Full Te ms & Condi ions o access and use can be ound a
h p://www. and online.com/ac ion/jou nalIn o ma ion?jou nalCode=zep 20
Download by: [Tampe e Uni e si y] Da e: 29 No embe 2017, A : 03:59
Eu opean Jou nal o Psycho auma ology
ISSN: 2000-8198 (P in ) 2000-8066 (Online) Jou nal homepage: h p://www. and online.com/loi/zep 20
Pe i auma ic dissocia ion p edic s pos auma ic
s ess diso de symp oms ia dys unc ional
auma- ela ed memo y among wa -a ec ed
child en
Ki si Pel onen, Samuli Kangaslampi, Jenni Sa anpää, Sami Qou a & Raija-
Leena Punamäki
To ci e his a icle: Ki si Pel onen, Samuli Kangaslampi, Jenni Sa anpää, Sami Qou a & Raija-
Leena Punamäki (2017) Pe i auma ic dissocia ion p edic s pos auma ic s ess diso de symp oms
ia dys unc ional auma- ela ed memo y among wa -a ec ed child en, Eu opean Jou nal o
Psycho auma ology, 8:sup3, 1375828, DOI: 10.1080/20008198.2017.1375828
To link o his a icle: h ps://doi.o g/10.1080/20008198.2017.1375828
© 2017 The Au ho (s). Published by In o ma
UK Limi ed, ading as Taylo & F ancis
G oup.
Published online: 10 Oc 2017.
Submi you a icle o his jou nal
A icle iews: 112
View ela ed a icles
View C ossma k da a
BASIC RESEARCH ARTICLE
Pe i auma ic dissocia ion p edic s pos auma ic s ess diso de symp oms
ia dys unc ional auma- ela ed memo y among wa -a ec ed child en
Ki si Pel onen
a
, Samuli Kangaslampi
a
, Jenni Sa anpää
b
, Sami Qou a
c
and Raija-Leena Punamäki
a
a
Uni e si y o Tampe e, Finland/Facul y o Social Sciences/Psychology, Tampe e, Finland;
b
Lapua De elopmen al and Family
Counselling, Lapua, Finland;
c
Islamic Uni e si y o Gaza, Depa men o Educa ion and Psychology, Gaza
ABSTRACT
Backg ound: Among adul s he e is s ong e idence abou pe i auma ic dissocia ion (PD)
p edic ing pos auma ic s ess diso de (PTSD), ye e idence among child en is e y limi ed.
I has been sugges ed ha dis u bances in memo y unc ioning migh explain he associa-
ion be ween PD and PTSD, bu his has no ye been empi ically es ed.
Objec i e: We aimed o es he hypo heses ha g ea e PD would be associa ed wi h mo e
pos auma ic s ess diso de (PTSD) symp oms, and ha some o his associa ion would be
media ed by diso ganized and non- e bal memo ies abou he auma ic e en .
Me hod: The sample included 197 Pales inian child en (10–12-yea s) li ing in he Gaza S ip,
pa icipa ing in he a e ma h o he 2008/9 wa . Sel - epo ques ionnai es we e used o
measu e PD (Pe i auma ic Dissocia i e Expe iences Ques ionnai e) h ee mon hs pos -wa , as
well as auma- ela ed memo y (T auma Memo y Quali y Ques ionnai e) and PTSD symp oms
(Child en’s Re ised Impac o E en Scale) six mon hs la e . Exposu e o wa auma was
assessed by a checklis . S uc u al equa ion modelling was used o examine di ec and indi ec
pa hs om PD o pos auma ic PTSS, con olling o numbe o auma ic wa e en s.
Resul s: S uc u al equa ion modelling esul s showed ha g ea e sel - epo ed PD p e-
dic ed highe le els o PTSS nine mon hs pos -wa , and ha a signi ican pa , bu no all, o
his ela ionship was media ed ia he quali y o auma- ela ed memo ies.
Conclusions: This s udy p o ided empi ical e idence ha , among wa -a ec ed child en,
g ea e PD du ing auma ic e en s is linked wi h highe le els o PTSD symp oms se e al
mon hs la e , e en when accoun ing o hei pe sonal exposu e o wa auma. Fu he , he
s udy suppo ed he idea ha he de imen al e ec s o dissocia ion du ing a auma ic
e en may be due o dys unc ional memo ies cha ac e ized by diso ganiza ion and lack o
access o e bal and cohe ence. Fu he es s o hese hypo heses wi h la ge samples and
mo e poin s o measu emen a e called o .
La disociación pe i aumá ica p edice sín omas de as o no de es és
pos aumá ico median e los ecue dos dis uncionales elacionada con
el auma en e niños a ec ados po la gue a
Plan eamien o: En e los adul os exis e mucha e idencia sob e la disociación
pe i aumá ica (DP) que p edice el as o no de es és pos aumá ico (TEPT); sin emba go,
la e idencia en niños es muy limi ada. Se ha suge ido que las al e aciones en el unciona-
mien o de la memo ia pod ían explica la asociación en e la DP y el TEPT, pe o es o aún no
ha sido p obado empí icamen e.
Obje i o: Se in en ó p oba la hipó esis de que una mayo DP es a ía asociada con sín omas
de as o no de es és pos aumá ico (TEPT), y que pa e de es a asociación es a ía mediada
po ecue dos deso ganizados y no e bales sob e el e en o aumá ico.
Mé odo: La mues a incluyó a 197 niños pales inos (10–12 años) que i ían en la F anja de
Gaza, que i ie on las secuelas de la gue a de 2008/9. Se u iliza on cues iona ios de au o-
in o me pa a medi la DP (Pe i auma ic Dissocia i e Expe iences Ques ionnai e) es meses
después de la gue a, así como la memo ia elacionada con aumas (T auma Memo y
Quali y Ques ionnai e) y los sín omas de TEPT (Child en’s Re ised Impac o E en Scale)
seis meses después. La exposición al auma de gue a se e aluó median e una lis a de
e i icación. Se u ilizó el modelado de ecuaciones es uc u ales pa a examina las ayec o -
ias di ec as e indi ec as de la DP al TEPT, con olando el núme o de e en os de gue a
aumá icos.
