Childhood trauma exposure while growing up during war and PTSD symptoms in adulthood

Abstract

Background: Exposure to war in childhood and adolescence can have enduring effects on mental health, particularly posttraumatic stress disorder (PTSD). The long-term role of both wartime and postwar traumatic experiences, and the moderating influence of gender, remain insufficiently understood. Purpose: This study examined the contribution of potentially traumatic events (PTEs) during and after the Croatian Homeland War (1991–1995) to PTSD symptoms in adulthood, with attention to gender differences. Research Design: A cross-sectional, retrospective design was used to link childhood and adolescent trauma exposure to adult PTSD symptoms. Study Sample: Participants were 298 adults (197 women, 101 men) who were 3–18 years old during the war and currently living in three war-affected Croatian counties. Data Collection and/or Analysis: Self-report measures included sociodemographic characteristics, 26 PTEs experienced during or after the war, and PTSD symptoms (PCL-5). Analyses included correlations, multilevel linear mixed models, and multigroup structural equation modeling to test predictive effects and gender moderation. Results: Thirteen wartime and ten postwar PTEs were significantly associated with PTSD symptoms. Wartime exposure explained 11.7% of the variance, while combined wartime and postwar exposure explained 24.5%. Key predictors were sexual or nonsexual assault by a family member or known person and deprivation of food or water. Women reported more severe PTSD symptoms and showed greater vulnerability across contexts. Conclusions: Interpersonal violence and deprivation, rather than combat-related experiences, predicted adult PTSD. Gender-sensitive interventions that ensure safety, address deprivation, and strengthen caregiving are essential for supporting the long-term wellbeing of war-affected children.

Keywords

Children and adolescents gender differences PTSD symptoms traumatic events during and after war

Introduction

War exemplifies the destructive potential of conflicts for humans by subjecting individuals to a range of distressing and traumatic experiences, including exposure to direct violence, loss of loved ones, displacement, and destruction of homes and communities. Armed conflict is also a significant driver of food and water insecurity, often used as a weapon to weaken opposing populations (FAO et al., 2017, 2021). Strategies such as polluting wells and restricting access to essential resources have been employed historically and continue into modern conflicts (Garry & Checchi, 2020; Riedel, 2004). These tactics not only exacerbate physical deprivation but also contribute to negative mental health outcomes (Garry & Checchi, 2020; Wutich et al., 2020). Traumatic experiences vary widely in their nature, severity, and duration, with different types of trauma potentially having distinct psychological consequences. Broadly, trauma can be categorized as interpersonal or non-interpersonal, violent or non-violent, and acute or chronic. War-related trauma is often chronic, interpersonal, and violent, involving direct exposure to combat, forced displacement, or assault. In contrast, non-war-related trauma may include natural disasters, economic hardship, or sudden loss of a loved one, which can be non-interpersonal and non-violent. Accordingly, research suggests that trauma resulting from natural disasters tends to have a less severe impact on mental health compared to trauma caused by man-made disasters (Bromet et al., 2017; Galea et al., 2015). The detrimental effects of war on the mental health of civilian populations are well documented (Bogic et al., 2015; Carpiniello, 2023; Lim et al., 2022; Priebe et al., 2013). In this context, children and adolescents are particularly vulnerable (e.g. Calam, 2017). In armed conflicts, they are often unable to fulfill their basic needs, lack psychological support, and lack educational opportunities and other resources that promote psychosocial resilience (Frounfelker et al., 2019). However, research suggests that children might struggle to effectively process and coherently respond to traumatic events (van der Kolk, 2005) and that their developing brains could be more susceptible to adverse effects of prolonged stress (Samara et al., 2020). This prolonged exposure to stress in childhood can change children’s natural stress response that can become maladaptive, leading to toxic stress that disrupts the interaction between neuroendocrine and immune systems, leading to long-term impacts on brain development, immune function, and emotional well-being (Bucci et al., 2016), what could contribute to psychiatric disorders and mental health difficulties in adulthood (Samara et al., 2020). Accordingly, traumatic events experienced during childhood seem to be linked to a greater level of psychological distress than trauma experienced in adulthood. Therefore, it is not surprising that, along with symptoms of depression and anxiety, PTSD symptoms are most often reported as a negative mental health consequence later in life due to children’s and adolescents’ exposure to war events. While these symptoms diminish over time, for some children and adolescents, the symptoms persist and extend into adulthood (Llabre et al., 2015; Sack et al., 1999; Strauss et al., 2011).

