Trauma Skips a Generation

Does intergenerational transmission of trauma skip a generation?

No meta-analytic evidence for tertiary traumatization with third

generation of Holocaust survivors

Abraham Sagi-Schwartza*, Marinus H. van IJzendoornb andMarian J. Bakermans-Kranenburgb

aCenter for the Study of Child Development, University of Haifa, Israel;bCentre for Child and Family Studies, Leiden University, the Netherlands

In a series of meta-analyses with the second generation of Holocaust survivors, noevidence for secondary traumatization was found (Van IJzendoorn, Bakermans-Kranenburg, & Sagi-Schwartz, 2003). With regard to third generation traumatization,various reports suggest the presence of intergenerational transmission of trauma. Somescholars argue that intergenerational transmission of trauma might skip a generation.Therefore, we focus in this study on the transmission of trauma to the third generationoffspring (the grandchildren) of the first generation’s traumatic Holocaust experiences(referred to as ‘‘tertiary traumatization’’), and we present a narrative review of thepertinent studies. Meta-analytic results of 13 non-clinical samples involving 1012participants showed no evidence for tertiary traumatization in Holocaust survivorfamilies. Our previous meta-analytic study on secondary traumatization and the presentone on third generation’s psychological consequences of the Holocaust indicate aremarkable resilience of profoundly traumatized survivors in their (grand-)parental roles.

Keywords: Holocaust; tertiary traumatization; meta-analysis

Introduction

Whereas clinically based reports on offspring of Holocaust survivors point tointergenerational transmission of traumatic experiences, more controlled studies havenot found much psychopathology (Van IJzendoorn et al., 2003), except when second-generation subjects were confronted with life-threatening situations (Baider, Peretz,Hadani, Perry, Avramov, & De Nour, 2000; Solomon, Kotler, & Mikulincer, 1988; seeVan IJzendoorn et al., 2003). Thus, a germane question is whether the trauma has been‘‘passed on’’ to the offspring in the third generation (Bar-On et al., 1998). The question isof critical importance because of the large scale of the Holocaust. The existence of long-term psychological effects of the Holocaust on the survivors and their offspring still keepsthe scientific and clinical literature divided (Bar-On et al., 1998).

This issue is not only important for the study of the Holocaust. Unfortunately, duringthe past century, genocide has not been restricted to World War II. In the Internationalhandbook of multigenerational legacies of trauma (Danieli, 1998), genocides in Armenia,

*Corresponding author. Email: [email protected] or [email protected] [email protected]

Attachment & Human Development

Vol. 10, No. 2, June 2008, 105–121

ISSN 1461-6734 print/ISSN 1469-2988 online

� 2008 Taylor & Francis

DOI: 10.1080/14616730802113661

http://www.informaworld.com

Cambodia, former Yugoslavia, Rwanda, and Nigeria are mentioned, and these constituteonly a selection. The Holocaust was a unique genocide because of its scale, its almostindustrial design, and its uselessness in political, economic, or military respects (Lacqueur,2001). Nevertheless, we may learn from the Holocaust survivors and their (grand-)childrenabout the long-term and intergenerational effects of traumatic experiences, and developinsights into the fate of survivors and offspring of more recent and future genocidalcatastrophes.

In order to resolve the divergence of the clinical and non-clinical findings onintergenerational transmission of trauma, between qualitative and quantitative ap-proaches, and between methodologically more robust versus less robust studies, wedeveloped a programmatic series of studies to address the issue. We began with our firstpublished study (Sagi-Schwartz et al., 2003) in which careful matching of Holocaustsurvivors and comparisons was employed to form a research design with three generations,including 98 families with grandmother, mother, and their infant, who were engaged inattachment- and trauma-related interviews, questionnaires, and observational procedures.Holocaust child survivors (now grandmothers) showed severe signs of traumatic stress andmore often lack of resolution of trauma than comparisons, but they were not impaired intheir general adaptation. Also, the traumatic effects did not transmit across secondgeneration (mothers) and third generation (infants). We concluded that Holocaust childsurvivors may have been able to protect their offspring from their war experiences,although they themselves still suffered from the Holocaust.

Because the findings of our first study ran against the wide spread belief that Holocaustsurvivors do transmit the trauma even across more than one generation, we felt that the fieldmight be reluctant to accept our conclusions despite the fact that very robust sampling andmethodology had been employed in our study (for more details, see Sagi-Schwartz et al.,2003). Therefore our next step was to carry out a series of meta-analyses on 32 samplesinvolving 4418 second generation participants; the hypothesis was tested that secondarytraumatization in Holocaust survivor families exist. We found that, largely, there is noevidence for secondary traumatization (Van IJzendoorn et al., 2003). More specifically,secondary traumatization emerged only in studies that consisted of participants who wererecruited through clinical practices or Holocaust survivor support groups and similarorganizations (‘‘select’’ samples). In a set of adequately designed studies, with what wasreferred to as ‘‘non-select’’ samples, no evidence for the influence of the parents’ traumaticHolocaust experiences on their children was found. A stress-diathesis model was used tointerpret the remarkable resilience in Holocaust survivors and their offspring (Paris, 2000).