Resul ados: Los esul ados del modelado de la ecuación es uc u al mos a on que los au o-
in o mes de mayo DP p edecían ni eles más al os de TEPT nue e meses después de la
gue a, y que una pa e signi ica i a, pe o no oda, de es a elación ue mediada po calidad
de los ecue dos elacionados con el auma.
Conclusiones: Es e es udio p opo cionó e idencia empí ica de que, en e los niños a ec a-
dos po la gue a, una mayo DP du an e los e en os aumá icos es á elacionada con
ni eles más al os de sín omas de TEPT a ios meses después, incluso cuando se explica su
exposición pe sonal a un auma de gue a. Además, el es udio espalda la idea de que los
ARTICLE HISTORY
Recei ed 22 Decembe 2016
Accep ed 18 Augus 2017
KEYWORDS
Wa auma; child en;
pe i auma ic dissocia ion;
auma- ela ed memo y;
pos auma ic s ess diso de
PALABRAS CLAVE
auma de gue a; niños;
disociación pe i aumá ica;
ecue do elacionado con el
auma; as o no de es és
pos aumá ico
关键词
战争创伤;儿童;围创伤期
分离;创伤相关记忆;创伤
后应激障碍
HIGHLIGHTS
•Child en’s sel - epo ed
dissocia ion (PD) du ing
hei exposu e o ecen wa
auma p edic ed
pos auma ic s ess (PTSD)
symp oms nine mon hs
pos -wa .
•The associa ion be ween
PD and PTSD symp oms was
pa ially media ed by
dys unc ional memo y
p ocessing o auma.
•The wa impac s may be
symp om-speci ic, as high
exposu e co ela ed wi h
in usi e and dyspho ia
symp oms, bu no wi h
a oidance o hype a ousal.
•The na u e o auma ic
e en s may ma e mo e
han he sole numbe s, as,
o ins ance, wi nessing
ho i ying scenes wi h
mul iple senso y s imuli may
o m especially se e e isk
o in usi e symp oms.
CONTACT Ki si Pel onen [email p o ec ed] Facul y o Social Sciences/Psychology, Uni e si y o Tampe e, 33014 Finland
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY, 2017
VOL. 8, 1375828
h ps://doi.o g/10.1080/20008198.2017.1375828
© 2017 The Au ho (s). Published by In o ma UK Limi ed, ading as Taylo & F ancis G oup.
This is an Open Access a icle dis ibu ed unde he e ms o he C ea i e Commons A ibu ion License (h p://c ea i ecommons.o g/licenses/by/4.0/), which pe mi s
un es ic ed use, dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly ci ed.
Downloaded by [Tampe e Uni e si y] a 03:59 29 No embe 2017
e ec os pe judiciales de la disociación du an e un e en o aumá ico pueden se debidos a
los ecue dos dis uncionales ca ac e izados po deso ganización y al a de acceso a lo e bal
y a la cohe encia. Se equie en más p uebas de es as hipó esis con mues as más g andes y
más pun os de medición.
标题：在受战争影响的儿童中围创伤期分离通过异常创伤相关记忆预测
创伤后应激障碍
背景：在成人中有强证据支持围创伤期分离（PD）预测创伤后应激障碍（PTSD），但是在
儿童中的证据有限。记忆功能受损或许可以解释PD和PTSD的关联，但还未被实证验证过。
目标：我们想要验证更高PD和更多PTSD症状关联的假设，其中有些关联路径可能被对创
伤事件的杂乱的和非语言性记忆中介。
方法：样本包括了197名住在加沙地带的巴勒斯坦儿童（10–12岁），在2008年9月的战争后
参加研究。用围创伤期分离体验问卷（Pe i auma ic Dissocia i e Expe iences Ques ionnai e）
测量战后三个月的PD，创伤记忆质量问卷T auma Memo y Quali y Ques ionnai e）测量创伤
相关记忆，修订后儿童版事件影响量表（Child en’sRe ised Impac o E en Scale）测量6个
月后的PTSD。并使用一个清单量表评测对战争创伤的暴露。使用结构方程模型来考察控制
战争创伤事件后PD到PTSS直接和间接的路径。
结果：结构方程模型的结果显示更多地自我报告PD预测9个月后更高水平的PTSS，这种关
联中的大部分（并非全部）被创伤相关记忆的质量中介了。
结论：本研究提供了实证证据支持在受战争影响的儿童中，经历创伤事件时更多PD和几
个月之后更高水平的PTSD症状有关联，在控制了个体的战争创伤暴露程度之后也如此。
进一步地，本研究支持了分离症状在创伤事件中的有害影响可能是因为异常记忆通常表
现出的混乱和难以用语言表达和缺乏连贯性。未来需要在更大样本中使用更多测量点对
这些假设进行进一步验证。
1. In oduc ion
Cumula i e auma ic expe iences inc ease he isk o
psychia ic diso de s and symp oms such as pos au-
ma ic s ess diso de (PTSD), gene alized anxie y, au-
ma ic g ie , and dep ession among child en li ing in wa
a eas (Be ancou e al., 2012;Ca anie al.,2009). The
p e alence o PTSD, howe e , a ies conside ably among
wa -a ec ed child en. Fo ins ance, among Pales inian
child en exposed o majo wa s in he Gaza S ip, he
p e alence o PTSD a ied be ween 22% and 34%
(Al awil, Nel, Aske , Sama a, & Ha old, 2008;Thabe
& Vos anis, 2015). Resea che s a e in e es ed in explana-
ions o such a ia ion and a e especially seeking ea ly
isk ac o s ha p edic he diagnosis o PTSD among
child en (Dalgleish e al., 2008). Resea ch sugges s p e-,
pe i-, and pos - auma esponses o be decisi e o he
de elopmen o PTSD (Ol e al., 2015), wi h acu e s ess
diso de (ASD) and pe i auma ic dissocia ion (PD)
playing an impo an ole (Kassam-Adams e al., 2012).
