Keywords

Introduction

This chapter focuses on three humanitarian crisis contexts, which constitute potentially traumatic events or experiences that impact children worldwide—namely, natural disasters, war, and forced displacement. In considering how these three contexts relate to each other, it is important to recognize that the refugee experience is typically linked to exposure to armed conflict or war—indeed, the necessity of escape from armed conflict or persecution (e.g., religious or ethnic) is the defining feature of the term “refugee.” On the other hand, the majority of conflict or war-exposed children do not also experience being a refugee. Finally, the experience of being exposed to a natural disaster can occur independently of exposure to war and/or displacement; or, in combination with one or both of these other potentially traumatic contexts (thus, a child exposed to a natural disaster may also be growing up in a war-torn community and/or become displaced).

This chapter presents a brief overview of similarities and differences across the three crisis contexts; before focusing on each context separately. Each of the three crisis contexts discussed in this chapter is associated with adverse mental health outcomes for children. Yet, not all—or indeed most—children will experience enduring mental health difficulties as a result of being exposed to these potentially traumatic experiences. In keeping with research in the area of mass trauma, this chapter follows a risk and resilience framework—where resilience is viewed as an individual’s or a system’s capacity to withstand or recover from significant adversity (Bonanno, Brewin, Kaniasty, & La Greca, 2010; Masten, 2011; Masten & Narayan, 2012). Thus, for each of the three contexts, the following topics are reviewed to the extent that the research exists: child mental health outcomes as a consequence of exposure to that context; risk and protective factors (which, following ecological approaches, are broken into individual child/youth-level, parentFootnote 1 and family-level, and community-level factors) in relation to child outcomes; and outcomes of evaluated parent interventions. It should be noted that, both risk and protective factors—though separated into different ecological categories in this chapter—are more frequently interrelated than they are distinct (for example, exposure might be associated with poor parent and child mental health, with these two exerting a pattern of reciprocal influence on one another).

Similarities and Differences Across Contexts

Similarities

The experiences of displacement and being exposed to war or natural disaster share a number of important common threads—they all represent humanitarian crises; and contexts in which exposure to potentially traumatic experience(s) is shared (to different degrees) by the child’s family and community. In other words, the experience does not affect the child or youth alone, but rather all significant people—adults and peers—in their lives. Another important commonality is that each of the humanitarian crisis contexts discussed in this chapter is typically associated with a cascade of potential stressors (such as increased family-level violence or economic pressure) that persist and impact children and families long after the index event or experience (i.e., the event or experience which triggers the symptoms of posttraumatic stress) ends.

Differences

The issue of an “end” to the index experience raises an important point. An endpoint to a crisis may depend on the severity of the emergency, effectiveness of the humanitarian response, the level of resources available to the community, and a child’s opportunities to remain with their family, access schooling, and regain a normal routine quickly. These factors will vary across disasters occurring in high-, middle-, and low-income settings. For youth exposed to conflict, the endpoint will often be less clear—among a number of possibilities, the conflict may have been occurring on and off for months or years. For refugee youth, the issue is perhaps even more complex. The literature suggests that the refugee experience (in terms of an index experience) is best conceptualized as consisting of a number of stages that end in resettlement (which brings its own risks). But, even when resettlement in a new country has been achieved, does that guarantee an end to the displacement experience for young people? For many, the answer would be “no.” Another important difference between exposure to a natural disaster compared with exposure to war and displacement is that natural disasters can occur independently of any other potentially traumatic experience. In other words, natural disaster exposure can constitute a single potentially traumatic event (or what is referred to as a single incident trauma) for a child. However, in many low resource areas, natural disasters further exacerbate the range of risks and hardships that arise from poverty. War and the experience of being a refugee, on the other hand, inevitably involve exposure to repeated and/or prolonged experiences; and/or multiple forms of interpersonal traumatic experiences—in other words, a sequence of potentially traumatic experiences with cumulative effects for mental health (Betancourt, Borisova, de la Soudière, & Williamson, 2011; Fazel, Reed, Panter-Brick, & Stein, 2012).

The Importance of Parents: The Protective Shield

Parents have a crucial role to play in protecting children’s mental health in humanitarian crisis contexts, with the family environment more generally also representing a significant potentially protective buffer for children’s mental health outcomes (Panter-Brick, Goodman, Tol, & Eggerman, 2011). Effective parenting may provide a protective shield (Bell, Flay, & Paikoff, 2002) for children in times of danger, upheaval, and uncertainty. Conceptualized as an emotional defense against environmental factors that have real or perceived potential to harm a child (Pynoos, Steinberg, & Piacentini, 1999; Spoth, Trudeau, Guyll, & Shin, 2012), parents’ capacity to provide a protective shield in times of crisis can become compromised in each of the three contexts reviewed here—as they contend with challenges on many fronts (including their own distress and the nature and quality of their interactions with their children).

Parent Intervention

A long-standing question in relation to humanitarian crises and mental health needs relates to the place and timing of psychosocial interventions (Annan, Sim, Puffer, Salhi, & Betancourt, 2016). Do such interventions have the capacity to be effective when individuals’ more basic needs (including safety) may be ongoing concerns? Research on the role of parent and family factors in children’s mental health outcomes has highlighted the importance of interventions that address not only individual but also family- and community-level factors in terms of risk and resilience (Panter-Brick, Grimon, & Eggerman, 2014). While parenting interventions have frequently been recommended for families in all three contexts, there is a marked lack of research evaluating such interventions. This is unfortunate given that the three contexts discussed in this chapter represent potentially traumatic experiences in which parents (because they are typically directly impacted) may particularly benefit from support in helping their children to make sense of, and cope with the effect of these experiences.

Natural Disasters

The Situation

In 2015, almost 23,000 people were killed and over 98 million were affected by 346 documented natural disasters worldwide; incurring an economic cost of ~US$67 billion (Guha-Sapir, 2016). As the earth’s climate changes, extreme weather events and natural disasters have increased in frequency (Pall et al., 2011); disproportionately affecting people in resource-limited areas. Thus, understanding the emotional impact of these events for children—an especially vulnerable group in a post-disaster environment (McMichael, Neira, & Heymann, 2008)—becomes more important than ever before.

Adverse Outcomes for Children

A review of studies examining children’s post-disaster mental health outcomes concluded that 30–50% of exposed children exhibited moderate to severe posttraumatic stress symptoms (PTSS), with 5–10% meeting criteria for a diagnosis of posttraumatic stress disorder (PTSD ; La Greca & Prinstein, 2002). Similar rates of PTSS and PTSD have been reported across different countries and different types of natural disasters (Bokszczanin, 2007). Post-disaster, rates of depressive symptoms in children have been reported to range from 2% to 69% (Lai, Auslander, Fitzpatrick, & Podkowirow, 2014). Trajectory research among children exposed to different natural disasters has identified the same three PTSS trajectories over time: resilient (initially low levels of PTSS that showed improvement over time), recovering (initially high levels of PTSS that showed significant improvement over time), and chronic distress (initially high levels of PTSS that did not reduce over time) (La Greca, Lai, Joormann, Auslander, & Short, 2013; Self-Brown, Lai, Thompson, McGill, & Kelley, 2013). The two studies differed in their group distributions however, Self-Brown et al. (2013) in their 2-year follow-up (compared with the 10-month follow-up study conducted by La Greca et al. (2013)) reported a higher proportion of children to be in the resilient group (71%) and lower proportions to be in the recovering (25%) and chronic (4%) groups following exposure to Hurricane Katrina.

