Want to Help Refugee Children Thrive? Support Their Parents.

Source: Chonnnanit/Shutterstock

Millions of children displaced by war are growing up in overcrowded and impoverished refugee camps, living in tents or small shelters that offer paltry protection from the intense summer sun or the freezing winds of winter . They struggle with hunger, and community violence, and a lack of access to clean water, medicine, or schools. Some work in exploitative and dangerous jobs to help generate income for their families. Many face discrimination and hostility from other children in their host society. At home, refugee children depend on parents who are often highly stressed, raising their families in harsh circumstances while coping as well as they can with the impact of war-related violence and loss. Not surprisingly, these multiple stressors increase refugee kids' risk of both short-term and more enduring psychological difficulties.

Humanitarian organizations have traditionally sought to strengthen refugee children’s social and emotional wellbeing through a combination of preventive and clinical interventions provided directly to children—sometimes individually, more often in groups run in community settings such as schools or so-called “child friendly spaces”. This approach is relatively straightforward: typically, community members with a minimum level of education and relevant experience are trained to implement activity-based interventions with children, with groups meeting weekly from anywhere from 5 to 20 sessions. Clinical interventions for distressed children typically draw on evidence-based methods of healing trauma, depression, anxiety and other common forms of distress, while prevention programs focus on strengthening children’s resilience through a variety of expressive arts and play-based activities.

A recent systematic review, which I summarized in a previous post, critically examined the effectiveness of such interventions. The results were generally discouraging. In contrast to interventions for adults, the available data suggest that (1) the benefits of clinical programs for distressed children were typically modest and of limited duration, and (2) prevention programs showed similarly modest and inconsistent benefits overall. Limited effects can still be meaningful, of course, especially when achieved among large numbers of children. But on several outcomes, there has been no demonstrated effect at all, while on others, modest gains raise the question, why have we not been able to achieve more?

One possibility is that direct work with refugee children is inherently limited in what it can achieve, because of the constellation of continuous stressors children deal with on a daily basis. Numerous studies have examined the family environment, for example, and found that distress among war-affected children (including refugees) is due at least as strongly to parental distress and family violence as it is to their exposure to the actual violence of war. This means that humanitarian organizations which focus solely on direct work with children may unwittingly be failing to address critical sources of stress that affect children, potentially undermining the impact of their interventions.

Source: Thomas Koch/Shutterstock, Inc.

This isn’t about parent-blaming. On the contrary, it’s a recognition that raising children, which can be challenging under the best of circumstances, is dramatically more difficult in in the highly stressful context of refugee camps and conflict zones. It’s hard to imagine parenting not being adversely affected by the chronically high levels of stress refugees experience, especially when coupled with experiences of trauma and profound grief over loved ones and worlds left behind. Persistent stress affects parenting, and there is compelling evidence that highly stressed parents, as well parents struggling with unresolved trauma or depression, are more likely to have children with insecure attachments and a greater vulnerability to developing emotional and behavioral problems later in life (Biglan, Flay, Egmond, & Sandler, 2012; McLoyd, 1990; Mesman & Koot, 2000).

In high income countries, parenting interventions have been developed for families living in chronic adversity (e.g., poverty, racism, community violence), and with parents of children experiencing specific emotional and behavioral problems. Results have been cautiously encouraging, with stronger effects generally found in programs targeting parents of older children rather than infants and toddlers (Barlow et al., 2016; Raaijmakers et al., 2015). Such programs typically emphasize variations on “positive parenting”, an array of evidence-based parenting techniques that have been shown to foster healthy child development and positive psychosocial outcomes. A collateral benefit of parenting programs has been a modest improvement in parents’ own wellbeing, perhaps a result of improved child wellbeing, less frequent parent-child conflict, and the social support of the group.

Several international humanitarian organizations (NGOS), such as the International Rescue Committee, have taken their cue from these findings and successfully adapted parenting programs for use in refugee communities, as complementary approaches to their direct work with children. At War Child Holland, we have adopted a somewhat different approach to supporting refugee parents. In light of extensive research showing the harmful impact of chronic stress (and distress) on parenting, we wondered whether the conventional emphasis on parenting knowledge and skills might be overly deficit-focused—that is, it assumes that a lack of such knowledge and skills underlies sub-optimal parenting. We assume that many refugee parents were doing just fine before they were confronted with armed conflict and the difficulties of raising their children in refugee communities. While all parents can benefit from increased parenting knowledge and skills (raising kids, although joyful, is also tough!), our guiding assumption is that chronically high stress can get in the way of parents using the knowledge and skills they already possess. We therefore developed the Caregiver Support Intervention (CSI) to strengthen parents’ own psychosocial wellbeing, layering on positive parenting sessions only after participants have gained some mastery of stress management and relaxation techniques and strengthened their social support networks. Rather than viewing improved parental wellbeing as a side benefit of the intervention, we've made it a primary outcome—a key aim of the program. Our hope is that improving parents’ own sense of wellbeing will enable them to make better use of the knowledge and skills they already possess, as well those learned in the intervention.

