1.61	1.05	0.47	2.37	0.60	0.14	2.58	0.83	0.35	1.93	1.08	0.45	2.57

p ⩽ .01.

Discussion

Mental health problems among children in Afghanistan were common, with almost two-thirds of children reporting any type of mental health problems. The present study demonstrated that these problems were associated with traumatic event experiences in their caregivers. Indeed, we found robust associations between parental reports of interpersonal violence exposure with offspring emotional, conduct and hyperactivity problems, and the risk of child mental health problems were highest in parents reporting three or more traumatic events. Taken together, these results underscore that familial environment and exposure are important sources of risk for child mental health problems. In countries like Afghanistan, with significant exposure to trauma across the life course, ensuring that mental health care is extended across the family unit is critical.

Our results are consistent with a larger body of research demonstrating that parental experiences of and response to trauma, can elicit a range of reactions in children that may be indicative of the development of mental health problems and psychiatric distress. These results align with previous systematic reviews and meta-analyses that document the influence of trauma exposure on familial health and mental health (Dashorst et al., 2019; Leen-Feldner et al., 2013). Research on families exposed to natural disasters, war, and violence has demonstrated that parental traumatic event exposure is among the most salient predictors of youth mental health response (Green et al., 1991; Plant et al., 2018; Pynoos et al., 1987; Sack et al., 1995). There are several different mechanisms with empirical support that underly the validity of these associations. Parents exposed to trauma, especially those exposed to repeated events as we observed in the present study, may not have the emotional capacity to support emotional distress in their children. A substantial body of literature has documented how trauma affects families intergenerationally (Yehuda & Lehrner, 2018); parental trauma exposure influences parenting practices, can disrupt attachment relationships (Kostova & Matanova, 2024), and affect how children learn emotion regulation (Kumar et al., 2020). Available animal evidence suggests that there may be biological underpinnings of intergenerational trauma transmission through epigenetic pathways as well (Yehuda & Lehrner, 2018). Further, children may exhibit fear and separation anxiety in the wake of a parent who experiences threat to physical integrity, eliciting increased psychological distress (Wolmer et al., 2000). Studies have shown that parents exposed to trauma may demonstrate more harsh parenting, aggression, and higher levels of parental discipline, which is suggested to mediate child conduct problems and other externalizing behaviors (Collishaw et al., 2007; Cort et al., 2011). In addition, violence leads to violence: Afghan women who experienced intimate partner or other violence from a family member were more likely to use violence against their own children (Ndungu et al., 2021).

Additional pathways include how trauma shapes the mental health of parents. Indeed, trauma is a causal risk factor for numerous mental health disorders, including PTSD, depression, anxiety and substance use disorder (Fernandes & Osório, 2015; Maël & Daniel, 2022; Wang et al., 2023). Children of parents experiencing psychiatric disorders are at increased risk of developing mental health problems, both through the mechanisms stated above as well as independent mechanisms. Parental psychiatric disorders are thus a key mechanism through which parental trauma may impact children, and future studies with robust designs for testing mediation are an important additional research area.

In unadjusted analyses, a range of traumatic event exposures were associated with child mental health outcomes, but upon adjustment, our results indicate that exposure to interpersonal violence was particularly salient. The pattern of risk factors for girls and boys varied. While caregivers’ exposure to accidental injury was significant for internalizing mental health problems in girls, caregivers’ exposure to interpersonal violence significantly increased the risk of having both internal and external mental health problems among boys. The large sample size of the present study provided ample statistical opportunity to control for a range of potential confounders, allowing the specific associations through interpersonal violence to emerge. The identification of interpersonal violence as a risk factor among boys is consistent with decades of literature that exposure to factors such as violence within the family is a strong risk factor for child mental health problems (Doroudchi et al., 2023; McCloskey et al., 1995; McFarlane et al., 2014). These results are also consistent with previous research conducted within the context of Afghanistan. For instance, Panter-Brick et al. demonstrated that, among children aged 11 to 16, family violence emerged as a strong risk factor for the persistence of psychiatric disorders across 1 year (Panter-Brick et al., 2011). Boys’ and girls’ mental health problems differ, as has been reported in most countries: boys tend to have more externalized problems and girls more internalized problems. This gender gap may be influenced by sociopolitical environments. For instance, access to education (i.e. school) has been found to buffer the impact of trauma on children equally for boys and girls, but girls often have less access to school than boys (Kovess-Masfety et al., 2023; Kovess-Masfety, Woodward, et al., 2021). Future research may consider studying girls and boys separately as gender-based discrimination is widespread in Afghanistan. Engaging qualitative methodologies could also help clarify how boys and girls in Afghanistan conceptualize and experience traumatic events differently in their families and communities.

Finally, we identified demographic characteristics of children and families who are particularly at risk of increased mental health problems. We found that children in families where parents were in low-income group compared with the middle- and high-income groups were at increased risk. This indicates that families experiencing financial distress may be a particularly vulnerable group (Takeuchi et al., 1991). Providing additional support for mental health for vulnerable families through access to affordable mental health care is challenging in settings that are already resource compromised; however, it is in these areas that mental health services are most in need. As health systems are strengthened in Afghanistan (Alemi et al., 2023), identifying and supporting areas with vulnerable families will yield the most population mental health benefits.

