Katie Murphy, Early Childhood Development Technical Advisor, New York, NY, USA; Sandra Maignant, Child Protection Technical Advisor, London; Laura Boone, Senior Child Protection Technical Advisor, London, UK; and Sarah Smith, Director of Child and Youth Protection and Development, New York, NY, USA; International Rescue Committee
Humanitarian interventions to support and guide parents and caregivers in times of war can mitigate the negative effects of violence and chaos on children and promote their resilience and development. This article highlights recent findings from the International Rescue Committee’s parenting programmes in Syria, underscoring the importance of such programmes not only in strengthening caregiving practices but also in addressing the psychological needs of parents.
Harrowing accounts of the multidimensional effects of war on children point to the long-term impact of violence, displacement and terror, and the threat it poses to the future peace, prosperity and well-being of global society. In December 2014, an estimated 230 million children, or one in ten, were living in a country affected by armed conflict (UNICEF, 2014). At the start of the fifth brutal year of the Syrian conflict, an estimated 14 million children living in the region have been affected by conflicts in Syria and Iraq (UNICEF, 2015). Global analyses of the geopolitical climate provide a pessimistic outlook for the years to come, as the World Economic Forum’s Global Risks 2015 report ranked ‘interstate conflict with regional consequences’ as the most likely global risk for the period of 2015–2025 (World Economic Forum, 2015). Considering the scope and severity of global conflicts, there is an urgent need for evidence-based strategies to protect children and families from the traumatic impact of war and to reduce the intergenerational transmission of violence.
Children are particularly vulnerable to the negative effects of war, as exposure to violence, political instability, degraded infrastructure, displacement and fractured social systems are associated with high levels of post-traumatic stress disorder (PTSD), depression and anxiety disorders (Barbarin et al., 2001; Attanayake et al., 2009). Young children are also highly sensitive to ambient violence, and the trauma they endure when learning of a family member’s violent experience or witnessing violence is analogous to the trauma of directly being victims (Barbarin et al., 2001). Evidence indicates that parents and caregivers can help build children’s resilience and support children’s health and development through nurturing, responsive and consistent care (Shonkoff et al., 2012; Masten and Monn, 2015). Yet for adults living in times of war, their ability to provide nurturing care is often hampered by their own experiences of trauma and adversity, which can result in an increased incidence of children’s exposure to interfamilial conflict, violence or emotional neglect (Osofsky, 1999; Barbarin et al., 2001; Galovski and Lyons, 2004; Betancourt, 2015).
War’s effects on parents and children
The psychological and emotional well-being of caregivers serves as an important predictor for the physical, social and emotional health of war-affected children (Dybdahl, 2001). Beginning in utero, maternal stress and depression can affect the child’s growth and development, and are associated with childhood undernutrition, stunting, and negative impacts on children’s cognitive, physical and socio-emotional development (Thabet et al., 2009; Feldman et al., 2013). While the precise mechanisms that link maternal distress and depression with children’s developmental outcomes are the subject of ongoing investigation, evidence suggests that the cross-placental transmission of stress hormones causes a disruption in the development of the fetal prefrontal cortex and stress response system (Van den Bergh et al., 2005). The mechanisms for the postnatal transmission of stress from caregiver to child are potentially linked to the manifestation of maladaptive caregiving practices, as high levels of anxiety, stress and depression are associated with unresponsive, neglectful or abusive caregiving practices, and can result in low levels of parent–child attachment (McMahon et al., 2006; Field, 2010). In turn, the absence of consistent, nurturing care can have negative impacts on the child’s epigenetic processes and neurological development with long-term implications for intellectual, physical and socio-emotional well-being (Belsky and de Haan, 2011; Shonkoff et al., 2012).
Exposure to violence can have multiple deleterious effects on parenting, as it is associated with increased incidence of marital tensions, domestic violence, stress, depression, harsh discipline and punitive parenting styles (Dybdahl, 2001; Galovski and Lyons, 2004; Betancourt, 2015). A caregiver’s response to violence is also associated with young children’s behavioural adjustment. For instance, in South African families exposed to community violence, the mother’s level of distress was significantly associated with 6-year-old children’s symptoms of attention deficits, aggression, anxiety and depression (Barbarin et al., 2001).
