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Preventing intergenerational trauma transmission: A critical interpretive

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Article in Journal of Clinical Nursing · December 2018

DOI: 10.1111/jocn.14735

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Received: 26 October 2017 | Revised: 25 November 2018 | Accepted: 30 November 2018

DOI: 10.1111/jocn.14735

REVIEW

Preventing intergenerational trauma transmission: A critical

interpretive synthesis

Sophie Isobel1,2 | Melinda Goodyear3 | Trentham Furness4 | Kim Foster4

1
ACU School of Nursing, Midwifery and
Paramedicine, Melbourne, Victoria, Australia Abstract
2
Mental Health Research, Sydney Local Aim and objective: To synthesise and critically interpret literature of relevance to
Health District, Sydney, New South Wales,
intervening in intergenerational transmission of relational trauma within parent–in-
Australia
3 fant relationships.
Monash University & the Parenting
Research Centre, Melbourne, Victoria, Background: Intergenerational trauma is a discrete process and form of psychologi-
Australia
cal trauma transmitted within families and communities. Intergenerational trauma
4
Melbourne Health, Australian Catholic
University & North Western Mental Health, can be transmitted through attachment relationships where the parent has experi-
Melbourne, Victoria, Australia enced relational trauma and have significant impacts upon individuals across the

Correspondence lifespan, including predisposition to further trauma.

Sophie Isobel, Concord Centre for Mental Design: Critical interpretive synthesis (CIS) was used. CIS is an inductive qualitative
Health, Sydney Local Health District,
Sydney, NSW, Australia. process that generates new theory grounded within reviewed literature.
Email: sophie.isobel@health.nsw.gov.au Methods: The review commenced by systematically searching for literature on inter-

Funding information ventions for intergenerational trauma. As the core theoretical construct emerged,
Australian Government Research Training elements that may contribute to preventing intergenerational trauma were identified
Program Scholarship
iteratively and influenced further searching. In the final synthesis, 77 articles were
included from the fields of intergenerational trauma, trauma interventions and at-
tachment interventions. The review adhered to the Preferred Reporting Items for
Systematic Reviews and Meta‐Analyses checklist.
Results: The key construct is that prevention of intergenerational trauma trans-
mission is the key intervention. The two contributing constructs were identified
as “resolving parental trauma” and “actively supporting parent–infant
attachment.”
Conclusions: Prevention is the most effective intervention approach for intergenera-
tional transmission of trauma. Prevention requires trauma‐specific interventions
with adults and attachment‐focused interventions within families. Preventative
strategies need to target individual, relationship, familial, community and societal lev-
els, as addressing and preventing trauma requires a multipronged, multisystemic
approach.
Relevance to clinical practice: Systematic trauma‐informed attachment‐focused in-
terventions in health and social service settings are recommended. There are oppor-
tunities to provide multifocal individual and relational interventions within existing
services that work with parents to help prevent the likelihood and impact of trans-
mission of intergenerational relational trauma within families. Nurses are well placed

J Clin Nurs. 2019;1–14. wileyonlinelibrary.com/journal/jocn

© 2018 John Wiley & Sons Ltd | 1
2 |
to provide preventative interventions in mental health, early childhood and primary
health settings.
KEYWORDS
attachment, critical interpretive synthesis, intergenerational trauma, prevention, relational
trauma
1 | I NTRO D U C TI O N
Psychological trauma can result from circumstances that are expe-
rienced as physically or emotionally harmful or life‐threatening and
that have lasting adverse effects on well‐being (Substance Abuse and
Mental Health Services Administration (SAMHSA) 2014). The term
“trauma” encompasses the event(s), the individual's experiences and
the effects. Sustained trauma that commences in early childhood
results in alterations to neurobiological integration and processing,
including mechanisms of coping with stressful stimuli and regulating
emotion (Schore, 2009), creating a predisposition or vulnerability to
further harm and interpersonal and intrapersonal difficulties (Lyons‐
Ruth & Jacobvitz, 1999). Childhood trauma has impacts across the
lifespan (Van der Kolk, 2005), with many adult health problems re-
lated to strategies, coping mechanisms and behaviours developed by
the child to protect themselves from adversity (Felitti et al., 1998).
Increasing understanding of trauma has resulted in the identification
of differing types, categorised by the nature of the events, experi-
ences and/or effects (Isobel, Goodyear, & Foster, 2017).
Relational trauma is a term used to describe trauma that occurs
within relationships, usually familial, and often attachment‐specific
(Schore, 2002). Relational trauma may include maltreatment, abuse
and neglect experiences as well as serious and pervasive disruptions
in caregiving as a consequence of parental mental illness, substance
use or abrupt separation (D'Andrea, Ford, Stolbach, Spinazzola, &
van der Kolk, 2012). Relational trauma can also refer directly to pat-
terns of attachment interaction from parent to infant, characterised
by conflicting signals, intrusive behaviours, withdrawing or antago-
nistic behaviours or a lack of soothing (Amos, Furber, & Segal, 2011).
Adults who have experienced early childhood relational trauma are
at increased risk of transmitting traumatic effects to their own in-
fants through their attachment and interaction styles (Fraiberg,
Adelson, & Shapiro, 1975). Relational trauma develops in relation-
ships and has the potential to affect future relationships.
Trauma that is relationally transmitted across generations, di-
rectly or indirectly, can result in a discrete form of trauma known
as intergenerational (or transgenerational) trauma. Hesse and Main
(2000) define intergenerational trauma as the process by which
parents with unresolved trauma transmit this to their children via
specific interactional patterns, resulting in the effects of trauma
being experienced without the original traumatic experience or
event. While Albeck (1992) recommended that discussion of inter-
generational trauma should focus on the intergenerational aspects
of trauma instead of transmission, more recently Kellerman (2001)
ISOBEL et al.
What does this paper contribute to the wider global
clinical community?
• New understandings of intergenerational trauma
intervention.
• New understandings of the components of intervention
that contribute to prevention of intergenerational
trauma transmission.
• Linking of intergenerational trauma prevention to clini-
cal practice and healthcare delivery.
has argued that transmission is a useful concept for understanding
the discrete nature of intergenerational trauma as opposed to other
secondary or vicarious effects of indirect trauma exposure. These
differences in conceptualisation also reflect dispute about whether
the trauma that is transmitted is a replication of the first‐generation
trauma, a reaction to their trauma or a vulnerability to a unique en-
tity of trauma.
Much of the intergenerational trauma literature has emerged
from work with cultural and historical traumas in populations of
Holocaust survivors and Indigenous peoples (Giladi & Bell, 2013;
Stevens, Andrade, Korchmaros, & Sharron, 2015). In some circum-
stances, families affected by historical traumas can display residual
effects of disrupted differentiation of self, traumatic stress (Giladi
& Bell, 2013) and emotional and psychosocial disorders (O’Neill,
Fraser, Kitchenham, & McDonald, 2016) three generations after the
traumatic events. Individuals may display primary effects of trauma
despite not having experienced the events directly. Traumatic ef-
fects can seemingly become embedded in collective, cultural mem-
ory and passed on by the same mechanisms through which culture
itself is transmitted, as well as being individually passed from parent
to child (Atkinson, 2013).
There is increasing understanding of the potential for in-
tergenerational transmission of all forms of relational trauma
through parent–infant relationships (Schore, 2002). Any rela-
tional trauma experienced by an individual may be replicated in
their children via the attachment relationship due to the rela-
tional nature of early childhood neurobiological development.
The uniqueness of intergenerational trauma therefore lies in
its existence as a relational process. Rather than an event or
events, intergenerational trauma is both an antecedent and
outcome of traumatic attachment (Salberg, 2015). It may be
ISOBEL et al. | 3

