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American Journal of  Medical 
Science and Innovation (AJMSI) 

The Impact of  War Trauma and Adverse Childhood Experiences in Bosnia and
Herzegovina: The Case of  the Srebrenica Genocide

Malik Burić1*

Volume 4 Issue 2, Year 2025
ISSN: 2836-8509 (Online)

DOI: https://doi.org/10.54536/ajmsi.v4i2.5281
https://journals.e-palli.com/home/index.php/ajmsi

Article Information ABSTRACT

Received: September 12, 2025
Accepted: October 13, 2025
Published: December 17, 2025

Adverse Childhood Experiences (ACE) represent a major determinant of  adult mental 
and physical health outcomes, encompassing abuse, neglect, and dysfunctional family 
environments. When compounded by war trauma, their impact becomes substantially more 
severe. This review systematically examines research published between 1995 and 2023 on 
the combined effects of  ACE and war trauma in Bosnia and Herzegovina, with a specific 
focus on the Srebrenica genocide. The search was conducted across PubMed, Scopus, and 
Web of  Science databases using predefined inclusion criteria. Studies consistently indicate 
high exposure rates among children, with PTSD prevalence ranging from 30–70% and 
depression from 25–60%. The cumulative impact of  early adversity and war exposure 
contributes to chronic somatic diseases, including cardiovascular and metabolic disorders, 
as well as intergenerational psychological transmission. This review identifies a research 
gap concerning integrated psychosocial and biological models of  trauma recovery in post-
conflict societies. Findings underscore the need for public health strategies that prioritize 
early trauma screening, community-based interventions, and long-term mental health 
programs for survivors and their descendants.

Keywords
ACE, Genocide, Intergenerational 
Effects, PTSD, Srebrenica, 
Trauma

1 University of  Sarajevo, Faculty of  Health Studies, Bosnia and Herzegovina
* Corresponding author’s e-mail: malik.buric@fzs.unsa.ba

INTRODUCTION
Adverse Childhood Experiences (ACE) represent a 
significant risk factor for the development of  mental 
and physical disorders in adulthood (Felitti et al., 1998). 
ACE include physical, emotional, and sexual abuse, 
neglect, and dysfunctional family environments (Anda 
et al., 2006). War trauma further amplifies the effects of  
ACE, exposing children to violence, parental loss, forced 
displacement, and uncertainty (Macksoud & Aber, 1996). 
Children affected by the war in Bosnia and Herzegovina, 
particularly survivors of  the Srebrenica genocide, exhibit 
increased risks of  post-traumatic stress disorder (PTSD), 
depression, and anxiety (Ajdukovic, 2003). Long-
term consequences include somatic conditions such as 
cardiovascular and metabolic diseases, which increase 
overall morbidity (Danese & Tan, 2014). The combination 
of  ACE and war trauma creates cumulative risks that 
persist into adulthood (Shonkoff  et al., 2012). Moreover, 
the intergenerational transmission of  trauma affects the 
descendants of  survivors, who may develop psychological 
and social difficulties even without direct exposure to war-
related violence (Sagi-Schwartz et al., 2008; Yehuda et al., 
2000). Understanding these interactions, with a specific 
focus on Srebrenica, is essential for the development of  
public health strategies, early detection mechanisms, and 
effective therapeutic interventions (Hamber & Wilson, 
2002). Further research is required to design targeted 
support programs for populations affected by war (Musa, 
2018; Kravić, 2013). 

LITERATURE REVIEW
Previous research demonstrates that children exposed to 

war trauma and ACE are highly vulnerable, with complex 
and multidimensional consequences (Betancourt & 
Williams, 2008). Systematic reviews confirm that 
individuals with multiple ACEs have significantly higher 
risks of  PTSD and depression (Hughes et al., 2017).
Studies conducted in Bosnia and Herzegovina indicate 
that over 60% of  children were directly exposed to 
wartime violence, resulting in high prevalence rates 
of  PTSD, depression, and anxiety (UNICEF, 1996; 
Ajdukovic, 2003). Survivors of  the Srebrenica genocide 
displayed particularly elevated risks, with PTSD rates 
between 50–70% and depression between 40–60% 
(Hamber & Wilson, 2002).
The intergenerational transmission of  trauma has also 
been documented, with children of  survivors showing 
symptoms of  PTSD, depression, and social dysfunction 
even without direct exposure (Sagi-Schwartz et al., 2008; 
Yehuda et al., 2000). Neurobiological research suggests 
that alterations in the hypothalamic-pituitary-adrenal 
(HPA) axis and epigenetic mechanisms contribute to 
increased vulnerability (Yehuda & Lehrner, 2018).

