Expressions of Parental Warmth and Harshness in War-Affected Co-Exposed Families: A Systematic Qualitative Meta-Synthesis
Masterthesis Forensische Orthopedagogiek University of Amsterdam
Lorena Linssen 11136545
First assessor: Hend Eltanamly Second assessor: Patty Leijten
Table of Contents
Abstract……….………..4
Introduction……….…………5
The present study………..…………..8
Method..……….……….…………9
Literature search……….……….……….……...9
Selection of studies……….……...9
Data extraction………...………...……….…..….10
Data analysis strategy….………...……....10
Results………...………12
Description of the reviewed studies………..………...…….12
Expressions of parental warmth and harshness………...…...………...12
Expressions of parental warmth...………...….…………...12
Expressions of parental harshness………...…...13
Changes in parental warmth and harshness: The role of stressors...………...14
Economic stressors………14
Unsafety……….15
Emotional and behavioral problems of children………...………16
Changes in parental warmth and harshness: The role of type of trauma………..16
Forcibly displaced families………18
Families exposed to interpersonal trauma………...………..19
Families living under threat………..………19
Discussion………...………..20
References………...………..25
Table 1………...………...…….32 Figure 1………..………...……35
Abstract
Knowledge about underlying mechanisms of parental warmth and harshness among war-affected co-exposed families is scarce. There is a high need to enlarge understanding, as parenting is vital for children’s adjustment after trauma. Therefore, a systematic qualitative meta-synthesis was conducted, to research how parental warmth and harshness are expressed in war-affected families, and why expressions of parental warmth and harshness might change. Nine electronic databases were searched, and qualitative studies about co-exposed families with children with a maximum age of 18 were included (k = 10, N = 908). Parental warmth was expressed by sensitivity, responsivity, patience, understanding, providing a feeling of safety, attuning communication, acquiescence to requests, gifts, spending time together, dancing, singing, doing old habits, and hugs and kisses. Parental harshness was expressed by physical punishment, shouting, hitting, and threatening. Changes were explained by war-related stressors, such as economic stressors, unsafety, and children’s emotional and behavioral problems. Outcomes on the expressions depended on type of trauma. Displacement stressors caused parental distress and negative emotions, which led to less warmth and more harshness. Bereavement caused sympathy for children, and therefore more warmth and less harshness. Raped mothers were reminded of their trauma when they saw their children, which led to less warmth. Mothers living under threat were able to normalize their family life and expressed more warmth. This study provided a foundation for future quantitative research to further investigate the possible mechanisms of how war might change parenting. Family-based interventions should take into account the possible impact of specific war-experiences.
Expressions of Parental Warmth and Harshness in War-Affected Co-Exposed Families: A Systematic Qualitative Meta-Synthesis
Nowadays, millions of children are affected by war (War Child, 2016). Parents have an important role in protecting children from the mental damage of war trauma (Dekel & Solomon, 2016; Kuterovac Jagodić, 2015; Thabet, Ibraheem, Shivram, Winter & Vostanis, 2009). However, war induces multiple stressors that could challenge parenting behavior, such as poverty and unsafety, loss of a network for individual and practical support, and loss of property. Also, families might be forced to displace due to a dangerous environment, which causes dramatic life changes. As a consequence of these stressors, lots of parents have feelings of distress (Dekel & Goldblatt, 2008; Kuterovac Jagodić, 2015; Letica-Crepulja, Salcioglu, Frančišković & Basoglu, 2011). Additionally, war-affected families could have been through emotionally disturbing experiences, such as exposure to violence, bombing, shelling, or losing family members or friends. As an outcome, parents might also have mental problems, such as trauma, depression, and feelings of anxiety (Dekel & Solomon, 2016; Kuterovac Jagodić, 2015; Miller & Rasmussen, 2010). Parental distress and mental health problems might cause less availability in the parent-child interaction (Berz, Taft, Watkins & Monson, 2008; Davidson & Mellor, 2001; Kuterovac Jagodić, 2015). Also, parents might reflect their negative emotions, such as anger and frustration, on their children (Kuterovac Jagodić, 2015; Punamäki, Qouta & El Sarraj, 1997). Therefore, expressions of parental warmth and harshness might change (Banyard, Williams & Siegel, 2003; Booth, Macdonald & Youssef, 2018; Van Ee, Kleber & Mooren, 2012). However, literature about expressions of parental warmth and harshness among war-affected co-exposed families is scarce. To
illustrate, existing reviews about parenting in war-affected families mainly focus on veterans and intergenerational trauma (e.g., Dekel & Goldblatt, 2008), while it is also necessary to focus on parenting behavior in families who are co-exposed to war, which means that parents
and children have witnessed war together. It is important to understand underlying
mechanisms of expressions of parental warmth and harshness among war-affected families, because it would help clinicians and intervention workers to identify the possible impact of war-exposure on parenting, and address the needs of war-affected families. Therefore, it is required to synthesize available qualitative studies to research how parental warmth and harshness are expressed in war-affected families, and why expressions of parental warmth and harshness could change. Namely, qualitative methods provide a comprehensive picture of the effects of war exposure, grounded in the experiences and perspectives of war-survivors. Mixing the available qualitative studies will provide a cross-cultural view and the possibility to explore possible pathways in multiple contexts.