Risk

Individual Child/Youth-Level

Children’s degree of exposure to the disaster (typically examined using variables such as proximity, and extent of home damage sustained) has been reliably related to children’s risk of developing PTSS following a disaster (Furr, Comer, Edmunds, & Kendall, 2010; Lonigan, Shannon, Taylor, Finch, & Sallee, 1994). Personal losses as well as total disaster-related deaths have also been associated with increased risk (Furr et al., 2010). Demographic variables have been implicated as risk factors, with some studies finding that being younger constituted a risk factor in predicting ongoing PTSS and depression (Kronenberg et al., 2010; McDermott, Berry, & Cobham, 2012). Younger children are of course more dependent on their parents and family unit; in addition, they are less well equipped in terms of cognitive functioning to make sense of, and cope with disaster exposure independently. Being female has also been found to place children at higher risk for developing PTSS post-disaster—with some studies finding that girls are approximately three times as likely as boys to develop severe to very severe PTSS (Furr et al., 2010; Lonigan et al., 1994; McDermott et al., 2012; McDermott, Cobham, Berry, & Stallman, 2010). Somewhat counterintuitively, having a history of previous mental health difficulties was found to be unrelated to the development of PTSS in children exposed to a cyclone disaster (McDermott et al., 2010), while high trait anxiety has been identified as a risk factor (Lonigan et al., 1994; McDermott, Lee, Judd, & Gibbon, 2005). Finally, children’s threat appraisal has been found to constitute a unique risk factor over and above other related factors, such as exposure. Thus, children who thought that they were going to die during the disaster have been found to be at significantly increased risk of developing PTSS across disasters compared to other children (Furr et al., 2010; McDermott et al., 2010, 2012).

Parent/Family-Level

Post-disaster, the link between parent and child distress and mental health difficulties is well established (Bonanno et al., 2010; Masten & Narayan, 2012; Morris, Gabert-Quillen, & Delahanty, 2012). It has been suggested that children’s post-disaster distress may impact parent distress in a pattern of reciprocal influence. Juth and colleagues examined the direction of the association between parent and child distress following the 2006 Indonesian earthquake (Juth, Silver, Seyle, Widyatmoko, & Tan, 2015). They found that, even after controlling for extent of exposure, parent PTSS contributed to children’s general distress, but not vice versa. One of the ways in which parent mental health post-disaster has been proposed to impact children’s mental health outcomes is via the mechanism of altered parenting (Dyb, Jensen, & Nygaard, 2011).

In research that is not specific to the humanitarian crisis contexts discussed here, it has been found that mothers with PTSD (compared to healthy controls) report using more punitive and physical strategies when disciplining their children (Chemtob & Carlson, 2004; Leen-Feldner, Feldner, Bunaciu, & Blumenthal, 2011). In keeping with this research, parents of children who reported greater loss following Hurricane Katrina reported increased use of corporal punishment with their children (Kelley et al., 2010). This was, in turn associated with children being at greater risk for PTSS at both the 4- to 7-month follow-up point and the 14- to 17-month follow-up (Kelley et al., 2010).

Following a storm disaster, children whose parents reported that their parenting had altered (becoming more protective, more likely to communicate a sense of danger and less likely to allow child autonomy) post-disaster were at increased risk for PTSS, even after controlling for disaster exposure (Cobham & McDermott, 2014). When parents’ own distress was taken into account, it became apparent that the pattern of altered, more “anxious” parenting was only associated with elevated levels of child PTSS when parental distress was high. This is consistent with earlier research in which, over 2 years after a flood disaster, adolescents’ perceptions of parental overprotection had both a unique effect on self-reported PTSD, and moderated the relationship between disaster exposure and adolescent distress (Bokszczanin, 2008).

It has often been hypothesized that following exposure to a humanitarian crisis (such as disaster, war or displacement) parents’ compromised capacity to see and respond to their children’s distress appropriately may be a crucial mechanism in the maintenance of children’s distress. However, little empirical research has examined this question. One qualitative study conducted with Norwegian parents whose families were exposed to the south-east Asian tsunami in 2004 while on holiday, found that parents who experienced disaster-related distress also noted that their ability to notice and react to their children’s distress was diminished (Hafstad, Haavind, & Jensen, 2012).

Communication, conflict, and support have also been implicated. Thus, there is some empirical evidence for the importance of communication post-disaster, with children experiencing high levels of PTSS following the 2010 Chilean earthquake indicating that parents’ unavailability/unwillingness (as perceived by the children) to discuss the earthquake was related to higher levels of child PTSS (Garfin et al., 2014). Children in the same study indicated a positive association between parent–child conflict and child PTSS. This is consistent with a longitudinal study of predominantly African-American children exposed to Hurricane Katrina, in which, after controlling for child PTSS at the 1-year post hurricane time point, parent–child conflict predicted child PTSS 2 years after the hurricane (Gil-Rivas & Kilmer, 2013). A lack of perceived parental support has also been found to be associated with elevated levels of youth distress following a flood disaster (Bokszczanin, 2008). The interested reader is referred to Cobham, McDermott, Haslam, and Sanders (2016) for a more thorough review of parent- and parenting-related factors in children’s post-disaster mental health.

Family variables have also been implicated. Youth who endorsed being worried about their family and perceived low family connectedness 2–3 years after Hurricane Katrina were at increased risk for ongoing PTSS and depressive symptoms (Kronenberg et al., 2010). Youth perceptions of family conflict post-disaster have been associated with youth PTSD, over and above disaster exposure (Bokszczanin, 2008). Following a cyclone disaster in Australia, parent ratings of family dysfunction more generally were associated with increased risk for parent-rated internalizing symptoms (McDermott & Cobham, 2012). This is consistent with earlier research. Following a bushfire disaster, disrupted family functioning was found to be a more significant predictor of child PTSS than either disaster exposure or loss (McFarlane, 1987); while adolescent-rated family dysfunction predicted youth anxiety following the 1999 earthquake in Turkey (Kiliç, Özgüven, & Sayil, 2003).

Community-Level

Lack of peer support has been found to predict chronic symptom trajectories (Self-Brown et al., 2013). This is consistent with earlier work following a cyclone disaster in which, after other predictor variables were accounted for, children endorsing low levels of social connectedness were almost four times as likely as other children to develop severe to very severe levels of PTSS (McDermott et al., 2012). Finally, children’s exposure to disaster-related media has been associated with adverse mental health outcomes (La Greca & Prinstein, 2002; Weems & Overstreet, 2008). A recent prospective study, followed children exposed to Hurricane Katrina, but prior to their exposure to Hurricane Gustav (Weems, Scott, Banks, & Graham, 2012). After controlling for exposure, disaster-related media exposure 24 and 30 months after Hurricane Katrina was associated with PTSD symptoms 1 month after Hurricane Gustav, with this relationship not being accounted for by preexisting PTSD symptoms.

Protective Factors

Individual Child-/Youth-Level

Self-regulation skills and cognitive abilities (including cognitive flexibility and general intelligence) appear to be protective factors for children exposed to a wide range of potentially dangerous and traumatic environments, including disasters (Masten & Narayan, 2012). Thus, effortful control abilities buffered children’s PTSS following exposure to Hurricane Katrina (Terranova, Boxer, & Morris, 2009). A sense of competence or mastery has also been found to be related to posttraumatic growth (or positive psychological change in response to adversity) in disaster-exposed children (Cryder, Kilmer, Tedeschi, & Calhoun, 2006).