MATERIALS AND METHODS
This study represents a structured review of  published 
research addressing the intersection of  Adverse 
Childhood Experiences (ACE) and war trauma, with 
a particular focus on the Srebrenica genocide and its 
long-term psychosocial and somatic consequences. 
The methodological approach followed the principles 
of  systematic review design to ensure transparency, 
reproducibility, and analytical rigor.
A comprehensive literature search was conducted across 



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Am. J. Med. Sci. Innov. 4(2) 136-138, 2025

three major scientific databases PubMed, Scopus, and 
Web of  Science covering the period from 1995 to 2023. 
The search strategy employed the following combinations 
of  keywords and Boolean operators: “Adverse Childhood 
Experiences” OR “ACE” AND “war trauma” AND 
“Bosnia and Herzegovina” AND “Srebrenica” AND 
(“mental health” OR “PTSD” OR “intergenerational 
trauma”). Reference lists of  relevant articles were also 
screened to identify additional eligible studies.

Inclusion and Exclusion Criteria
Studies Were Included If  They

1. Reported empirical or review data related to 
childhood adversity, trauma, or post-conflict psychosocial 
outcomes in Bosnia and Herzegovina;

2. Focused on war-affected or genocide-survivor 
populations;

3. Were published in peer-reviewed journals or credible 
institutional reports;

4. Provided quantitative or qualitative data on 
psychological, biological, or social consequences.

Exclusion Criteria Encompassed
1. Editorials, conference abstracts, and non-peer-

reviewed commentaries;
2. Studies unrelated to war trauma or ACE;
3. Articles lacking methodological transparency or data 

relevant to the Bosnian context.

Data Extraction and Quality Assessment
Data from eligible studies were extracted using a 
standardized framework covering study design, population 
characteristics, type of  trauma exposure, outcome 
measures, and key findings. To assess methodological 
quality and reduce bias, included studies were evaluated 
according to adapted criteria from the Joanna Briggs 
Institute (JBI) Critical Appraisal Tools for cross-
sectional and review studies. This ensured consistency in 
evaluating sample size adequacy, validity of  measurement 
instruments, and clarity of  analytical methods.

Analytical Approach
Findings were synthesized narratively, given the 
heterogeneity of  study designs and outcomes. Emphasis 
was placed on converging patterns across epidemiological, 
clinical, and neurobiological domains. The synthesis 
particularly focused on the interplay between ACE and 
war trauma and their cumulative influence on long-
term psychosocial and health outcomes, including 
intergenerational effects observed among descendants of  
Srebrenica survivors.

RESULTS AND DISCUSSION
Adverse Childhood Experiences and Mental Health 
Outcomes
ACE strongly correlate with mental disorders in 
adulthood. Individuals exposed to three or more ACEs 
demonstrate a two- to fourfold increase in the likelihood 
of  developing post-traumatic stress disorder (PTSD) 

and depression (Hughes et al., 2017). Neglect, emotional 
abuse, and physical maltreatment are also associated with 
higher rates of  anxiety, substance misuse, and suicidal 
behavior (Norman et al., 2012). Biological mechanisms 
mediating these outcomes include dysregulation of  the 
hypothalamic–pituitary–adrenal (HPA) axis, chronic 
inflammatory responses, and epigenetic modifications 
(Heim & Nemeroff, 2001). These findings indicate that 
early-life adversities embed long-lasting physiological and 
psychological vulnerability.
Somatic consequences of  ACE include cardiovascular 
disease, type 2 diabetes, obesity, and metabolic syndrome 
(Danese & Tan, 2014). In post-conflict environments, 
these risks are amplified by additional stressors such 
as poverty, social disruption, and ongoing uncertainty 
(Shonkoff  et al., 2012). This highlights the cumulative 
burden of  ACE compounded by war-related trauma.