Although experiencing only one traumatic event can cause PTSD symptoms and mental health problems (Karam et al., 2014), experiencing traumatic incidents over a period of time seems to be a significant risk for the persistence of posttraumatic stress and associated psychological disorders (McFarlane & Van Hooff, 2009). At the same time, it was reported that most trauma survivors typically do not undergo only one traumatic event; instead, they live through multiple instances of traumatic exposure (Kessler, 2000). Studies have shown the negative effect of cumulative traumatic experiences on mental health—a greater extent of exposure to trauma was linked to a greater number of PTSD symptoms (e.g. Briere et al., 2016; Cloitre et al., 2009).

Studies consistently show that women are more likely to develop PTSD, even though men tend to report a greater incidence of potentially traumatic events (Olff et al., 2007; Stein et al., 2000). Interestingly, women face an increased risk of PTSD when violent assaults are followed by nonviolent traumas, a pattern not observed in men (Breslau & Anthony, 2007). These gender differences seem to emerge during adolescence (Alisic et al., 2014; Garza & Jovanovic, 2017), as confirmed by studies conducted on adolescents affected by war in the Gaza area (El-Khodary et al., 2020). Furthermore, while both adolescent males and females are at risk for mental health issues when directly exposed to violence, females are more susceptible to the effects of indirect violence, such as hearing about or witnessing violence against people they know (Javdani et al., 2014). Similarly, women who endure wartime stress, whether as civilians or combatants, often face a greater mental health burden compared to men, largely due to their roles in protecting families and their involvement in military activities with less support and preparation (Young et al., 2022).

In the context of this research, it is important to mention the Homeland War in Croatia, which was an armed conflict that took place between 1991 and 1995 following the breakup of Yugoslavia. The conflict led to widespread displacement of populations, significant loss of life, massive traumatization, and destruction of infrastructure (Benčić, 2017). Studies on civilian populations have shown increased levels of stress, depression, anxiety, and PTSD in children and adolescents (Ajduković & Ajduković, 1998; Kuterovac-Jagodić, 2003). Symptoms were more evident in adolescent females than in adolescent males (Ajduković, 1998). Kuterovac-Jagodić (2003) showed that the abovementioned symptoms in children and adolescents decreased over time, although for some of them, symptoms significantly increased even 30 months after the war ended. In adults, Ajduković et al. (2007) reported that living in a postwar community can have a detrimental effect on mental health: more than one-third (36%) of the participants met the criteria for one or more mental health disorders. Priebe et al. (2013) reported that approximately 8 years after the war, general psychopathological symptoms, specifically PTSD symptoms, were more common among people living in war-impacted communities in the Balkans than among refugees from the same area who found refuge in West European countries. Specific war-related experiences as well as potentially traumatic events (PTEs) following the war were linked to increased levels of overall psychological symptoms and PTSD symptoms. In their study conducted in southern Croatia, Munjiza et al. (2017) discovered that exposure to severe war-related trauma is a risk factor for interpersonal dysfunction even 15 years after individuals experience armed conflict.

Overall, there is a lack of research investigating the long-lasting effects of exposure to war-related traumatization during childhood or adolescence on mental health in adulthood, also taking into account the possible effects of surviving other PTEs in the aftermath of war. Furthermore, although there is growing awareness of gender differences in PTSD, research focusing on possible long-term gender effects from childhood and adolescence into adulthood is still scarce.

Our study aims to investigate the lasting effects of childhood or adolescent trauma exposure during and after war, focusing on how these experiences contribute to the development of PTSD symptoms in adulthood. Specifically, we seek to explore whether early war-related trauma and postwar exposure are significant predictors of PTSD, and how gender may moderate these relationships. Exploring the causal effects are out of the scope of the present paper as we examined associations between past traumatic experiences and current PSTD symptom severity.

Therefore, our research questions are as follows: 1) Are potentially traumatic events (PTEs) during the war in childhood or adolescence predictive of the development of PTSD symptoms in adulthood? 2) Does accounting for PTE during the postwar period change the possible effect of earlier trauma exposure during the wartime period? 3) Does gender moderate the relationships among early war-related trauma experiences, postwar trauma exposure, and the development of PTSD symptoms in adulthood?

Method

Participants and procedure

The data for the present study were collected as part of a larger project involving adolescents and their parents from three Croatian counties that have been heavily affected by the Homeland War (1991–1995). The participants were recruited through their children attending the randomly selected schools and classes. In a two-stage cluster sampling, the first stage included randomly selected high schools, and in the second stage, first-grade classes in each schools were randomly selected. The approval of the Ethics Committee Faculty of Law of the University of Zagreb and the approval of Ministry of Science and Education of the Republic of Croatia were obtained for conducting the research.

For the purposes of this study, only the data of the parents who have been children or adolescents during the war were used. A total of 821 parents participated in the study, 523 of whom were removed from the dataset due to inconsistent responses, excessive missing data or being over 18 years old during the war. The final sample consisted of 298 parents aged 33–44 years (M = 40.7; SD = 2.65), among which 197 women aged 33–44 years (M = 40.5; SD = 2.64) and 101 men aged 34–44 years (M = 41.2; SD = 2.61) constituted 66% and 34% of the sample, respectively. Their age during the war was 3–18 years (M = 14.75; SD = 2.646). In total, 162 participants were pairs of mothers and fathers (81 pairs), and 136 participants were without a pair.