best conceptualised as the genetic or learned transmission of
vulnerability and adaptations to circumstance (Forrest‐Perkins,
2017). It results in a disrupted construction of intersubjective
self and identity (Connolly, 2011), due to the blurring of self
and other, where trauma experienced by the important other
becomes incorporated into the self of the recipient (Bradfield,
2013). There is increasing exploration and understanding of po-
tential biological pathways of intergenerational trauma trans-
mission including through neuroendocrine, neuroanatomical
and epigenetic changes (Ramo‐Fernández, Schneider, Wilker,
& Kolassa, 2015). Conceptualising trauma as something that
can be transmitted between people in its original and derived
forms, psycho‐dynamically and/or biologically, creates oppor-
tunities to consider mechanisms for intervening to reduce im-
pact across generations.
The symptoms of trauma, including dissociation, can prevent
accurate identification of trauma and its effects on an individual
(Goldsmith, Barlow, & Freyd, 2004). This can complicate inter-
vention. If individuals who have experienced relational trauma
do seek services, it may be due to the distress from the effects
of trauma or mental health concerns (Edwards, Holden, Felitti,
& Anda, 2003) rather than the trauma itself (Goldsmith et al.,
2004). As such, there is an onus of responsibility on services
that have opportunistic contact with individuals with expe-
riences of trauma to deliver service in a way that is informed
about trauma, sensitive to its dynamics, and to recognise the role
that trauma may play in any presentation to a care setting (Raja,
Hasnain, Hoersch, Gove‐Yin, & Rajagopalan, 2015). Trauma‐in-
formed service systems are emerging as ways for programmes,
organisations or systems to incorporate realisations about the
widespread impact of trauma and potential paths for recovery.
They require recognition of the signs and symptoms of trauma
in clients, families, staff and others involved with the system;
and integration of knowledge about trauma into policies, pro-
cedures and practices, while preventing re‐traumatisation
(SAMSHA, 2014). Trauma‐informed care is a paradigm shift for
services where a broad understanding of trauma is integrated
into organisations, including an appreciation that individual, fam-
ily and historical traumas occur with intersectionality (Sweeney,
Filson, Kennedy, Collinson, & Gillard, 2018). To be truly Trauma‐
informed, understandings of the mechanisms, effects and inter-
ventions for trauma including its potential for intergenerational
transmission are necessary.
However, the complexities and a lack of understanding of inter-
generational trauma may mean that its past or future presence re-
mains invisible even within such approaches.
Examination of intergenerational trauma intervention inevita-
bly requires analysis of how trauma is transmitted, as well as what
is transmitted. Kellerman (2001) has proposed detailed theoretical
models of trauma transmission across generations which have been
synthesised in Table 1.
These theoretical models describe potential processes of trans-
mission as well as the vulnerabilities that may be passed on. All of
them attempt to explain the same phenomena; that is, how trauma
from a past generation may be evident in subsequent generations.
Of course, within any parent–infant dyad (or triad) there are a num-
ber of differing variables within the behaviours of the parents and
the child, the effects on the child and the parent, and the wider
context of both that may affect both the transmission process and
the product. It is understood that by whichever method intergener-
ational trauma is passed on, it is a relationally transmitted exposure
and vulnerability (Baranowsky, Young, Johnson‐Douglas, Williams‐
Keeler, & McCarrey, 1998) and both a familial process and an indi-
vidual one (Berger, 2014).

TA B L E 1 Models of intergenerational
Model Process of transmission
trauma transmission (synthesised from
Kellerman, 2001) Psychodynamic Unconscious displaced emotions are
model transmitted through interpersonal
relations
Sociocultural Social norms are passed down through
models social learning
Family systems Enmeshed patterns of vicarious
model experiences or paradoxical nonverbal
ambiguous communication including
pervasive silence
Biological model Altered neurochemical states are
replicated through neural organisation.
Biological genetic memories and
responses to trauma are transmitted
through electro‐chemical processes in
the brain
Product that is transmitted
Undifferentiated develop-
ment of self and other and
the unconscious
absorption of repressed
or unprocessed experi-
ences of parents
Vicarious observation and
imitation. Learnt
understandings of the self
and the world
Unspoken experiences
without attached
narrative or emotion;
difficulties with differen-
tiation and separation
Fear, hyper‐alertness,
epigenetic vulnerability to
post‐traumatic stress
disorder
4 | ISOBEL et al.

Once transmitted, the trauma has its own consequences and
individual effects as per all psychological and interpersonally
developed traumas, including vulnerability for further trans-
mission of trauma to subsequent generations (Schwerdtfeger &
Goff, 2007). How to intervene to minimise transmission across
generations is not well documented. In cultural and historical
trauma studies, family cohesion (Kaitz, Levy, Ebstein, Faraone,
& Mankuta, 2009), open patterns of communication about trau-
matic events (Giladi & Bell, 2013), support with individuation
and separation processes (Wiseman et al., 2002), and engage-
ment with community, ritual and ceremony (Buse, Bernacchio, &
Burker, 2013) have been identified as culturally protective factors
against transmission of trauma.
In this review, intergenerational trauma is identified as the
transmission of parental relational trauma to the next generation
through attachment relationships. The word “parent” is used to
describe the role of someone who provides primary caregiving
to an infant to support their development, with respect to wide
definitions and structures of parents, parenting and families. The
emphasis is on the context rather than genetics of this relation-
ship. The purpose of the review is to identify constructs that can
be used to guide the development of intervention strategies for
intergenerational relational trauma, particularly in parent–infant
relationships.
1.1 | Aim
To synthesise and critically interpret literature of relevance to in-
tervening in intergenerational transmission of relational trauma
through parent–infant relationships.