The influence of war exposure on parental warmth and harshness can be viewed from an ecological perspective. According to this, war-related stressors have an important influence on parenting behavior. Namely, families might be impacted in different ecosystems, from far to close: the macro-system, the exo-system, the meso-system, and the micro-system
(Bronfenbrenner, 1977; Cummings et al., 2009). To illustrate, war induces political tensions. Also, it shapes general cultural norms, such as norms about violence (Cummings et al., 2009), which all disrupts families’ most distant system, the macro-system. In addition, war induces poverty and often leads to a loss of economic opportunities and unemployment. Exposure to war is therefore a threat for parents’ ability to provide basic needs to their children and take care of them (Kuterovac Jagodić, 2015; Letica-Crepulja et al., 2011; Osofsky, 1995). Also, war might cause a lack of resources, such as adequate support systems, which all disrupts families exo-system (Brody, Flor & Gibson, 1999; Dekel & Goldblatt, 2008; Miller & Rasmussen, 2009). In a closer level, war might lead to more dangerous neighborhoods. Moreover, families could be forced to displace and may not be able to return to their own regions that are damaged, which all disrupts their meso-system. Being forcibly displaced
changes the situation of families drastically and causes new external stressors, such as bad living conditions in refugee camps, a dangerous environment, and little economic
opportunities (Kuterovac Jagodić, 2015; Letica-Crepulja et al., 2011; Peteet, 2005). All war-related stressors might directly or indirectly impact families’ microsystem, which includes expressions of parental warmth and harshness (Bronfenbrenner, 1977).
Parental warmth encompasses behaviors that communicate love and security to children. It is expressed by being attuned, responsive, supportive, available, affective, and acquiescent to children’s requests (Baumrind, 1995). Children need parental warmth to develop basic trust and security (Osofsky, 1995). After war exposure, parental warmth is especially needful for children, because it can protect children through times of adversity and promotes their emotional well-being (Appleyard & Osofsky, 2003; Dekel & Solomon, 2016; Thabet et al., 2009). Moreover, it helps children in their adjustment after war trauma (Dekel & Solomon, 2016; Kuterovac Jagodić, 2015; Thabet et al., 2009). War exposure might change expressions of parental warmth in different ways. On the one hand, parents could become extra aware of their role as caretaker and might therefore show more warmth to compensate for the damage of the war (Palosaari, Punamäki, Qouta & Diab, 2013; Scheeringa & Zeanah, 2001). On the other hand, parents might have to cope with war-related stressors which takes a lot of energy. Therefore, they could have less attention to express parental warmth (Booth et al., 2018, Kuterovac Jagodić, 2015). Also, distressed parents might have problems regulating affect and arousal, which is needed for the provision of parental warmth (Van Ee et al., 2012; Ruscio, Weathers, King & King, 2002). Additionally, war trauma could lead to less
availability in the parent-child interaction and therefore to less parental warmth (Appleyard & Osofsky, 1995; Scheeringa & Zeanah, 2001).
Parental harshness encompasses behaviors that communicate anger, irritation, and dominance to children. It is expressed by yelling, criticism, harmful threats, and physical
aggression (Buehler, Benson & Gerard, 2006). Parental harshness is harmful for children and a risk for their development of a basic of trust and security. For example, it possibly leads to insecure attachment of children (Baer & Martinez, 2006). Also, it discourages their emotional development, such as the development of their emotional regulation (Chang, Schwartz, Dodge & McBride-Chang, 2003). Moreover, the restriction of parental harshness is vital to children’s adjustment to traumatic war experiences (Dekel & Solomon, 2016; Kuterovac Jagodić, 2015; Thabet et al., 2009). Exposure to war could influence expressions of parental harshness in different ways. On the one hand, parents could realize their role as caretaker and therefore show less negative parenting behavior, such as expressions of harshness (Palosaari et al., 2013; Scheeringa & Zeanah, 2001). On the other hand, new parental challenges due to war-related stressors might cause parental distress. As an outcome of their distress, parents might feel more negative emotions, such as anger, helplessness, and frustration, which they could vent on their children (Osofsky, 1995). Additionally, distressed parents might percept their children’s behavior more negatively, which could lead to more parental harshness (Van Ee et al., 2012; Kuterovac Jagodić, 2015).