The date gathering was done from March to June 2022. One of the included counties has been severely affected by the major earthquake in December 2020.

Measures

Sociodemographic measures

The questionnaire for collecting sociodemographic data was developed for the purpose of this study and included information on age, gender, the size of the place of residence, education level, work and marital status, and assessment of the family’s financial status.

Experienced traumatic and stressful events during and after the war

The scale of potentially traumatic events was created for the purpose of this research following the Life Stressor Checklist-Revised (LSC-R) approach (Wolfe et al., 1997) and was adapted to the context of the participants’ lives. Hence, following the approach of Ajduković et al. (2007), distinctive content relevant for civilian victims of the conflict in the former Yugoslavia region was included. The scale included 26 potentially traumatic events (PTEs) that individuals might have experienced during or after the war, starting from the war’s conclusion in 1995 to the present. Nine items were adapted from the original LSC-R scale, while 17 additional items related to war experiences were included. Among these, seven items were directly associated with wartime events, while the remaining ten items encompassed events commonly encountered in war but also experienced in other life situations (item example: “Did you experience combat?”, “Did you survive shelling?”). The individual PTE score was calculated as the frequency of endorsed items., i.e., of different modalities of trauma exposure.

PTSD symptoms

The PCL–5 is a self-report instrument consisting of 20 items that measures the presence and severity of PTSD symptoms in the previous month according to DSM–5 criteria (Weathers et al., 2013). Participants report the intensity of specific symptoms (e.g., “Recurrent, disturbing dreams about a stressful experience”) by rating each item on a 5-point Likert scale ranging from 0 (“Not at all”) to 4 (“Extremely”). The total score (range 0 to 80) indicates the overall severity of PTSD symptoms. Current research suggests a cutoff score ranging from 31–33 is indicative of a PTSD diagnosis (Bovin et al., 2016). Considering the extended passage of time, the disruptive impact of symptoms on daily life, and the absence of a clinical sample in the study, we opted to utilize a cutoff of 31 in this study.

Data analysis

All analyses were performed using R v4.2.1 (R Core Team, 2022). First, descriptive statistics for sociodemographic characteristics and PTSD symptoms and the frequencies of PTEs experienced were calculated. The significance of the bivariate correlations between specific PTEs experienced during and after the war and the severity of PTSD symptoms was explored using the Pearson correlation coefficient. To determine the possibility of PTEs potentially traumatic experiences during and after the war to predict PTSD symptoms in adulthood, a multilevel approach in which family status was used as the clusterization variable was used. This was necessary due to the potential nesting within the families that results in the within-family correlations, which was supported by the size of the intraclass correlations (ICC) in the analyses. All linear mixed models were constructed using the nlme package. Within the models, Nakagawa conditional and marginal R² values were calculated using the r2_nakagawa function from the performance package. Marginal R² considers only the variance of fixed effects, and conditional R² accounts for both fixed and random effects. The criterion variable was the number of PTSD symptoms and models included initial intercept only model, the model with gender as a confounding variable, the model with war related PTEs and the final model with post-war PTEs. The moderation effect of participant gender was analyzed using multigroup SEM with a regression model from the multilevel analysis using the lavaan package. The predictor variables included war related PTEs and post-war PTEs and the criterion variable was the number of PTSD symptoms. The difference in R² coefficients was calculated using Fisher’s r-to-z transformation. This approach was used because it allows for simultaneous model and paths estimation, thus reducing issues related to multiple comparisons. It also allows for the calculation and the comparison of the coefficient of determination (R²) for men and women, unlike the standard regression with the interaction terms.

It should also be noted that in our primary regression models, gender was treated as a covariate to control for its potential confounding effects on the relationship between trauma exposure and PTSD symptoms. However, to assess whether gender moderates these relationships, we used a multigroup SEM approach. This distinction ensures that our results address both general gender-related differences in PTSD risk and potential interaction effects in trauma responses.

Results

Participants’ sociodemographic characteristics

The majority of participants were residents of small communities, with 80.5% residing in villages or small towns. Furthermore, a substantial 90.3% of respondents were either married or engaged in a stable partnership. The majority of participants had a secondary level of education (67.8%), were employed (83.2%), and assessed their material conditions as average (69.5%).

Severity of the symptoms of PSTD

The descriptive analysis of PTSD symptoms revealed that, on average, the participants had relatively low symptom scores (M = 13.2; SD = 13.03), with a positively skewed distribution (skewness = 1.20). The analysis revealed that women had more PTSD symptoms (M = 15.2; SD = 14.04) than men did (M = 9.2; SD = 9.94; t = 4.26, p < .001).