Initial search of published literature for

relevant articles using terms ‘intergenerational’
Initial review

OR ‘transgenerational’ AND ‘trauma’

Screening based on relevance to

intergenerational psychological trauma

Excluded based on irrelevance to emerging research questions and theory

intervention n = 76

Core organising
Prevention of transmission between
construct developed
generations identified as key intervention

Search widened to potential and actual

searching
Iterative

intergenerational trauma prevention strategies

including through reference chaining and
literature from adjacent fields. Screening
based on relevance to research question n = 31

Subconstructs Key components of prevention identified as

adult trauma interventions and parent–child
developed
attachment interventions
Theoretical

Individual trauma intervention papers Individual/dyad/family attachment

identified as relevant
sampling

interventions identified as relevant

n = 30 n = 15

Theoretical papers Theoretical papers

n = 20 n=8
Identification
Purposive
selection

Intervention papers Intervention papers

Screening

n=7 n=6
Eligibility

Inlcuded

Review papers Review papers

n=3 n=1

Inclusion based Papers sourced to expand on emerging theory n = 9

on theoretical
saturation
Papers included in final synthesis n = 77

FIGURE 1 Search strategy using modified PRISMA

ISOBEL et al.
F I G U R E 2 Constructs of theory of intervention in
intergenerational trauma
2 | M E TH O D O LO G Y
Critical interpretive synthesis (CIS) method was used. CIS is an
inductive qualitative review process that generates new theory
grounded within existing literature (Dixon‐Woods et al., 2006).
While conventional reviews seek to aggregate data (Dixon‐
Woods et al, 2006), the critical scrutiny used in CIS allows
questioning and reconceptualisation of findings from large and
diverse bodies of literature, using induction and interpretation to
integrate concepts and theory into new understandings (Dixon‐
Woods et al., 2006). While CIS is sensitised to systematic review
methods, it does not use a highly structured search strategy, but
rather an evolving strategy based on emergent constructs. Unlike
other review methods therefore, searching, selection, data ex-
traction, critique and synthesis occur reflexively, dynamically
and fluidly (Dixon‐Woods et al., 2006). The areas of literature
searched and the papers included in this review were iteratively
revised throughout the process. Literature searching used on-
going theoretical review and critique of relevance rather than
a formal process of appraisal of suitability (Dixon‐Woods et al.,
2006). Unlike systematic reviews, explicit and replicable search
strategies are not required; the emergent method requires wide‐
ranging sources to be gathered throughout the process using
judgements of relevance and theoretical sampling (Dixon‐Woods
et al., 2006). The search strategy (see Figure 1) using a modi-
fied PRISMA diagram (Moher, Liberati, Tetzlaff, & Altman, 2009),
as well as the supplementary PRISMA checklist (see Supporting
Information File S1), is included to show the nonlinear process of
review. The iterative approach increases rather than decreases
rigour (McDougall, 2015); articles were included and excluded
as the question was refined and the synthesising argument and
| 5
constructs were developed. As per CIS guidance, the review
sought to review diverse and large bodies of literature and not
individual studies (Dixon‐Woods et al., 2006).
The review commenced by searching for literature on inter-
ventions for intergenerational trauma. Initial review of articles
indicated a lack of clear articulation of intervention due to the
complexities of identifying intergenerational trauma presenta-
tions as distinct from any other primary psychological trauma.
Throughout these early stages, the construct of prevention
emerged. Subsequent papers were sourced that included ac-
tual or potential elements that may contribute to preventing
intergenerational trauma from being transmitted. Papers were
purposively selected using thorough searching of multiple
sources and methods (databases, search engines, reference
chaining) and included with discretion based on their contribu-
tion to intended findings and an ongoing critique of emerging
theoretical concepts (Dixon‐Woods et al., 2006). Theoretical
saturation was used to determine when enough papers had
been sourced on contributing constructs. Theoretical, inter-
vention and review papers were considered from the fields
of trauma intervention, attachment intervention and related
concepts. Other incidental exclusions were determined based
on judgements of relevance; for example, papers that focused
solely on children's trauma interventions were excluded as al-
though the trauma may be intergenerational, it is rarely pri-
marily identified as such and the interventions described occur
beyond the window of prevention.
Consistent with CIS methodology, data extraction and analysis
involved gradual identification of recurring constructs while con-
currently forming the core synthesising argument of prevention.
Analysis occurred using line of argument and refutational synthe-
sis (Dixon‐Woods et al., 2006). Key elements of relevance to inter-
generational trauma were identified and the relationship between
them was interpreted. A synthesising argument of prevention
forming the key intervention (based on the integration of evidence
across studies into a framework of constructs and relationships;
Dixon‐Woods et al., 2006) was formed by building general inter-
pretation in constant comparison across works. The construct of
prevention was tested against the data through reflexive critique
during synthesis and interpretation. The synthetic constructs or
new conceptualisations (prevention occurring through resolving
parental trauma and actively supporting attachment) were gen-
erated by identifying discrete but inter‐related aspects of the
phenomena across works. Ethical approval was not required to
undertake the review.
3 | FI N D I N G S
Seventy‐seven articles informed the final synthesis. Findings are
presented under the core organising construct: Prevention is the
key intervention and the two subconstructs of resolving trauma and
actively supporting parent–infant attachment. See Figure 2.
6 |
3.1 | Core organising construct: Prevention as the
key intervention
A general lack of guiding theory on intergenerational relational
trauma and intervention was identified during the early stages of
the review. This may be because individuals with experiences of
intergenerational trauma usually only become aware of their trau-
matology when they present to services with their own difficulties,
making identification of aetiology difficult. The core construct was
interpreted as prevention being the key intervention that is needed
to intervene in intergenerational trauma transmission. Prevention
here refers to “intervention” that is targeted at stopping parental re-
lational trauma (or its effects) being transmitted to infants through
the dyadic relationship. The preferred point of any intervention is
prevention; however, for intergenerational trauma this is particularly
pertinent as it is likely a transmitted vulnerability that may manifest
in any number of nondiscrete ways in the next generation.
Due to the complexity of the phenomena of intergenerational
trauma, the lack of individuals’ conscious awareness of processes of
transmission and the pervasive effects of trauma upon child devel-
opment, prevention of transmission is needed to minimise the ef-
fects of trauma transmission in subsequent generations. Prevention
needs to interrupt the transmission, replication or effects of primary
trauma on the next generation.
Within targeted individual and family‐focused prevention in-
terventions, there are primary, secondary and tertiary levels of
preventative approach (Gordon, 1983) that can be applied to inter-
generational trauma. Primary prevention refers to prevention of the