The Present Study
Although it is clear that exposure to war could influence expressions of parental warmth and harshness, little is known about the underlying mechanisms. This systematic qualitative meta-synthesis will therefore synthesize how parental warmth and harshness are expressed in war-affected families, and why expressions of parental warmth and harshness might change in war-affected families. The inductive nature of this study will develop possible explanations about expressions of parental warmth and harshness among war-affected co-exposed families, which will provide a foundation for future research. Namely, based on the findings of this study, quantitative studies will be able to test possible pathways of why war might influence expressions of parental warmth and harshness. Additionally,
more insight into parenting in war-affected families will help family-based intervention workers to take into account the possible impact of war exposure on parenting.
Method
This systematic qualitative meta-synthesis was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines [PRISMA] (Moher, Liberati, Tetzlaff, Altman & The PRISMA Group, 2009).
Literature Search
The current meta-synthesis contributes to a larger research project researching parenting in war-affected families. This project has formed a database of existing literature, from which studies were collected for this meta-synthesis. Qualitative and quantitative peer-reviewed studies published until March 2018 were searched. As first, literature was searched in nine electronic databases: PsycINFO, MEDLINE, Web of Science, Scopus, Sociological Abstracts, Anthropology Plus, PILOTS, CINAHL, and Cochrane Library. In the computerized literature search, the following search words were used in different combinations: war,
terrorism, political revolution or unrest, genocide, refugees, asylum seekers, parenting, and childrearing. Additionally, reference lists from identified studies were inspected to find more studies by citation tracking. Finally, experts in the field were asked by e-mail about possible studies for inclusion.
Selection of Studies
In Figure 1 (Appendix B) is systematically shown in a flowchart how the selection of studies was done. The systematic literature search resulted in 6,076 citations. These studies were imported in RefWorks to check for duplicates. After this, 4,147 unique publications were screened by their title and abstract, to assess whether they were relevant to the research. Three independent team members screened the abstracts of the identified studies and excluded studies that did not match with the inclusion criteria of the project (86.5% agreement). Next, a
total of 158 publications were reviewed fully and assessed for eligibility. When the team members disagreed about the in- or exclusion of a study, they started a consultation to discuss and compromise their decisions. Finally, qualitative studies were selected for this meta-synthesis. The following studies were included: (1) studies about parents and children who were co-exposed to war, and (2) studies about children with a maximum age of 18. The following studies were excluded: (1) studies about other types of trauma, not caused by war exposure, and (2) studies about short-time violence, such as a one-time terrorist attack, because we were interested in families exposed to persistent long-term traumatic war
experiences, which might cause lifelong posttraumatic symptoms and dysfunction (Lahad & Doron, 2010). The included studies are marked with an * in the references.
Data Extraction
After the collection of data, the data was extracted using the qualitative data analysis computer software package NVivo 12. All the included studies were uploaded in this software. The extraction was done by dividing the contents of the literature into markings that were named with a code, which is called coding (Boeije, 2014). Specifically, I coded ideas, perspectives, and experiences of the studies’ participants about how parental warmth and harshness were expressed, and how these expressions might be explained. “Parental warmth” was operationalized as parental behaviors that communicate love, security, and understanding to children. “Parental harshness” was operationalized as parental behaviors that communicate anger, irritation, and dominance to children.
Data Analysis Strategy
I analyzed the data using a grounded theory approach, which means that I worked towards conceptualizing and formulating a theory as it emerged from the data (Glaser & Strauss, 1967; Patton, 1990). While analyzing, I used the ecological model of Bronfenbrenner (1977) as a guiding framework for coding (Bowen, 2006). Namely, it provided me a starting
point to analyze (Glaser, 1978), which means that I tried to analyze the data with an ecological view. For example, the ecological model helped me to enlarge my insight into which ecological systems of families were affected, and how environmental stressors impacted the family.