Identifying strategies to mitigate the negative effects of war on parenting has the potential to improve children’s well-being and to strengthen children’s resilience (Betancourt and Khan, 2008). A growing body of evidence of effective parenting interventions in low-resource contexts identifies key programme elements that are associated with increases in positive parenting practices, parental knowledge, parent–child attachment, and decreases in harsh physical and psychological discipline. These include:
• the use of adult learning strategies that draw on Bandura’s Social Learning Theory and employ active demonstrations, collaborative discussions, positive reinforcement, and home visits that engage caregivers and children in interactive activities
• comprehensive training of staff and para-professionals, using an evidenced-based curriculum
• programme content that recognises and builds on existing positive parenting practices
• community support systems to strengthen social cohesion
(Engle et al., 2011; Mejia et al., 2012; Aboud et al., 2013; Yousafzai et al., 2014).
For caregivers living in conflict and post-conflict settings, key programme elements also include trauma-focused psychosocial support for parents and caregivers, along with specific content that addresses daily stressors experienced by caregivers (Miller and Rasmussen, 2010; Betancourt, 2015), and content that aims to strengthen caregivers’ responses to children’s trauma, to aid recovery and healing.
Building on the insights generated through past decades of early childhood development and parenting research, the International Rescue Committee (IRC) has been working to reduce violence against children in the home and improve the developmental outcomes of children in crisis through parenting programmes since 2009. The IRC’s parenting programmes have expanded across eight countries and include workforce-strengthening initiatives in Tanzania designed to support a new cadre of trained social workers to facilitate parenting programmes at scale. The programmes typically include ten two-hour sessions for small groups of caregivers led by a pair of trained facilitators. The curriculum draws on evidence-based parenting programmes and is grounded in social learning theory, using demonstrations, positive reinforcement and coaching to develop and strengthen positive parenting practices. Randomised impact evaluations conducted with research partners from Duke University and the Harvard School of Public Health have demonstrated that the IRC’s parenting programmes confer significant benefits on the lives of post-conflict and displaced families in Burundi, Liberia and on the Thai-Burmese border. For example, among the 270 families with children aged 3–7 years that participated in the Parents Make the Difference programme in Liberia, caregivers reported an average decrease of 56% in the use of harsh physical punishment and a 29% decrease in psychological punishment (Sim et al., 2014). Significant improvements among participants were also detected in the quality of caregiver–child interactions and the use of positive behaviour management practices.
Guided by past experiences, and learning from the implementation and research of parenting programmes in post-conflict settings, the IRC has dedicated time and resources to the development of culturally adapted parenting programmes to respond to the needs of caregivers that have endured the trauma of war. Focusing on examples of the IRC’s parenting programmes in conflict settings, the following section provides a brief overview of key lessons from these programmes in the Syrian response region. While the preliminary findings that have emerged are not part of randomised controlled trials, they provide insights into the process of adapting and implementing family interventions in crisis contexts that may be used to inform future implementations of wartime parenting programmes.
Parenting programmes in Syria
During the IRC’s initial rapid assessment of protection needs in Iraq, Jordan, Lebanon, and Northern Syria in 2013, parents and caregivers reported high levels of stress. Focus group discussions with parents in northern Syria revealed that the parents felt that their heightened levels of stress led them to lose patience with their children, which resulted in a higher frequency of parents practising abusive and neglectful behaviours toward their children. As one parent shared, ‘because we are in a state of psychological distress, we beat our children. Before we didn’t, but now we do.’ Family visits conducted by the IRC child protection team underscored the high levels of stress experienced by children, not only resulting from the experience of crisis (loss of homes, friends, education, etc.), but also due to the lack of parental support. These observations were confirmed in Lebanon by the results of the Strengths and Difficulties Questionnaire conducted with 226 randomly sampled children aged 3 to 17 from three of the Lebanese Governorates where the IRC operates that had enrolled in psychosocial support services; these results found 50% of the children to be at risk of developing mental health disorders, with significant long-term implications for children who do not receive treatment (IRC, 2015a).