Parent/Family-Level

There is some evidence that the quality of the parent–child relationship (as rated by parents) may reduce the risk of post-disaster distress among adolescents (Felix, You, Vernberg, & Canino, 2013; Wickrama & Kaspar, 2007). Following a hurricane disaster, adolescents’ perceptions of their parents’ availability and willingness to spend time with them, appeared to reduce the risk for internalizing symptoms—although only when parents had no history of, or current mental health issues of their own (Felix et al., 2013). In other studies, higher levels of youth-rated parental support did not act as a protective factor against PTSS (Bokszczanin, 2008). Finally, in relation to family factors, Thai youth exposed to the 2004 tsunami indicated that positive family functioning was protective against the development of behavioral problems (Tuicomepee & Romano, 2008).

Community-Level

Longitudinal research indicates that, even after accounting for hurricane exposure, peer social support appeared to be protective in terms of development of PTSD, depression and anxiety among youth exposed to Hurricane Katrina (Banks & Weems, 2014). Similarly, high levels of self-reported social connectedness were associated with children being significantly less likely to develop PTSS following a cyclone disaster (McDermott et al., 2012); while peer support has been found to protect children from chronic symptom course (Self-Brown et al., 2013).

Parent Interventions

Traditionally, intervention in the field of children’s experience of natural disasters (and indeed, of any mass trauma) has focused on reducing psychopathology in individual children. In parallel with the move towards a risk and resilience framework (as opposed to a focus on risk alone), there has been a call for the development and evaluation of more strengths-based, family-focused interventions designed to support parents and children in the aftermath of disaster (Cobham et al., 2016; Cobham & McDermott, 2014). To date, two evaluations of universal programs for parents in a post-disaster context have been published. The Caregivers Journey of Hope (JoH) workshop was delivered to parents following an earthquake in New Zealand in 2011 (Powell & Leytham, 2014). A 3-h program, the JoH workshop is psychoeducational in nature, covering topics such as children’s responses to trauma, how stress impacts the body, and building community assets and supports. From pre- to post-workshop, parents reported improvements in their: knowledge of stress in relation to themselves; understanding of coping strategies for managing their stress; current stress levels; ability to identify strengths in managing their stress; knowledge of available social and community supports; and the likelihood of a positive future for their community. Disaster Recovery Triple P—Positive Parenting Program (Cobham, McDermott, & Sanders, 2011) was developed following severe flooding in Australia in 2011. Also psychoeducational, this 2-h parenting workshop was designed to help parents to be aware of and mitigate potential parent- and family-related risk factors (e.g., avoiding conversation about the disaster), while simultaneously promoting resilience-enhancing strategies (e.g., dealing with media exposure, and having a dangerous weather plan). Disaster Recovery Triple P was evaluated in Australia following a flooding disaster in 2011. Attendees reported a high level of satisfaction with the program, as well as statistically significant reductions in children’s emotional and behavioral problems from pre-workshop to the 6-month follow-up point (Cobham, McDermott, & Sanders, 2017). Both of these parenting intervention evaluations were limited by the lack of a waitlist control group.

Box 1 Case Study

Amita* is 13 years old and lives in Gorkha, Nepal. Gorkha was heavily affected by the April 2015 earthquakes that resulted in the death of more than 8800 people and displacement of hundreds of thousands. Amita spoke with our research team 9 months after the first earthquake. The recovery process has been frustratingly slow and many houses and buildings remain in ruins. Amita described her fears and concerns, one of her greatest worries being that the earthquakes would return again. Her father saved her life during the earthquake by carrying her to safety when their house began to shake, but he died from health complications 2 months later and her mother was left to raise Amita and her two younger brothers alone. Amita’s mother, Sajita, experienced significant trauma during Nepal’s civil war and continues to suffer from bouts of depression, made worse by the earthquakes. Amita and her family continue to live in a temporary shelter, with poor sanitation and little protection from the cold in winter. Accessing toilets and maintaining privacy when bathing are ongoing concerns for Amita, who described some of the security issues that adolescent girls face in the camps. Her friends confirmed that men harass them when going to the toilets or changing clothes, and Sajita worries about Amita’s safety, having heard that many girls have been sexually assaulted in the camps. Amita had hoped to study nursing, but now worries that she will not be able to pursue her interests because her family’s economic situation has worsened significantly. She will likely have to find work rather than continue her studies this year. Amita hopes that the family’s situation will improve and that she can return to training in the future.

*Names and identifying details have been changed for protection.

War

The Situation

Nearly 250 million children live in areas impacted by armed conflict (UNICEF, 2016a). Children and adolescents affected by war may be exposed to a range of severe traumas, including physical and sexual violence, deprivation of food, water and shelter, loss of family members, forced perpetration, and the destruction of housing and community infrastructure (Amone-P’Olak & Ovuga, 2017; Betancourt, Newnham, McBain, & Brennan, 2013). Families living in a war zone are at risk of ongoing exposure to violence, which may have a cumulative effect over months or years. The scale of trauma for war-affected families is further compounded by ongoing political, economic and social insecurity, as well as a lack of services that would normally protect and support families in need. In recent years, attention has turned to a subset of children in this group—youth under the age of 18 years who have become active participants in armed forces (commonly known as child soldiers). Although it is difficult to be exact, ~300,000 children worldwide could be termed child soldiers at any moment in time (UNICEF, 2016a). This group represents a significant minority of children who are affected in the most extreme ways by the experience of conflict. Typically, as both victims and perpetrators of violence and abuse, child soldiers may act in a variety of different roles within an armed group—ranging from servants and cooks through to soldiers and minesweepers (Coalition to Stop the Use of Child Soldiers, 2008).

Adverse Child Outcomes

The direct and indirect adverse consequences of exposure to conflict on children’s physical and emotional health have been well documented (Jordans, Tol, Komproe, & de Jong, 2009). Although this chapter focuses on mental health consequences, it is important to note the lost opportunities caused by conflict exposure, specifically educational and economic opportunities (Blattman & Annan, 2010).

A large proportion of children exposed to war or armed conflict demonstrate symptoms of mental health difficulties (Marwa, 2013; Ozer, Irin, & Oppedal, 2013). A systematic review of just under 8000 children living in ongoing or post-conflict areas found substantially increased rates of PTSD (47%), depression (43%), and anxiety (27%) relative to the general youth population (Attanayake et al., 2009). A more recent review focusing on children living in war-affected areas in the Middle East estimated the prevalence of PTSD to be 5–8% in Israel; 23–70% in Palestine; and 10–30% in Iraq (Dimitry, 2012). A review of quantitative research examining the psychosocial adjustment of former child soldiers noted that the prevalence rates across studies reflected the irregularity of the methodologies used (Betancourt et al., 2013). Thus, in work with abducted former child soldiers in Northern Uganda, 99% were reported to meet criteria for PTSD (Amone-P’Olak, 2005; Amone-P’Olak, Garnefski, & Kraaij, 2007), compared to the 27% reported to meet criteria for PTSD in another study of former North Ugandan child soldiers (Okello, Onen, & Musisi, 2007). The interested reader is referred to Betancourt, Borisova, et al. (2013) for a thorough review of the psychosocial adjustment of former child soldiers.