occurrence of a phenomenon in the population, for example, trauma
screening and preventative parenting programmes in services that
have contact with any parent or potential parent and community so-
cial awareness campaigns about attachment and trauma. Secondary
prevention requires targeted intervention in at‐risk populations and
is likely the key domain of intergenerational trauma transmission
where prevention requires awareness that there is primary trauma
that can be transmitted across generations. Tertiary prevention ap-
plies to improving outcomes for affected individuals (Magruder,
Kassam‐Adams, Thoresen, & Olff, 2016); for example, targeting
parents known to have experienced trauma whose children require
intervention.
Socio‐ecological models of prevention are less focused on levels
of intervention and instead focus on recognition that many groups
within society have high prevalence of sustained stress, trauma
and adaptation and that prevention initiatives may be most effec-
tive when universally integrated. Such frameworks (Cyr, Michel, &
Dumais, 2013) emphasise risk across levels; individuals interact with
their families and others and exist within their communities and so-
cieties. This means prevention work can occur in community and
primary health settings as well as in therapeutic or clinical contexts.
Understanding that people are influenced by their environments
in multiple ways is important at a public policy level, where “high‐risk”
populations and families (in this case, families where primary trauma
exists) are recognised to be influenced by wider social dynamics and
ISOBEL et al.
that interventions targeting individuals need to consider the wider
context within which individuals and families may be compromised
(Isobel et al, 2017). This also includes recognition of the resilience,
strategies and strengths that already exist within family, social and
cultural groups. While services and individuals developing under-
standings of the pathways of transmission of psychological trauma
between individuals, including transgenerationally within families,
create opportunities for prevention (Isobel et al, 2017), preventing
sustained effects of trauma is undoubtedly a multisystemic issue.
This review sought to identify specific contributing constructs
that could inform the development and practice of prevention of
transmission of intergenerational relational trauma in dyads where
parental relational trauma is identified. The dearth of literature
describing preventative practice in intergenerational trauma trans-
mission indicated a need for analysis of adjacent relevant fields of
knowledge that may inform prevention approaches for families. Key
elements of intergenerational trauma guided the identification of
the constructs, namely the incapacity of the initial trauma survivor
(parent) to resolve the trauma and the trauma then affecting the in-
terchange between parent and child, with attachment playing a crit-
ical role in buffering, protecting from, not protecting from, repairing,
causing vulnerability to, directly causing, or contributing, to trauma
(Schwerdtfeger & Goff, 2007). Prevention of intergenerational
transmission emerged to be comprised of the two subconstructs:
resolving parental trauma in the adult and actively supporting the
attachment bond that connects the infant or child to the adult, as the
attachment relationship is the conduit of the trauma between indi-
viduals. Resolving parental trauma ideally occurs first but both can
occur concurrently. Either may be helpful independently but both
are likely to be required for effective prevention.
3.2 | Subconstruct: Resolving parental trauma
3.2.1 | Defining “resolving”
The most efficient means of intervening in intergenerational trau-
mas (as opposed to any other trauma) is preventing the trauma of an
individual being transmitted to their offspring. This involves working
directly to identify and manage any effects of trauma on the parent.
In the field of attachment, it has been identified that “unresolved
trauma” in attachment figures can create a second‐generation ef-
fect of disrupted attachment which can itself present as trauma and
be traumatic (Hesse & Main, 2000). The term “unresolved” refers
to a lack of integration into consciousness of the occurrence or im-
plications of events (Lyons‐Ruth, Yellin, Melnick, & Atwood, 2003).
The term emerged from the final stage of mourning where the loss
of an attachment figure is accepted and life restructured around it.
The translation of “unresolved” to trauma therefore incorporates the
processing and mourning of events and experiences from the past
with acceptance and accommodation of their effects in the present
(Jacobvitz, Leon, & Hazen, 2006). Unresolved trauma is also linked to
psychoanalytic notions of “unsymbolised trauma” or events, which
are too painful or destabilising to process and are relegated to the
ISOBEL et al.
unconscious (Bion, 1962; Freud, 1920). To resolve trauma is not to
erase it but to move experiences and effects to conscious awareness.
3.2.2 | Trauma interventions
There are numerous approaches to treating adult trauma includ-
ing cognitive behavioural therapy (Gillies, Taylor, Gray, O'Brien,
& D'Abrew, 2013), dialectical behavioural therapy, mindfulness,
emotional regulation training (Siegel, 2013), eye movement desen-
sitization and reprocessing (Shapiro & Maxfield, 2002), conversa-
tion‐based psychotherapy (Meares, 2004), art therapy (Chong,
2015) and yoga (Van der Kolk et al., 2014). It is beyond the scope
of this review to assess each approach for its efficacy. The theory
of complex trauma was identified to be of particular relevance to
intergenerational trauma intervention, as complex traumas encom-
pass the multiple effects of cumulative experiences that begin in
childhood, are usually interpersonal and occur within the caregiving
system (Courtois, 2004). In intergenerational relational trauma, pa-
rental complex trauma may result in trauma occurring intergenera-
tionally, or any parental trauma may manifest as complex trauma in
the recipient (Isobel et al., 2017).
Complex interpersonal trauma is thought to be best addressed
in a multimodal (Allen, 2013) trans‐theoretical way (Courtois, 2004)
based on the underlying assumption that central to the experi-
ence of interpersonal trauma is helplessness, meaninglessness and
disconnection. The recovery and resolution process are therefore
based on empowerment and creation of new connection and mean-
ing commencing with the development of safety (Herman, 1992). A
staged process of guided recovery from complex intergenerational
trauma, inclusive of family and connections, is important in guiding
the care of any individual who has experienced trauma and through
recognising the wider context of relational safety required prior to
processing trauma.
Most adult trauma intervention approaches reviewed in this
synthesis were underpinned by an understanding of the need to es-
tablish a therapeutic relationship within which traumatic effects can
be explored, trauma‐induced reactions identified and modified, and
self‐efficacy increased. The quality of the therapeutic relationship
itself is known to be one of the most important factors to effect
improvement regardless of therapeutic model used (Zilberstein,
2014). A trauma and attachment lens needs to be implicit within such
therapeutic relationships, as trauma that occurs within attachment
relationships affects the ability to feel safe and to experience empa-
thy and understanding in other attachment relationships, including
therapeutic ones (Allen, 2013).
3.2.3 | Creating safety
Survivors of trauma may not feel safe in interpersonal interactions
(Cozolino, 2002) and as such, frontline clinicians, including nurses,
need to focus on creating psychological safety within any contact.
The concept of psychological safety is related to psychoanalytic no-
tions of attachment and containment within relationships but also
| 7
linked more widely to the need to establish trust and interpersonal
