From an ecological perspective, proximal factors and processes within the family microsystem have the most powerful impact on children`s development and well-being (Bronfenbrenner, 1986; Lynch &
Cicchetti, 1998; Miller & Rasmussen, 2017). Among refugee families living in resource-poor camps close to ongoing conflict, these processes may be particularly salient given families` exposure to past trauma and current adversities of camp life. However, it is still unclear whether and how these factors
contribute to the mental health and adjustment of refugee children and adolescents living in camps.
Therefore, this research focused on parental psychopathology as a family-level risk factor as well as child maltreatment and the parent-child relationship as proximal processes. The following section presents existing evidence for these variables in non-refugee and refugee populations and points out important limitations in the literature.
2.4.1.1 Parental psychopathology
Numerous studies with non-refugee families have consistently demonstrated that children of parents suffering from psychopathology are at an increased risk for developing psychopathology themselves (e.g. S. H. Goodman & Gotlib, 1999; Lambert et al., 2014; McLaughlin et al., 2012). Although the majority of studies have been conducted with mothers, there is also a robust evidence base for the association between fathers` and children`s psychopathology (e.g. Barker et al., 2017; Kane & Garber, 2004; Ramchandani & Psychogiou, 2009). Besides a documented genetic heritability of mental disorders (Beardslee et al., 2011; Duncan et al., 2018; Hicks et al., 2004) and potential epigenetic mechanisms (Lehrner & Yehuda, 2018), environmental factors such as problems in the parent-child relationship and maladaptive parenting behaviors have been proposed as potential mechanisms underlying the transgenerational transmission of psychopathology including PTSD, depression and externalizing problems (Bailey et al., 2009; Cummings & Davies, 1994; van Ee, Kleber, & Jongmans, 2016). For example, meta-analytic reviews demonstrated less positive, e.g. warm, sensitive and supportive, and more negative, e.g. hostile, critical and coercive, parenting behaviors in depressed mothers and fathers (Lovejoy et al., 2000; S. Wilson & Durbin, 2010). Similarly, maladaptive
relational patterns and an increased risk of child abuse were found in parents with PTSD (Montgomery et al., 2019; van Ee, Kleber, & Jongmans, 2016). However, a major limitation of many studies is the overreliance on parents` self-report of their relationship with their children and their parenting
behaviors, which may be biased by mental health symptoms associated with negative affect and views of oneself and others (Banyard et al., 2003; Ringoot et al., 2015).
In their comprehensive systematic review, Reed and colleagues (2012) noted that the role of parents` mental health for refugee children`s well-being has rarely been studied, particularly in low- and middle-income settings, where parents might be particularly distressed. However, there is
increasing evidence documenting associations between parental and child psychopathology in refugee families both in high-income countries (Beiser & Hou, 2016; Fazel et al., 2012; Javanbakht et al., 2018; Wiegersma et al., 2011) and in refugee camps and urban settings in low-and middle-income countries (Betancourt, Yudron, et al., 2012; Eruyar, Maltby, et al., 2018; Meyer, Steinhaus, et al., 2017; Miller, 1996). For example, higher depression symptoms in caregivers were related to more depression and anxiety symptoms in South Sudanese adolescents living in Ugandan refugee camps (Meyer, Steinhaus, et al., 2017), while caregiver distress was prospectively associated with
adolescents` internalizing and externalizing problems in an Ethiopian refugee camp (Betancourt,
Yudron, et al., 2012). Mothers` good mental health and coping abilities have also been shown to be a protective factor for the mental health of refugee children in camps (Ajduković & Ajduković, 1993;
Ekblad, 1993).