And yet, returning to the earlier theme of resilience, despite the consistent finding that exposure to conflict is linked to poor outcomes for many children, both cross-sectional and longitudinal research also indicates that many conflict-exposed children develop normally, maintaining their mental health in the face of war (Diab, Peltonen, Qouta, Palosaari, & Punamäki, 2015). In one of a small number of longitudinal studies—focusing on former child soldiers in Mozambique—Boothby and colleagues concluded that the majority of these youth had grown into productive and caring adults, with few symptoms of ongoing distress (Boothby, Crawford, & Halperin, 2006). Indeed, when looking at both intervention and longitudinal research (Betancourt, Newnham, et al., 2013; Bolton et al., 2007; Jordans et al., 2010; Tol et al., 2008), most research appears to indicate a process of natural remission for PTSS over time even in the absence of significant sociopolitical changes having occurred. Even among former child soldiers, longitudinal research indicates that rates of PTSD tended to reduce over a 4-year follow-up period (Betancourt, Newnham, et al., 2013); however, rates of anxiety and depression were found to increase across three separate assessment waves (Betancourt, Brennan, Rubin-Smith, Fitzmaurice, & Gilman, 2010). Trajectory research focusing on PTSS in Palestinian children assessed 3, 5 and 11 months after the 2008/2009 War on Gaza has identified three groups: recovery (high level of symptoms that decrease over time; 76%); resistant (low level of symptoms that remain low; 12%); and, increasing symptoms (high and increasing symptoms; 11%; Punamäki, Palosaari, Diab, Peltonen, & Qouta, 2015).

Risk Factors

Individual Child/Youth-Level

Cumulative violence exposure is deemed to be one of the most potent risk factors in terms of conflict-exposed children’s adverse outcomes (Dimitry, 2012). A review of 95 empirical studies with conflict-exposed youth found that almost all the studies that measured PTSS reported a positive association between PTSS and exposure (Barber & Schluterman, 2009). A longitudinal study of 901 Israeli and 600 Palestinian youths and their parents assessed at three 1-year intervals, found that higher rates of cumulative exposure to violence across the first two time points predicted higher levels of PTSS in youth, even when their initial levels of PTSS were controlled for (Dubow et al., 2012). Among former child soldiers, it appears that particular types of violence exposure (e.g., being sexually abused, witnessing the violent death of a family member) may be more strongly predictive of youth distress over time (Betancourt et al., 2010; Kohrt et al., 2008). Interestingly, recent research on risk is shifting the focus from conflict experiences to the post-conflict environment. Thus, in a study examining PTSS and depression among war-exposed Sierra Leonean youth 6 years after the end of the war, the relationship between number of war exposures and PTSS was largely mediated by daily stressors (e.g., financial and housing insecurity, interpersonal conflicts) experienced in the past year; while a direct pathway between current daily stressors (but not war exposures) was found for depressive symptoms (Newnham, Pearson, Stein, & Betancourt, 2015).

Demographic variables have also been identified as risk factors. Thus, unsurprisingly, older children have been consistently reported to experience more conflict-related exposures compared to younger children (Boxer et al., 2013; Qouta, Punamäki, Miller, & El-Sarraj, 2008; Thabet, Ibraheem, Shivram, Winter, & Vostanis, 2009a), with the majority of studies finding that older children have higher rates of PTSS (Khamis, 2005; Laor et al., 2006). The impact of gender is less clear. While most studies indicate that boys experience higher levels of objective conflict-related exposure compared to girls (Dubow et al., 2012; Giacaman, Shannon, Saab, Arya, & Boyce, 2007; Thabet, Abed, & Vostanis, 2004), others suggest that war exposures are experienced at equivalent rates across genders, with girls reporting higher levels of sexual assault and death of a parent (Betancourt, Borisova, et al., 2013). War-affected girls are generally found to endorse higher levels of PTSS (Farbstein et al., 2010; Thabet, Ibraheem, Shivram, Winter, & Vostanis, 2009b) and depression (Pat-Horenczyk et al., 2007), perhaps due to the interpersonal nature of traumas more often reported by girls. In most studies, female former child soldiers report more significant psychosocial difficulties and greater challenges with reintegration compared to male former child soldiers (Betancourt, Borisova, et al., 2013). Kohrt et al. (2008) examined the interaction between gender and child soldier status (civilian versus soldier) and found that, in Nepal, girls appeared to experience greater distress compared to boys as a direct result of the soldiering experience, making them more likely to develop PTSD. Boys, on the other hand, tend to demonstrate more behavioral difficulties (Abdel Aziz, Thabet & Vostanis, 2000) and aggression (Qouta et al., 2008). In relation to former child soldiers specifically, being younger at the time of first involvement has been reported to predict increased depressive symptoms over time (Betancourt, Borisova, et al., 2010).

Finally, children’s appraisals—specifically, their posttraumatic cognitions (persistent negative thoughts about themselves and/or the world; PTCs)—have been found to represent a risk factor for the development of PTSS. A recent study examining Palestinian children’s PTCs found that PTCs were both predicted by and mediated the effects of war exposure, psychological maltreatment, peer unpopularity, and sibling conflict on children’s self-reported PTSS over time (Palosaari, Punamäki, Peltonen, Diab, & Qouta, 2016).

Parent/Family-Level

Parent distress and mental health have been proposed to influence child mental health outcomes, with the majority of studies (both cross-sectional and longitudinal) finding an association between parental distress and children’s mental health outcomes among conflict-exposed youth. Thus, maternal PTSD and maternal anxiety have been found to be associated with child PTSD and anxiety respectively (Thabet, Tawahina, El Sarraj, & Vostanis, 2008; Zeidner, Klingman, & Itskowitz, 1993), while parents’ distress has been reported to both mediate and moderate the impact of war exposure on children’s behavioral and emotional outcomes (Khamis, 2016). In another recent longitudinal study examining the association between parent and child mental health outcomes—in this case, among Afghan families—parent mental health was prospectively associated with a variety of child mental health outcomes (including PTSS, depression, general psychiatric difficulties, overall impairment, and prosocial strength) 1 year later (Panter-Brick et al., 2014). Indeed, these researchers noted that, when it came to predicting child PTSS, the impact of parent mental health approached the risk associated with the child having experienced one or two lifetime trauma events. When predicting child depression, the impact of parent mental health was comparable to the risk associated with being of female gender (Panter-Brick et al., 2014). Panter-Brick et al. (2014) concluded that, in the context of conflict-exposure, there appears to be a mental health “cascade” across generations that links parent and child mental health outcomes, even when individual-level risk factors (e.g., lifetime trauma exposure) are taken into account.

In a study investigating the intergenerational effects of parents’ war exposure on Palestinian children’s well-being, Palosaari and colleagues concluded that fathers’ (but not mothers’) past war exposure constituted a risk factor for children’s attachment insecurity and mental health via the mechanism of psychological maltreatment (emotional neglect, abuse, and corrupting, such as being encouraged by parents to lie or cheat) as reported by children (Palosaari, Punamäki, Qouta, & Diab, 2013). This finding supports earlier research indicating that high levels of exposure to war trauma constituted a risk factor for punitive and neglecting parenting, which was then associated with poor child mental health outcomes (Punamäki, Qouta, & El Sarraj, 1997).

More specifically, punitive parenting has been found to be associated with aggressive behavior in children in Gaza (Qouta et al., 2008) as well as less resilient attitudes among youth (Qouta, Punamäki, Montgomery, & El Sarraj, 2007). Psychological maltreatment (neglect, abuse, and corrupting) by parents has also been found to have an indirect effect (mediated by children’s posttraumatic cognitions, such as “the frightening event has changed me forever”) on children’s PTSS (Palosaari et al., 2016). At the family level, both Afghan parents and youth identified violence as a risk factor over time for children’s total difficulties score on the Strengths and Difficulties Questionnaire (Panter-Brick et al., 2014). This is consistent with other research by Panter-Brick and colleagues with Afghan families, where family-level violence (including family conflicts as well as past year reports of violence such as experiencing and/or witnessing severe beatings) was found to predict negative changes in children’s mental health 1 year after initial assessment (Panter-Brick et al., 2011). Importantly, in this study, family violence negatively impacted the well-being of both children and parents. As Panter-Brick et al. (2011) note, family-level violence is a common response to the experience of living in a context of collective violence. In an earlier study with Afghan families, participants clearly linked the community-level pressures of economic stress and political insecurity with violent interpersonal relationships (Eggerman & Panter-Brick, 2010).