Among adul s he e is e idence abou PD p edic ing
PTSD ( o a me a-analysis, see Lens el -Mulde s e al.,
2008;Oze ,Bes ,Lipsey,&Weiss,2003), especially in he
sho un (Thomas, Saumie , & B une , 2012; ande
Velden & Wi man, 2008). Ye , among child en and
adolescen s e idence is e y limi ed and indings a e
inconclusi e, as some esea ch among young ehicle-
acciden su i o s has con i med ha PD o ms a se e e
isk o PTSD (Bui e al., 2010), while o he s showed
mino impo ance (Dalgleish e al., 2008). We could no
ind esea ch on PD among child en in wa condi ions.
The p esen s udy analyses he associa ion o PD and
PTSD symp oms among Pales inian child en in he a e -
ma h o a majo wa , he 2008/9 Wa on Gaza.
Excessi e auma can o e whelm child en’s capaci y
o in eg a ing sensa ions, emo ions, and hinking in o
cohe en memo ies, esul ing in a high isk o auma-
ela ed diso de s, especially PTSD (Dalgleish e al., 2008;
Ehle s & Cla k, 2000; Meise -S edman, Dalgleish e al.,
2007). Dissocia i e esponses a e an exp ession o he
‘shu -down’o no mal in o ma ion p ocessing du ing
he auma ic e en . PD in ol es a dis o ed sense o
ime and place and leads o a sense o un eali y, appea ing
as depe sonaliza ion wi h a lack o subjec i e emo ions,
ou -o -body expe iences, and al e ed pain pe cep ions
(Ma ma , Weiss, & Me zle , 1998). Dis up ions o mem-
o y a e common and dis o ions o ime, ei he as decel-
e a ed o accele a ed, may be expe ienced (Ame ican
Psychia ic Associa ion, 2013; Schaue & Elbe , 2015).
Biological and psychosocial mechanisms ha e been
sugges ed o explain he associa ion be ween PD and
PTSD (Ap el e al., 2011; Schaue & Elbe , 2015), wi h
dis u bances in memo y unc ioning p o iding one p o-
mising app oach (Beda d-Gilligan & Zoellne , 2012;
Spiegel, Koopmen, Ca dena, & Classen, 1996). The co i-
colimbic model o dissocia ion sugges s ha in a s a e o
high anxie y, he p e on al co ex inhibi s emo ional
p ocessing in limbic s uc u es such as he amygdala.
Subsequen ly, sympa he ic ou pu is dampened and emo-
ional expe iencing is educed (Lanius, Bluhm, Lanius, &
Pain, 2006). Subsequen ly, auma- ela ed memo ies a e
agmen ed and lack ch onological o de , consis ency,
and na a i e quali y. Vic ims a e la e able o e ie e
p edominan ly senso y-based memo ies o images,
oices, odou s, o eelings ha a e no e bally accessible
(Engelha d, an den Hou , Kind , A n z, & Schou en,
2003; Meise -S edman, Smi h, Yule, & Dalgleish, 2007).
2K. PELTONEN ET AL.
Downloaded by [Tampe e Uni e si y] a 03:59 29 No embe 2017
They ace di icul ies consciously ecalling a cohe en ,
ch onological memo y abou he e en bu ins ead
expe ience impulsi e sensa ions ha may uncon ollably
in ade he mind (B ewin, Dalgleish, & Joseph, 1996;
Ehle s & Cla k, 2000). Encoun e s wi h auma emin-
de s may igge he same dissocia i e esponses expe i-
enced du ing he auma, which in u n main ain
memo y dys unc ion. Theo is s sugges ha PTSD de el-
ops, a leas pa ly, as a consequence o he auma ized
pe son’s inabili y o p ocess he e en a a symbolic and
e bal le el (B ewin e al., 1996;Ehle s&Cla k,2000).
Howe e , he pa hway om PD o PTSD ia dys unc-
ional auma- ela ed memo ies has no been es ed, o
ou knowledge, among child en.
1.1. Resea ch ques ions
We examined whe he pe i auma ic dissocia ion (PD)
associa es wi h dys unc ional auma- ela ed memo y
and PTSD symp oms and whe he he auma- ela ed
memo y media es he associa ion be ween PD and
PTSD symp oms. Pales inian child en we e ollowed
om h ee mon hs a e a majo wa (T1) un il
nine mon hs pos -wa (T3). We hypo hesized ha :
(1) Child- epo ed pe i auma ic dissocia ion a T1
will p edic hei epo ed PTSD symp oms a T3;
and (2) dys unc ional auma- ela ed memo ies med-
ia e he associa ion be ween PD and PTSD symp oms.
2. Me hod
2.1. Pa icipan s and p ocedu e
The pa icipan s we e 197 Pales inian schoolchild en
li ing in he Gaza S ip (10–12 yea s, M = 11.35,
SD = .57; 49.4% gi ls), and de i ed om he con ol
g oup (n = 240). They o med he con ol g oup in a
andomized con olled ial o an in e en ion a e he
2008/9 Wa on Gaza (Kangaslampi, Punamäki, Qou a,
Diab, & Pel onen, 2016). Pa icipan s comple ed he
measu emen s h ee mon hs a e he wa a baseline,
wo mon hs a e he in e en ion, and a a six-mon h
ollow-up. The subsample o 197 consis s o child en
who ha e comple e da a om assessmen s a baseline
(T1) and ollow-up (T3). The e hical boa ds a he
Pales inian Minis y o Educa ion and he Gaza
Communi y Men al Heal h P og amme (GCMHP)
e iewed and accep ed he s udy p o ocol and mea-
su emen s. Pe missions o he s udy we e ecei ed
om school au ho i ies. In o ma ion shee s we e p e-
pa ed o he child en and hei pa en s explaining he
pu pose o he s udy, and only e bal consen o
pa icipa e in he s udy was equi ed. Resea ch assis-
an s conduc ed he ieldwo k in school classes and
child en ecei ed de ailed e bal and w i en ins uc-
ions be o e hey comple ed ques ionnai es. GCMHP
p o ided consul a ion o pa en s and eache s who had
high le els o wo y conce ning he child en in he
a e ma h o he wa .