Notwithstanding, with very few exceptions (Ahmad et al., 2000; Javanbakht et al., 2018), fathers have not been included in studies despite the documented independent impact of paternal factors on family functioning and children`s mental health in the aftermath of war and conflict (Palosaari et al., 2013; Punamäki et al., 2001; Saile et al., 2014). An even more important gap is that studies investigating associations between parental and child psychopathology in refugee families have hardly examined potentially underlying mechanisms. Studies with refugee parents and their children who were born in exile in high-income countries point to the importance of parenting and family factors, but these children were not exposed to conflict-related violence and flight stress themselves (Dalgaard et al., 2016; Daud et al., 2008; Field et al., 2013; van Ee, Kleber, & Jongmans, 2016). From an ecological perspective on risk and resilience, children`s mental health problems stemming from war and displacement are likely to play an important role in family processes that may contribute to the transmission of psychopathology in refugee families (Catani, 2018; Timshel et al., 2017). Two studies with trauma-exposed refugee families suggest that impaired parenting may play a key role. Caregiver PTSD (Bryant et al., 2018) and psychological distress (Sim, Bowes, et al., 2018) due to exposure to war and displacement-related stressors were linked to more negative parenting behavior, which was in turn related to higher levels of children`s emotional and behavioral problems.
However, these studies assessed parenting and child psychopathology through caregivers` reports and did not consider children`s own trauma exposure.
2.4.1.2 Child maltreatment
Acts of child maltreatment represent extreme forms of impaired parenting behaviors that are the result of escalations in the immediate context of parent-child interactions (Belsky, 1993). Thus, a pathogenic parent-child relationship lies at the core of child maltreatment (Valentino, 2017). Despite ratifications of agendas and treaties such as the United Nations Conventions on the Rights of the Child, which declared child maltreatment illegal worldwide, child abuse and neglect is still widespread around the world. In a review of meta-analyses, the overall worldwide prevalence rates for self-report studies were 127/1000 for sexual abuse, 226/1000 for physical abuse, 363/1000 for emotional abuse, 163/1000 for physical and 184/1000 for emotional neglect (Stoltenborgh et al., 2015).
Child maltreatment has devastating consequences for the individual victims that may persist throughout life, including mental health problems and suicide attempts (Norman et al., 2012), an increased risk for chronical physical diseases and mortality (Felitti et al., 1998), epigenetic changes (Cecil et al., 2020) as well as lower educational attainment and socioeconomic well-being (Currie &
Spatz Widom, 2010; R. Mills et al., 2019). On a societal level, child maltreatment entails enormous direct, e.g. child welfare and health care, and indirect, e. g. loss of productivity, costs (Fang et al.,
2012). For children and adolescents, maltreatment has been shown to have an immediate detrimental impact on their mental health and socioemotional development, including deficits in emotion
regulation, insecure attachment relationships, peer problems, depressive and anxiety symptoms, externalizing problems such as aggression and attention problems and PTSD (e.g. Bolger & Patterson, 2001; Cicchetti & Toth, 2005; Cullerton-Sen et al., 2008; Cyr et al., 2010; De Bellis, 2001; Gershoff, 2002; Kim & Cicchetti, 2009). Importantly, these negative sequelae of child maltreatment have been documented across a wide range of different cultures (e. g. Hecker et al., 2014; Lansford et al., 2005;
Palosaari et al., 2013; Tran et al., 2017).
In addition, studies suggest an association between child maltreatment and deficits in cognitive functioning including memory and learning, attention and executive functions such as planning and cognitive control (De Bellis & Zisk, 2014; Irigaray et al., 2013; Kavanaugh et al., 2017;
K. Wilson et al., 2011). However, most studies have been conducted with adult victims of childhood maltreatment and evidence for children and adolescents is inconsistent. This may be partly due to an exclusive grouping approach broadly comparing maltreated and non-maltreated children and a reliance on clinical samples, which leaves the independent contributions of maltreatment per se and associated mental health problems unclear (Hart & Rubia, 2012; K. Wilson et al., 2011). Socioemotional and cognitive deficits are likely to play an important role in explaining the documented link between child maltreatment and impaired academic performance (Romano et al., 2015). The pervasive impact of child maltreatment on the functioning of biological stress systems such as the hypothalamus-pituitary-adrenal (HPA) axis as well as brain structure and function has been proposed to mediate mental health problems and cognitive deficits in maltreated individuals (Hart & Rubia, 2012; McCrory et al., 2010;
Teicher & Samson, 2016). For example, childhood maltreatment was associated with volume abnormalities in the hippocampus, a brain region crucial for memory and learning, in young adults (Teicher et al., 2012, 2018). Even when using non-clinical samples, most studies in high-income countries investigating associations between child maltreatment and mental health as well as cognitive functioning included children who had been identified by child welfare and protective services
(Augusti & Melinder, 2013; Kim & Cicchetti, 2009). Thus, it may be assumed that measures had been taken to protect these children from further maltreatment by caregivers.