Community-Level

For returned former child soldiers, community stigma (e.g., rejection and social exclusion) is an important risk factor, with a longitudinal study conducted in Sierra Leone indicating that, even after taking conflict exposure into account, stigma predicted deficits in prosocial behaviors as well as elevated levels of externalizing problems and hostility over time (Betancourt, Agnew-Blais, Gilman, Williams, & Ellis, 2010; Betancourt, Brennan, et al., 2010). Importantly, for returned former child soldiers, there is an interaction between gender and community acceptance, with females experiencing higher rates of stigma compared to boys (Betancourt, Agnew-Blais, et al., 2010). Stigma is likely to play an important role in family adjustment after war, as parents simultaneously attempt to support the rehabilitation and reintegration of their children in the community, and address the stigma associated with their past (Betancourt, McBain, Newnham, & Brennan, 2015).

Protective Factors

Individual Child/Youth-Level

In their longitudinal study of Israeli and Palestinian youth and their parents, Dubow and colleagues found that youth self-esteem significantly moderated the longitudinal relationship between conflict exposure and subsequent PTSS (Dubow et al., 2012). Thus, the relationship between greater cumulative exposure to violence and higher PTSS was non-significant for youth who reported high levels of self-esteem. At the level of the individual child, higher levels of self-esteem seemed to protect youth from developing PTSS when exposed to high levels of conflict. Possibly, higher levels of self-esteem may be associated with greater capacity to cope effectively with potentially traumatic events (Dubow et al., 2012). This finding is in keeping with earlier research conducted with Lebanese children indicating that, despite high levels of war exposure, higher levels of problem-solving skills, self-efficacy, and cognitive functioning were associated with lower relative risk of PTSD (Saigh, Yasik, Oberfield, Halamandaris, & Bremner, 2006). Having a flexible cognitive style (relating to attention, learning, and capacity to make sense of experiences) has been found to be protective in terms of Palestinian children’s (Qouta, El-Sarraj, & Punamäki, 2001) and adolescents’ (Punamäki & Puhakka, 1997) mental health. Low levels of negative posttraumatic cognitive appraisals have been reported to be characteristic of children who demonstrate a “resistant” PTSS trajectory (low level symptoms initially that demonstrate little change over time) (Peltonen, Qouta, Diab, & Punamäki, 2014).

Higher socioeconomic status has been found to be associated with fewer mental health symptoms, less social impairment and family problems among war-impacted youth in the Middle East (Al-Krenawi, Graham, & Kanat-Maymon, 2009). There is some evidence that religious faith and perceived spiritual support may act as a protective factor among conflict-exposed adolescents, and be associated with posttraumatic resilience in former child soldiers (Klasen et al., 2010; Schiff, 2006).

Parent/Family-Level Factors

The evidence for good parental mental health as a protective factor in terms of children’s mental health outcomes is somewhat unclear, with some studies finding no moderating effect (Qouta, Punamäki, & Sarraj, 2005) and other studies indicating that good maternal mental health predicts more positive adjustment in conflict-exposed youth (Laor, Wolmer, & Cohen, 2001). Taking a longitudinal perspective, improvement in parental mental health has been associated with predicting improvement over a 4-year period in internalizing symptoms (anxiety and depression) among returned former child soldiers in Sierra Leone over and above other predictive variables (Betancourt et al., 2015). Although research examining the impact of war on parenting is lacking (Murphy, Rodrigues, Costigan, & Annan, 2017), several studies have examined the relationship between parenting style and child mental health outcomes. A supportive, non-punitive parenting style seems to be a protective factor for conflict-exposed youth (Thabet et al., 2009b). In a survey of 7000 Palestinian youth conducted 2 years after the First Intifada, higher levels of youth-perceived parental support were related to more positive adjustment while higher levels of youth-perceived parental control were associated with more negative outcomes (Barber, 1999). In other large studies of Palestinian youth, high levels of parenting style perceived as warm, non-punitive and supportive appeared to be protective for conflict-exposed Palestinian children and adolescents, where perceived parent support and acceptance appeared to buffer adolescents against the risk of developing antisocial behaviors (Barber, 2001; Punamäki, Qouta, & El-Sarraj, 2001). Supportive parenting has been found to be associated with better psychosocial outcomes in returned former Ugandan child soldiers (Derluyn, Broekaert, Schuyten, & Temmerman, 2004).

In their longitudinal study of Israeli and Palestinian youth and their parents, Dubow and colleagues found that positive parenting (measured by parent-report on an index of non-violent discipline) significantly moderated the longitudinal relationship between conflict exposure and subsequent PTSS (Dubow et al., 2012). Thus, the relationship between greater cumulative exposure to violence and higher PTSS was non-significant for youth whose parents reported high levels of positive parenting (i.e., non-physical strategies such as rewarding/praising for doing something right). The finding that positive parenting acted as a protective factor in the face of conflict exposure is consistent with cross-sectional studies (Qouta et al., 2008). In terms of more general family-related variables, qualitative research with Afghan participants has suggested that wahdat and ittifaq (family “unity and harmony”) are key cultural values that emerged as strongly embedded within children’s narratives of their experiences of conflict-related adversity, risk and resilience (Eggerman & Panter-Brick, 2010). “Better home life” was associated with positive change over time in child-rated total difficulties and impairment scores on the Strengths and Difficulties Questionnaire (SDQ), whereas “family unity” was positively related to prosocial scores and negatively related to impairment scores on the SDQ (Panter-Brick et al., 2014). Having a supportive family has been identified as a buffer against PTSD among conflict-exposed youth (Cummings et al., 2011; Thabet et al., 2009b). In their longitudinal study of returned former child soldiers, Betancourt et al. (2015) reported that an increase in perceived family acceptance between baseline and follow-up was associated with a significant reduction in youth internalizing symptoms. Sibling relationships characterized by high levels of intimacy and low levels of rivalry have also been found to be protective for conflict-exposed youth (Peltonen, Qouta, El Sarraj, & Punamäki, 2010).

Community-Level

Higher levels of community social support have been found to predict better psychosocial adjustment (specifically, increased prosocial behaviors) over time in returned former child soldiers in Sierra Leone (Betancourt, Agnew-Blais, et al., 2010). Community reintegration support has also been reported to predict lower levels of depression, PTSD and functional impairment in returned Nepalese former child soldiers (Kohrt et al., 2010). Interestingly, within this study, peer social support was found to be the strongest predictor of lower levels of functional impairment and PTSD, as well as improved hope (Morley & Kohrt, 2013). Peer relationships have also been found to be associated with greater resilience among Palestinian youth, particularly boys (Peltonen et al., 2014).

Finally, longitudinal studies have noted the importance of school attendance as a resilience-enhancing factor (Ahmad, Mohamed, & Ameen, 1998). The importance of educational opportunities was highlighted in the Sierra Leone longitudinal study of returned former child soldiers, where reentering and maintaining attendance at school was linked to more prosocial behaviors and greater self-confidence (Betancourt, Brennan, et al., 2010). In an important link between family and community factors, youth with higher levels of family social support have been reported to be more likely to remain in school (Zuilkowski & Betancourt, 2014). Qualitative data echo these findings, with Afghan children articulating their perception of school as a means to maintaining family unity and reducing economic stressors (Eggerman & Panter-Brick, 2010).