In the analyzing process, I first read and reread the data. After this, I started to code open, which means that I coded articles line-by-line, and added codes to the text fragments as accurately as possible. According to the grounded theory, I created codes based on the data itself, instead of using predefined codes. I also used the constant comparison method, which means that I constantly compared new codes to existing ones (Glaser & Strauss, 1967). For instance, when I named a text fragment with a code, I searched if this sentence fitted in my existing codes. When necessary, I changed, removed or added new codes. To detect how parental warmth and harshness were expressed in the families, I coded different types of expressions of these practices. To discover why expressions of parental warmth and harshness changed, I also coded experiences that influenced parental warmth and harshness, such as different war-related stressors and feelings of parental distress. While coding, different categories of the codes arose, such as “Parental sensitivity”, and “Economic stressors”. Further, I coded axial, which means that I organized the data by comparing the originated categories to each other (Bowen, 2006; Glaser & Strauss, 1967). In the final code tree, categories of parents’ expressions of parental warmth and harshness were sorted under overarching categories called “Parental warmth” and “Parental harshness”. Further, categories of war-related stressors that influenced parental behavior were sorted under the overarching category “War-related stressors”. Finally, different feelings of parental psychological distress, such as depression, trauma, and anxiety were coded under the category “Parental distress”.
During the coding process, I tried to link the themes from the categories to each other (Bowen, 2006), which means that I looked for general patterns, similarities, and differences of
how parental warmth and harshness were expressed and why these expressions might have changed. Finally, I aimed to translate the findings towards formulating possible theories which explained why parental warmth and harshness might change in war-affected families. Results
Description of the Reviewed Studies
The final sample of this qualitative meta-synthesis included ten qualitative studies (k), covering seven samples, with a total sample size of N = 908 participants. The characteristics of the included studies are shown in Table 1 (Appendix A). The studies covered a 25-year period from 1993 to 2018. Families in the included studies were from Afghanistan (66.01%), Croatia (20.15%), Syria (9.13%), Palestine (1.32%), Iraq (.66%), Kosovo (.33%), and
Kurdistan (.33%). Most of the families were forcibly displaced (n = 878; k = 7). Other families were exposed to interpersonal trauma, such as bereavement (n = 16; k = 1) and rape (n = 3; k = 1). Also, there were families who were living under threat (n = 11; k = 1). Expressions of Parental Warmth and Harshness
Expressions of parental warmth. Families reported different expressions of parental warmth. First, parents were sensitive to their children: “He doesn’t talk a lot, but you can tell from his eyes.” (El-Khani, Ulph, Peters & Calam, 2016, p. 105). Also, parents expressed warmth by being responsive. For example, they reacted on the distress of children, by soothing and distracting them when they were upset: “Most parents described using positive parenting strategies such as praise, rewards, and play to encourage positive behavior or to distract and soothe children when they were upset.” (Sim, Fazel, Bowes & Gardner, 2018, p. 24). Also, parents tried to be patient and understanding: “They reported pushing themselves, even when they themselves were emotionally exhausted, to be more understanding and patient.” (El-Khani, Ulph, Peters & Calam, 2017, pp. 38-39). Moreover, parents tried to provide their children a feeling of safety. For instance, they attuned their communication
about the war: “I was completely hidden away (…) I have been at war for 8 years and I am really happy that I wasn’t told what the war was about, why and who was at war, while I was in the middle of it and wasn’t told until afterwards when I could better relate to it.” (Bek-Pedersen & Montgomery, 2017, p. 108) Further, parents were acquiescence to their children’s requests: “We give into their demands more, we can only plan for today so we give them things they want (…) if the kids want something we let them have it.” (Abbott, 2009, p. 122). Another way of expressing warmth was by giving gifts: “Parents said they often rewarded children with small gifts such as sweets and new clothes, both to make them feel better when they were upset but also to encourage them in good behavior.” (De Berry et al., 2003, p. 19). Parents also expressed warmth by spending more time together with their children: “I try to be closer to them, talk to them more, and spend time with them.” (Abbott, 2009, p. 122). Further, parents used positive child contact to make them feel happy, such as dancing and singing: “Another mother told of making concerted efforts to make her home a fun place that her children would enjoy. Inundated by the daily news of terror attacks, she ‘switched the television to the music station for children, and we just dance and sing. This is the way we deal with it.’” (Dekel, 2004, p. 33). Additionally, parental warmth was expressed by using old habits: “Just having the chance to think about how I am as a mother and remember how I was before, has made me feel better already and I found myself doing old habits with [daughter].” (El-Khani, Ulph, Peters & Calam, 2018, p. 25). Finally, parents expressed warmth to their children by giving hugs and kisses: “And I would hug him all the time and kiss him – maybe this is the last time I’ll see him.” (Dekel, 2004, p. 33).
Expressions of parental harshness. Families reported different expressions of parental harshness. For example, parents used physical punishment to educate their children: “Parents referred to physical punishment as one of the most effective means of disciplining their children.” (De Berry et al., 2003, p. 18). Also, parents hit their children to express their
negative emotions: “S: I’m getting really angry. Interviewer: Did you get really angry before in this way, when you were leaving your home? S: No, not at all. Interviewer: And when you angry what do you do? S: I want to hit him and do hit.” (El-Khani et al, 2016, p. 107).