All ques ionnai es and ins uc ions we e adminis-
e ed in A abic. Measu es o Wa auma, PD, and
PTSD symp oms we e a ailable in A abic. The mea-
su e o auma- ela ed memo y was ansla ed and
back- ansla ed om and o English by he bilingual
esea che s. All scales we e pilo - es ed.
2.2. Measu es
2.2.1. Wa auma a T1
A checklis o 29 auma ic e en s was cons uc ed
o his s udy. I co e s ypical e en s du ing he Wa
on Gaza 2008/9 and he mili a y siege ela ed o
wi nessing ac s o iolence, losses, inju y and des uc-
ion, and being pe sonally he a ge o iolence.
Child en epo ed a T1 whe he hey had expe i-
enced each auma ic e en (1 = yes;0=no). A sum
a iable was cons uc ed by coun ing he a i ma i e
answe s o 14 ques ions abou e en s ul illing he
DSM-IV de ini ion o auma.
2.2.2. Pe i auma ic dissocia ion a T1
The 10-i em Pe i auma ic Dissocia i e Expe iences
Ques ionnai e (PDEQ; Ma shall, O lando, Jaycox,
Foy, & Belzbe g, 2002) desc ibes expe iences o depe -
sonaliza ion, hough con usion, and lack o emo ion. I
has been alida ed in di e en cul u al con ex s, and
good psychome ic p ope ies we e ound e.g. among
wa - auma ized Ugandan child en (Klasen e al.,
2010). Child en we e asked o ecall hei expe iences
du ing he las wa , and epo whe he hey had each
ype o dissocia i e esponses (1 = yes;0=no). A sum
a iable was cons uc ed. C onbach’sα= .71.
2.2.3. T auma- ela ed memo y a T3
The 11-i em T auma Memo y Quali y Ques ionnai e
(TMQQ; Meise -S edman, Smi h e al., 2007)wasapplied
o assess child en’smemo yquali y.Thissel - epo
ques ionnai e inqui es abou he ways su i o s emem-
be he auma ic e en . Fo example: ‘My memo ies o
he igh ening e en a e mos ly pic u es o images’.
Child en e alua ed on a 4-poin scale how well he s a e-
men s i hem (1 = no a all;4=comple ely). A sum
a iable was cons uc ed, and he alue o αwas .73.
2.2.4. Pos auma ic s ess diso de (PTSD)
symp oms a T3
PTSD symp oms we e measu ed by he 13-i em
Child en’sRe ised Impac o E en s Scale (CRIES;
Smi h, Pe in, Dy eg o , & Yule, 2003). On his sel -
epo ques ionnai e, based on DSM-IV c i e ia, child en
e alua ed on a 4-poin scale how o en hey had expe i-
enced a pa icula symp om o e he las wo weeks
(0 = no a all,1= a ely,3=some imes,5=o en).
CRIES has shown adequa e eliabili y and alidi y in
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 3
Downloaded by [Tampe e Uni e si y] a 03:59 29 No embe 2017
Pales inian samples (Koll ei e al., 2012). C onbach’sα
was .63
2.3. S a is ical analysis
The cu en s udy is a seconda y analysis o he sample,
es ing he hypo hesis o dys unc ional auma- ela ed
memo y media ing he associa ion be ween PD and
PTSD symp oms. The 197 child en o whom ollow-
up measu emen s we e a ailable we e included in his
s udy. The e we e no missing indi idual da a poin s.
S uc u al equa ion modelling wi h a mix o la en
and mani es a iables was used o es ima e di ec and
media ed e ec s. Pos auma ic s ess symp oms we e
modelled as a la en a iable. Based on ea lie analyses
wi h his da a (Palosaa i, Punamäki, Diab, & Qou a,
2013), a ou - ac o s uc u e simila o ha iden i ied
among comba e e ans (Simms, Wa son, &
Doebbeling, 2002) was selec ed o his pu pose. Pa cel
indica o s we e cons uc ed co esponding o in usion
(a e age o ou i ems on he CRIES), a oidance ( ou
i ems), dyspho ia/nega i e a ec i i y ( h ee i ems) and
hype a ousal ( wo i ems) symp oms. Pe i auma ic dis-
socia ion, numbe o auma ic wa e en s, and auma-
ela ed memo y we e ea ed as mani es sum a iables.
The i o a measu emen model, whe e all a iables
we e allowed o co a y eely, was i s e alua ed. A
s uc u al model wi h cons ain s ep esen ing he
s udy hypo heses was hen applied o c ea e he inal
model. In his s uc u al model, pos auma ic s ess
symp oms we e eg essed on pe i auma ic dissocia-
ion, auma- ela ed memo y, and wa auma, while
auma- ela ed memo y quali y was eg essed on pe i-
auma ic dissocia ion. The i o he inal model and i s
es ima ed pa ame e s we e hen e alua ed.
All analyses we e ca ied ou using R (R Co e
Team, 2016) and he la aan package (Rosseel, 2012).
Fo s uc u al equa ion modelling, ull in o ma ion
maximum likelihood es ima ion wi h boo s apped
s anda d e o s om 5000 esamples was used.
Asymme ic con idence in e als based on bias-co -
ec ed boo s ap es ima es we e cons uc ed o o al,
indi ec , and di ec e ec s o ensu e accu a e assess-
men o hei signi icance and ake in o accoun he
non-no mal dis ibu ion o he indi ec e ec
(MacKinnon, Lockwood, & Williams, 2004).
3. Resul s
3.1. Desc ip i e esul s
Ou o an o iginal sample o 240 pa icipan s 49%
we e gi ls. A majo i y li ed in u ban a eas (86%), 12%
in e ugee camps, and 3% in illages. A qua e o
a he s (25%) and 8% o mo he s had uni e si y-le el
educa ion, while 24% o a he s and 42% o mo he s
had only inished seconda y le el. Mo he s we e on
a e age 37.6 and a he s 42.4 yea s old. The e was a
high a e o unemployed a he s (49%), which co e-
sponds wi h gene al Pales inian s a is ics in he Gaza
S ip du ing he in e na ional siege and economic
blockade (UN OCHA, 2009). Mos o he mo he s
(98%) wo ked a home. The numbe o auma ic
e en s expe ienced by he pa icipa ing child en a -
ied be ween 1–21, he mean and he median being
eigh e en s.