However, little is known about the mental health and cognitive sequelae of maltreatment among refugee children and adolescents, despite the accumulation of ongoing risk factors for
maladaptive parenting and child maltreatment in their social ecology (Lebrun et al., 2015; Timshel et al., 2017), particularly in refugee camp settings with widespread poverty, disrupted community and family structures, overcrowded housing, changing gender roles, neighborhood insecurity and
dysfunctional child protection systems (El-Khani et al., 2016; Horn, 2010; Meyer et al., 2013; Murphy et al., 2017; Rubenstein & Stark, 2017). Independent of specific displacement-related risk factors, refugees living in camps often come from societies that view violence against children as rather normative and acceptable, e.g. in Sub-Saharan Africa and Middle Eastern countries (Lansford et al.,
2015). Two recent cross-sectional studies conducted in refugee camps in Rwanda and Uganda found that adolescents` higher exposure to maltreatment was associated with higher levels of anxiety (Meyer, Yu, et al., 2017) and depression symptoms (Meyer, Steinhaus, et al., 2017; Meyer, Yu, et al., 2017).
To date, there are no studies investigating links between maltreatment and cognitive functioning in refugee children and adolescents. However, in a study with Nicaraguan refugee mothers and their young children, certain aspects of the mother-child relationship, namely the mothers` emotional responsivity to their child and the organization of the child`s physical and temporal environment, as well as the child`s nutritional status were positively related to the child`s cognitive development (Laude, 1999). In a recent study with Syrian refugee adolescents and their Jordanian peers, ongoing poverty, but not trauma exposure and PTSD symptoms, were related to working memory deficits (Chen et al., 2019).
2.4.1.3 Attachment relationships
The formation of a secure attachment relationship with a caregiver is one of the most important developmental tasks for a child in the first two years of life (Cicchetti & Toth, 2005; Valentino, 2017).
Interactions with a consistently sensitive and emotionally available parent instill the child with a sense of security and the young child can use the parent as a secure base from which to explore the
environment (Bowlby, 1969; De Wolff & van Ijzendoorn, 1997). However, if the parent is not seen as responsive and available, the infant will not be able to derive feelings of security from this relationship and most likely develop an insecure attachment (Toth et al., 2013). Among children whose parents`
interactional behaviors are extremely inconsistent, harsh or even frightening, a disorganized
attachment pattern has been described (Valentino, 2017). Based on these early interactions, children will develop attachment representations of their primary caregivers and themselves, also called internal working models, which will be generalized to future relationships with other people (Bowlby, 1969). In contrast to securely attached children, children with insecure and disorganized attachments are likely to enter new relationships with negative expectations of how others will behave and how acceptable they are themselves (Cicchetti & Toth, 1995).
Although parent-child attachment is particularly salient in children`s early years of life, it continues to be important in late childhood and adolescence (Cicchetti & Toth, 2005). Independent of the child`s age, the ultimate goal of the attachment system is to gain and maintain the caregiver`s proximity and protection when the child is threatened, endangered or stressed (George, 1996).
However, as children grow older, the attachment relationship develops from one marked by dependency and rather passive behaviors by children, e.g. crying and clinging, to a “goal-directed partnership”, to which children actively contribute and adapt by balancing their own and their
caregivers` attachment needs (George, 1996). Insecure and disorganized attachments with parents have been associated with a range of negative developmental outcomes such as internalizing and
externalizing symptoms, peer problems and reduced cognitive abilities (Brumariu & Kerns, 2010;
Cohn, 1990; Colonnesi et al., 2011; Fearon et al., 2010; Jacobsen et al., 1994). In contrast, the importance of secure parent-child attachment for socioemotional, behavioral, academic and
physiological development has been well established (Bohlin et al., 2000; Laible & Thompson, 1998;
Moss & St-Laurent, 2001; Schore, 2001).