Given the fact that there does not seem to be solid empirical evidence for a higherprevalence of psychological problems in the second-generation offspring, it may be arguedthat no transmission to the third generation should be expected either, especially with non-select samples. At the same time, studies such as ‘‘Multigenerational occurrence ofsurvivor syndrome symptoms in families of Holocaust survivors’’ (Rubenstein, Cutter, &Templer, 1989–1990) and ‘‘The intergenerational transmission of increased anxiety traitsin third-generation Holocaust survivors’’ (Wetter, 1998), characterize many of the existingreports about the intergenerational effects of the Holocaust. Such far reaching statementshave become ingrained to a large extent in the belief system within the professional as wellas the wider community (not necessarily with sound conceptual or theoretical basis forsuch a transmission) and therefore there is a need to set the record straight on the issue oftertiary traumatization by an integrative review and analysis of all available studies.

Also, because some scholars still argue that intergenerational transmission of profoundtraumas might skip a generation, using metaphorically the case of some biologically

106 A. Sagi-Schwartz et al.

inherited diseases (Bulmer, 1998), the field still seems to beg for further systematicexamination of third generation effects, even in light of the absence of evidence-basedsecond generation effects. A psychological model for transmission to the third generationmight be the idea of more intensive learning and communication of the third generationabout the Holocaust compared to the second generation. The era of the ‘‘conspiracy ofsilence’’ approached an end in the 1980s, and survivors gradually began to be consideredheroes more than ‘‘lambs led to the slaughter’’ (Bar-On, 1999). Grandchildren were urgedto learn about their grandparents’ past through interviews for school roots projects. Forthe aging grandparents, time was ripe to return to their past and to create a sense ofcoherence of their Holocaust experiences (Van der Hal-van Raalte, Van IJzendoorn, &Bakermans-Kranenburg, in press). Since the last decade of the past century, thousands ofstudents have participated in Holocaust-centered excursions to Poland, and it is stillunclear what meaning this confrontation with the Holocaust might have (Chaitin, 2000),but traumatizing effects on at least some of the participants cannot be excluded.

Lastly, as will be discussed, one may also raise the possibility of domain-specific effects,namely that third generation effects may emerge in one area of functioning (e.g.,internalizing or externalizing symptoms) but not in other areas such as attachment.Therefore, in this review and meta-analysis we wish to shed further light on thetransmission of the Holocaust traumatic experiences, this time to the third generationoffspring.

Narrative review of third generation Holocaust studies

Qualitative case studies in non-clinical groups

In her first qualitative study, Chaitin (2000) examined the meaning of the Holocaust forIsraeli families of survivors in which there are three generations, and participants wereasked to tell their life story. The second and the third generations tended to value bothfamily teamwork and more non-conforming behavior. The second study (Chaitin, 2002)looked at how three generations in Israeli families of Holocaust survivors work throughthe past. The interviews were analyzed for central themes and values. For all generations,family relationships and the emotional difficulty of dealing with the Holocaust wereimportant. The grandchildren stressed both close family ties and conflict, but alsoemphasized the importance of teaching younger generations about the Holocaust. It wasconcluded that the working through process poses different problems for each generation.The case study by Bar-On and Gilad (1994) exhibits a diverse picture of optimism,coping, and difficulties, in a narrative that portrays various aspects in the life of theinterviewees.

In an American study (Hogman, 1998) that adopted a qualitative methodology with afew cases, the author described both second and third generations as a group of purposefulpeople who believe in the preciousness of life. They were also described as thoughtful,empathic, and as being aware of social and political inequities. Moreover, the third-generation members of the family seemed to feel somewhat burdened by the legacy of theHolocaust and at the same time they felt obligated to stand up for Jewish identity and besuccessful in their own lives. The author suggested that as the third generation’s identitybecomes intimately intertwined with its origins, a feeling of continuity is developed whichprovides a sense of affirmation of the group and of the self. It also includes an awareness ofthe suffering of the Holocaust group and the suffering of other groups subjected toviolence throughout the world.

Attachment & Human Development 107

Clinical correlational and case studies

Five papers pertain to clinical samples. The three reports by Berger-Reiss (1997),Rosenthal and Rosenthal (1980), and Winship and Knowles (1996) are case studies thatprovide clinical impressions and interpretations. The first report was on the effects ofanxiety on third generation offspring in a therapy context. The second case report aimed tomake psychiatrists aware of what is being referred to as a ‘‘psycho-historical’’ approach tothe diagnosis and treatment of patients who are the third generation of the Holocaust, andthe need to identify the nature of the multigenerational processes within such families. Thelast report attempted to characterize what is referred to as ‘‘the transgenerational impactof cultural trauma’’ and its links to treatment of third generation survivors of theHolocaust.

Two more publications that concern clinical samples are quantitative in their design.The work of Bienstock (1989) compared third generation offspring of Holocaust survivorsand non-Holocaust survivors regarding their relationship to their maternal grandmothers.The study reported by Sigal, DiNicola, and Buonvino (1988) allowed for a comparisonbetween third-generation offspring with Holocaust versus non-Holocaust background.The study examined the reported complaints of patients in a child psychiatry clinic and itfound a large difference between the two groups, with an effect size of d ¼ 1.76 (95% CI1.29 * 2.23; p 5 .001, our re-computation), indicating that third generation survivorsdid function much less well, according to the parents’ reports, than offspring of non-Holocaust survivors. The study consisted of clinical participants only. In a non-clinicalsample without a comparison group, Jurkowitz (1996) found that openness ofcommunication between the second and third generation was related to a decrease indepression, shame, and guilt in the third generation. However, there was no effect ofproblem communication between the second and third generation on these three variables.