Ou o he 240 child en assessed a T1, T3 mea-
su emen s we e a ailable o 197. The e we e no
e usals o pa icipa e a T3 –ins ead, d opou s
we e child en who changed schools, d opped ou o
school al oge he o we e no p esen a school du -
ing measu emen s a T3 o o he easons. The e
we e no signi ican di e ences be ween d opou s
and hose emaining in age, numbe o auma ic
expe iences o PTSS a T1. Howe e , signi ican ly
mo e boys han gi ls d opped ou be o e T3 (25.2%
boys s. 14.9% gi ls, χ
2
(1) = 8.54, p = .003), and
d opou s epo ed mo e pe i auma ic dissocia ion
(M= 7.19 s. M= 6.17, 95% CI
di
[.07, 1.96],
(238) = 2.23, p= .03). Con olling o gende ,
d opou did no signi ican ly p edic le el o pe i au-
ma ic dissocia ion, sugges ing ha he di e ence was
mos ly explained by highe pe i auma ic dissocia ion
among boys o e all.
3.2. Di ec and media ed e ec s
Table 1 p esen s he bi a ia e co ela ions be ween a i-
ables included in he s uc u al equa ion model. The
measu emen model i he da a well (χ
2
(11) = 12.53,
p= .325, RMSEA = .02, 90% CI [.00, .08], CFI = 0.99,
TLI = 0.98, SRMR = .04). The inal s uc u al equa ion
model also had a good i (χ
2
(12) = 12.84, p= .381,
RMSEA = .02, 90% CI [.00, .08], CFI = 0.99, TLI = 0.99,
SRMR = .04).
The inal model wi h es ima ed pa ame e s is
shown in Figu e 1. The inal model explained 40.0%
o he a iance in he la en pos auma ic s ess symp-
oms a iable (R
2
= .399, p< .0001). As hypo hesized,
PD a h ee mon hs pos -wa signi ican ly p edic ed
PTSS six mon hs la e (uns anda dized o al
Table 1. Ze o-o de bi a ia e co ela ions be ween pe i au-
ma ic dissocia ion, auma memo y quali y, auma ic e en s,
and pos auma ic s ess symp oms.
Measu e 1 2 3 4 5 6
1 Pe i auma ic
dissocia ion
2 T auma memo y quali y .33***
3 T auma ic e en s .22** .11
4 In usions .29*** .41*** .16*
5 A oidance .07 .23** −.03 .20**
6 Dyspho ia .20** .25** .17* .25** .02
7 Hype a ousal .14* .27*** .10 .22** .07 .25***
N= 197. * p< .05; ** p< .01; *** p< .001
4K. PELTONEN ET AL.
Downloaded by [Tampe e Uni e si y] a 03:59 29 No embe 2017

e ec = .094, 95% CI [.046, .15]; ully s anda dized
e ec = .36, SE =.09,p< .0001). In line wi h ou
second hypo hesis, pe i auma ic dissocia ion had an
indi ec e ec on pos auma ic symp oms ia e ec s
on auma memo y quali y (uns anda dized indi ec
e ec = 0.043, 95% CI [.023, .073]; ully s anda dized
e ec = .17, SE =.05,p= .001). Howe e , e en aking
his indi ec e ec in o accoun , he di ec pa h om
PD o PTSS was also s ill signi ican (uns anda dized
e ec = .051, 95% CI [.004, .10]; ully s anda dized
e ec = .20, SE =.09,p= .03), indica ing pa ial, bu
no o al, media ion.
4. Discussion
Dissocia ion du ing exposu e o auma ic e en s is
conside ed a se e e isk o he su i o ’s men al
heal h, and e idence o his is subs an ial among
adul s (e.g. Oze e al., 2003). Along hese lines, ou
esul s showed ha child en’s sel - epo ed dissocia-
ion (PD) du ing hei exposu e o ecen wa auma
p edic ed pos auma ic s ess (PTSD) symp oms
nine mon hs pos -wa . Ou indings u he con-
i med ha he associa ion be ween PD and PTSD
symp oms was pa ially media ed by dys unc ional
memo y p ocessing o auma. This is in acco dance
wi h heo ies sugges ing ha isks and main enance
o PTSD a e due o de icien encoding o auma ic
memo ies and la e dys unc ional ecalling and p o-
cessing o e en s, as well as ailu e in symboliza ion
and in eg a ion o auma ic scenes (B ewin,
Dalgleish, & Joseph, 1996; Ehle s & Cla k, 2000).
The impo ance o PD in p edic ing PTSD among
hese Pales inian child en concu s wi h adul su i o s
o wa and peace- ime aumas (Lens el -Mulde s e al.,
2008; Thomas e al., 2012) bu di e s om some ind-
ings among child en exposed o single peace- ime
auma (Dalgleish e al., 2008). The impo ance o PD
as a se e e isk o PTSD symp oms among wa -a ec ed
Pales inian child en may lie in he ch onici y o li e
h ea and ad e si ies. I is possible ha pa icipa ing
child en aced mul iple eminde s o h ea s and
ho o s, which ac i a ed hei wa - ela ed ulne abil-
i ies. Due o he in e na ional boyco and Is aeli mili-
a y siege hei amilies con inued o li e in highly
insecu e and dep i ed condi ions in e e ing wi h op i-
mal eco e y, amily li e, and auma p ocessing.
As hypo hesized, dys unc ional auma- ela ed
memo ies media ed he associa ion be ween PD on
PTSD symp oms. These memo ies we e ypically
uncon ollable and agmen ed, and o en b ough
back ho i ic scenes wi h possible s ong senso y
and p ocedu al cues, such as odou s o u gency o
lee. We could no de ec p e ious media ion analyses
wi h auma- ela ed memo ies explaining he impo -
ance o PD on PTSD, bu he e is e idence o a oi-
dan coping s yle and hough supp ession o he
auma ic e en as media o s (Engelha d e al., 2003;
Pacella e al., 2011), as well as loss o con ol and
eelings o helplessness and li e- h ea (Ge shuny,
Cloi e, & O o, 2003). These esul s indica e, simila
o ou s, ha pe i auma ic dissocia ions nega i ely
al e su i o s’a emp s o p ocess hei auma ic
expe iences, which in u n o m a men al heal h.
