The Association between War-Related Traumatic Events and Parental Warmth
in War-Affected Families: A Multilevel Meta-Analysis
Masterthesis Forensic Orthopedagogics Graduate School of Child Development and Education University of Amsterdam
I.M. Olthaar 11425032 First assessor: mw. dr. P. H. O. Leijten
Second assessor: mw. H. Eltanamly Amsterdam, July 2018
Abstract
Modern war tactics increase the risk of families becoming direct targets of violence. Co-exposure of traumatic events is frequently linked with changes in parental functioning, however there is controversy in the existing literature about the direction of this change. A multilevel meta-analysis of 12 publications, with 10 independent samples containing 20 effect sizes, was performed to investigate the association between war-related traumatic events and parental warmth. The total sample consisted of N = 13,347 participants. In addition, a
moderator analysis was performed on country of origin. Results showed no overall significant association, reflecting no association between war exposure and parental warmth. In addition, country of origin did not emerge as a moderator on the association between war exposure and parental warmth. Future research should be alert on generalizing war related traumatic events and take individual perceptions into account, while ideally using a longitudinal study design.
Table of Contents Introduction ... 4 Method ... 10 Literature Search ... 10 Selection of Articles ... 10 Inclusion criteria. ... 11 Exclusion criteria. ... 11 Data Extraction ... 11 Parental warmth. ... 11 Supportive information. ... 11
War-related traumatic events. ... 12
Effect Size ... 12
Statistical Analysis ... 13
Preliminary analyses. ... 13
Multilevel random effects model. ... 14
Sensitivity analysis. ... 15
Results ... 15
Characteristics of Included Studies ... 15
Preliminary Results ... 15
Outliers. ... 15
Publication bias. ... 16
Heterogeneity. ... 16
Multilevel Random Effects Model ... 16
Sensitivity analysis. ... 16 Moderator Analysis ... 17 Discussion ... 17 Conclusion ... 22 References ... 24 Table 1 ... 35 Table 2 ... 36 Figure 1. ... 37 Figure 2. ... 38 Figure 3. ... 39
The Association between War-Related Traumatic Events and Parental Warmth in War-Affected Families: A Multilevel Meta-Analysis
Over the past years a growing disregard for the rules of war has led to an increased number of families living in war-affected areas (Macksoud, 2000; Save the Children, 2018). It has been argued that exposure to traumatic events disrupt normal patterns of family life and basic parental assumptions, and therefore encounter difficulties in parenting (Magwaza, 1999; Weine et al., 2004). The importance of parental functioning following trauma is researched extensively and points to negative as well as positive associations on parenting in regard to war exposure (e.g., Blankers, 2013; Tedeschi & Calhoun, 2004). However, these efforts are typically focused on the moderating role of parental functioning to protect children from the adverse effects of trauma exposure (e.g., Slone & Mann, 2016; Slone & Shoshani, 2017). Besides, most publications focused on parental functioning in families of traumatized parents and their difficulties providing parental warmth, whereas in war-affected families both parents and children are co-exposed to trauma (e.g., Blankers, 2013). Despite the recognition of increased numbers of families living in war-affected areas, less is known about the direct effects of co-exposure to traumatic events and the association with parental warmth.
Therefore, the present meta-analysis will examine the direct association between war-related traumatic events and parental warmth in war-affected families. In the light of co-exposure and the including emotional and behavioral changes parents face, I hypothesized that war-related traumatic events will be negatively associated with parental warmth. Furthermore, I expected an interaction effect by country of origin on the association based on cultural differences. In the following paragraphs the importance of parental warmth and arguments for the hypotheses will be presented.