Parent Interventions

In conflict settings, violence prevention and strengthening of family unity at the family-level have been identified as crucial issues for intervention (Panter-Brick et al., 2014), yet the evidence base on parenting interventions in post-conflict settings is nascent. The associations found between child outcomes and a number of parent variables (such as mental health, parenting, and family environment) underline the potential utility of parenting programs in conflict-affected communities. However, at this point, psychosocial interventions that have been evaluated have focused on working directly with children to reduce psychological symptoms (Jordans et al., 2009), or less commonly, increase resilience (Diab et al., 2015; Zuilkowski, Collet, Jambai, Akinsulure-Smith, & Betancourt, 2016). Almost no evidence exists to inform the implementation of parenting programs in war-exposed communities (Murphy et al., 2017). To the best of our knowledge, only one evaluated parenting intervention has been tailored to the needs of a war-exposed parent population. Wieling and colleagues developed, adapted and tested their intervention (“Enhancing Family Connections”; EFC) in close collaboration with local Ugandan community members (Wieling et al., 2015). EFC consists of 9 sessions, with three sessions focusing on educational content (the intergenerational transmission of violence, the impact of psychological trauma, and the relationship between trauma exposure and substance use) and six focusing on parenting strategies (enhancing positive parental involvement, giving instructions and teaching through encouragement, monitoring, effective limit setting, and staying calm while disciplining children). At post-intervention and the 5-month follow-up point, participant mothers reported a high level of satisfaction with the intervention, while quantitative measures and qualitative interviews with both mothers and their children indicated an increase in the use of encouragement and praise, and love and respect in their relationship. Use of time-out and removal of privileges were also reported to increase from preintervention, alongside a reduction in the use of physical beatings (Wieling et al., 2015). Initial findings from the feasibility study are promising, but more rigorous evaluation is required. Murphy et al. (2017) suggested a number of important recommendations in terms of the implementation of parenting programs in conflict-affected communities. These include linking parenting interventions with interventions focusing on economic outcomes where possible; targeting family-level violence; and addressing the safety issues relevant to a specific community and conflict.

Forced Displacement

The Situation

Armed conflicts and complex emergencies have resulted in more than 65 million people displaced globally (UNHCR, 2016). Any person who flees their home country due to a well-founded fear of persecution is eligible to claim refugee status in a country of safety. Those who are seeking protection but have yet to receive assessment of their claim are known as asylum seekers, which comprise the vast majority of people displaced across international borders. For the purposes of this chapter however, all persons seeking protection from persecution will be referred to as refugees. Refugees often originate from areas affected by armed conflict—thus, much of the content relating to war exposure above will apply to child refugees and their families. Worldwide, 28 million children (defined as under the age of 18 years) are currently refugees (UNICEF, 2016b). That figure represents 1 in 200 children, or 0.5% of all children in the world. In 2015, twice as many child refugees came under the mandate of the UNHCR compared to 2005, with almost half of children coming from Syria and Afghanistan (UNICEF, 2016b). Concerningly, the number of refugee children who are unaccompanied by a parent has also increased—with an estimated 100,000 unaccompanied children filing for asylum in 2015; three times as many as the previous year (UNICEF, 2016b).

In making sense of the research in this field, it is important to understand that the refugee process (Williams, 2010) consists of a number of distinct stages, each of which presents their own stressors and challenges. Indeed, Williams (2010) proposed a four stage ecological model of refugee parenting—with parents and children hypothesized to be impacted by multiple determinants at each stage (Lustig et al., 2004; Slobodin & de Jong, 2015): the country of origin; the pre-flight stage; departure (flight) stress—which includes periods of transition, such as refugee reception centers; and, resettlement. The family (or its absence) plays an important role at each stage for refugee youth. The adverse events and experiences that necessitated a family’s flight are typically only the beginning of a journey characterized by uncertainty and upheaval. Many spend years awaiting processing of their asylum claim, or living in places of transit (Halcón et al., 2004). As alluded to earlier, the literal end point of the journey—resettlement—does not mark the end of the experience of being a refugee; rather the challenges faced are simply of a different nature (Fazel et al., 2012). In attempting to understand the refugee experience, the full spectrum of possible experiences must be considered—as opposed to focusing on the pre-flight environment (typically one of conflict), or assuming that the challenges end with resettlement (Fazel et al., 2012). It is also important to remember that there is no way to truly determine the unique contribution made to child and adolescent refugees’ distress by each of the component parts of their experience or the cumulative effect of some or all of these factors (Felsman, Leong, Johnson, & Felsman, 1990).

Adverse Outcomes for Children

Overall, the majority of studies indicate elevated prevalence rates of mental health problems in refugee children, particularly anxiety, depression, and posttraumatic stress (Porter & Haslam, 2005; Tousignant et al., 1999). A reasonable amount of research examining the relationship between conflict exposure and children’s mental health outcomes (see previous section on war-impacted children) exists, with cumulative exposure to violence being associated with a range of psychological problems in refugee children (Almqvist & Broberg, 1999; Ellis, MacDonald, Lincoln, & Cabral, 2008).

However, the additive potential risks posed by displacement and resettlement for refugee children have not received adequate attention (Fazel et al., 2012). In one of the few studies that have examined displacement as a risk factor, compared to non-displaced children from the same conflict-impacted areas in Croatia, displaced children experienced worse psychosocial adaptation, which did not improve with time, although symptoms of PTSS, depression and somatic complaints did reduce in both groups over a 30-month follow-up (PSIH, 2000). In another study however, the prevalence of depression was comparable in displaced compared to non-displaced children (Zivcić, 1993). The small body of research, with its inconclusive findings, makes it difficult to determine whether the experience of being displaced from one’s home increases a child’s risk—further research is required. Among displaced children in refugee camps in Southern Darfur, 75% were reported to meet diagnostic criteria for PTSD and 38% for depression (Morgos, Worden, & Gupta, 2008). In a sample of refugee children resettled in a high income country (Canada), 21% of youth met criteria for a psychiatric diagnosis compared with 11% of non-refugee adolescents in the community (Tousignant et al., 1999). A systematic review focusing on the prevalence of mental disorders among refugees resettled in western nations found that 11% of children in the studies examined met criteria for PTSD (Fazel, Wheeler, & Danesh, 2005).

Immigration detention, a policy of deterrence practiced in more than 60 nations, has been associated with the maintenance, worsening and independent onset of psychiatric difficulties in children and youth (Fazel, Karunakara & Newnham, 2014). Severe depression, anxiety, PTSS, social withdrawal, developmental regression, self-harm, and suicide have been reported at concerning levels among detained child and adolescent refugees (Dudley, Steel, Mares, & Newman, 2012; Lorek et al., 2009). Considering the stages that represent the experience of being a refugee, it is important to assess outcomes at different points in time, while bearing in mind that it is extremely difficult to disentangle the differential impacts of potentially traumatic experiences.