Regarding the indication of possible PTSD diagnosis, 33 participants (11.1%) scored above the cutoff of 31. There were 5 male participants and 28 female participants, and this difference was statistically significant (Fisher’s exact p = .018).

Prevalence of potentially traumatic events

The results in Table 1 show that the adults in our sample who were children or adolescents during the war in Croatia (1991–1995) most often experienced shelling, bombing and exile as PTEs during the war. Among the stressful events they experienced after the war, the most common were the sudden death of a close person due to natural causes and the experience of a natural disaster, which was expected considering that there was a severe earthquake in one of the counties included in the study in December 2020 (Table 1).

Table 1.

Percentages of participants who experienced potentially traumatic events and correlations with PTSD symptoms (N = 298).

Event	% Participants who experienced PTE		Correlation with PTSD symptoms
Event	During war	After war	During war	After war
Survived a serious accident, fire or explosion	14.4	12.1	0.00	0.16**
Experienced a natural disaster	2.7	21.5	0.10	0.18**
Experienced a nonsexual attack by a family member or someone you knew	2.3	5.4	0.22***	0.28***
Experienced a nonsexual attack by an unknown person	4.0	6.4	0.15*	0.00
Experienced a sexual assault by a family member or someone you knew	0.3	0.7	0.19***	0.15**
Experienced a sexual assault by an unknown person	1.0	0.7	0.20***	0.20***
Stayed in prison	0.0	0.3	X	−0.03
Survived a life-threatening disease	0.0	5.4	X	0.10
Sudden death of a close person due to natural causes	14.1	52.3	0.17**	0.15**
Prolonged hunger or lack of water	6.0	2.7	0.12*	0.16**
Being sick and could not be treated	1.0	0.7	0.05	0.18**
Being without shelter (during shelling/bombing or fighting)	11.1	–	0.10	–
Flight under threat	19.5	–	0.04	–
Experienced combat	0.0	–	X	–
Survived shelling	60.1	–	0.05	–
Survived bombing	52.3	–	0.12*	–
Experienced exile/refugee	45.6	–	0.17**	–
Lived under siege	9.4	-	0.06	–
Serious injury	1.0	2.3	−0.07	0.00
Witnessed abuse, murder or a violent death of a one or more people	5.0	1.7	0.11	0.03
Found out about a murder or a violent death of a close person	24.2	3.4	0.18**	0.07
Found out about a disappearance of a close person	13.8	1.0	0.20***	−0.09
Exposed to torture (physical or mental suffering)	1.0	1.3	0.17**	0.17**
Being lost, not knowing where you are	4.0	0.7	0.15*	0.01
Kidnapped or taken away	0.0	0.0	X	–
Experienced any other threatening situation or felt life threat	11.7	5.0	0.17**	0.20***

“–”: variable not measured; “X”: no participants reported experiencing specific PTEs; *p < .05; **p < .01; ***p < .001.

The results show that 76.8% of the participants experienced more than one kind of PTE during the war, with the highest number of modalities during the war being 17. The number of modalities after the war is more skewed, with approximately 2/3 of participants experiencing more than one modality (the highest number is 10). On average, our participants experienced more PTE modalities during the wartime period than during the postwar period. There were no differences between females and males regarding PTEs during and after the war.

Preliminary correlation analyses

Based on the results from Table 1, out of a total of 26 rated events, 13 of those that were experienced during the war and 10 that were experienced after the war were significantly related to the severity of PTSD symptoms. Experienced nonsexual assault by a family member or someone known, sexual assault by a family member or someone known, sexual assault by an unknown person, sudden death of a close person due to natural causes, prolonged hunger or lack of water, and torture were events that were positively correlated with PTSD symptoms for both periods—during and after the war.

Prediction of PTSD symptoms due to traumatic events during and after the war

To predict trauma exposure in children and adolescents during the war and in the aftermath of the war for PTSD symptoms in adulthood, a multilevel approach was used. Although it can be expected that the participants experienced PTEs during the war without the cluster effect, at the time of reporting the PTSD symptoms, it can be expected that these observations were not independent, i.e., the cluster effect due to family membership is likely. Therefore, the family was used as the clustering variable.

Due to the large number of predictors compared to the number of participants, only those predictors whose bivariate correlations with PTSD symptoms proved to be statistically significant were included in the analysis. The inclusion of all predictors in the regression model would lead to excessive number of predictors for the model (41+gender) thus leaving the participants to predictors ratio on 7.1:1. To obtain interpretable results, it was necessary to reduce the number of predictors. The results are shown in Table 2. and only the two final models are shown in the table due to brevity.

Table 2.