Further, harshness was expressed by shouting and threatening: “We tell them don’t do this and don’t do that. First time, second time. Either shouting or threatening, then hitting.” (El-Khani et al., 2016, p. 107).
Changes in parental warmth and harshness: The role of stressors
Families explained how war-related stressors from different ecological systems influenced their expressions of parental warmth and harshness. Different pathways will be explained based on three important war-related stressors: economic stressors, unsafety, and emotional and behavioral problems of children.
Economic stressors. Families with limited access to economic resources reported big challenges being responsible for their children’s basic needs, such as food, water, and
clothing. Consequently, they felt like they were not able to meet children’s needs: “She knew that sweets would make her children feel better and cure their distress but she did not have the money to buy sweets. In this way she could not give the support she knew her children
needed.” (De Berry et al., 2003, p. 28). Furthermore, as an outcome of the struggle for everyday survival, parents were burdened and stressed: “The parents are in charge of
providing everything the children need, this is making them so stressed, extremely stressed.” (El-Khani et al., 2016, p. 10). As an outcome of economic stressors, parents had little time and energy to provide warmth to their children: “We used to live in peace; my kids and I understand each other more than we do now. Now, I leave them all morning, so there is a gap between us. I live with them like a ghost. They are raising themselves … There is no time to spend with the kids. When I come back home in the evening, I just sleep right away because I come back too tired to do anything else.” (Sim et al., 2018, p. 22). As an outcome, parents did
not have enough resources, time, and energy to express warmth to their children.
Additionally, economic stressors caused distress and negative emotions, such as anger and frustration. Parents vented these feelings on children, which translated in parental harshness: “High levels of stress and frustration, primarily from economic pressures, contributed to reduced emotional regulation, greater propensity for losing one's temper, and venting negative emotions on children.” (Sim et al., 2018, p. 24).
Unsafety. Parents reported unsafety as a big concern. For instance, parents who were living under threat experienced challenges to protect their children: “The mothers’
preoccupation stemmed from their awareness that, short of highly impractical house arrest, there was little they could do to ensure their children’s safety, given the randomness and ubiquity of the terror.” (Dekel, 2004, p. 29). Parents who were living in refugee camps also experienced unsafety in their environment: “They were concerned about the people their children were now exposed to, and consequently for their safety.” (El-Khani et al., 2016, p. 103). On the one hand, there were parents who tried to provide their children a feeling of safety, and therefore expressed more warmth: “The mother’s response was driven by her desire to calm her child and make him feel safe.” (Dekel, 2004, p. 31). On the other hand, worries about the unsafety contributed to parents’ distress, feelings of being overburdened, and being unable to cope with daily challenges: “I’m an adult, 35years old, I promise you when I hear strong winds and loud noises in the camps I get so scared. I feel like my body is exhausted and my head is aching.” (El-Khani et al., 2016, p. 106). Consequently, parents had not enough energy to provide warmth. Also, unsafety led to feelings of helplessness, and there were parents who saw harshness as the only way to protect children against unsafety: “That’s why we end up smacking, as they don’t listen otherwise (…) we cry as we feel heavy hearted doing it, but they don’t listen. How else can we protect them?” (El-Khani et al., 2016, p. 106).
Emotional and behavioral problems of children. Parents reported both emotional and behavioral problems of their children after war-exposure: “Parents described their children as ‘more difficult’, ‘stubborn’, ‘aggressive’, and ‘irritable’, as well as ‘sad’, ‘nervous’, ‘agitated’, and ‘lonely’.” (Sim et al., 2018, p. 23). An outcome was that parents did not want to make their children feel sadder, and therefore became more acquiescent to children’s request, which is a depiction of parental warmth: “If the kids want something we let them have it.” (Abbott, 2009, p. 122). Also, they deliberately reduced their harshness: “I don’t beat them anymore; I can’t make any of them feel sad.” (Abbott, 2009, p. 122). Another outcome was that
emotional and behavioral problems of children were challenging to deal with: “You know things that we tell them to do. But nothing is helping.” (El-Khani et al., 2016, p. 106). Additionally, it caused parental distress: “Parents found it very distressing seeing their children crying, feeling sad and unlike how they were previously.” (El-Khani et al., 2016 p. 105). Consequently, parents did not know how to respond to them, which led to less parental warmth: “There must be a way or direction to point the children, something to say to help their minds remove the images, to make them sleep (…) we don’t know how to help them be children.” (El-Khani et al., 2018, p. 23). Because of their distress, parents tend to interpret their children’s behavior more negatively. Also, parents felt helpless and frustrated, which translated into parental harshness. Finally, another outcome was that symptoms of children’s trauma reminded mothers of their own trauma, feelings of helplessness, and inability to protect their children. Consequently, they withdrew from caregiving and displayed less warmth: “She could not stand being close to them as their whimpering and clinging behavior provoked flashbacks and made her feel as helpless as when she was raped. She only got irritated if they tried to come near her and used to remain in bed all day.” (Almqvist & Broberg, 2003, p. 372).