The fundamental theme of this meta-analysis involves the importance of
are co-exposed to war-related traumatic events. Parental warmth is the central assumption of a secure parent-child attachment, holding sensitive responsive behavior, availability and
support of the parent toward the child and the child’s needs as primary determinants (Ainsworth & Bowlby, 1991; Baumrind, 2005; Bowlby, 1971). To be able to cope with traumatic events, secure attachment with a parent is important for the child (Ainsworth, Blehar, Waters, & Wall 1978). However, previous research on traumatized parents shows that it is challenging to establish a secure attachment with the child (Harwood, 2006; Koren-Karie, Oppenheim, & Getzler-Yosef, 2004; Lieberman, 2004). As seen in traumatized parents, they are more likely to show insensitive behavior toward the child, resulting in ambivalent and unpredictable parenting behavior that often has a negative effect on the parent-child relationship (Ainsworth et al., 1978; Goldberg, Benoit, Blokland, & Madigan, 2003; Schuengel, van IJzendoorn, Bakermans-Kranenburg, & Blom, 1996). Given that these scenarios are based on the assumption that children are not directly exposed to traumatic events, war-affected families may even face more challenges providing parental warmth. The risk of both parents and children experiencing shocking events, that have high chances of being traumatic or a violation of their human rights, provides a new aspect of research on parental warmth (American Psychiatric Association, 2013; Save the Children, 2018; UN Commission on Human Rights). Exposure to traumatic events can have a damaging effect on the parent-child relationship and might translate into decreased parental functioning and disruption of normal patterns of family life (Weine et al., 2004). This said, I assume that co-exposure possibly increases negative effects of trauma on the parent child relationship and therefore decreases parental warmth.
Living in a war-affected area with your family may undermine the capacity of parents to provide safety for their child. In order to establish a secure feeling for their child, parents may cope with the situation by denying the danger or avoiding discussions about traumatic
events (Punamäki, 1987). However, this emotional unavailability of the parent may ignore the child’s needs, because expressing emotions tends to help people processing traumatic events (Weine et al., 2004). Besides, as seen in couples, unawareness of a traumatic event and decreased communication can lead to feelings of reduced togetherness and therefore negatively affect the quality of their intimate relationship (Bodenmann, Ledermann, & Bradbury, 2007; Goff et al., 2006). This implies that parents may reduce their parental warmth as a result of trying to protect their child.
Sharing the same traumatic event with your child may provide different risks for a decrease in parental warmth. Co-exposure confirms parent’s inability to provide safety for their child, and therefore parents may experience feelings of guilt, fear and worthlessness (Almqvist & Broberg, 2003). As seen in co-exposed mothers and their children, every time the mother saw her child, she relived the event and her feelings of shame (Almqvist & Broberg, 2003). This implies that parents can project their trauma on their child what makes their child work as a situational trigger. Because confrontation with their child reawake negative emotional reactions, parents may avoid their child or show symptoms of emotional numbing (Almqvist & Broberg, 2003; Lieberman, 2004). Additionally, parents may be
limited in responding sensitive to the distress of their child who is also traumatized, because it reminds them of their own trauma (Almqvist & Broberg, 2003; Scheeringa & Zeanah, 2001). As a result, co-exposure may affect the parent-child closeness and therefore decrease parental warmth.
War exposure can also have negative long-term consequences for parental warmth because of the development of mental health problems (American Psychiatric Association, 2013). Although it is not an inevitable outcome, war exposure is commonly associated with post-traumatic stress disorder (PTSD) and the more people experience traumatic events, the more they report PTSD (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995; Steel et al.,
2009). Earlier research showed that symptoms related to post-traumatic stress have negative influences on the parent-child relationship (Creech, Hadley, & Borsari, 2014; Feldman & Vengrober, 2011; Marsanic, Margetic, Jukic, Matko, & Grgic, 2014; Ruscio, Weathers, King & King, 2002; Samper, Taft, King & King, 2004; Scheeringa & Zeanah, 2001). For example, due to processing their own traumas, parents may experience difficulties regulating their distance and closeness to the child and therefore show ambivalent signals about their
availability (Dekel & Goldblatt, 2008). Also, parents who reoccurrence their traumatic event may have difficulties interpreting the child’s thoughts and feelings correctly (Slade, 2005). Moreover, parents who are avoidant of reminders of trauma, may experience difficulties in responding sensitive to the child’s needs (Scheeringa & Zeanah, 2001). Consequently, long-term effects of war trauma possibly make parents emotionally and functionally unavailable and therefore decrease parental warmth.