Risk Factors

Child/Youth-Level

Exposure to violence is the single risk factor with the strongest evidence base among child refugee samples. Refugee children have potentially been exposed to a wide variety of violent and other potentially traumatic events at different points along their journey; beginning with their country of origin and progressing through the flight and resettlement stages (Reed, Fazel, Jones, Panter-Brick, & Stein, 2012). The cumulative number of lifetime adverse events (Morgos et al., 2008; Thabet et al., 2004; Trentacosta, McLear, Ziadni, Lumley, & Arfken, 2016); the extent of direct exposure to threat (Allwood, Bell-Dolan, & Husain, 2002; Goldstein, Wampler, & Wise, 1997; Morgos et al., 2008), and duration of exposure (Ahmad, Sofi, Sundelin-Wahlsten, & von Knorring, 2000) all consistently increase children’s risk of mental health symptoms. In line with the research focusing on conflict-exposed youth, particular types of exposures—namely those that directly disrupt or imperil the integrity of the individual and/or family safety—appear to be especially consequential, for example, witnessing a family member’s death or torture (Goldstein et al., 1997). In terms of demographic factors, there is some evidence that being older (specifically, over the age of 12 years) when exposed to forced displacement is associated with worse outcomes, particularly depression—though this needs to be considered in terms of a number of contextual variables including: normative age-related prevalence rates (with depression becoming more frequent in adolescence); the likelihood of older children having greater exposure to potentially traumatic experiences; and the tendency for many older child refugees to take on adult responsibilities, particularly when the family has been disrupted (Allwood et al., 2002; Morgos et al., 2008; Thabet et al., 2004). Being female has been identified as a risk factor for depression among refugee youth in some studies (Morgos et al., 2008; Sujoldzić, Peternel, Kulenović, & Terzić, 2006) but not others (Ellis et al., 2008), with boys found to be more likely to develop externalizing disorders (Mels, Derluyn, Broekaert, & Rosseel, 2010). Of course, this pattern of symptom development is normative for non-exposed youth populations. Unaccompanied children will often have experienced more adverse events compared to accompanied children (Bean, Derluyn, Eurelings-Bontekoe, Broekaert, & Spinhoven, 2007; Hodes, Jagdev, Chandra, & Cunniff, 2008; Mels et al., 2010) and are at increased risk of developing psychological disorders.

Parent/Family-Level

In terms of parent mental health, relatively little research has examined the association between parent and child mental health outcomes among refugee populations. However, there is some evidence that poor mental health in parents is associated with poor mental health outcomes in refugee youth (Ajduković & Ajduković, 1993). A heterogeneous clinical sample of refugee children resettled in the USA reported an increased likelihood of having an impaired caregiver compared with US-origin children (Betancourt et al., 2017). Among Guatemalan refugee children, depressive symptoms in girls were found to be closely associated with maternal well-being (Shisana & Celentano, 1985), whereas PTSD in parents did not independently predict PTSD in Kurdish Iraqi children, with the association mediated by shared exposure (Ahmad et al., 2000). Importantly, some types of parental exposures (e.g., torture or abduction) have been found to be more strongly related to children’s mental health problems than children’s own exposures (Daud, af Klinteberg, & Rydelius, 2008; Montgomery & Foldspang, 2006; Rousseau, Drapeau, & Rahimi, 2003). Limited evidence suggests that living in a refugee camp has been linked to greater likelihood of psychological maltreatment of youth by parents (Khamis, 2000), as well as increased rates of intrafamilial violence (Catani, Schauer, & Neuner, 2008; Panter-Brick, Eggerman, Gonzalez, & Safdar, 2009). In terms of parenting, it has been noted that parents living in refugee camp settings appropriately shift their focus to prioritize physical daily needs over psychological needs, leading to a pattern of altered parenting (McElroy, Muyinda, Atim, Spittal, & Backman, 2012). Following on from this research, a recent qualitative study examined the challenges experienced by Syrian mothers (with at least one child aged 4–10 years) living in a refugee camp (El-Khani, Ulph, Peters, & Calam, 2016). A downward spiral was identified; with camp living conditions, changes in children’s behavior (more violent play and more aggressive communication) and emotions (sadness, lack of motivation) impacting mothers’ sense of competence in their parenting. Mothers’ actual parenting behaviors were affected in turn (more frequent uses of physical discipline strategies and aggressive communication), with some of this impact attributed by mothers to their own distress and not knowing how to respond to their children’s needs. Children were perceived as reacting negatively to mothers’ own distress, mothers’ altered parenting, and mothers’ lack of confidence in their parenting. Maternal competence decreased further while children’s behavioral problems increased. This study suggests one way of understanding the high levels of child maltreatment evidenced in refugee camps (Lustig et al., 2004), as well as linking back to the prospective finding that family-level violence is a key predictor of child mental health outcomes, even in the context of ongoing military conflict (Panter-Brick et al., 2011).

Community-Level

In host countries, the arrival of refugees can lead to tensions for many reasons (Farwell, 2003), including the real or perceived threat to the availability of resources (Pedersen, 2002). This in turn can result in child refugees being exposed to harassment, as well as sexual and physical violence in the community (Betancourt et al., 2012; Dolma, Singh, Lohfeld, Orbinski, & Mills, 2006; Farwell, 2003). Recent violence from peers in the context of resettlement of low/middle income countries has been associated with anxiety, depressive and psychosomatic symptoms among refugee youth (Sujoldzić et al., 2006). Related to this, backlash trauma (discrimination by individuals and institutions, combined with negative media portrayals) was predictive of mental health problems in Iraqi Muslim adolescents (Kira, Lewandowski, Chiodo, & Ibrahim, 2014). Another important community-level factor is the process of cultural negotiation (Frounfelker, Assefa, Smith, Hussein, & Betancourt, 2017), often also known as acculturation (i.e., the process of adapting to a new culture). Parents in resettled refugee families often experience a significant sense of loss of their culture of origin (El-Khani et al., 2016; Renzaho, McCabe, & Sainsbury, 2011) in addition to uncertainty, as they navigate the expectations and norms of a new culture. Compared to their parents, children tend to acculturate quite rapidly, embracing the independence and freedom that often comes with the new culture (Renzaho & Vignjevic, 2011). This can result in what is referred to as acculturative family distancing, in which an acculturation gap develops between parents and their children, leading to tensions and conflict (Telzer, 2011). In a recent qualitative study with Somali Bantu refugee parents and youth resettled in the USA, it was concluded that the strategies of cultural negotiation used by adults and children had two key consequences: an increase in conflict within the parent–child dyad; and a strengthening of relationships between siblings, as youth look to each other for support in navigating both the cultural negotiation and the impact on this on their relationship with their parents (Frounfelker et al., 2017).

Protective Factors

Child/Youth-Level

High self-esteem has been found to be a resilience-enhancing factor among refugee youth (Daud et al., 2008). Acculturation (i.e., the ability to integrate into the host society) and language skills have also been associated with better psychosocial functioning over time among resettled refugee youth (Halcón et al., 2004). However, the importance of maintaining a sense of one’s original cultural identity is also crucial. A matched sample study of youth seeking treatment for trauma-related difficulties in the USA suggested that refugee youth reported higher levels of trauma exposure, but lower rates of substance abuse and oppositional defiant disorder than US-origin youth (Betancourt et al., 2017). It may be the case that a range of unique protective factors, including cultural norms, play an important role in shielding refugee youth from behavioral and substance use issues. Similarly, an assessment of coping methods among Somali and Oromo youth resettled in the USA suggested that most engaged in a range of healthy coping behaviors to deal with sadness (Halcón et al., 2004). Despite the high levels of coping evident among refugee children and youth, little attention has been paid to the specific protective factors that contribute to pathways of resilience in these populations. Further research that examines the factors associated with resilience among refugee children and adolescents will strengthen the field.