The different outcomes on expressions of parental warmth and harshness can be explained based on the role of type of trauma. Namely, war-exposure had different meanings for families, which led to contrasting changes in expressions of parental warmth and
harshness. To illustrate, types of trauma caused specific stressors for families, which disrupted certain ecological levels. Their experiences led to a perception of those stressors, which impacted parental warmth and harshness in a certain way. Thus, similar pathways after exposure to types of war trauma will be explained.
Forcibly displaced families.
Forcibly displaced families were heavily disrupted in their meso-system, which had big consequences for the direct environment of the family. Displacement stressors, such as economic stressors, unsafety, and bad living conditions, caused a lot of challenges for parents responsible for their children’s basic needs, health care, and food. Parents therefore were burdened and stressed: “Daily stressors associated with displacement contributed to
significant psychological difficulties, with adult participants reporting feeling psychologically exhausted, stressed out, depressed, nervous, and under pressure.” (Sim et al., 2018, p. 23). Consequently, they did not have enough energy to express warmth to their children. Further, forcibly displaced parents did not know how to control and protect their children in the new situation. Therefore, they saw shouting, threating, and beating their children as the only way. Also, their distress led to more negative emotions, such as anger and frustration. Additionally, it led to a reduced emotional regulation. Consequently, parents vented their negative emotions on their children, which translated in harsh parental practices: “I became so unfair with my children, nothing is suitable for us here because we’re not in our country and so I vent my anger on my children, I hit them, I suffer so much. When I send them to school, I feel more relieved and relaxed, but I feel angry when they return.” (Sim et al., 2018, p. 23).
Families exposed to interpersonal trauma. Bereaved families and mothers who were raped in the presence of their child were both directly affected in their micro-system. Also, parents in both groups suffered from trauma. Additionally, their children’s trauma translated in emotional and behavioral problems. However, they showed opposing pathways in
expressions of parental warmth and harshness, which can be explained based on exposure to different types of trauma. To illustrate, bereaved parents felt sympathy towards their children. Hence, they did not want to make their children sadder and tried to compensate for the
damage of the trauma. Therefore, they became close with their children and restricted from physical punishment. Thus, they displayed high levels of parental warmth and deliberately reduced their use of harshness.
Children of raped mothers suffered emotional problems, such as anxiety and nightmares, and showed increased attachment behavior. When the mothers saw their children’s symptomatic behavior, they were reminded of their own trauma and feelings of helplessness. It confronted them with the fact that they were not able to protect their children from traumatic exposure. Consequently, they could not see themselves as caring, nurturing, and protective parents anymore. They therefore were not able to respond to their children with corresponding caregiving behavior. At the same time, they had feelings of anxiety and
depression, which led to a more negative interpretation of their children’s behavior. As an outcome of the interpersonal trauma, they displayed less parental responsivity and withdrew emotionally from caregiving. Thus, they displayed less parental warmth.
This comparison is based on only two studies with small samples. Therefore, further studies with representative samples are needed to generalize findings.
Families living under threat. Families living under threat were disrupted in their macro-system, while their other systems remained unaffected. For instance, they still had their homes, finances, and cars. Thus, although they were worried about the safety of themselves
and their children, they were able to normalize their family life. Moreover, the risk of becoming a victim of attack made them scared of death and to leave their children without a mother, which translated into consciousness of their role as a parent. They therefore attempted to adjust their parenting behavior to the situation and tried to compensate for the damage of the war. Consequently, parents had the desire to make their children feel happy and safe, despite living under threat. As a result, they expressed more warmth to their children.
The sample of mothers who were living under threat was small. Therefore, further studies with representative samples are needed to generalize findings.