Culture may intervene as a framework for trauma-related symptoms, and therefore might affect parental warmth (Hinton & Lewis-Fernández, 2011). Research on different cultures found that people from collectivistic cultures showed less trauma-related symptoms than people from individualistic cultures, because their local community functioned as a social network (Elsass, 2001). Moreover, people from Middle Eastern countries tend to show significantly less symptoms of avoidance, compared to the other trauma symptoms (Norris & Aroian, 2008). On the other hand, research found generally lower frequencies of avoidance, regardless of culture (Shalev, 2002). Besides, individualistic cultures encourage people to express their thoughts and feelings more, what might increase parental warmth (Markus & Kitayama, 1991; Mullen & Yi, 1995). Because of these contrary findings, participant’s country of origin was used as a moderator to examine if it interacts with the association between war exposure and parental warmth.
Contrary to the previously discussed expectations of reductions in parental warmth, there might also be elements of resilience. Research shows that war-affected families may experience increased appreciation of togetherness after realizing that their relationship is finite, and can quickly be lost (Abbott, 2009; Tedeschi & Calhoun, 1996). Another
explanation for increased parental warmth following trauma is that people may try to cope with their own distress by showing emphatic behavior, focusing on comforting and helping others (Abbott, 2009; Frazier et al., 2013; Macksoud & Aber, 1996; Raboteg-Saric, Zuzul, & Kerestes, 1994; Steffen & Fothergill, 2009). Since empathic people are characterized as highly sensitive, this may increase parental warmth. Furthermore, another explanation for resilience was given through experiences of improvement after surviving a traumatic event. People reported valuable psychological benefits as a result of successful coping with the event, such as a better sense of self-improvement (Aldwin, Levenson, & Spiro III, 1994; Elder & Clipp, 1989; Fontana & Rosenheck, 1998; Tedeschi & Calhoun, 2004). Given that a sense of self-improvement may allow people to continue functioning normally, this may contribute to remaining levels of parental warmth. These explanations reflect that both trying to cope with trauma and successful coping with trauma, may result in togetherness and sensitive behavior, and therefore might not negatively affect parental warmth.
War-affected families provide an interesting case of research on parental warmth. Unlike research on traumatized parents, war-affected families face the risk of both parents and children being affected profoundly by traumatic events. Co-occurrence of post-traumatic symptoms in the parent and the child may exacerbate each other (Scheeringa & Zeanah, 2001). Since children may show various new kinds of behavior following trauma, such as anxiety (Basu & Dutta, 2010), aggressiveness (Zahr, 1996), sadness (Dybdahl, 2001) or mental health issues (Feldman & Vengrober, 2011; Slone & Mann, 2016), parents face remarkable additional risk factors for a damaged parent-child relationship. It may be difficult
for parents to cope with this unknown child behavior, especially while parents are
simultaneously struggling with their own trauma responses (Lieberman, 2004; Scheeringa & Zeanah, 2001). For example, children may not want to talk about the past or show withdrawal from their parents (Weine et al., 2004; Lieberman, 2004). Studies suggest that the child’s behavior may be an antecedent of maternal responses. For example, driven by the child’s PTSD symptoms or aversive behavior, mothers may show a decrease in parental warmth (Feldman & Vengrober, 2011; Schechter, et al., 2010; Panaccione & Wahler, 1986). However, symptoms of the parents can lead to potential changes in children’s symptoms. Even though the co-occurrence indicates that one should consider reciprocal effects of traumatic events on parental warmth, it is mostly the symptoms of the parent that exacerbate the symptoms of the child (Scheeringa & Zeanah, 2001). This highlights the importance of examining parental functioning, and therefore I propose that understanding the association between war-related traumatic events and parental warmth in co-exposed families provides a good opportunity to limit harmful effects of traumatic events and clarify families needs.