Fu he s udies should simul aneously es mul iple
media ing pa hs be ween child en’s dissocia ion du -
ing auma and a ious men al heal h and de elop-
men al p oblems.
In ou model o auma- ela ed memo ies media ing
be ween PD and PTSD symp oms, child en’s pe sonal
exposu e o wa auma was no associa ed wi h he
la en cons uc o PTSD symp oms nine mon h a e -
wa ds. Ye , co ela ion analysis e ealed ha he wa
impac s may be symp om-speci ic, as high exposu e
co ela ed wi h in usi e and dyspho ia symp oms,
bu no wi h a oidance o hype a ousal. Analysis also
showed ha a oidance symp oms did no co ela e wi h
o he PTSD symp oms, which may hin a hei psy-
chological unc ionali y in ch onic insecu e and ad e se
condi ions. Ea lie indings among Pales inian child en
simila ly showed ha he accumula ion o auma ic
wa e en s was no a signi ican p edic o o PTSD
symp oms (Pel onen, Qou a, El Sa aj, & Punamäki,
2010). We sugges ha he na u e o auma ic e en s
ma e s mo e han he sole numbe s, as, o ins ance,
Figu e 1. S uc u al equa ion model o auma- ela ed memo y media ing he e ec o pe i auma ic dissocia ion on pos au-
ma ic s ess diso de symp oms. Fully s anda dized maximum likelihood es ima es o pa h coe icien s p esen ed. Residual
a iances omi ed o cla i y.
No e: *p < .05; **p < .01; ***p < .001
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 5
Downloaded by [Tampe e Uni e si y] a 03:59 29 No embe 2017
wi nessing ho i ying scenes wi h mul iple senso y s i-
muli may o m especially se e e isk o in usi e symp-
oms. Clinically, i would be pi o al o know how
child en emembe he auma ic si ua ion, wha mean-
ings and associa ions hey inco po a e o i , and how
hey ha e a emp ed o cope wi h and p ocess he
auma.
Knowledge abou he cogni i e, emo ional, and
psychophysiological p ocesses unde lying he link
be ween auma and PTSD and o he symp oms is
pi o al when ailo ing he apy and ea men o
wa -a ec ed child en. Cogni i e beha iou al he -
apy (CBT) app oaches aim o in eg a e sha e ed
psychic p ocesses, including auma memo ies,
in o in eg a ed and con ollable li e his o ies
(Pel onen & Punamäki, 2010). Howe e , ea men
o dissocia ion is no a ou ine elemen in hese
ea men s (Schaue & Elbe , 2015). Ou esul s
on bo h di ec and pa ially media ed impac s o
PD on pos auma ic symp oms sugges ha chil-
d en migh need speci ic help in dealing wi h and
p ocessing dissocia i e s a es ha may be con-
s an ly e-e oked in pos -wa condi ions. Se e e
PD in e e es wi h op imal eco e y om auma,
which equi es mul imodal and symbolic p oces-
sing o auma ic expe iences.
This esea ch dese es c i icism o he sel -
epo ed na u e o he measu es and he pa ly
c oss-sec ional se ing. A e iew conce ning adul
pa ien s concluded ha he associa ion be ween dis-
socia ion and memo y dys unc ion was signi ican
when based on sel - a ings, bu less p ominen
when a e -coded o compu e -gene a ed measu es
we e used (Beda d-Gilligan & Zoellne , 2012). The
esul s should hus be eplica ed in a se ing wi h
clinical in e iews, obse ed dissocia ion da a, and
be e measu es o memo y agmen a ion and bias.
Fu he , he ac ha auma- ela ed memo y quali y
and PTSD symp oms we e assessed a he same ime
is an impo an limi a ion o his media ion analysis.
Al hough a measu e o PTSD symp oms used in his
s udy (CRIES) has shown adequa e eliabili y and
alidi y in Pales inian samples (Koll ei e al.,
2012), i showed ela i ely modes eliabili y in his
ial.
Acknowledgemen s
We a e g a e ul o he child en and hei amilies o
hei pa icipa ion and o he Academy o Finland (#
215555) o he inancing o he s udy. This s udy could
no ha e been ealized wi hou he g ea commi ed
ield wo ke s Mohmed Shame, Mohmed Mo e , Amel
Hossen, Reham Faed, and Ahmed Syied, who wo ked
unde ex emely ha sh condi ions in he a e ma h o
wa . We’d like o hank he Minis y o Educa ion, and
he headmas e s and eache s o he schools who kindly
helped us du ing he da a collec ion.
Disclosu e s a emen
No po en ial con lic o in e es was epo ed by he
au ho s.
Funding
This wo k was suppo ed by Academy o Finland
[#215555].
No es on con ibu o
All au ho s (K.P, S.K, J.S, S.Q, R-L.P) ha e ead and
app o ed he inal manusc ip . All au ho s ha e: (1) ha e
made subs an ial con ibu ions o he concep ion and
design, o acquisi ion o da a, o analysis and in e p e a ion
o da a; AND (2) ha e been in ol ed in d a ing he manu-
sc ip o e ising i c i ically o impo an in ellec ual
con en ; AND (3) ha e gi en inal app o al o he e sion
o be published.
Re e ences
Al awil, M., Nel, P. W., Aske , A., Sama a, M., & Ha old,
D. (2008). The e ec s o ch onic wa auma among
Pales inian child en. In M. Pa sons (Ed.), Child en: The
in isible ic ims o wa - An in e disciplina y s udy.
Pe e bo ough: DSM Technical Publica ions L d.
Ame ican Psychia ic Associa ion. (2013). Diagnos ic and
s a is ical manual o men al diso de s (5 h ed.).
Washing on, DC: Au ho .
Ap el,B.A.,O e,C.,Inslich ,S.S.,McCaslin,S.E.,
Henn-Haase,C.,Me zle ,T.J.,&Ma ma ,C.R.