security within interactions (Seager, 2006). Through a trauma lens,
establishing safety becomes a key role for all care providers and re-
quires understanding of its importance, factors and relationship to
trauma. Awareness of the role of trauma in compromising the safety
that is often assumed in therapeutic relationships (Cozolino, 2002)
is important in any trauma‐informed interaction but has direct rel-
evance to intergenerational trauma, where critical attachment re-
lationships may have embedded conflicting safe/unsafe dynamics
between parent and child. Establishment of interpersonal safety is
required before any other intervention will be effective (Geller &
Porges, 2014; Herman, 1992), including preventative intergenera-
tional interventions.
3.2.4 | Creating a narrative of trauma
Trauma intervention literature frequently identifies the need to
look beyond verbal communication approaches due to the effects
of trauma on the areas of the brain used for verbalizing experiences
(Hull, 2002) and the common existence of dissociative symptomol-
ogy (Cozolino, 2002; Gorden, 2011). Lasting emotional experiences
of trauma can exist primarily in sensations, images and impressions
and may benefit from being expressed similarly (Schore, 2002).
Nonverbal therapies may play an important role in processing inter-
generational trauma as it is often experienced without a clear associ-
ated narrative or event.
Yet despite the potential limitations of verbal processing, hav-
ing a narrative of life is important for creating a sense of reality
and a meaningful and authentic sense of self (Connolly, 2011). To
integrate experience, experience must be comprehensible (Sroufe,
2005). Creating such a narrative within trauma can be difficult
due to the defensive structures of the brain and the complexi-
ties of memory and dissociation (McCollum, 2015); yet in inter-
generational relational trauma, the construction of a narrative
of causative trauma may be essential to distinguish reality from
unconsciously constructed versions of another's reality (Bohleber,
2007). A common clinical feature of familial traumas is the silence
that can occur in families surrounding traumatic experiences
(Abrams, 1999). Within familial‐based trauma work aimed at re-
ducing intergenerational transmission, development of a shared
narrative of the trauma may be beneficial to separate the current
generation and their experience from that of the previous or fu-
ture generation.
The way a parent talks about their self links forward to attach-
ment patterns and the development of self in the next generation
(Holmes, 1999). The lack of a consistent or coherent self‐narrative
has been linked directly to second‐generation attachment inse-
curity (Fonagy, Steele, & Steele, 1991; Gorden, 2011). A lack of
shared narrative also creates a lack of capability for integration
and processing that may be partially contributory to the traumatic
effect of intergenerational trauma and may play a role in its trans-
mission. In one of the few identified iatrogenic risks of individual
therapy, Abrams (1999) suggests that in intergenerational trauma,
8 |
if traumatic experiences are not addressed or safely and openly
discussed within therapy, the therapy may replicate the silence
within which the trauma was transmitted. Open dialogue of the
past, where possible, is crucial to the prevention of transmission
of trauma across generations. The relational context of creating
narratives is thought to allow nonverbal trauma reactions to be
semantically processed (Schore, 2001), which in itself may lead to
a more coherent autobiographical and intergenerational narrative
that protects against unprocessed trauma being intergeneration-
ally transmitted.
3.3 | Subconstruct: Actively supporting parent–
infant attachment
The second subconstruct within the core construct of prevention is
actively supporting the attachment relationship. This is an important
component to prevention of intergenerational trauma transmission,
as it mediates the relational space where transmission or prevention
could occur.
Attachment relationships have been extensively discussed and
studied (Koren‐Karie, Sagi‐Schwartz, & Joels, 2003). Attachment
theory describes the ways that individuals interact with people with
whom they have a significant dependent relationship, particularly
under conditions of threat, establishing patterns through which af-
fect is regulated and distress managed. Attachment theory is inher-
ently intergenerational, as the degree to which parents are able to
respond sensitively to their infants is directly related to their own
attachment experiences. The attachment system guides the care-
giving system (Bowlby, 1988), which modulates attunement to the
infant's needs. The quality of moment‐to‐moment interactions with
an infant depends on the parent's intuitive understanding of how to
nurture and protect the child, which is embedded within an attach-
ment paradigm (Blizard, 2006).
3.3.1 | Attachment interventions
Documented potential approaches aimed at supporting attach-
ment are multiple with no clear “best” treatment, as treatment
must be individualised (Courtois, 2004). Attachment interventions
can be broadly categorised into indirect and direct approaches.
Indirect approaches focus on interventions targeting psychosocial
risk factors including parental mental illness, substance abuse,
or disorganised attachment and assumedly known or suspected
trauma. Removal or mitigation of these risk factors may enable
parents to become more sensitive and responsive to their infants,
thus indirectly promoting secure attachment (Letourneau et al.,
2015). While resolving parent trauma is an indirect approach to
supporting attachment, direct approaches are also required.
Direct approaches focus specifically on developing appropriate
parental responses to the infant or child's signals and developing
reflective functioning of the parent to both reflect on the infant's
experience and reflect on their own experiences and reactions
(Letourneau et al., 2015).
ISOBEL et al.
3.3.2 | Mentalisation
Sensitivity and reflective function are regarded as critical parental ante-
cedents to infant attachment security, and thus, these constructs are the
most proximal and effective targets for interventions aimed at improving
attachment quality (Letourneau et al., 2015). Mentalisation is a complex
reflective process that allows for thinking about both self and others as
psychological beings and considering underlying mental states and moti-
vations when interpreting behaviours (Berthelot et al., 2015). Mentalising
mediates attachment but is also thought to contribute to resilience pro-
cesses following relational trauma (Berthelot et al., 2015) as it allows a
separation of self and other. Of particular relevance to trauma transmis-
sion may be a parent's capacity to think about and symbolise traumatic
events and to consider their impacts in psychological terms, to maintain
a perspective that is aware of their own reactivity to their infant and ena-
bles them to remain able to soothe their infant despite the infant's dis-
tress triggering their own traumatic past. Parents’ capacity to coherently
structure their understanding of their own attachment experiences and
its impacts is inherently linked to their narrative coherence of their infants’
attachment. This cyclical nature of attachment is important for preven-
tion models, as parents require reflective functioning (Fonagy et al., 1991;
Allen, 2013) or the capacity to attune and respond to their infant's internal
states, in order to support the infant's development of mentalisation. By
assisting the infant or child to regulate and experience their own affect
responses as manageable, future experiences can be anticipated with-
out fear of becoming overwhelmed. Capacity to mentalise is required to
model mentalising and may form an important component of prevention.
3.3.3 | Epigenetic modification and resilience