Quasi-experimental studies

We identified 13 third-generation Holocaust studies that aimed at comparing theadjustment of third generation children of Holocaust survivors with that of a comparisongroup. These so-called ‘‘quasi-experimental’’ investigations with more or less carefulcomparisons between third generation offspring of Holocaust survivors and their peerswith grandparents who were not Holocaust survivors were also quantitatively combined ina series of meta-analyses (see below). Six studies consisted of non-select samples and sevenstudies of select samples (corresponding to the terms used in our study with second-generation traumatization).

Non-select samples

Five out of the six studies with non-select samples were carried out in Israel, covering awide spectrum of outcome measures including aggression, communication, self-esteem,attachment, coping, and adjustment. In one study, Bachar, Cale, Eisenberg, and Dasberg(1994) examined aggression of early adolescents who were recruited from the main sectorsof the East European community of immigrants who came to Israel after the end of theWorld War II. They lived in urban areas and rural kibbutzim. Grandchildren of Holocaustsurvivors did not differ from controls on the level of reported aggressiveness. In threestudies, attachment security of the third generation was assessed. In one study (Sagi,Grossmann, Joels, Grossmann, Scharf, & Van IJzendoorn, 1999; Sagi-Schwartz et al.,


2003; Van IJzendoorn, Grossmann, Grossmann, Joels, Sagi, & Scharf, 1999) infantattachment security/insecurity (third generation) with the mother (second generation) wasassessed using the Strange Situation procedure (Ainsworth, Blehar, Waters, & Wall, 1978);no significant differences were found between the infant–mother attachment status ofchildren with and without Holocaust background of their grandmothers. In the other twostudies (Goldberg & Wiseman, 2006; Wiseman, 2005), two non-clinical high school-basedsamples consisted of late adolescents of Israeli-born parents and from intact families, halfhaving grandparents who suffered the Holocaust and half with no Holocaust background.In both studies, the Experiences in Close Relationships scale (Brennan, Clark, & Shaver,1998) was used to assess the adolescents’ appraisal of their attachment status, with scalesfor attachment anxiety and avoidance. In one study, no significant differences werereported on the attachment anxiety scale (Wiseman, 2005), whereas in another study(Goldberg & Wiseman, 2006) grandchildren of Holocaust survivors reported a higher levelof attachment anxiety than did their non-Holocaust counterparts, but similarly to the first-mentioned study (Wiseman, 2005) no differences were found on the attachment avoidancescale. In these two studies also no significant differences were found between grandchildrenof Holocaust survivors and comparisons on measures of communication and self-esteem.Given that the study was carried out during the period of terror bombing attacks in citiesin Israel, the higher attachment anxiety may be interpreted as indicating greatervulnerability to life-threatening and extremely stressful situations (comparable to Baideret al., 2000; Solomon et al., 1988). However, this explanation needs to be further exploredin future studies on the third generation of the Holocaust (H. Wiseman, personalcommunication, February 2008).

In one more study in Israel with third generation of adolescent grandchildren ofHolocaust survivors and their comparisons, Scharf (2007) differentiated between familiesin which both parents, one parent, or no parent were offspring of Holocaust survivors.They found that families with both parents being offspring of Holocaust survivors showedmost distress symptoms. The grandchildren in these families reported lower self-esteem,and their peers rated them as functioning poorer in Israeli military service (Scharf, 2007).Adolescents with one parent being Holocaust survivor offspring functioned similarly tothe comparisons without any Holocaust background.

Lastly, a large community study with a non-select sample of grandchildren was carriedout in Canada (Sigal & Weinfeld, 1989). In this study, parents rated their children (whowere the third generation children of Holocaust survivors or of a comparison group) usinga 50-item behavior problem checklist. The combined scores did not show a significantdifference between the two groups, but on three of the six factors that were extracted fromthe questionnaire the grandchildren of Holocaust survivors were functioning better thanthe comparisons. In sum, in the six studies with non-select samples the differences betweenoffspring of survivors and comparisons were found to be for the most part non-significant.

Select samples

In the seven studies with select samples also a wide range of measures were used, albeitmore of a clinical nature. The measures were: therapy use, SCL-90, fear, psychopathology,anxiety, depression, eating problems, partner and parent relationship, and adjustment. Allseven studies were conducted in the USA. Two studies found significant effects, i.e., thestudies by Huttman (2003) and Wetter (1998) reporting respectively more difficulties inrelations with parents and higher rates of anxiety and despression among third generationoffspring with Holocaust background. In another study (Gopen, 2001) assessing


‘‘normative’’ functioning, participants who were recruited during a memorial day for theHolocaust were asked to describe their intimate relationships and family climate; nosignificant differences emerged between those participants whose grandparents weresurvivors of the Holocaust and those who were not.