(2011). P e auma ic p olonged ele a ion o sali a y
MHPG p edic s pe i auma ic dis ess and symp oms
o pos - auma ic s ess diso de . Jou nal o
Psychia ic Resea ch,45(6), 735–741. doi:10.1016/j.
jpsychi es.2010.11.016
Beda d-Gilligan, M., & Zoellne , L. A. (2012). Dissocia ion
and memo y agmen a ion in pos - auma ic s ess dis-
o de : An e alua ion o he dissocia i e encoding
hypo hesis. Memo y,20, 277–299. doi:10.1080/
09658211.2012.655747
Be ancou , T., Newnham, E., Layne, C., Kim, S., S einbe g,
A., Ellis, H., & Bi man, D. (2012). T auma his o y and
psychopa hology in wa -a ec ed e ugee child en
e e ed o auma- ela ed men al heal h se ices in
he Uni ed S a es. Jou nal o T auma ic S ess,25, 682–
690. doi:10.1002/j s.21749
B ewin, C. R., Dalgleish, T., & Joseph, S. (1996). A dual
ep esen a ion heo y o pos auma ic s ess diso de .
Psychological Re iew,103(4), 670–686. doi:10.1037/0033-
295X.103.4.670
B ewin, C. R., Dalgleish, T., & Joseph, S. A. (1996). Dual
ep esen a ion heo y o pos auma ic s ess diso de .
Psycholoy Re iew,103, 670–686.
Bui, E., B une , A., Allenou, C., Camassel, C., Raynaud, J.-
P., Claude , I., . . . Schmi , L. (2010). Pe i auma ic eac-
ions and pos auma ic s ess symp oms in school-aged
child en ic ims o oad a ic acciden . Gene al
Hospi al Psychia y,32(3), 330–333. doi:10.1016/j.
genhosppsych.2010.01.014
Ca ani, C., Schaue , E., Elbe , T., Missmahl, I., Be e, J.-P.,
& Neune , F. (2009). Wa auma, child labo , and
6K. PELTONEN ET AL.
Downloaded by [Tampe e Uni e si y] a 03:59 29 No embe 2017
amily iolence: Li e ad e si ies and PTSD in a sample o
school child en in Kabul. Jou nal o T auma ic S ess,22,
163–171. doi:10.1002/j s.20415
Dalgleish, T., Meise -S edman, R., Kassam-Adams, N.,
Ehle s, A., Wins on, F., Smi h, P., . . . Yule, W. (2008).
P edic i e alidi y o acu e s ess diso de in child en
and adolescen s. B i ish Jou nal o Psychia y,192, 392–
393. doi:10.1192/bjp.bp.107.040451
Ehle s, A., & Cla k, D. M. (2000). A cogni i e model o
pos auma ic s ess diso de . Beha iou Resea ch and
The apy,38,319–345. doi:10.1016/s0005-7967(99)00123-0
Engelha d, I. M., an den Hou , M. A., Kind , M., A n z,
A., & Schou en, E. (2003). Pe i auma ic dissocia ion
and pos auma ic s ess a e p egnancy loss: A p o-
spec i e s udy. Beha iou Resea ch and The apy,41,
67–78. doi:10.1016/S0005-7967(01)00130-9
Ge shuny, B. S., Cloi e, M., & O o, M. W. (2003).
Pe i auma ic dissocia ion and PTSD se e i y: Do e en
ela ed ea s abou dea h and con ol media e hei ela-
ion? Beha iou Resea ch and The apy,41, 157–166.
doi:10.1016/S0005-7967(01)00134-6
Kangaslampi, S., Punamäki, R.-L., Qou a, S., Diab, M., &
Pel onen, K. (2016). Psychosocial g oup in e en ion
among wa -a ec ed child en: An analysis o changes in
pos auma ic cogni ions. Jou nal o T auma ic S ess,
29, 479–582. doi:10.1002/j s.22149
Kassam-Adams, N., Palmie i, P. A., Ro k, K., Delahan y, D.
L., Kena dy, J., Kohse , K. L., & McG a h, C. (2012).
Acu e s ess symp oms in child en: Resul s om an in e -
na ional da a a chi e. Jou nal o he Ame ican Academy o
Child and Adolescen Psychia y,51,812–820.
doi:10.1016/j.jaac.2012.05.013
Klasen, F., Oe ingen, G., Daniels, J., Pos , M., Hoye , C., &
Adam, H. (2010). Pos auma ic esilience in o me
Ugandan child soldie s. Child De elopmen ,81, 1096–
1113. doi:10.1111/j.1467-8624.2010.01456.x
Koll ei , S., Lange-Nielsen, I. I., Thabe , A. A. M.,
Dy eg o , A., Pallesen, S., Johnsen, T. B., & Labe g, J.
C. (2012). Risk ac o s o PTSD, anxie y, and dep ession
among adolescen s in Gaza. Jou nal o T auma ic S ess,
25, 164–170. doi:10.1002/j s.21680
Lanius, R. A., Bluhm, R., Lanius, U., & Pain, C. (2006). A
e iew o neu oimaging s udies in PTSD: He e ogenei y
o esponse o symp om p o oca ion. Jou nal o
Psychia ic Resea ch,40, 709–729. doi:10.1016/j.
psychi es.2005.07.007
Lens el -Mulde s, G., an De Ha , O., an Och en, J. M.,
an Son, M. J. M., S eele, K., & B eeman, L. (2008).
Rela ions among pe i auma ic dissocia ion and pos -
auma ic s ess: A me a-analysis. Clinical Psychology
Re iew,28(7), 1138–1151. doi:10.1016/j.cp .2008.03.006
MacKinnon, D., Lockwood, C., & Williams, J. (2004).
Con idence limi s o he indi ec e ec : Dis ibu ion o he
p oduc and esampling me hods. Mul i a ia e Beha io al
Resea ch,39(1), 99. doi:10.1207/s15327906mb 3901_4
Ma ma , C. R., Weiss, D. S., & Me zle , T. (1998).