The Present Study
Previous literature points to the disruption of war on families as a whole and highlights the importance of parental functioning in children’s adjustment to traumatic experiences. Even though families may be able to gain positive consequences of war trauma, it may be hard to remain parental warmth in the light of co-exposure and the including emotional and behavioral changes parents face. Therefore, this meta-analysis aims to answer the question whether there is an association between war-related traumatic events and parental warmth in war-affected families, using a multilevel random effects model with 10 independent studies containing 20 effects sizes. In this approach, I hypothesized that war-related traumatic events negatively associate with parental warmth. Furthermore, I expected an interaction effect by country of origin on the association between war exposure and parental warmth. This
meta-analysis contributes to a better understanding of the association between war exposure and parental warmth, and therefore will maybe contribute to find the right form of support for parents and children who experienced war-related traumatic events, considering parental warmth.
To summarize, the present meta-analysis focused on the following research questions: (1) Is there an association between war-related traumatic events and parental warmth? (2) Does country of origin moderate the association between war-related traumatic events and parental warmth?
Method Literature Search
This meta-analysis is part of a larger research project on parenting in war time. The database for this project was formed until November 2016 following Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria (http://www.prisma-statement.org). Quantitative and qualitative studies were identified by systematic searches in nine electronic databases: PsycINFO, MEDLINE, Web of Science, Scopus, Sociological Abstracts,
Anthropology Plus, PILOTS, CINAHL and Cochrane Library. The following search terms were used in various combinations: war, terrorism, political revolution or unrest, genocide, refugees, asylum seekers, parenting, childrearing. In addition, citation tracking was
performed to identify publications by reference lists from identified studies. Finally, experts in the field were contacted by email to inquire about additional published or unpublished literature that was not identified using the first two search strategies. Publications for present meta-analysis were collected out of this database.
Selection of Articles
The search process resulted in a total number of 12 publications to be included in the present meta-analysis (Figure 1). The initial systematic literature search retrieved 5,177 citations. After removing the duplicates 3,652 unique publications were identified. Inspection
of the title and abstract reduced this number to 140 relevant publications. All 140 publications were read in full by three independent team members to assess for eligibility adhering to the inclusion and exclusion criteria (86.5% agreement). Consensus was reached by discussion about the different screenings.
Inclusion criteria. Several inclusion criteria were used to select the publications for this meta-analysis. First, publications were included if they reported data on parents and children being co-exposed to war-related traumatic events. Second, included publications reported about the association between the traumatic event and parental warmth. Third, publications were included if they reported a maximum child age of 18 years, because of the marked decrease in conformity to parents and the separation from the security of the family after the age of 18 years (Berndt, 1979).
Exclusion criteria. Publications not adhering to the inclusion criteria were excluded.
First, publications were excluded if they reported about a single family member being exposed to war (e.g., war veterans, child soldiers), since this meta-analysis focused on co-exposure in families. Second, publications were excluded which reported war co-exposure confounded by another traumatic experience (e.g., natural disasters). Third, studies that reported on short-term traumatic events like one-time terroristic attacks were excluded.
Data Extraction
Parental warmth. The research team specified parental warmth as a continuous
construct measured by parental behaviors representing acceptance, support, availability, warmth, reciprocity and attachment as parental warmth. Negatively worded parental behaviors such as unavailability and avoidance were reverse coded to indicate parental warmth. Parental warmth is the dependent variable in this meta-analysis.
Supportive information. In addition, the following variables were extracted from
standard deviation; gender; (b) demographic features about the parents including country of origin; country of residence; education; income; employment; social economic status; ethnicity; mean age; gender; (c) design features including the study design and sample size; (d) first author and publication year.
War-related traumatic events. Continuous ratings of exposure to war-related
traumatic events were used. Participants of the included studies reported frequency or severity of traumatic events, such as the death of a relative, observing objects thrown or property damage. The research team categorized war-related traumatic events into low, medium or high levels. For example, war-related traumatic events as witnessing killing or gunfire where categorized as high, whether knowing someone who got killed was categorized as medium level and TV exposure as low level of war exposure. Also, the research team coded whether participants in initial studies were displaced. Finally, 6-point war intensity scale was
computed to rate war exposure. This scale was only used to describe the publications and not used in the analyses. War-related traumatic events is the independent variable in this meta-analysis.