In a study by Liebenau (1992), focusing on various adjustment measures, theparticipants were referred from an organization known as Second Generation of LosAngeles, and from friends and family members of the investigator. Additionally, theinvestigator recruited subjects during the American Gathering of Holocaust Survivors inLos Angeles. Outcomes in this study were not compared to a control group but werecontrasted to existing norms on self-esteem, locus of control, behavior problems, andsocial problems to determine whether they were manifesting significantly higher or lowerlevels of adjustment, testing the hypothesis that individuals of third generationdescendants of Holocaust survivors would demonstrate significantly less strength andmore problems than the norm. All the hypotheses remained without support.

The remaining three select samples focused on psychological symptoms, psycho-pathology, and clinical outcomes. In a study carried out by Ganz (2002), young adultswho were grandchildren of Holocaust survivors and comparisons with no Holocaustbackground were recruited on the basis of the author’s personal network and bycirculating flyers in Jewish synagogues in New York City asking to volunteer to the study.No differences between the groups were found on psychological symptoms checklist andon the use of therapy. In another study testing for multigenerational occurrence ofpsychopathological symptoms in families of Holocaust survivors, third generation adultparticipants with Holocaust background were recruited through Jewish organizations andthe comparisons were friends and acquaintances referred by the participants who belongedto the Holocaust group (Rubenstein et al., 1989–1990). The authors inferred atransmission effect on the basis of various reported indicators of psychopathology. Ourown re-computations showed a significant third generation effect for aggression, but anon-significant overall effect based on the combined psychopathology measures used inthe study.

The last select study (Zelman, 1997) examined eating problems among third generationfemale participants ranging from age 14 to age 25. These grandchildren of Holocaustsurvivors were recruited from the records of the United States Holocaust MemorialMuseum in Washington, DC, and their comparisons without Holocaust background wererecruited from an undergraduate pool of students at the University of Hartford. The twogroups were not found to differ on eating problems.

In all, the set of select samples suggests a mixed picture of findings with both significantand non-significant differences between grandchildren of Holocaust survivors andcomparisons without Holocaust background. Moreover, a rather wide range of measuresand assessments were used in these studies, ranging from aggression to eating problems,anxiety, and attachment. Such a variety of measures may represent three global domainsof internalizing symptoms, externalizing symptoms, and attachment patterns. In the meta-analysis, we will differentiate between these dimensions.

A meta-analytic approach

In a research domain with conflicting results, the method of narrative review may beinsufficient to create a coherent picture (Cooper & Hedges, 1994). Counting studies withsupporting versus falsifying evidence might be an inadequate approach to reconcilingdiverging study outcomes, as it does not take into account the highly heterogeneous


quality and size of the studies (Kellermann, 2001). A quantitative analysis and synthesis ofthe tertiary traumatization literature is needed to come to a more definite conclusion.Through meta-analysis, it is possible to compute the average effect size across studies, andto explain differences in outcome between studies on the basis of study characteristics(Mullen, 1989; Rosenthal, 1991, 1995). Thus, in order to overcome the ‘‘clinical-sciencegap,’’ which leads to inconsistent conclusions, we present meta-analytic findings that arebased on all existing studies with third generation which meet the basic criteria forinclusion in a meta-analysis. Given the lack of a clear and adequate conceptual model thatmay endorse the existence of tertiary traumatization and given the mixture of findings inprior research, we left the question of transmission to the third generation open withoutassuming a specific hypothesis in comparing third generation offspring of Holocaustsurvivors with those of non-Holocaust survivors. We also explored whether anydifferences emerged in the areas of externalizing, internalizing, and attachment issues.

Methods

Data collection

Pertinent studies were collected systematically, using three different search strategies(Mullen, 1989; Rosenthal, 1991). First, PsychInfo, Medline, and PILOTS (a comprehen-sive database on posttraumatic stress) were searched with keywords ‘‘Holocaust,’’ ‘‘thirdgeneration,’’ ‘‘grandchildren,’’ and ‘‘survivors.’’ Second, the references of the collectedpapers, books, and book chapters were searched for relevant Holocaust studies. Third,some recent narrative reviews were used as a source for relevant papers, in particular theexhaustive review of Kellermann (2001).

Holocaust survivors spent the war in Nazi-occupied Europe, either in concentration/labor camps, or in various hideaway shelters, being ‘‘adopted’’ by gentile families, or usinga combination of escape and survival strategies. More often than not, they lost parents andother family members. ‘‘Second and third generation Holocaust survivors’’ have becomeaccepted terms to refer to offspring of Holocaust survivors (Solomon, 1998). For obviousreasons, the number of studies with third generation offspring is much smaller than that onfirst and second generation. Thus, our selection criteria were rather broad, in order toinclude as many Holocaust studies as possible, regardless of research design and platformof publication. We included any formal platform such as journals, books, PhDdissertations, conference presentations, and final reports to grant foundations.