Results from a linear mixed model for the prediction of PTSD symptoms.

Variable	DW		DW + AW
Variable	B [95%CI]	p	B [95%CI]	p
(Intercept)	16.49 [12.85, 20.13]	0.000	14.96 [11.06, 18.85]	0.000
Gender (M > F)	−4.46 [−6.61, −2.31]	0.000	−4.45 [−6.62, −2.29]	0.000
DW: Experienced a nonsexual attack by a family member or someone you knew	13.58 [1.92, 25.25]	0.027	7.59 [−5.04, 20.23]	0.254
DW: Experienced a nonsexual attack by an unknown person	0.73 [−8.42, 9.88]	0.877	4.55 [−4.65, 13.76]	0.347
DW: Experienced a sexual assault by a family member or someone you knew	32.94 [3.95, 61.93]	0.030	23.21 [−23.89, 70.31]	0.349
DW: Experienced a sexual assault by an unknown person	7.15 [−12.74, 27.04]	0.487	15.57 [−7.89, 39.03]	0.208
DW: Sudden death of a close person due to natural causes	2.49 [−1.52, 6.5]	0.232	2.53 [−1.51, 6.57]	0.235
DW: Prolonged hunger or lack of water	−1.79 [−8.07, 4.5]	0.583	−9.27 [−16.33, −2.22]	0.015
DW: Survived bombing	1.36 [−1.49, 4.2]	0.357	1.28 [−1.51, 4.08]	0.382
DW: Experienced exile/refugee	1.16 [−1.66, 3.99]	0.426	2.24 [−0.56, 5.04]	0.130
DW: Found out about a murder or a violent death of a close person	1.89 [−1.57, 5.35]	0.292	1.73 [−1.69, 5.16]	0.335
DW: Found out about a disappearance of your closest persons	3.21 [−1.27, 7.69]	0.168	2.67 [−1.76, 7.1]	0.253
DW: Were tortured (exposed to physical or mental suffering)	−9.71 [−28.95, 9.54]	0.330	−3.33 [−24.35, 17.68]	0.762
DW: Were in a situation when you did not know where you are (were lost)	7.03 [−1.91, 15.97]	0.131	5.53 [−3.59, 14.64]	0.250
DW: Were in any other threatening situation or in a situation where you felt your life is endangered	−0.78 [−5.49, 3.93]	0.748	−1.33 [−6.02, 3.35]	0.587
AW: Survived a serious accident, fire or explosion			2.22 [−1.97, 6.42]	0.314
AW: Experienced a natural disaster			1.67 [−1.77, 5.11]	0.356
AW: Experienced a nonsexual attack by a family member or someone you knew			12.58 [5.94, 19.22]	0.001
AW: Experienced a sexual assault by a family member or someone you knew			−7.53 [−31.51, 16.45]	0.550
AW: Experienced a sexual assault by an unknown person			12.57 [−12.34, 37.49]	0.338
AW: Sudden death of a close person due to natural causes			−0.44 [−3.18, 2.29]	0.756
AW: Prolonged hunger or lack of water			16.97 [8.06, 25.88]	0.001
AW: Being sick and could not be treated			−1.41 [−45.01, 42.19]	0.951
AW: Were tortured (exposed to physical or mental suffering)			−12.27 [−30.58, 6.04]	0.204
AW: Were in any other threatening situation or in a situation where you felt your life is endangered			2.21 [−4.47, 8.89]	0.528
AIC	2326.393		2312.241
BIC	2389.243		2412.062
ICC	0.635		0.577
Conditional R²	0.690		0.680
Marginal R²	0.149		0.245
p (change)	0.000		0.000

DW: during war; AW: after war.

The results show that the multilevel approach is justified, and that the introduction of a random intercept significantly improves the model, with an ICC of 0.635 (Hayes, 2006). In the starting model, gender was introduced as a predictor, and the results showed that women reported more PTSD symptoms than men did, explaining 3.2% of the variance in PTSD symptoms. Gender remains a significant predictor in all models. With the introduction of PTEs during the war, the predictor variables explained an additional 11.7% of the variance in PTSD symptoms. The only two significant PTEs were the experience of both sexual and nonsexual assault by a family member or a known person.

The results from the final model change the structure of the predictors, indicating that more recent events could play a larger role in the expression of PTSD symptoms. Namely, while the total variance explained rises to 24.5%, the PTEs experienced during war lose their significance with the experience of prolonged hunger or lack of water having a suppressive effect. The remaining significant trauma-related predictors were the experience of a nonsexual assault by a family member or a known person and prolonged hunger or lack of water.