War Trauma as an Extreme Form of  ACE
Children in Bosnia and Herzegovina experienced 
multiple traumatic stressors, including bombardment, 
parental loss, direct violence, and forced displacement. 
More than 60% of  children were directly affected by 
war-related violence (UNICEF, 1996). PTSD prevalence 
among war-affected children ranged from 30% to 50%, 
while depression and anxiety affected 25% to 40% 
(Ajdukovic, 2003). Social disruptions, such as interrupted 
education and reduced peer support, further exacerbated 
psychological stress (Muehlenkamp et al., 2005). These 
findings demonstrate that war trauma acts as an intensifier 
of  ACE effects, creating prolonged psychological and 
somatic vulnerability.

The Srebrenica Genocide
The Srebrenica genocide represents one of  the most 
extreme manifestations of  war trauma. Survivors exhibited 
particularly high prevalence of  PTSD (50%–70%), 
depression (40%–60%), and anxiety disorders (30%–
50%) (Hamber & Wilson, 2002). Beyond individual 
psychopathology, survivors experienced collective grief, 
moral injury, and disruption of  social identity. Comparative 
studies of  post-genocide populations, such as Holocaust 
and Rwandan genocide survivors, suggest that such 
extreme trauma generates long-term intergenerational 
effects, affecting community cohesion, family functioning, 
and social adaptation (Sagi-Schwartz et al., 2008).

Intergenerational Transmission of  Trauma
Trauma can be transmitted across generations through 
psychological, social, and biological mechanisms (Van 
IJzendoorn & Bakermans-Kranenburg, 1997). Epigenetic 
changes and dysregulation of  stress-response systems have 
been observed among children of  survivors (Yehuda & 
Lehrner, 2018). Intergenerational transmission manifests 
as heightened vulnerability to anxiety, depressive 
symptoms, and social dysfunction, even without direct 
exposure to war. These findings underscore the need for 
trauma-informed, multilevel interventions targeting both 
survivors and their descendants (Musa, 2018; Kravić, 2013).



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Implications for Public Health and Clinical Practice
The synthesis of  these findings demonstrates a clear 
need for trauma-informed policies within Bosnia and 
Herzegovina’s public health and social service systems. 
Early screening for ACE and war-related trauma should 
be integrated into primary healthcare, schools, and 
community programs. Mental health interventions 
must adopt culturally sensitive frameworks, combining 
individual therapy with collective healing approaches 
rooted in local traditions. Long-term interventions 
should address intergenerational effects, promoting 
resilience among descendants of  survivors (Hamber & 
Wilson, 2002; Musa, 2018). These strategies are essential 
for reducing the cumulative psychosocial burden of  
childhood adversity and war trauma.

CONCLUSION
The combined impact of  Adverse Childhood Experiences 
(ACE) and war trauma significantly increases psychosocial 
risks in children, with consequences that persist into 
adulthood. Evidence from Bosnia and Herzegovina, 
particularly the Srebrenica genocide, demonstrates 
that extreme traumatic experiences contribute to high 
prevalence of  PTSD, depression, anxiety, and long-term 
somatic disorders. Furthermore, trauma is transmitted 
intergenerationally through psychological, social, and 
biological mechanisms, highlighting vulnerabilities among 
descendants of  survivors even without direct exposure to 
war-related violence.
These findings emphasize the urgent need for trauma-
informed public health strategies, early detection 
programs, and culturally sensitive clinical interventions. 
Multidisciplinary approaches, combining mental health 
services, social support, community-based programs, 
and parental education, are essential for mitigating both 
immediate and long-term consequences of  ACE and war 
trauma. Future research should focus on the development 
and evaluation of  targeted support programs that address 
intergenerational trauma and promote resilience in post-
conflict populations.
In conclusion, integrating empirical evidence on ACE, 
war trauma, and intergenerational effects into public 
health policy and clinical practice is critical to reduce 
cumulative psychosocial burdens and to foster adaptive 
functioning in affected communities.

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