It is important to note that despite significant evidence of the trans-
mission of attachment styles across generations (both traumatic
and nontraumatic), this transmission pathway may not always occur
(Iyengar, Kim, Martinez, Fonagy, & Strathearn, 2014). Individuals can
reorganise their attachments using a variety of methods via external
and internally driven processes, as well as develop sustained rela-
tional security through resilience (Iyengar et al., 2014). Fostering and
supporting these mechanisms may result in altering the transmission
of attachment patterns and trauma across generations. The role of
epigenetic modifications to resilient phenotypes on a continuum with
trauma and stress (Cadet, 2016) is an emerging field that may also aid
in identifying the ways that intergenerational trauma may be, in some
circumstances, protective against lifetime stress and adversity.
Through this review, some challenges were thematically iden-
tified in the literature that may impede progression of knowledge
related to intergenerational trauma prevention. Two of these chal-
lenges are discussed below.
3.3.4 | Critique of the individualised nature of
trauma interventions
This review identified that despite known risks of trauma being
transmitted within families (and the importance of relationships
ISOBEL et al.
in intervention), the majority of trauma interventions are focused
on individuals only. Due to the identified need for both trauma
treatment and attachment‐focused work, the individual focus of
the majority of documented trauma interventions may not aid in
preventing trauma being transmitted across generations prior,
during or potentially after the substantial process of individual
therapy has been undertaken. Much of the trauma‐specific lit-
erature evokes normative assumptions about the role of therapy
in preventing intergenerational trauma through its work with the
individual, but there is a need to actively focus on intergenera-
tional trauma as a distinct component of trauma and also a criti-
cal point and outcome of intervention. Despite some theoretical
acknowledgement that psychotherapeutic treatment of a parent
or parent should include their infant or child (Perez, 2009), most
documented adult trauma work remains individually focused even
when it occurs during early parenthood. Attachment is certainly
recognised to be a component of relational trauma treatment
(Pearlman & Courtois, 2005) but is often reflected upon within
the therapy relationship or past relationships rather than in the
context of any current dependents. The embedded nature of re-
lational traumas is such that their full effects may not be realised
until a similar relationship is engaged in (Amos et al., 2011), and
while the relationship with a therapist or clinician forms an im-
portant space for this to occur, how to strengthen current attach-
ment relationships beyond the clinical relationship is not widely
discussed.
This also impacts upon the lack of widespread recognition in
mainstream health and social services of the existence of trans-
generational transmission of trauma (as opposed to vulnerability).
Within literature on the need for trauma‐informed approaches
in services, the details of intergenerational trauma remain sparse.
Through a socio‐ecological lens, recognition of relational and social
contexts of individuals and recovery is critical for any care, well be-
yond models of risk and resilience. There risks being a widening gap
between awareness and treatment unless opportunities for, and re-
sponsibilities to support, prevention with individuals and their cur-
rent and future offspring are well delineated.
3.3.5 | Critique of the language of trauma
It may be that there is not a lack of preventative trauma interven-
tions being undertaken with parents, infants and families in practice,
but rather there is a lack of conceptual clarity and communication
of intent of purpose in the literature. This may be in part due to
complexities of the phenomena but also is perhaps due to an ap-
parent compartmentalisation of the evidence base. Across trauma
literature broadly, there is an acknowledged lack of shared defini-
tion of the term trauma, with attempts to define it labelled prob-
lematic (McNally, 2010). Papers in this review referred to stress,
adverse childhood experiences, traumatic stress, complex trauma,
developmental trauma, relational trauma and disorganised attach-
ment to refer to similar processes and contributors to intergenera-
tional trauma. In addition, intergenerational “effects,” “mechanisms,”
| 9
“dynamics,” “responses,” “consequences,” “alterations” and “trans-
missions” of trauma were discussed. While some variation in lan-
guage is to be expected, the wide scope of this review allowed a
broad view of some overarching linguistic and methodological ob-
stacles that stand in the way of progression of understanding of
prevention of intergenerational trauma. Differing disciplines, fields
or groups using the same or similar words with subtle or major con-
ceptual differences in interpretation can impede cohesion (Isobel et
al, 2017). Importantly, intergenerational, secondary and historical
traumas are terms used at times used interchangeably, with poten-
tially negative impacts upon all subconstructs. In individual studies,
attempts are made to define specific traumatic events and their ef-
fects as well as distinctions made, or not made, between trauma as an
experience and as a diagnosis. Language used in the well‐researched
field of attachment interventions does not always overlap with that
used in trauma interventions and both are challenged by movements
towards resilience and strength‐based approaches. Undoubtedly, in
practice, some individuals may identify with the term “trauma” as a
way of understanding their experiences and adaptations and those
of their family members; for others, the term alone may alienate indi-
viduals and families from seeking or receiving support. Lessons from
historical and cultural trauma fields may need to be more overtly
academically transferred to the intergenerational trauma field to en-
sure that the concepts of recovery, resilience and identity are closely
entwined within any discourse of trauma.
Methodologically, as the transmissible effects of trauma and the
importance of context are recognised, researchers accustomed to
working with and measuring the individual impact of traumas and
efficacy of intervention may also need to rethink their methodol-
ogies in order to capture familial and societal impacts (Magruder
et al, 2016). Currently, efficacy is oft demonstrated through symp-
tom reduction, self‐report or objective interaction or attachment
assessment. Certainly, intergenerational studies are not without
their challenges; however, as preventive efforts move to the family,
community and societal levels, multimodal approaches to measur-
ing effectiveness are required to enhance clinical translation and to
manage conflicts between disciplines of science and their definitions
of rigour and evidence.
4 | D I S CU S S I O N
The review set out to identify intervention approaches for intergen-
erational trauma, yet due to a lack of literature, the review evolved
to critically draw upon adjacent fields and build theory on preven-
tion of intergenerational trauma transmission in parent–infant dyads
through resolving parental trauma and supporting parent–infant
attachment. The emergent synthesis of existing knowledge found
that while there is limited evidence on intervening specifically with
intergenerational transmission of trauma, prevention is the key in-
tervention with parents, dyads and families known to have experi-
enced relational trauma. The review found that prevention is likely
to require targeted efforts to resolve parental trauma and support
10 | ISOBEL et al.
the parent–child attachment relationship. The findings of the review
provide an important theoretical contribution to understanding the
impacts and implications of intergenerational trauma as a discrete