Notwithstanding older children`s increasing contribution to the attachment relationship, parental characteristics play a major role. The parenting qualities that are crucial determinants of the attachment relationship, i.e. sensitivity and emotional availability, have been shown to be impaired in various kinds of psychopathology including PTSD, anxiety and depression (Lovejoy et al., 2000; van Ee, Kleber, & Jongmans, 2016; S. Wilson & Durbin, 2010). Consequently, attachment may be one pathway through which parental and child psychopathology are related (Cummings & Davies, 1994;
van Ee, Kleber, & Jongmans, 2016; Wan & Green, 2009).
Research further suggests an intricate link between attachment and maltreatment by parents.
Acts of abuse and neglect by parents constitute, by definition, the extreme opposite of sensitive caregiving and may frighten the child. Therefore, it is hardly surprising that increased rates of insecure and disorganized attachment patterns have been consistently found in maltreated children of different ages compared to non-maltreated peers (Cyr et al., 2010; Finzi et al., 2000; Lynch & Cicchetti, 1991;
Morton & Browne, 1998; Stronach et al., 2011). At the same time, in line with the notion that maltreatment constitutes in its essence a pathogenic parent-child relationship (Valentino, 2017), parent-child interactions that are indicative of an insecure attachment, including increased dependency, negative emotions and withdrawal, may increase children`s ongoing risk of experiencing further maltreatment (Belsky, 1993; Cummings & Davies, 1994; Stith et al., 2009). This is also underscored by findings showing that interventions aiming at improving the parent-child relationship were able to reduce child maltreatment (Toth et al., 2013; Valentino, 2017).
Given that the attachment system is activated under conditions of extreme stress and threat, focusing on attachment may help to explain both adjustment problems and resilient outcomes among individuals and families exposed to war and trauma (Juang et al., 2018; Masten & Narayan, 2012;
Riggs & Riggs, 2011). For war-affected children, secure attachment relationships with their parents have been shown to be an important protective factor for their mental health (Betancourt & Khan, 2008; Masten & Narayan, 2012). Conversely, insecure attachment representations of parents were associated with higher levels of mental health problems in the aftermath of violent conflict (Okello et al., 2014; Punamäki et al., 2017). Applying an attachment theoretical perspective to the experience of refugee families, it has been suggested that traumatic experiences damage parents` internal attachment representations of themselves as caregivers and of their children, which undermines their capacity of acting as a safe haven for their children and lead them to withdraw from the interaction with their children (Almqvist & Broberg, 2003; De Haene et al., 2010). As a consequence, children may realize that their parents are unable to meet their attachment needs and adapt to this interactional style in ways
that may reinforce parents` feelings of powerlessness and increase the risk of further problematic parent-child interactions (Almqvist & Broberg, 2003).
Accordingly, in two studies with refugee parents and their young children in the Netherlands, parental PTSD was associated with lower emotional availability by mothers and children (van Ee et al., 2012) and with children`s insecure and disorganized attachment (van Ee, Kleber, Jongmans, et al., 2016). Emotional availability did not mediate the association between mothers` PTSD and children`s psychosocial adjustment (van Ee et al., 2012). In a study with Middle Eastern refugee families resettled in Denmark, children`s more insecure attachment representations tended to be related to higher levels of parent-reported emotional and behavioral problems (Dalgaard et al., 2016). However, these studies focused on young children who were born in exile and had no history of trauma.