The most important criterion was that the study should contain at least onecomparison group, and that it presented data to derive the pertinent meta-analyticstatistics from. As with our meta-analytic study on secondary traumatization (VanIJzendoorn et al., 2003), the idea was to test empirically also with third generation theinfluence of design features, and therefore not to exclude any quantitative study on a priorigrounds (Rosenthal, 1995). Case studies and qualitative publications were excludedbecause they do not fit into a meta-analysis paradigm. In Tables 1 and 2 we listed allexisting publications, including case studies and qualitative studies, so as to inform thereader about all available work in the field. As a result of our search, 23 papers wereidentified, of which 13 met the set of criteria for inclusion in the meta-analysis. For anoverview, see Table 1 for studies not included in the meta-analysis and Tables 2 and 3 forstudies included in the meta-analysis. All but one of the studies suitable for a meta-analyticanalysis were non-clinical, so that it was impossible to test the moderating role of clinicalstatus in our meta-analyses. We therefore decided that findings would be more robust if wekept the meta-analysis more homogenous by including only non-clinical samples.


Coding system

A coding system was used to rate every Holocaust study on design, sample, andmeasurement characteristics (see Table 2). We coded sample size (grandchildren ofHolocaust survivors and comparison group in the study) and recruitment as designcharacteristics. Studies were coded as ‘‘non-select’’ when participants were randomlysampled, e.g., from several neighborhoods or a population registry, or when the entireJewish population of a certain country was involved. They were coded as ‘‘select’’ whensamples were recruited through, e.g., Holocaust survivor meetings, personal contacts, oradvertisements. We also coded gender of the samples (male, female, or mixed). Elevenstudies were represented by both males and females, whereas one sample consisted of all-males only and one sample of all-female only. Moreover, we coded whether the samplewas clinical or non-clinical, and we registered the current country of residence of thesample (Israel, Canada, and USA).

We coded an overall type of outcome, namely adjustment, which was defined broadly,and involved positive indicators such as general adjustment, attachment security, selfesteem, partner relationship and family climate, close relationship, coping, and negativeindicators like anxiety/depression, aggression, eating problems, clinical referrals,psychopathology. All these constructs were measured with standard and validinstruments, commonly used for the assessment of mental health, posttraumatic stress,coping, adaptation, and maladaptation. Furthermore, we distinguished three categories offunctioning, relating to externalizing, internalizing, and attachment issues. Whenoutcomes in more than one domain of functioning were reported within a study, weselected the outcome that most unambiguously reflected one of the three domains offunctioning, and at the same time led to the largest numbers of effect sizes in the variousdomains (resulting in k ¼ 3 studies for externalizing, k ¼ 5 studies for internalizing, andk ¼ 5 studies for attachment, see Table 3). As an example, Rubenstein et al.’ s (1989–1990)study provided a combined outcome for psychopathology that was used in the

Table 1. Studies on third generation Holocaust survivors not included in the meta-analysis.

Author N GenderCountryof residence Outcome

Non-clinical samples 120

Bar-On and Gilad(1994)

1 Female Israel Themes and values/Qualitative

Chaitin (2002) 12 Mixed Israel Themes and values/QualitativeChaitin (2000) 9 Mixed Israel Themes and values/QualitativeHogman (1998) 7 Mixed USA Themes and values/QualitativeJurkowitz (1996)1 91 Mixed USA Communication openness/Quantitative

Clinical samples 162

Sigal et al. (1988)2 127 Mixed Canada Clinical referrals/QuantitativeBienstock (1989)3 30 Female USA Parents’ behavior (PBI)/QuantitativeBerger-Reiss (1997) 1 Female USA Clinical impressionsRosenthal andRosenthal (1980)

1 Male USA Clinical impressions

Winship andKnowles (1996)

3 Mixed UK Clinical impressions

1Quantitative data available but correlational study: no control.2Quantitative data available for meta-analysis but clinical study (d ¼ 1.76; 95% CI (1.29 * 2.23); p 5 .001).3Outcome measure is based on third generation’s report about parent’s behavior.


Table

2.

GeneraladaptationofthirdgenerationHolocaust

offspringin

non-clinicalstudiessuitable

formeta-analysis.

Author

NGender

Country

ofresidence

Outcome

d95%

CI

p

Totalsamples

1012

0.04

(70.14*

0.23)

.66

Non-selectsamples

Bacharet

al.(1994)

97

Mixed

Israel

Aggression

0.25

(70.15*

0.65)

.22

GoldbergandWisem

an(2006)

160

Mixed

Israel

Attachment/communication/self-esteem

0.16

(70.15*

0.47)

.32

Sagi-Schwartzet

al.(2003)

VanIJzendoorn

etal.(1999)

95

Mixed

Israel

Attachmentsecurity

0.07

(70.33*

0.47)

.73

Scharf

(2007)

79

Male

Israel

Distresscoping/problem

coping/

peer-reported

distressandfunctioning

0.03

(70.23*

0.29)

.82

SigalandWeinfeld

(1989)

118

Mixed

Canada

Conduct

problems/strangeness/

hypersensitivity/self-esteem

/psychopathology/coping

70.36

(70.73*

0.02)

.06

Wisem

an(2005)

67

Mixed

Israel

Attachment/communication/self-esteem

70.02

(70.51*

0.47)

.24

Totalnon-selectsamples

616

0.032

(70.11*

0.17)

.69

Selectsamples

Ganz(2002)

60

Mixed

USA

Therapyuse/SCL-90/Fear

0.11

(70.19*

0.41)

.83

Gopen

(2001)

72

Mixed

USA

Partner

relationship

andattachment

toparent

70.16

(70.63*

0.31)

.51

Huttman(2003)

74

Mixed

USA

Close

relationship

70.62

(70.99*

7.25)