The moderating role of gender in the prediction of PTSD symptoms

The third research question was to examine whether gender moderates the statistical association between early trauma exposure and PTSD symptoms in adulthood. For this analysis, the clustering effect was excluded, and mothers and fathers were treated as completely independent observations. The moderation of gender was analyzed using multigroup SEM with a regression model from the multilevel analysis. Although this analysis can be performed by adding interaction effects to the OLS regression model, this leads to a significant increase in the number of predictors and a lack of information on the group-level R². Due to the lack of variance in the subsamples, eight variables were excluded from the analysis. The results of this analysis are shown in Table 3. Since the model was completely identified, no fit parameters are shown.

Table 3.

Moderation effect of gender (N_F = 197; N_M = 101) on the prediction of PTSD symptoms.

Variable	Female		Male		p (ΔB)
Variable	B [95%CI]	p	B [95%CI]	p	p (ΔB)
DW: Experienced a nonsexual attack by a family member or someone you knew	6.03 [−9.57, 21.62]	0.449	14.55 [−1.43, 30.53]	0.074	0.454
DW: Experienced a nonsexual attack by an unknown person	4.49 [−8.98, 17.96]	0.514	4.33 [−6.1, 14.77]	0.416	0.986
DW: Sudden death of a close person due to natural causes	5.33 [−0.42, 11.09]	0.069	0.39 [−5.59, 6.37]	0.899	0.243
DW: Prolonged hunger or lack of water	−8.69 [−17.7, 0.32]	0.059	−13.29 [−25.99, −0.59]	0.040	0.563
DW: Survived bombing	1.20 [−2.42, 4.82]	0.515	−0.30 [−4.25, 3.65]	0.882	0.582
DW: Experienced exile/refugee	2.27 [−1.41, 5.94]	0.226	1.98 [−2.02, 5.98]	0.332	0.918
DW: Found out about a murder or a violent death of a close person	2.22 [−2.65, 7.09]	0.371	0.77 [−4.77, 6.32]	0.785	0.701
DW: Found out about a disappearance of your closest persons	1.17 [−5.07, 7.42]	0.713	7.95 [1.15, 14.75]	0.022	0.150
DW: Were in a situation when you did not know where you are (were lost)	1.50 [−9.42, 12.43]	0.787	10.11 [−1.32, 21.55]	0.083	0.286
DW: Were in any other threatening situation or in a situation where you felt your life is endangered	3.53 [−2.26, 9.33]	0.232	−7.27 [−15.36, 0.82]	0.078	0.033
AW: Survived a serious accident, fire or explosion	4.43 [−1.31, 10.18]	0.130	−0.11 [−6.26, 6.03]	0.972	0.290
AW: Experienced a natural disaster	3.11 [−1.31, 7.53]	0.167	2.05 [−2.68, 6.78]	0.396	0.747
AW: Experienced a nonsexual attack by a family member or someone you knew	15.19 [7.8, 22.59]	0.000	0.30 [−12.38, 13]	0.962	0.047
AW: Sudden death of a close person due to natural causes	−1.10 [−4.9, 2.7]	0.570	−0.01 [−3.82, 3.8]	0.995	0.692
AW: Prolonged hunger or lack of water	18.03 [6.73, 29.32]	0.002	14.87 [−2.72, 32.45]	0.098	0.767
AW: Were in any other threatening situation or in a situation where you felt your life is endangered	6.43 [−2.75, 15.62]	0.170	4.56 [−5.44, 14.55]	0.372	0.786
R²	0.256		0.229		0.770

DW: during war; AW: after war.

Different structure of significant predictors were obtained for men and women. For women, the significant predictors were a nonsexual assault by a known person after the war and extreme deprivation of food and water after the war; for men, the significant predictors were the disappearance of their close persons during the war and a significant suppression effect of hunger or lack of water during the war. In the context of R², the complete model explained 25.6% of the variance in PTSD symptoms for females and 22.9% for males, while the difference between the coefficients was not significant.

Discussion

The adults who were children and adolescents during the Homeland War in Croatia (1991–1995) experienced a number of different PTEs, with a higher occurrence during the war than during the postwar period.

One of the localities was severely hit by an earthquake, which provided an additional source of traumatic stress. However, its impact was not examined due to experience heterogeneity requiring a larger sample and because of the potential different pathways of a PTEs related to natural disasters compared to war trauma, given their specific characteristics such as chronicity, violence or intention (Bromet et al., 2017; Galea et al., 2015).

Our findings indicate that trauma exposure during and after the war is associated with PTSD symptoms in adulthood, as shown in previous studies (Karam et al., 2014; Llabre et al., 2015; Strauss et al., 2011). However, to our knowledge, no prior studies have examined these effects after such a long delay—nearly 30 years. Notably, the strength of these associations varies depending on trauma type. Specifically, interpersonal trauma (e.g., assault by a family member or known person) had a stronger and more persistent association with PTSD symptoms than war-specific experiences such as exposure to shelling or displacement. This aligns with previous research indicating that interpersonal traumas are particularly traumatic and accounted for a significant proportion of PTSD (Darves-Bornoz et al., 2008).