Responding to the urgent need for psycho-social support services for caregivers and children, the IRC began implementing the Families Make the Difference parenting programme in the Syrian response region in 2014. The programme includes 10 culturally adapted sessions based on cognitive, developmental and behavioural theory that aim to strengthen caregivers’ resilience and psycho-social well-being, and to encourage positive caregiving practices. The group-based programme targets caregivers of children aged 0 to 8 years and was adapted from the Parents Make the Difference programme, implemented in Liberia, to fit the cultural context of the Middle East. Additional sessions were developed to respond to caregivers’ stress and to strengthen children’s resilience in the midst of conflict and displacement.
Assessments were conducted before and after participation in the Families Make the Difference programme with a convenience sample of 74 female caregivers across three regions in Lebanon and 66 in two camps in northern Syria. These found that the majority of parents showed an improvement in caregiving practices. After participating in the ten sessions, caregivers reported significant increases in the use of positive coping strategies, such as setting aside time with children, processing feelings by writing or talking to other adults, or using coping strategies such as writing, exercising or deep breathing (an average increase of 55% in Lebanon and of 72% in Syria1) (IRC, 2015a, 2015b). Using the child discipline module of UNICEF’s Multiple Indicator Cluster Survey (MICS), significant decreases were also detected in the self-reported use of violent discipline, which is a sub-scale that includes psychological punishment, physical punishment and severe physical punishment (a 37% decrease in Lebanon and a 72% decrease in Syria2). The programmes also found significant decreases in the prevalence of negative feelings, and increases in caregiver resilience. At the same time, the limitations of the study design, such as the lack of control groups and the use of self-report rather than more objective measures, restrict the ability to draw causal inferences regarding the effects of the programme; nonetheless, these preliminary findings point to the potential role of programmes that address parent’s well-being by fostering positive support networks and strengthening caregiver skills.
While the parenting modules show promise as an effective strategy for strengthening caregiver skills and coping mechanisms, the results from the pre- and post-programme assessments on caregivers’ psychological well-being and sense of parenting competence indicate that further efforts are needed to restore caregivers’ sense of hopefulness and feelings of empowerment in providing for their children. As an example of one response to these observations, field staff offered doll-making workshops to teach caregivers techniques for creating dolls and toys using locally available resources. Such workshops offer additional opportunities for caregivers to build social cohesion and to help rekindle their feelings of personal agency in being able to provide their child with basic play materials.
As highlighted by decades of research from the fields of developmental psychology, epigenetics and neurology, nurturing, consistent and responsive care during early childhood is an essential human need that has significant implications for society’s future health and well-being. Ensuring that young children receive sufficient care should therefore be an essential component of any humanitarian response. The work of the IRC and other organisations involved in parenting programmes has shown that parents and caregivers living in adversity are often struggling to provide support for their children, that they are interested in participating in group-based and home visiting programmes, and that parenting programmes can offer a promising strategy towards improving caregiving practices. At the same time, practical experiences from programme implementation point to the important links between caregivers’ psychological well-being, caregiving practices, and children’s developmental outcomes in humanitarian settings, which are often not addressed in existing parenting programmes. While existing research on these associations provides a theoretical foundation for developing responsive programming to address the needs of parents and children in wartime, there is a dearth of rigorous studies from conflict settings to shed light on effective intervention strategies.
Focused investigations of the impact of violence and war-related stress on parenting behaviours and the implications for children’s developmental outcomes could help shape humanitarian interventions seeking to tailor programmes to the needs of war-affected populations. Additionally, research on the effectiveness of contextually adapted behaviour change techniques, used in parenting interventions to increase responsive caregiving practices, reduce violence and promote children’s resilience, would provide further guidance for the development of wartime parenting interventions. By increasing support for and attention to the issue of parenting in contexts of war, researchers, practitioners, donors, policymakers, communities, caregivers and children can work together to change the developmental trajectory of millions of children at risk of poor outcomes and improve the future health and well-being of war-torn communities.
1 On average, the reported use of the three types of coping strategies at baseline was 51% in Lebanon and 53% in Syria. After participation in the programme, the average use of the three types of coping strategies was 79% in Lebanon and 92% in Syria.
2 In Lebanon, the combined total of self-reported violent disciplinary techniques used by caregivers in the month before beginning the programme was 241, which dropped to 152 after the programme. In Syria, the combined total of violent disciplinary techniques use by caregivers in the month prior to participation was 239, and dropped to 67 after the programme. In both surveys, caregivers were permitted to identify more than one type of disciplinary technique used.
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