Attachment behaviors and representations may be particularly salient among children whose
attachment system has been activated by direct trauma exposure. Other limitations of these studies are that they relied on parents` reports of children`s mental health and did not distinguish between
attachment to mothers and fathers. A noticeable exception is a recent study with Syrian refugee minors between 8 and 17 years living in community settings in Turkey, which found that insecure attachment representations of both mothers and fathers were related to children`s self-reported PTSD symptoms and general mental health problems (Eruyar et al., 2020). Nevertheless, the mediational role of
attachment representations in the association between parental and child psychopathology has not been assessed in refugee families living in refugee camps.
2.4.2 Other ecological factors contributing to resilience
Besides factors within the family microsystem, other factors related to the individual child, the peer microsystem and the exosystem may contribute to refugee children`s resilience. On the individual level, coping can be defined as action-oriented and intrapsychic efforts to manage the demands created by stressful events (Taylor & Stanton, 2007). Coping strategies can focus on engaging with or
approaching the stressor, for example by seeking support, acceptance and changing the way of viewing things, and on disengaging from or avoiding the stressor, for example by denying or wishful thinking (Carver & Connor-Smith, 2010). Ample research with non-refugee populations has shown that engagement coping is associated with better mental health outcomes and higher well-being, whereas disengagement coping is linked to less optimal mental health outcomes including anxiety, depression and increased stress (Carver & Connor-Smith, 2010; Taylor & Stanton, 2007). As refugee children often face multiple highly stressful conditions and situations before, during and after their flight, the way they cope with these experiences may be particularly relevant for their adjustment.
Notwithstanding, there is little evidence for the role of coping strategies for refugee children`s mental health (Eruyar, Huemer, et al., 2018). In a study with unaccompanied refugee youth in Norway, disengagement coping predicted lower life satisfaction and more depressive symptoms, but
engagement coping did not predict less depressive symptoms (Seglem et al., 2014). In another study
with Bosnian refugee youth in Denmark, the use of engagement coping strategies was related to the presence of PTSD (Elklit et al., 2012). Only one study examined coping strategies among refugee children living in a resource-poor camp (Paardekooper et al., 1999): South Sudanese refugee children used more different and more disengagement strategies than local Ugandan children. The authors reasoned that in the context of the refugee camp with high dependence on external aid and
bureaucracy, children had few opportunities to use engagement or problem-focused coping strategies (Paardekooper et al., 1999). It is important to better understand the role of coping for children`s well-being in such a setting rife with daily stressors as a potential target for prevention and intervention strategies.
Friendships and positive peer relationships constitute microsystem factors that are linked to many aspects of children`s and adolescents` positive development including their general well-being, life satisfaction, self-esteem, academic success and prosocial behavior (Holder & Coleman, 2015). A main function of children`s peer relationships is to provide social support, which is likely to be protective in the face of severe adversity (Betancourt & Khan, 2008). For example, peer relations moderated the association between the experience of political violence and antisocial behavior in Palestinian youth (Barber, 2001). A systematic review identified self-reported support from friends as a protective factor for the mental health of refugee children who resettled in high-income countries (Fazel et al., 2012). Less is known about the role of peer relationships for the mental health of refugee children living in low- and middle-income countries. South Sudanese children living in a Ugandan camp were less satisfied with their social support network compared to local Ugandan children
(Paardekooper et al., 1999). For Namibian refugee adolescents residing in a Sub-Saharan host country, higher levels of social support ameliorated the effect of chronic stress as represented by an increased time in exile on depressive symptoms (Shisana & Celentano, 1985). However, these studies did not assess whether the source of social support were actually youth`s peers. While there is no reason to assume that peer relationships have a different influence on camp-dwelling refugee children`s mental health, they may be particularly relevant for this group to the extent that other social support networks
(Paardekooper et al., 1999). For Namibian refugee adolescents residing in a Sub-Saharan host country, higher levels of social support ameliorated the effect of chronic stress as represented by an increased time in exile on depressive symptoms (Shisana & Celentano, 1985). However, these studies did not assess whether the source of social support were actually youth`s peers. While there is no reason to assume that peer relationships have a different influence on camp-dwelling refugee children`s mental health, they may be particularly relevant for this group to the extent that other social support networks