.001

Liebenau(1992)1

36

Mixed

USA

Adjustment

70.71

(72.14*

0.72)

.33

Rubinsteinet

al.(1989–1990)

51

Mixed

USA

Psychopathology

0.27

(70.30*

0.84)

.35

Wetter(1998)

74

Mixed

USA

Anxiety/depression

0.73

(0.27*

1.19)

.002

Zelman(1997)

29

Fem

ale

USA

Eatingproblems

0.24

(70.54*

1.01)

.55

Totalselect

samples

396

0.07

(70.22*

0.35)

.65

1Outcomes

are

notcomparedto

acontrolgroupbutcontrasted

toexistingnorm

s.2Homogeneoussetofoutcomes.


meta-analysis on general adjustment, and an outcome for aggression (as part of thepsychopathology outcome) that was included in the externalizing category of the meta-analysis exploring the differences in functioning in the three domains.

Data analysis

Because the studies included in this series of meta-analyses reported various statistics, theoutcomes of all studies were re-computed with Mullen’s (1989) Advanced BASIC Meta-analysis program, and transformed into Cohen’s d (the standardized difference in means

Table 3. Externalizing, internalizing and attachment differences in non-clinical third generationHolocaust offspring.

Author N GenderCountryof residence Outcome d 95% CI p

ExternalizingBachar et al.(1994)

97 Mixed Israel Aggression 0.25 70.15 * 0.65 .22

Sigal andWeinfeld(1989)

118 Mixed Canada Conductproblems

70.30 70.67 * 0.07 .11

Rubinstein et al.(1989–1990)

51 Mixed USA Aggression 0.68 0.02 * 1.34 .04

Total 0.15 7 0.32 * 0.61 .54

InternalizingScharf (2007) 79 Male Israel Peer-reported

distress andfunctioning

70.06 70.51 * 0.39 .81

Ganz (2002) 60 Mixed USA Fear 70.06 70.58 * 0.46 .82Liebenau (1992)1 36 Mixed USA Self esteem 71.20 72.63 * 0.23 .10Wetter (1998) 74 Mixed USA Anxiety/

depression0.73 0.27 * 1.19 .002

Zelman (1997) 29 Female USA Eatingproblems

0.24 70.54 * 1.01 .55

Total 0.12 70.29 * 0.53 .56

AttachmentGoldberg andWiseman(2006)

160 Mixed Israel Attachment 0.25 70.06 * 0.57 .12

Sagi-Schwartzet al. (2003)

95 Mixed Israel Attachmentsecurity

0.07 70.33 * 0.47 .73

Van IJzendoornet al. (1999)

Wiseman (2005) 67 Mixed Israel Attachment 70.16 70.65 * 0.33 .52Gopen (2001) 72 Mixed USA Attachment

to parent70.22 70.70 * 0.25 .36

Huttman (2003) 74 Mixed USA Affectiverelationshipto parent

70.63 71.16 *70.10 .02

Total 70.032 70.22 * 0.15 .73

Contrast for effect sizes of the various domains: Qbetween ¼ 1.03, p ¼ .60.1Outcomes are not compared to a control group but contrasted to existing norms.2Homogeneous set of outcomes.


between the third generation of Holocaust survivors and comparisons). In several cases,we had to compute the effect sizes on the basis of means and standard deviations providedin the study report. When more than one outcome was reported (e.g., Wiseman, 2005),they were meta-analytically combined into one effect size for adjustment, that is Cohen’s d.Moreover, an overall effect size for general adjustment based on available positive andnegative indicators for adjustment was computed for each study in order to avoid countinga study or participant more than once.

The resulting set of effect sizes were inserted into Borenstein, Rothstein, and Cohen’s(2000) Comprehensive Meta-Analysis (CMA) program that computed fixed as well asrandom effect model parameters. CMA also computed confidence intervals around thepoint estimate of an effect size. Because the leading hypothesis in this area of research isthat the grandchildren of Holocaust survivors would be less well-adapted, we used thisdirected hypothesis and present here the 95% confidence boundaries of the point estimatesfor the effect sizes (with alpha set at .05; see Tables 2 and 3). Thus, for meta-analyticpurposes, we assigned positive signs to those effects that indicated the presence of a thirdgeneration effect (i.e., negative outcomes for the third generation compared tocomparisons without Holocaust background), and negative signs to effects that indicatedbetter outcomes for the Holocaust third generation offspring.

Significance tests and moderator analyses in fixed effects models are based on theassumption that differences between studies leading to differences in effects are notrandom, and that in principle the set of study effect sizes is homogeneous at the populationlevel. Significance testing is based on the total number of subjects, but generalization isrestricted to other participants that might have been included in the same studies of themeta-analysis (Rosenthal, 1995). Statistical inferences may be regarded as applying only tothe specific set of studies at hand (Hedges, 1994). In random effects models thisassumption is not made (Hedges & Olkin, 1985), and they allow for the possibility thateach separate study has its own population parameter. In random effects modelssignificance testing is based only on the total number of studies and generalization is to thepopulation of studies from which the current set of studies was drawn (Rosenthal, 1995). Ithas been argued that random effects models more adequately mirror the heterogeneity inbehavioral studies, and use non-inflated alpha levels when the requirement of homogeneityhas not been met (Hunter & Schmidt, 2000). In our meta-analyses, some data sets wereheterogeneous. In those cases, the random effects model parameters (significance,confidence intervals) were presented (see Tables 2 and 3).