form of relational trauma and progress the conceptual basis of any
intervention work in this field. The findings have clinical implications
for therapists and trauma specialists but also for any individual or
service that has contact with individuals, parents or families. This
includes nurses working in a variety of settings.
With growing recognition of the implications and prevalence of
trauma, there is increasing work being done in all fields of trauma in-
terventions for both adults and children using a variety of approaches,
but there has been limited work that relates specifically to intergener-
ational trauma intervention. There is an urgent need for increased un-
derstanding of what may be effective in this field. Within work in the
identified contributing fields of trauma and attachment that emerged
in this review, there is also a need for ensuring that knowledge and
paradigms are shared across similar yet distinct fields and that shared
goals for individuals and families are recognised. Within each of the
identified subconstructs, there are a range of specific approaches
that may be effective; important components include individualised
trauma‐specific therapies for the parent, creation of therapeutic rela-
tional safety, development of a family narrative, supporting mentalisa-
tion and resilience, and attachment‐specific interventions with parent
and infant. There is also a need to clinically consider the interaction
and integration of any trauma and attachment interventions to ensure
they are seen as related and dynamic approaches.
One purpose of the review was to identify potential clinical impli-
cations for working directly with intergenerational trauma. With the
emergence of the role of prevention and opportunistic engagement, it
became clear that nurses may be well placed to engage in preventative
intervention in their roles where they have contact with parents and
families (Foster & Isobel, 2017). Nurses working in mental health, drug
health, child and family and primary health settings can commence
specific preventative intergenerational trauma interventions within
their existing therapeutic relationships with individuals and families.
This could occur directly through approaches identified in this review
or indirectly through referral to specialised trauma and attachment‐
specific services. The opportunities the nursing role poses for con-
sidering the effects or presence of trauma and creating interpersonal
safety such that it is then possible to explore the need for further
trauma and attachment intervention are crucial. Rather than being
seen as the work of specialist therapists, all healthcare profession-
als can implement preventative interventions, but this first requires
understanding of trauma, including its potential mechanisms of being
transmitted across generations through attachment relationships.
This review suggests that prevention of intergenerational relational
trauma is reliant upon increased identification of people with experi-
ences of trauma in nontrauma‐specific services, increased recognition
of the broad effects of trauma and dual focused (trauma and attach-
ment) support and intervention prior to conception, across the perina-
tal period and throughout parenting.
Beyond the role of individuals and services in identification of
prevention and its components, there is a need to be aware of the
systemic and social influences on prevention of intergenerational
transmission of relational trauma. Disentangling parent/infant envi-
ronmental stressors from transmitted trauma or stress is complex
(Bowers & Yehuda, 2016) and requires awareness of the macrolevel
inequalities that effect parenting (Marmot, 2007). While preventing
intergenerational relational trauma transmission may be as “simple”
as resolving parental trauma and supporting attachment, within each
of these components and within each dyad and their wider family,
social and environmental context, there are numerous complexities,
contributing factors and possibilities for intervention and effective-
ness. Interventions for either construct may be partially effective on
their own through enhancing parenting or reducing the impacts of
trauma; however, the complex processes of intergenerational trans-
mission suggest that both will be required for prevention.
The identified constructs of prevention are consistent with the
elements that guide work with the small population of parents who
have experienced abuse and have also been identified to be at risk of
maltreating their own children (Blizard, 2006). Namely, a therapeutic
relationship allows a one‐to‐one emotional connection of sufficient
length and continuity that the parent can develop a more secure at-
tachment style, address dissociative symptoms and their genesis in
traumatic relationships, work through memories of abuse and grieve
the loss of traumatic attachments. These have been identified to
need to occur alongside provision of services to families that help
parents cope with their own difficulties in responding to children's
needs (Blizard, 2006). While certainly helpful for targeting parent/
child dyads at known risk, these principles can also inform wider pri-
mary intergenerational trauma prevention.
Overt child maltreatment is a complex and multifaceted phe-
nomenon (Harden, Buhler, & Parra, 2016) and while the principles
of prevention may be similar, there is a need to be clear that inter-
generational transmission of trauma is not an intentional, harm-
ful act. A large proportion of people exposed to relational trauma
will be empathic and attuned parents (Lieberman, Padrón, Horn,
& Harris, 2005) without the need for intervention. Many groups,
families and individuals exposed to trauma experience transmis-
sion of cultural resilience through shared narratives of trauma and
cultural strength (Bombay, Matheson, & Anisman, 2009). While
the differentiating processes by which vulnerability and resilience
are transmitted remain unclear, there is potential to work with
families and individuals to foster the transmission of strengths.
There is a risk that in identifying the potential for intergenera-
tional transmission of trauma that families, parents and individuals
will experience increased stigma, including within care. Detailed
understanding by nurses and other professionals of intergenera-
tional trauma and the factors that contribute to its transmission
may aid in ensuring that all parents and infants receive support-
ive, strength‐focused care alongside recognition of risk. Education
about trauma and its mechanisms of transmission should include
updated understandings of relational trauma, neuroplasticity and
resilience.
The human brain experiences more growth and refinement
during infancy than at any other period of life (Jaffee & Christian,
ISOBEL et al.
2014). Developmental neuroplasticity is such that while early life
experiences are mapped onto the structure and functioning of the
brain, infant brains can also rebound from traumatic experiences,
particularly if they experience stable, nurturing caregiving (Harden
et al., 2016). While attachment is formed in early relationships, it
is also influenced by later relationships or circumstances (Bowlby,
1988; Iyengar et al, 2014) and can be effectively “reorganised.” The
reorganisation of attachment prior to parenting may result in signif-
icant alterations to the transmission of trauma through attachment
relationships (Iyengar et al., 2014). This may occur during trauma
therapy, but it also forms another potential component preven-
tion approaches not explored here. Similarly, while epigenetics and
neurobiology are promising fields of relevance to intergenerational
trauma, any examination of the biological impacts of trauma also re-
quires consideration of the strengths and resilience that parents and
families can transmit as well as the potential for neuroplasticity and
epigenetic reversibility (Weaver et al., 2005).
Proactive support with establishing and maintaining attachment