Parent/Family-Level

Good parental mental health—particularly in mothers—has been found to be a significant protective factor for refugee youth (Almqvist & Broberg, 1999; Hjern, Angel, & Jeppson, 1998). Youth perceptions of high parental support and family cohesion are associated with less distress in refugee children (Berthold, 1999; Kovacev & Shute, 2004; Sujoldzić et al., 2006; Trentacosta et al., 2016). Interestingly, in the study by Trentacosta et al. (2016) of Iraqi refugees resettled in the USA, supportive parental relationships only buffered the development of depressive symptoms when cumulative trauma exposure was low. Higher levels of family connectedness have been associated with lower rates of depression among displaced Bosnian adolescents (Sujoldzić et al., 2006). In relation to family communication about adverse experiences, a study of Bosnian refugees resettled in Sweden indicated that lack of discussion was protective in relation to children’s mental health (Angel, Hjern, & Ingleby, 2001). Family composition has been found to be protective in some studies, with boys living with both parents post-resettlement and boys who experienced fewer changes in family structure found to endorse significantly lower rates of psychological symptoms compared to boys living in other types of family structures (Tousignant et al., 1999).

Community-Level

Low levels of peer violence and discrimination have been associated with higher self-esteem among resettled Bosnian adolescents (Sujoldzić et al., 2006). Feeling supported by peers in the context of resettlement has been linked to improved psychosocial functioning (Kovacev & Shute, 2004). Among resettled refugee youth, a sense of safety at school has been linked to lower risk of PTSD (Geltman et al., 2005); while an increased sense of connection to school has been found to protect against depression (Kia-Keating & Ellis, 2007; Rousseau, Drapeau, & Platt, 2004; Sujoldzić et al., 2006), anxiety (Sujoldzić et al., 2006) and PTSS (Trentacosta et al., 2016), as well as being associated with higher youth self-esteem (Rousseau et al., 2004).

Parent Interventions

For refugee families living in a new society, parenting represents one of the most challenging issues to be negotiated (Renzaho, Green, Mellor, & Swinburn, 2011). Interventions that help refugee parents parent effectively given the context in which they find themselves, have the potential to significantly reduce risk factors and enhance resilience-enhancing factors throughout the journey to resettlement and beyond, and have been recommended as global mental health priorities (Williams, 2012). By targeting parenting factors specifically, it may be possible to influence the relationship between the impact of exposure to violence and displacement on children’s mental health outcomes (Diab et al., 2015; Tol et al., 2011). Unfortunately, there is very little research examining the parenting needs of refugee families (Reed et al., 2012). Given calls for parent education training in the early identification and management of children’s mental health issues to be offered in post-war settings (Panter-Brick et al., 2014; Williams, 2010), the recent qualitative study conducted by El-Khani et al. (2016) represents an important step in the right direction, focusing as it does on the challenges of parenting in a refugee camp. To the best of our knowledge, one evaluation of a parenting program tailored for refugee parents has been published. Conducted in Australia with resettled sub-Saharan African refugees (Renzaho & Vignjevic, 2011), the intervention (the African Migrant Parenting Program) consisted of eight sessions (~2 h duration), which were delivered in a group format. Content focused on the development of culturally competent parenting and educational material. Thirty-nine families completed pre- and post-treatment assessments, with results indicating that the program was highly acceptable to families. From pre- to post-treatment, significant positive change was found for: parental empathy towards children’s needs, parental expectations, understanding of parent–child family roles, and awareness and knowledge of alternative parenting strategies to corporal punishment. No change was observed on parents’ restriction of children’s autonomy and power, causing the researchers to suggest that participation in the program had not impacted parents’ attitudes regarding children’s independence or power within the family (Renzaho & Vignjevic, 2011). As the authors note, this study is limited by a lack of follow-up beyond post-treatment, as well as a small sample size. However, it represents an excellent beginning.

Limitations of Research Conducted in Humanitarian Contexts

Across the three humanitarian crisis contexts examined in this chapter, common methodological limitations to the research examining child outcomes, risk and protective factors, and the role of parents and the family environment exist and should be kept in mind. To begin with, research in these fields tends to focus on individual-level, as opposed to family- or community-level data—such that the individual youth is typically conceptualized both as the unit of analysis and as the target of intervention (Betancourt, McBain, Newnham, & Brennan, 2013; Catani, Jacob, Schauer, Kohila, & Neuner, 2008; Catani, Schauer, & Neuner, 2008; El-Khani et al., 2016; Fazel et al., 2012; Gewirtz, Forgatch, & Wieling, 2008; Panter-Brick et al., 2011). There is a problematic reliance on self- and parent-report (Cobham et al., 2016); as well as an exclusive focus on event or experience-related trauma and PTSS or PTSD, as opposed to a broader range of risk and outcome variables, including the post-emergency environment (Catani, Jacob, et al., 2008; Catani, Schauer, & Neuner, 2008; Miller & Rasmussen, 2010; Panter-Brick et al., 2011). The majority of empirical studies conducted in these humanitarian contexts is cross-sectional in nature (making it impossible to infer causality), with relatively few longitudinal studies or randomized trials conducted (Betancourt, Borisova, et al., 2013). Work in this area has also been characterized by a focus on the cumulative impact of exposure as opposed to examining associations between different types of potentially traumatic exposures and mental health outcomes (Reed et al., 2012). Finally, very little attention has been paid to cognitive, neurological, and epigenetic markers of stress in youth and parent populations exposed to disasters, conflict, and forced displacement (Nickerson et al., 2017; Ramo-Fernández, Schneider, Wilker, & Kolassa, 2015).

Having acknowledged these limitations, it is also important to note that conducting research with refugee youth and families and/or those who have been impacted by natural disasters or war, is inherently challenging and researchers in these fields are to be commended for the important insights their work has provided.

Conclusions

Humanitarian crises present a cascade of threats to vulnerable families. Beyond the direct threat of trauma; conflict and disaster often result in widespread economic insecurity, destruction of societal infrastructure, and heightened rates of exploitation and community violence (Miller & Rasmussen, 2010). Each of these risks has a direct effect on children, and compounds stressors for parents. Yet whether exposed to a natural disaster, armed conflict, or the range of experiences involved in forced displacement, the majority of children demonstrate resilience over time in the face of adversity. Across the three humanitarian crisis contexts, many of the same risk and protective factors for child mental health emerge. Important risk factors across all three contexts include exposure to trauma for children and parents, parental mental health, changes in parenting behaviors (which range from inattentive to overprotective), hardships and financial stress, domestic and community violence, and a lack of accessible services. Common protective factors include stable supportive parental relationships, strong family connectedness, and sustainable resources available to support families. Although these factors have been described separately throughout the chapter, in reality, the pathways to children’s risk and resilience are highly interrelated; and children’s needs in the three crisis contexts reviewed must be understood in the context of an integrated ecological framework. As highlighted by the World Health Organisation framework (WHO, 2008), children’s risks cannot simply be added up in order to predict their outcomes. However, what is clearly needed is a strengthened evidence base for interventions to support parents and children across the range of humanitarian crisis settings. While a small number of parenting programs delivered in post-disaster, post-conflict, and resettlement settings have demonstrated promising first results, rigorous evaluations are lacking. Drawing from the broader evidence base of parenting research from high-resource nations, and a growing evidence base emerging from crisis settings, will support the further development of culturally appropriate and sustainable interventions. As child and adolescent mental health becomes a growing focus of public health programming and policy, family-strengthening interventions will play an important role in addressing the significant mental health gap in humanitarian contexts.