The current analyses included 13 studies, including 1012 participants (grandchildren ofHolocaust survivors and comparisons). The sample sizes ranged from 29 (Zelman, 1997)to 160 (Goldberg & Wiseman, 2006). For each of the 13 samples, the standardizeddifference between the Holocaust and comparison group was computed (Cohen’s d;Mullen, 1989). For each sample, Fisher Z was computed as an equivalent to thecorrelation coefficient r (see Mullen, 1989). No outlying effect sizes were identified in theset of Holocaust studies on the basis of standardized z-values larger than 3.29 or smallerthan 73.29 (p 5 .001; Tabachnick & Fidell, 2001).

Results

Does tertiary traumatization exist?

In the total set of 13 samples on 1012 families, we did not find a significant difference inpsychological well-being and adaptation between the third generation Holocaust survivorsand their comparisons. The size of the combined effect was a Cohen’s d of 0.04 (p ¼ .66),


confidence interval 70.14 * 0.23 (see Table 2). Based on the overall effect size for generaladjustment in each sample, the third-generation Holocaust survivors did not differsignificantly from the comparisons.

Are study results associated with the type of recruitment of participants?

When the set of studies was divided in sub-sets with select and non-select samples, wefound basically similar outcomes. The seven select samples, including 616 subjects, showeda small but non-significant combined effect size of d ¼ 0.07 (p ¼ .65) for generaladjustment. The six non-select studies with a more adequate recruitment of participantsalso showed a non-significant effect size of d ¼ 0.03 (p ¼ .69) in a homogeneous set ofoutcomes. Thus, both studies with non-select and with select samples failed to show atertiary traumatization effect, that is, third generation Holocaust survivors did not showless well-being or adaptation than did the comparisons.

Does tertiary traumatization exist in specific domains of functioning?

Because convenience and non-convenience samples did not differ in combined effect sizes,we examined differences between studies addressing externalizing, internalizing, andattachment problems across the total set of studies. Table 3 presents the outcomes and thecombined effect sizes for the three categories of functioning (k ¼ 3 studies forexternalizing, k ¼ 5 studies for internalizing, and k ¼ 5 studies for attachment). Althoughthe number of study outcomes in the externalizing category was small, we decided toexplore the differences in combined effect sizes between these three domains. Forexternalizing, internalizing, and attachment the combined effect sizes were d ¼ 0.15,d ¼ 0.12, and d ¼ 70.03, respectively (see Table 3). These combined effect sizes for thethree domains were non-significant, and the contrast between the three sets was notsignificant either (Q(2) ¼ 1.03, p ¼ .60), see Table 3. Tertiary traumatization could not bedetected in the three domains of functioning separately or combined into the overarchingcategory of adaptation. It should be noted that our test of differences between domainswas only exploratory because of the small number of study outcomes in the externalizingcategory.

Discussion and conclusions

Our narrative review of studies on the transmission of trauma to the third generationoffspring of Holocaust survivors showed a mixed picture of significant and non-significantdifferences between grandchildren of Holocaust survivors and comparisons withoutHolocaust background. In a meta-analysis of 13 studies, involving over 1000 participants,no evidence for tertiary traumatization was found, whether or not participants wererecruited in a ‘‘select’’ or ‘‘non-select’’ manner, and whether or not we divided the studyoutcomes into three possible domains of traumatization, that is externalizing, internaliz-ing, or attachment issues.

We should not overlook the limited evidence that is presented for specifictraumatization effects in clinical (Sigal et al., 1988) or particularly vulnerable populations,evidence that might be lost or discounted in the meta-analysis. For example, in order toincrease statistical power, we had to merge the subgroups as reported by Scharf (2007).Although in that study grandchildren with both parents raised by Holocaust survivorsshowed more adaptation problems, the combined groups (with one and two parents raised


by survivors) did not differ significantly from the comparisons in other-reportedadjustment to military service. A potentially additive traumatization effect of havingtwo parents who were the offspring of Holocaust survivors might have been uncovered if alarger set of studies would have differentiated between these groups. Thus, as might be thecase with any meta- analytic approach, especially when the available number of studies isnot very large, some specific moderating effects may remain hidden. It should also benoted that some of the studies included in the meta-analysis were not published in peer-reviewed journals (e.g., doctoral dissertations, conference presentations). At the sametime, meta-analytic methodology requires the inclusion of unpublished material in orderto prevent publication biases to inflate the outcome of meta-analyses (Lipsey & Wilson,2001; Rosenthal, 1995).

Overall, however, we are inclined to take the absence of differences between offspringof Holocaust survivors and comparisons as a replicated fact. This meta-analytic findingmay be interpreted as a sign of resilience on the part of the survivors that facilitated thewell functioning of their second and third generation offspring. Already at the level ofrelationships between the first generation and the second generation, we noted animpressive resilience of Holocaust survivors who, as parents, seem to have managed toprotect their children from being affected by the Holocaust (Van IJzendoorn et al., 2003).Moreover, the idea that the trauma might skip a generation (i.e., the second) and that itmay emerge only in the next one (i.e., third), as might be the case with the transmissionof some biologically inherited diseases (Bulmer, 1998), did not receive support fromour meta-analytic investigation. Given an absence of a well-substantiated conceptualmodel for transmission of psychological effects to the third generation, a Mendelianmodel that might be appropriate for genetic inheritance might not be so for socialinheritance.