Discussion
This systematic qualitative meta-synthesis investigated how parental warmth and harshness are expressed in war-affected families, and why expressions of parental warmth and harshness might change in war-affected families. The results show that parents in the families expressed warmth by sensitivity, responsivity, patience, understanding, providing a feeling of safety, attuning communication about the war, acquiescence to children’s requests, giving gifts, spending time together, dancing, singing, doing old habits, and giving hugs and kisses. Parental harshness was expressed by the use of physical punishment, shouting, hitting, and threatening. Firstly, changes in expressions of parental warmth and harshness were explained by war-related stressors, such as economic stressors, unsafety, and emotional and behavioral problems of children. On the one hand, stressors caused parental distress and negative emotions and therefore led to less expressions of parental warmth and more expressions of harshness. On the other hand, parents who were able tried to compensate for the damage of stressors and war-trauma, and therefore expressed more warmth and less harshness to their children. Secondly, a plausible connection has been found between the nature of war trauma and changes in expressions of parental warmth and harshness. To illustrate, forcibly displaced parents were heavily affected in their meso-system, which led to distress and negative
emotions and therefore to less expressions of parental warmth and more harshness. Bereaved parents and raped mothers were both directly affected in their micro-system. However, they showed different pathways in how they expressed parental warmth and harshness. Bereaved parents felt sympathy for their surviving children and did not want to make them sadder. Therefore, they expressed more warmth and deliberately reduced their use of harshness. Raped mothers were reminded of their own trauma when they saw their children’s symptomatic behavior, and could therefore not see themselves as caring, nurturing, and protective parents anymore. Hence, they withdrew emotionally from caregiving and displayed less parental warmth. Mothers who were living under threat were affected more distantly in their macro-system, while other systems remained unaffected. As an outcome, they were able to normalize their family life, and managed to adjust their parenting behavior to provide their children a feeling of safety. Therefore, they expressed more parental warmth.
Our results confirm the view on parenting in war-affected families from an ecological perspective (Bronfenbrenner, 1977; Cummings et al., 2009). Namely, war-related stressors disrupted different ecological levels of families, which seemed to influence expressions of parental warmth and harshness. For instance, displacement stressors, such as economic stressors, unsafety, and bad living conditions, disrupted families’ meso-system. An outcome was that economic stressors forced parents to work outside the home. Consequently, they had less time to spend with their children, and had parental distress, which led to less expressions of parental warmth (Booth et al., 2018; Kuterovac Jagodić, 2015). Also, stressors led to more negative emotions, such as anger and frustration, and a reduced emotion regulation which might have led to more expressions of parental harshness (Van Ee et al., 2012; Osofsky, 1995).
Further, the results are in line with literature in which is emphasized the complexity and diversity of war-experiences and therefore its impact (Barber, 2008). To illustrate, parents
were exposed to different types of violence, such as bereavement or rape, which led to different perceptions of the meanings of war. Consequently, parents showed specific changes in expressions of parental warmth and harshness. In this light, the outcomes of parenting of the bereaved parents can be understood based on “posttraumatic growth” (Calhoun, Tedeschi, Cann & Hanks, 2010; Tedeschi & Calhoun, 2004). According to this phenomenon, exposure to trauma, such as bereavement, might reorganize parents’ assumptions about life.
Consequently, parents could have developed a cognitive process in which they reassembled their way of understanding the world. In this process, they might have become more grateful for their relationships, such as the relationships with their surviving family members. This process could have led to the parents’ feelings of sympathy for their surviving children. Their extreme grief could therefore have led to advantageous changes in parenting, such as
expressions of parental warmth and the restriction of parental harshness.
The remarkable low levels of parental warmth of the mothers who were raped in the presence of their children can be interpreted on the basis of the construct of “relational PTSD” (Scheeringa & Zeanah, 2001). In this sample, the symptomatic behavior of their children confronted raped mothers of not being able to protect their children from trauma. Also, their children reminded them of their own trauma. Additionally, their own trauma caused
avoidance and withdrawal symptoms, which causes less parental responsivity (Booth et al., 2018; Van Ee et al., 2012; Scheeringa & Zeanah, 2001). Consequently, the mothers showed low levels of parental warmth, which in turn caused more traumatic symptoms of their children.
The findings of this study need to be interpreted in the light of some limitations. Firstly, there is not much literature available about parenting in war-affected families. Also, some types of trauma are more studied than others. As a result, there was an
bereaved families, and families living under threat. Further, there were no longitudinal studies available to include in this study. Consequently, studies solely showed a snapshot of the experiences of participants. Thus, families’ long-term risks of war-exposure on expressions of parental warmth and harshness are still unknown. Second, this study solely focused on
qualitative studies. Therefore, the personal nature of qualitative data gathering might have caused subjectivity. Parents from the samples might not have been completely honest due to social desirability. Also, the writing of the authors of the included studies and their selection of reporting information might be not entirely objectively. Third, conducting a meta-synthesis causes the risk of mixing experiences of families from different contexts. Namely, it is
impossible to take into account all cultural and historical influences. To enrich the field and enlarge the insight into possible mechanisms, future research should focus on parenting in families exposed to different types of war trauma. Also, future research should conduct longitudinal studies to further investigate the long-term risks of war-exposure on parenting. Additionally, quantitative research is needed to test the causality of the influence of different kinds of war-experiences on expressions of parental warmth and harshness.