It seems that even during war times, a lack of essential safety provided by adults and the family environment is more critical for long-term trauma effects than specific war-related PTEs. Previous studies have shown that war experiences can directly endanger children’s well-being by exposing children to extreme adversities (e.g. Calam, 2017) but also through parenting practices, specifically inappropriate parental capacity to protect children from violence in close relationships. Eltanamly et al. (2021) showed that war compromised children’s wellbeing partly through less parental warmth and increased parental harshness. Our findings concur with those of the Slone and Mann study (2016), which showed that the home environment and parental functioning play crucial roles in moderating the impact of children’s exposure to war-related events on adverse psychological and behavioral outcomes and that these impacts have long-term effects. Based on our results, we cannot claim that the violence against the participants during their childhood or adolescence was perpetrated by their parents. It is possible that other well-known individuals, such as neighbors, family friends, or acquaintances, were involved. However, it is possible that their parents did not protect them from violence.

Regarding the second research question, in the third step of the regression analyses, the scores of the PTEs experienced after the war were added. The overall model explained 24.5% of the variance in PTSD symptoms. When more recent traumatic experiences, such as those that occurred in the participants’ lives after the war, were introduced into the prediction model of PTSD symptoms in adulthood, none of the predictors from the war period remained significant. In contrast, assault by a family member or a known person and extreme deprivation of food and water after the war were significant. Notably, the correlation between experiencing an assault by a family member or a known person during the war period and after it was 0.258, and that between experiencing prolonged hunger or a lack of water was 0.485. It seems that some children lacked safety and were exposed to extreme deprivation of basic needs throughout childhood, both during the war and later in life.

The Conservation of Resources Theory (COR, Hobfoll et al., 2016) emphasizes the more profound impacts of cumulative trauma than of single traumatic incidents. For example, if a child who was exposed to extreme deprivation during war also lost a significant family member who was their significant resource, the capacity to cope with later adverse trauma diminished. Hobfoll et al. (2016) suggested that cumulative trauma results in increased psychological distress due to the exhaustion of coping resources. Our data support the concept of cumulative trauma that introduces the dimension of time and the interaction between an individual and his/her context, possibly transforming a particular war-related PTE into a life vulnerability.

Extreme deprivation of basic needs after war as a predictor of PTSD symptoms in adulthood could be the specificity of this sample. The study was conducted in a part of the country that was heavily destroyed and deprived after the war (Ajduković et al., 2007; Opačić, 2022) and where basic children’s needs in poor and deprived communities were not met. Communities destroyed by the war often recover very slowly over a long period of time and remain ridden by increased community insecurity, a meagre perspective on prospects and growth, and a lack of social and mental health services (Ajduković et al., 2007, 2011; Opačić, 2022).

Consistent with the tenants of COR interventions aimed at children and adolescents who have survived, the war should focus on ensuring livelihoods and simultaneously enhancing parental warmth, availability, support, and protection from violence while simultaneously reducing parental harshness and hostility (Eltanamly et al., 2021). Maintaining supportive and warm caregiving despite wartime adversity can contribute to healthier child adjustment (Eltanamly et al., 2021) and support children’s resilience in such challenging situations (Masten & Narayan, 2012).

In sum, our findings, together with those of other scholars about the needs of children and adolescents in the postwar period (e.g., Copeland et al., 2018) and policy papers (e.g., Carpiniello, 2023), suggest that the priority should be the prevention of new adversities and the relief of childhood traumatic experiences since they have multifaceted effects on health and well-being across the lifespan. Individual and community interventions aimed at building inner and outer resources by strengthening resilience factors, instilling hope, providing opportunities and reducing distress should be available across the lifespan of adults who have been traumatized during the war.

Regarding the moderating role of gender in the prediction of PTSD symptoms, we found a slightly higher score for PTSD symptoms among women. Although there was no gender difference in PTE exposure during or after war, women had more PTSD symptoms than men did. In addition, in our sample, disproportionately more women met the criteria for possible PTSD diagnosis. The female-to-male ratio of the prevalence of PTSD is 5.6:1, which is much greater than the well-established 2:1 gender PTDS ratio (e.g., Christiansen & Berke, 2020). In line with Olff’s (2017) update on sex and gender differences in PTSD, it is necessary to pay more attention to the role of gender in traumatic responses to provide nuanced interventions to better meet the needs of women affected by war and postwar adversity, such as social support, which is the most consistent predictor of negative outcomes of trauma.