The CSI is a nine session weekly group intervention, co-facilitated by trained community members who receive regular supervision. Participants are given mp3 players and headphones with recordings of stress management and mindfulness exercises, and are asked to practice at least one technique three or more times each week (the recordings are also available as downloads for smartphones). Sessions 1-4 focus on parental wellbeing, sessions 5-8 on positive parenting and alternatives to harsh discipline, with a review and closing activities in session 9.

In our work thus far in Gaza and Lebanon, we have run separate groups for women and men. In a recent paper on the development of the CSI, based on focus groups with participants in both settings, we found a high utilization of the relaxation and stress management exercises, with positive evaluations of their impact on anxiety, sleep, anger management, and conflict with children and spouses. Parents reported feeling better able to respond constructively to their children's behavior, noting in particular the value of calming down before responding to misbehavior, and of making time to give greater positive attention to their children. They valued the social support of the group, and many participants, men and women, asked that the intervention last more than nine sessions. There were no drop-outs from any of the groups in Gaza, and only a few in Lebanon due to illness or a return to Syria; the great majority of participants attended all or nearly all the sessions.

Stress Essential Reads

How Creative Pursuits Can Quiet the Noise of Stress

2 Ways to Pick Positivity From Life's Challenges

I found that that relaxation techniques soothe me and help in taking me away from my sorrows for a while. I also became more tender and empathetic to my children and I started to be more careful and sensitive about my attitudes when I deal with them. - Father in Gaza

We learned new skills to deal with stress, for example the relaxation exercises were very useful, soothing, and relaxing. I also started to do the relaxation and the fun exercises that we implemented during the sessions with my children at home. - Mother in Gaza

In the past, my children used to wait for the day that I allow them to go to their cousins to play with them and enjoy their time, but now they wait for the day they can spend time with me to have fun and enjoy. - Father in Gaza

I used to ask my son for high grades and better performance at school so he used to draw me as the villain in his drawings. I never paid attention to this drawings before. But now I do and I understand why he is portraying me like this. The problem between us really decreased. I wanted to take him to see a psychologist because we would never see eye to eye but now after the program I realized the problem was with me, not him. The program really changed my relationship with my son. My son now tries to speak because I spend quality time with him and I now play with him. -Mother in Lebanon

The relaxation exercises helped me manage my reaction to things, slowed my thinking and gave me comfort. Comfort to me alone. It gave me emotional and physical comfort at the same time. It was a boost forward for me. - Mother in Lebanon

The sessions gave me back my humanity that I have lost and that was buried inside of me but had long been forgotten. The program taught me new useful methods. It taught me to focus on my children and be a good mother to them. They were victims as well. - Mother in Lebanon

It helped me to control my anger as my daughter got a low result in the mathematic exam, and I used to be angry with her, but I did something different this time. I told her that it’s ok and that I will help her to get better marks so I started to help her with studying by using a white board to solve mathematical propositions on it, and I started to be more encouraging and reinforcing with her and her grades became higher as she got 19/20 in her last exam. - Mother in Gaza

With the support of a generous grant from the Netherlands-based Bernard van Leer Foundation, we strengthened the CSI by adding additional content for parents of very young children. We recently completed a pilot randomized controlled trial of the revised CSI with 79 families (151 caregivers), the majority fo them Syrian refugees, in North Lebanon. CSI participants improved significantly (medium to large effect sizes) on every variable: lower distress, lower stress, increased psychosocial wellbeing, improved stress management abilities, and strengthened parenting including increased parental warmth and sensitivity and a reduction in harsh parenting. They also reported an improvement in children’s psychosocial wellbeing. Among caregivers in the waitlist control group, there were no significant changes on any variable. Findings of the study were published in the journal Child Abuse and Neglect and can be found here.

Thanks to generous support from the Open Society Foundations and ELMA Philanthropies, we were able to conduct a fully powered randomized control trial of the CSI with 240 families (480 parents/caregivers), again primarily Syrian refugees in the same area of North Lebanon. Ultimately, in addition to providing evidence for a scalable intervention for refugee families, we hope to also assess the validity of the model underlying the CSI–the idea that providing psychosocial support to refugee parents, in addition to conventional parenting support, will lead to meaningful and enduring effects for parents and children displaced by the violence and destruction of war.