Despite these limitations, there are several strengths of this study. First, a meta-synthesis is useful for enlarging understanding about complex social processes, such as the impact of war-exposure on parenting. Namely, it provides the possibility to focus on specific contexts, while at the same time creating a broad perspective of a complex phenomenon (Walsh & Downe, 2005). Second, the use of a grounded theory approach is appropriate for identifying and explaining social processes by conducting a qualitative meta-synthesis (Bowen, 2006; Kearney, 2000). Namely, the constant comparative method offers guidelines how to analyze data, such as multiple primary studies (Strauss & Corbin, 1998). Therefore, it provided the possibility to characterize expressions of parental warmth and harshness in war-affected families, and the process of change. Third, the use of open codes provided an
inductive nature, which made it possible to discover, understand, and interpret experiences of war-affected families, grounded in data of primary studies. All in all, this meta-synthesis was appropriate for enlarging the understanding about possible pathways of why war-exposure might change parenting.
Perhaps the most important lesson to be learned from this study is that experiences and therefore interpretations of the meaning of war differ between families, which might
lead to contrasting outcomes on expressions of parental warmth and harshness. Family-based interventions should take into account the complexity of the influence of war-exposure on families from an ecological perspective. When addressing the needs of war-affected families, it is necessary to pay attention to specific experiences and how these experiences might lead to changes in parental behavior, so that appropriate help can be provided. Also, is vital to continue studies to enlarge the insight into possible mechanisms of how war-exposure might impact parenting behavior, since parenting behavior could protect children against the mental damage caused by war. Therefore, this study provided a foundation for future research to further investigate the possible mechanisms of how war-exposure might influence parental behavior.
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Appendices
Appendix A: Table 1 Study- and Sample Characteristics of Included studies
Appendix A Table 1.
Study- and Sample Characteristics of Included Studies
Study Sample characteristics Methods
First author Year Focus N Participants Residence Data collection Data analysis
Abbott 2009 The influence of the loss of a family member on family interactions
16 Mothers and fathers Israel and Palestine Semi structured interviews Constant comparative method Adjucovic 1993 Psychological well-being of refugee
children
183 Mothers Croatia Structured interviews Quantification
Almqvist 2003 The influence of co-exposure to brutal violence on the parent-child relationship
3 Mothers Kosovo - -
Bek-Pedersen
2006 The construction of a family
identity of adolescents who escaped to Denmark 10 years ago
12 Adolescents Kurdistan, Iraq, Palestine
Open interviews, group interviews, participant observation, interviews
Narrative analysis
with the families DeBerry 2003 Children’s experience of daily life 600 Children,
mothers, fathers, and caregivers
Afghanista n
Focus group discussions -
Dekel 2004 The subjective experience of being a mother in an extreme period of terror and uncertainty
11 Mothers Israel Focus group discussions Content analysis
El-Khani 2016 Parenting experiences of Syrian families living in refugee camps
27 Mothers and professional aid workers
Syria Semi structured interviews, and focus group discussions
Thematic analysis
El-Khani 2017 Coping mechanisms utilized by displaced Syrian refugees who care for children
29 Mothers and professional aid workers
Syria Semi structured interviews, and focus group discussions
Thematic analysis
El-Khani 2018 Parenting support needs of Syrian parents who had recently fled
29 Mothers and professional
Syria Semi structured interviews, and focus
Thematic analysis
conflict and were residing in refugee camps and shelters in Syria and Turkey
aid workers group discussions
Sim 2018 Mechanisms underlying the effects of war and displacement on
parenting and child adjustment
54 Mothers, fathers, and children
Syria Individual interviews and focus groups
Grounded theory approach Note. N = number of participants.
Appendix B Figure 1.
The flowchart of screening according to PRISMA procedure.
Articles identified through database searching (n = 6,076) Screen in g Inc lude d Elig ib ili ty Id en tifi ca tio
n Additional articles identified through other sources
(n = 29)
Articles after duplicates removed (n = 6,105) Articles screened (n = 4,147) Articles excluded (n = 3,989) Full-text articles assessed for eligibility (n = 158) Full-text articles excluded, with reasons
(n = 148) Reasons for exclusion:
- Quantitative studies - Maximum age > 18 - No co-exposure Studies included in qualititative meta-synthesis (n = 10) Articles excluded (n = 1,030) Articles identified (n = 6,105)