For the lack of transmission of trauma from the first to the second generation and forthe remarkable resilience of first generation Holocaust survivors (Van IJzendoorn et al.,2003), we proposed a bio-psychological stress-diathesis model of PTSD (Paris, 2000)focusing on three important protective or risk factors which determine the intensity andduration of posttraumatic stress: repeated or lack of repeated exposure to traumaticevents, the presence or absence of a genetic predisposition for PTSD, and the availabilityor lack of availability of social support in coping with the traumatic experiences.

The remarkable resilience in Holocaust survivors from this stress-diathesis perspectivewas explained by noting that the traumatic experiences of the survivors were not inflictedby their own parents or other attachment figures (Sagi-Schwartz et al., 2003; VanIJzendoorn et al., 2003). These experiences, instead, emerged from an almost anonymous,destructive process with bureaucratic characteristics (Bauman, 1989). The Holocausttherefore may not have undermined the feelings of basic trust in their attachment figures,enabling them to adequately fulfill their own role as trusted parents for their children.Moreover, most survivors had experienced several pre-war years of normal family life, andwere thus able to establish secure attachment relationships with their parents or otherattachment figures. The survivors might have had adequate models of parenting availablewhen they became parents themselves.

With regard to genetic factors, as part of a stress-diathesis model we have alreadyspeculated that Holocaust survivors were not genetically biased to develop intenseposttraumatic stress reactions (Van IJzendoorn et al., 2003), as these responses would haveleft them vulnerable in their struggle for survival (Schwartz, Dohrenwend, & Levav, 1994).Sufferers from PTSD may have had a smaller chance of surviving the extremely stressfulcircumstances of hiding or being in camps. Survivors may have been protected against


PTSD through their genes (Goldberg, True, Eisen, & Henderson, 1990) as well as throughmyriads of other personality, social, and chance factors. This genetic protection againstPTSD might have been transmitted to the next generations. Children of Holocaustsurvivors, therefore, may not have been especially sensitive to potentially traumatic eventsor reports arising from their parents’ efforts to deal with the Holocaust atrocities. We arecurrently exploring the genetic component more directly by collecting DNA in our Israelistudy, in a search for vulnerability genes (Sagi-Schwartz et al., 2003).

The last factor in a stress-diathesis model concerns the presence or absence of socialsupport to cope with trauma afterwards. We proposed that after World War II thesurvivors were forced to find meaning in helping to build up a new society, everywherethey could, in Europe and Northern America, but also, and maybe especially, in Israel(Frankl, 1984). The newly founded State of Israel, to which many survivors emigratedafter the war, and also the success of many Jews throughout the Western world served assymbols of the ultimate failure of the ‘‘Final Solution’’ (Solomon, 1998). Ever since theestablishment of Israel, various memorials in Israel and subsequently also outside Israelhave been erected to commemorate the victims of the Holocaust and to support survivorsand their families in working through the traumatic memories of the past, all of whichmight have served as important social support for Holocaust survivors.

Unfortunately, due to the relatively small number of pertinent studies it was notpossible to test country differences meta-analytically (but see Van IJzendoorn et al., 2003).Similarly, no separate results were available in the various studies for males versus femalesand the variability in this set of studies was insufficient to test whether gender was amoderator. The search for moderators and mediators would have been very important,though, if the database in the different studies included in the meta-analyses would haveallowed for such analyses.

In sum, our series of meta-analyses show that second generation as well as thirdgeneration offspring of Holocaust survivors are, in general, well adapted. The provocativeidea that the intergenerational transmission of the trauma might skip a generation andthus may emerge in the third generation was not substantiated in our meta-analyses. Sucha potential ‘‘sleeper effect’’ does not appear to be the case, the youngest generation seemsalso to develop in a normal way. Protective factors in the offspring or in their environmentmay have lessened the impact of the first generation’s trauma. More plausibly, studies onthe second-generation and third-generation’s psychological consequences of the Holocaustindicate a remarkable resilience of traumatized survivors in their parental roles, even whenthey personally may be traumatized profoundly.

Clinically, every case is a unique constellation of etiological factors responsible forcurrent suffering, and the Holocaust experiences of the earlier generation might be one ofthose factors even though on the level of the population secondary and tertiarytraumatization are not the rule. The absence of tertiary traumatization, however, shouldsensitize clinicians working with (second or) third generation offspring of Holocaustsurvivors to the possibility that their clients may be stimulated to search for the roots oftheir problems in other directions besides the Holocaust experience of their grandparents.

Acknowledgement

Abraham Sagi-Schwartz was supported by the Mary Main Visiting Professional Chair at the Centrefor Child and family studies, Leiden University, the Netherlands. Marinus van IJzendoorn andMarian Bakermans-Kranenburg were supported by research awards from the NetherlandsOrganization for Scientific Research (NWO SPINOZA prize and VIDI grant no. 452-04-306,respectively).


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