Traumatic events explain 25.6% and 22.9% of PTSD symptoms for women and men, respectively. This difference was not statistically significant, but the structure of the significant predictors differed between men and women. In the female sample, the significant predictors were nonsexual attack by a family member or a known person and prolonged hunger or lack of water after the war. In the male sample, the significant predictor was the disappearance of close persons during the war. Since the after-war period referred to a number of years, the assaults by a family member in the female sample might include partner violence, but this was not probed in the study. Studies show that women are more vulnerable to family violence since gender-based violence increases during times of war and continues beyond the end of conflict (e.g., Kostovicova et al., 2020; Yadav & Horn, 2021).

Strengths, limitations and future research

This study addressed the long-term effects of 30 years of exposure to the trauma of growing up at war times on PTSD symptoms in adulthood. It also considered the possible effects of surviving potentially traumatic experiences in the aftermath of war. It revealed associations regarding the prevailing negative impact of exposure to assaults from close persons and deprivation, such as hunger, both during and after war. Previous studies often focused on a limited number of traumatic experiences, but our findings provide support for taking into account a broader context and scope of PTEs rather than focusing only on a specific traumatic event.

However, this study has certain limitations. Although the probabilistic sampling model allowed insight into the status of PTEs and PTSD symptoms in a representative population sample in the target areas of the country, it resulted in a relatively small number of participants with experiences with both wartime and postwartime PTEs. Future studies would benefit from using nonproportional samples that would enable oversampling in terms of participants who have or have not experienced war-related PTEs but, otherwise have similar life circumstances. Similarly, the better representation of participants with different levels of PTSD symptoms, especially in the male subgroup would improve the statistical power and allow for the detection of smaller effects.

Since our study was done on a community sample, which is its strength, further studies should attempt to include more participants with higher levels of PTSD symptoms.

Furthermore, previous research has consistently emphasized that traumatic events during childhood and adolescence increase the risk of developing PTSD symptoms. However, the relationship between a child’s age and this risk remains inconclusive. In our study, the wide range of participants’ ages (3–18 years) during the war may have impact on the findings. Therefore, future research should explore in more detail how a person’s age at the time of a traumatic event impacts the onset of PTSD symptoms.

Similar to most other studies, traumatic events were measured on a dichotomous scale that does not consider the frequency, severity, centrality, or consequences of a traumatic event. The reality of the multimodal experience of these events is thus limited to only one aspect. The content validity of listed events can be at risk both because of recollection issues and because of the understanding of the meaning of items (e.g., torture). Furthermore, the 30-year after-war period is not limited to immediate childhood and adolescence, and it can include PTEs experienced in more recent adulthood, including the current family. It is important to note that the sample includes only adults who are parents; thus, there is a possibility of selection bias.

Finally, this was a retrospective study based on the recollection of experiences that occurred 30 years before and also more recently. Recollection of more distant events may be poor, and more recent experiences might have a greater impact on the results. As Williams (1994) emphasized, recalling exactly what happened in the past is difficult and unpleasant, affecting recall accuracy and leading to the potential underreporting.

Future research should focus on understanding the relationship between children’s war trauma and life span-related problems, taking into account risk and protective factors in different developmental periods, and on planning and evaluating interventions aimed at alleviating childhood traumatic experiences from war times and in the aftermath.

Conclusions

The model for the prediction of PTSD symptoms that included both war-time and postwar potentially traumatic events demonstrated the importance of both sets of events. PTEs experienced during war explained a moderate amount of the variance in current PTSD symptoms in adulthood when controlling for postwar exposure. This indicates that the long-term effects of trauma persist during childhood and adolescence. Only PTEs that are not specific to war-related activities are significant predictors of later PTSD symptoms, such as sexual or nonsexual assault by a family member or a known person during war and nonsexual assault by a family member or a known person and extreme deprivation of food and water after the war.

Gender is a relevant moderator revealing the greater PTSD vulnerability of women both at the time of the war and in the aftermath. Gender differences indicate differences in the centrality of particular types of traumatic events.

The implications for policy and practice to promote the healthy development and wellbeing of war-affected children are that it is important to focus on supporting positive parenting practices, ensuring safety and meeting children’s other deprived basic needs, not only during war but also during the long period after the war. In future research, it might be enlightening to qualitatively study the mechanisms through which war-time trauma and parents’ practices in the postwar affect children’s well-being.

Footnotes

Declaration of conflicting interests

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

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study is the part of the research project “Intergenerational Transmission of Risk of Adolescent Mental Health” (INTRAD) financed by the Croatian Science Foundation under number IP-2014-09-8546.

Ethical approval

The approval of the Ethics Committee Faculty of Law of the University of Zagreb and the approval of the Ministry of Science and Education of the Republic of Croatia were obtained for conducting the research.

ORCID iDs

Marina Ajduković

Petra Kožljan

Miroslav Rajter

Data Availability Statement

Due to the sensitive nature of the data, the data are available upon request to the research team.*

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