Pe i auma ic dissocia ion and pos auma ic s ess dis-
o de . In T. J. D. B emne & C. R. Ma ma ( oim.),
T auma, memo y and dissocia ion (pp. 229–252).
Washing on, DC: Ame ican Psychia ic P ess.
Ma shall, G. N., O lando, M., Jaycox, L. H., Foy, D. W., &
Belzbe g, H. (2002). De elopmen and alida ion o a
modi ied e sion o he Pe i auma ic Dissocia i e
Expe iences Ques ionnai e. Psychological Assessmen ,
14, 123–134. doi:10.1037/1040-3590.14.2.123
Meise -S edman, R., Dalgleish, T., Smi h, P., Yule, W.,
B yan , B., Ehle s, A., . . . Wins on, F. (2007).
Dissocia i e symp oms and he acu e s ess diso de
diagnosis in child en and adolescen s: A eplica ion o
he Ha ey and B yan (1999) s udy. Jou nal o
T auma ic S ess,20(3), 359–364. doi:10.1002/j s.20211
Meise -S edman, R., Smi h, P., Yule, W., & Dalgleish, T. (2007).
The T auma Memo y Quali y Ques ionnai e: P elimina y
de elopmen and alida ion o a measu e o auma memo y
cha ac e is ics o child en and adolescen s. Memo y,15,
271–279. doi:10.1080/09658210701256498
Ol , M., A mou , C., B ewin, C., Cloi e, M., Fo d, J. D.,
He lihy, J., & Tu ne , S. (2015). T auma and PTSD:
Se ing he esea ch agenda. Eu opean Jou nal o
Psycho auma ology,6, 28092. doi:10.3402/ejp . 6.28092
Oze , E. J., Bes , S. R., Lipsey, T. L., & Weiss, D. S. (2003).
P edic o s o pos auma ic s ess diso de and symp-
oms in adul s: A me a-analysis. Psychological Bulle in,
129,52–73. doi:10.1037/0033-2909.129.1.52
Pacella, M. L., I ish, L., Os owski, S. A., Sledjeski, E.,
Ciesla, J. A., Fallon, W., . . . Delahan y, D. L. (2011).
A oidan coping as a media o be ween pe i auma ic
dissocia ion and pos auma ic s ess diso de symp-
oms. Jou nal o T auma ic S ess,24, 317–325.
doi:10.1002/j s.20641
Palosaa i, E., Punamäki, R.-L., Diab, M., & Qou a, S.
(2013). Pos auma ic cogni ions and pos auma ic
s ess symp oms among wa -a ec ed child en: A c oss-
lagged analysis. Jou nal o Abno mal Psychology,122,
656–661. doi:10.1037/a0033875
Pel onen, K., & Punamäki, R.-L. (2010). P e en i e in e -
en ions among child en exposed o auma o a med
con lic : A li e a u e e iew. Agg essi e Beha io ,36,95–
116. doi:10.1002/ab.20334
Pel onen, K., Qou a, S., El Sa aj, E., & Punamäki, R.-L.
(2010). Mili a y auma and social de elopmen : The
mode a ing and media ing oles o pee and sibling
ela ions in men al heal h. In e na ional Jou nal o
Beha io al De elopmen ,34, 554–560. doi:10.1177/
0165025410368943
R Co e Team. (2016). R: A language and en i onmen o
s a is ical compu ing. Vienna: R Founda ion o
S a is ical Compu ing.
Rosseel, Y. (2012). la aan: An R package o s uc u al
equa ion modeling. Jou nal o S a is ical So wa e,48
(2), 1–36. doi:10.18637/jss. 048.i02
Schaue ,M.,&Elbe ,T.(2015). Dissocia ion ollowing au-
ma ic s ess. Zei sch i ü Psychologie/Jou nal o Psychology,
218(2), 109–127. doi:10.107/0044-3409/a000018
Simms, L. J., Wa son, D., & Doebbeling, B. (2002).
Con i ma o y ac o analyses o pos auma ic s ess
symp oms in deployed and non-deployed e e ans o
he Gul Wa . Jou nal o Abno mal Psychology,111,
637–647. doi:10.1037/0021-843X.111.4.637
Smi h,P.,Pe in,S.,Dy eg o ,A.,&Yule,W.(2003). P incipal
componen s analysis o he impac o e en scale wi h chil-
d en in wa . Pe sonali y and Indi idual Di e ences,34,315–
322. doi:10.1016/S0191-8869(02)00047-8
Spiegel,D.,Koopmen,C.,Ca dena,C.,&Classen,C.(1996).
Dissocia i e symp oms in he diagnosis o acu e s ess dis-
o de . In T. L. K. Michelson & W. J. Ray ( oim.), Handbook
o dissocia ion (pp. 367–380). New Yo k: Plenum P ess.
Thabe , A., & Vos anis, P. (2015). Impac o auma on
Pales inian child en’s and he ole o coping s a egies.
B i ish Jou nal o Medicine & Medical Resea ch,5, 330–
340. doi:10.9734/BJMMR/2015/9578
Thomas, E., Saumie , D., & B une , A. (2012).
Pe i auma ic dis ess and he cou se o pos auma ic
s ess diso de symp oms: A me a-analysis. The
EUROPEAN JOURNAL OF PSYCHOTRAUMATOLOGY 7
Downloaded by [Tampe e Uni e si y] a 03:59 29 No embe 2017
Canadian Jou nal o Psychia y,57(2), 122–129.
doi:10.1177/070674371205700209
UN OCHA. (2009). Locked in: The humani a ian impac o he
wo yea blockade on he Gaza S ip Special ocus 2009.Eas
Je usalem: Uni ed Na ions O ice o he Coo dina ion o
Humani a ian A ai s occupied Pales inian Te i o y.
an de Velden, P. G., & Wi mann, L. (2008). The inde-
penden p edic i e alue o pe i auma ic dissocia ion
o PTSD symp oma ology a e ype I auma: A
sys ema ic e iew o p ospec i e s udies. Clinical
Psycholy Re iew,28, 1009–1020. doi:10.1016/j.
cp .2008.02.006
8K. PELTONEN ET AL.
Downloaded by [Tampe e Uni e si y] a 03:59 29 No embe 2017