relationships was identified in this review as essential to ensure that
the relational space can adequately buffer and protect infants from the
intersubjective transmission of trauma sequelae. Subsequently, once
a trauma survivor is a parent, any intervention aimed at addressing
trauma should include a component of interactive engagement within
the attachment space with the infant or child to ensure that the rela-
tionship is prioritised and can be a source of security and growth with-
out relational transmission of trauma. This can occur before and while
longer term trauma work is undertaken with the adult. Working with
trauma and its effects in an individual can be effective, yet if the next
generation are not proactively focused on within this process, any ben-
efits of intervention may be limited to the individual and an important
opportunity to prevent transmission across generations may be lost.
The challenges identified throughout this review suggest that
acceptance of diverse methods of exploring trauma and its effects
is required to strengthen the field. Broad and evolving understand-
ings of the definition and scope of trauma mean that knowledge
needs to be shared between clinical and theoretical fields. Through
the development of pathways of shared language and the cohesive
integration of research findings developed using diverse methods,
knowledge about how trauma manifests and is transmitted between
individuals and groups, as well as what best interrupts this process
and its effects, can be best translated into practice and policy in a
way that can expediently support communities and families.
4.1 | Limitations
The process used to select papers in CIS is not as transparent as
required by many other review strategies. However, the method re-
quires the constant evolution of a conceptual model until publica-
tion, resulting in a process that lacks auditability (Dixon‐Woods et al,
2006). While efforts have been made here to describe the process
and relate it to familiar review protocols and further progress under-
standing of this method, the process remains specific to the current
context of the review and the critique of the researchers.
| 11
CIS produces one possible interpretation of the evidence, and
although guided by a clear methodology, no claim of reproducibility
can be made. The included literature was selected according to the
review questions and may not include all papers on the rapidly emerg-
ing concept of intergenerational trauma or related fields. CIS demands
constant reflexivity to ensure that the researchers conduct conscien-
tious and thorough searches, make fair and appropriate selections of
materials and ensure that the theory they generate is, while critically
informed, plausible given the available evidence (Dixon‐Woods et al.,
2006). While efforts were made to minimise bias of the researchers,
it is not possible or even desirable to eradicate perspective from a
critical synthesis. Therefore, the findings may not be the same that
another group would produce within the same scope.
Due to the large scope of this review and methodology, there are
important concepts discussed but not explored in depth including
epigenetics, stigmatisation and attachment reorganisation. There
are also a number of intervention approaches mentioned but not
discussed. Future work is required to explore the direct relevance of
these approaches and concepts to intergenerational trauma and to
ensure that the theoretical constructs identified here can translate
into effective work within families and communities.
5 | CO N C LU S I O N
The review identified that prevention is the most effective interven-
tion approach for intergenerational trauma transmission. As trauma
that is passed between generations may present differently in the next
generation, intervention fidelity becomes complicated. Prevention
is the only clearly identifiable way to intervene effectively in the
transmission of trauma between generations. Prevention strategies
should be comprised of strategies to resolve the primary trauma and
strengthen attachment relationships. Trauma resolution in adults may
best include a combination of verbal and nonverbal psychotherapeutic
approaches aimed at developing safety, affect regulation and control,
processing of trauma and its narratives and subsequent integration
and restructuring of self. The development of a narrative of the trauma
in individual therapy may aid to contain it in the past and minimise
it being experienced in the present and transmitted to the future.
Constructing a narrative that acknowledges trauma and its effects but
also establishes a self and a life outside of trauma may also be impor-
tant in promoting intergenerational resilience. Interventions need to
concurrently work to ensure infant or child needs are being met and
to create and foster secure attachment and increase parental respon-
siveness. This may include active engagement within the relational
space to foster and develop attunement, safety and mentalisation.
As the widespread impacts of trauma become increasingly rec-
ognised as an international public health issue (Magruder et al., 2016;
Van der Kolk, 2005) and knowledge increases about trauma and its cy-
clical effects, urgent consideration of the need to prevent transmission
transgenerationally is required. Preventative public health strategies are
required to target individual, relationship, familial, community and soci-
etal levels, including social factors that impact upon parenting, quality
12 | ISOBEL et al.
of life and access to treatment. Addressing and preventing trauma
requires a multipronged, multisystemic approach. Acknowledgement
of intergenerational relational trauma requires identification that the
process of transmission is not just occurring from the past to the pres-
ent; it also flows from the present to the future (Atkinson, 2013) with
prevention providing the key opportunity for intervention.
6 | R E LE VA N C E TO C LI N I C A L PR AC TI C E
This review sought to synthesise and critically interpret literature
to begin to develop theory of relevance to clinical intervention
for intergenerational trauma. There is still more work to be done
to determine how effective this theory is in practice. Detailed un-
derstanding of the mechanisms and components of intergenera-
tional trauma transmission and prevention will, however, enable
the delivery of care within preventative frameworks in a number
of settings. Specifically, an understanding of trauma, its inter-
generational transmission and potential interventions can enable
nurses and other healthcare professionals, to identify and enable
access to important preventative interventions within their ex-
isting roles. Trauma‐informed care is an internationally emerging
model of practice, which supports nurses to consider the preva-
lence and impact of trauma upon individuals. There is opportunity
to expand trauma‐informed models to include awareness of the
components of prevention of intergenerational transmission and
to support nurses to use their frontline positions to directly enact
relatively simple preventative interventions which include identi-
fication of trauma, supporting attachments relationships, foster-
ing resilience, parenting support and referral to trauma‐specific
services. An important component of being trauma‐informed is
understanding of the relational transmission of trauma between
dyads and the factors that may contribute to its prevention.
AC K N OW L E D G E M E N T S
This research is supported by an Australian Government Research
Training Program Scholarship.
C O N FL I C T O F I N T E R E S T
The authors have no conflict of interest to declare.
ORCID
Sophie Isobel https://orcid.org/0000-0002-1027-5847
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How to cite this article: Isobel S, Goodyear M, Furness T,
Foster K. Preventing intergenerational trauma transmission:
A critical interpretive synthesis. J Clin Nurs. 2019;00:1–14.
https://doi.org/10.1111/jocn.14735