Limitations of the study should be noted. The mother/child dyad sample may slightly differ from the general Afghan child population since female caregiver respondents reported more problems than male caregivers (Kovess-Masfety et al., 2023). In addition, we excluded large households from our analyses. Despite this decision, we did not find any statistical difference by comparing the four child mental health categories between household size below 10 versus equal/above 10 (p = .481). The results presented here may be sensitive to reporting effects as the caregiver was asked to report on both exposure and outcome measures. Caregivers may overreport distress in their child due to heightened sensitivity. Alternatively, caregivers may underreport their personal trauma exposure and/or mental health outcomes in the child due to denial, stigma, or minimization. Future studies with data from multiple reporters (parent, child, teacher) that could be triangulated may improve measurement variance. We note that additional variables that may be on the causal pathway between traumatic events and child psychopathology (e.g. parental psychopathology) were not adjusted for in our analyses as they are likely mediators; future studies explicitly testing mediation pathways are warranted.

The study was cross-sectional thus the temporality of the relationships between child mental health problems and parental trauma cannot be established. Regardless, these results are consistent with longitudinal research, thus we anticipate that reverse causation is unlikely to explain the results. The current study found some inconsistencies between non-adjusted and adjusted regression models. For instance, collective violence, cause/witness harm and accidental injury were found to be associated with childhood mental health problems but when controlling for independent factors the association disappeared (Tables 3 and 4). We do not have detailed information on the traumatic events experienced, in terms of severity or frequency. We anticipate that associations would be stronger among those experiencing the most serious events and those with prolonged and repeated exposures. Child/parent pairs were included from multiple families within the household, and it could be assumed that the family is a coherent unit and share the same environment and events. Finally, these data were collected in 2017, prior to the political instability and increased financial distress that arose in 2021 when the governing political party changed. There was substantial displacement of the Afghan population after August 2021, and those who left the country may have elevated mental health problems due to stress associated with migration. We anticipate that mental health problems among those who remained in the Afghan population may have escalated since this time as well (Silove & Ventevogel, 2022), thus continued surveillance of the Afghan population is critical moving forward.

In conclusion, given the scope of mental health problems in the Afghan community, these results underscore that the family unit is critical when developing intervention strategies. Caregivers experiencing high levels of trauma exposure, and in particular interpersonal violence exposure, have a heightened risk of mental health problems in offspring (Ndungu et al., 2021). Prevention programs have been built and implemented in Afghanistan, notably a school-based peace education program aiming to reduce violence on children at the family- and school-level (Corboz et al., 2019). A recent review of four decades of interventions in Afghanistan insisted that programs should be culturally appropriate and rooted in faith and family relationships (Alemi et al., 2023). However, the review also noted that family-related conflicts may contribute to mental health problems and family members may act as gatekeepers to healthcare access. In response to these barriers, Alemi et al. (2023) advocated for using a community-based approach that incorporates capacity building into interventions to help families better manage stress. Such community-based approaches should ensure that specialized professional expertise and local knowledge and cultural competency is provided, especially given the complex political context and continued armed conflicts in Afghanistan (Cherepanov, 2021; Hassan et al., 2016). In addition to these community-level intervention tactics, mental health services need to be maintained at a logical point of access, such as primary health centers and general hospitals, within Afghanistan. Given that almost two-thirds of children experienced elevated mental health problems in Afghanistan, these data underscore the need for improved, multidimensional, and culturally relevant mental health care approaches.

Footnotes

Acknowledgements

We thank the participants who took part in this study and shared their information. We acknowledge that the implementation of this research would not be possible if we did not receive support from the Afghanistan Ministry of Public Health, the Conseil Santé and the Governance Institute of Afghanistan. We thank the excellent team of data collectors and provincial team supervisors, the data management office as well as individuals who supported with IT, administrative, and logistic details for the study. Furthermore, we also thank the Department of Epidemiology and Population & Family Health of Mailman School of Public Health, and LPPS, University of Paris for providing opportunities to further analyze the data and its dissemination.

ORCID iDs

Sabawoon Ajmal

Emma L. Sexton

Viviane Kovess-Masfety

Author Contributions

Writing—Original Draft, Sabawoon Ajmal, Katherine M. Keyes, Sabrina Hermosilla, Emma L. Sexton, Elie Karam and Viviane Kovess-Masfety. Analysis—Sabawoon Ajmal and Viviane Kovess-Masfety. All authors read and approved the final manuscript.

Ethical Considerations

The project was approved by the Afghanistan Institutional Review Board, National Public Health Institute, Ministry of Public health the 12/31/2016: IRB No. 335541.

Consent to Participate

All participants, or the parent and/or legal guardian of subjects under 18 years old, provided consent for participation. All methods were performed in accordance with the ethical standards as outlined in the Declaration of Helsinki and its later amendments or comparable ethical standards.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This survey was supported by the European Union (EU) (Grant number is EuropeAid/137–728/ DH/SER/AF/).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The datasets generated and/or analyzed in the current study are not publicly available due to the mandatory request of authorizations from the funder and the Afghan Ministry of Public Health; however, reasonable data use requests can be submitted to the corresponding author for consideration.*

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