Effect Size
Effect sizes were Pearson’s correlation coefficient (r) between war-related traumatic events and parental warmth. If multiple effect sizes were reported in a single publication, all relevant correlations were extracted. If betas were reported, they were converted into
correlations using the formula r = β + .05λ, where λ is 1 if β is non-negative and 0 if β is negative (Peterson & Brown, 2005). Values of r are between -1 and 1 and indicate the direction of the relationship. Specifically, the further r is in the negative direction from 0, the less parental warmth is showed. The values of r are interpreted as small (r ≤ .10), medium (r ≤ .30) or large (r ≤ .50) (Kraemer, Morgan, Leech, Gliner, Vaske, & Harmon, 2003). If
to made sure all publications assessed parental warmth in the same way across the different publications. Finally, I used Fisher’s z transformation to normally distribute the effect sizes (Lipsey & Wilson, 2001). In order to interpret the outcome, Fisher z-values were transformed back into r after the analyses.
Statistical Analysis
Preliminary analyses.
Outlier analysis. First, I checked for effect sizes with an z score above 3.29 SD or under -3.29 SD from the mean, indicating unusual scores in the data that are considered extreme (Hinkle, Wiersma, & Jurs, 2003; Tabachnick & Fidell, 2003). Identified outliers were adjusted, since outliers increase the risk of a false result.
Publication bias. Second, I checked if the included publications in the meta-analysis are an adequate representation of all conducted studies. Missing publications that met the inclusion criteria is a common problem in performing a meta-analysis, which can be fuelled by researchers only publishing articles that report significant results. This tendency of hiding the non-significant publications is also known as the ‘file drawer problem or publication bias’, and may lead to un upward bias in the summary effect (Rosenthal, 1979; Borenstein, Hedges, Higgins, & Rothstein, 2009). In order to determine a possible publication bias, I created a funnel plot which shows either symmetrical or asymmetrical distribution of the publications. An asymmetrical distribution implies a possible overestimation or underestimation of the mean effect, while a symmetrical distribution indicates the absence of a publication bias (Egger, Smith, Schneider, & Minder, 1997). I used visual inspection of the funnel plot to detect asymmetry. Finally, Egger’s method was used to statistically test for publication bias (Egger et al., 1997). Because there is no Egger test available for a multilevel random effects model, Egger test was performed using a random meta-analysis model and therefore this result should be interpreted with caution.
Heterogeneity. Third, likelihood ratio tests were used to statistically test for
heterogeneity by measuring the existence of significant variance across the weighted effect sizes at the two levels (Wibbelink & Assink, 2015). In case of heterogeneity, more variance is present than expected by the sampling variance and therefore I will conduct a moderation test on country of origin to investigate if this variable helps explaining the heterogeneity. To conduct the moderator test, I created a dummy variable distinguishing between Middle Eastern and European countries.
Multilevel random effects model. Statistical software R version 3.5.0 (R Core Team,
2018) with the packages dplyr (Wickham, François, Henry, & Müller, 2018), foreign (R Core Team, 2017) and metaphor (Viechtbauer, 2010) were used to perform the multilevel analyses. The inclusion of multiple effect sizes from the same publication violates the meta-analytic approach that the subject samples are independent, because effect sizes from the same study are in general more similar since they used the same sample size and study design, compared to effect sizes from different studies (Lipsey & Wilson, 2001; Assink & Wibbelink, 2016; Wibbelink & Assink, 2015). Therefore, a multilevel design was conducted, taking account for study dependency and hierarchical structures (Snijders & Bosker, 2012). The model is
specified by selecting 3 levels of analysis, including the sampling variances for each effect size (level 1), the variances between effect sizes within the study (level 2) and the variance between the studies (level 3) (Wibbelink & Assink, 2015). Because current meta-analysis is accumulating data from various publications, performed by independent operating
researchers, the true effect may vary between the studies and therefore the effect sizes were reported by a multilevel random effects model (Snijders & Bosker, 2012; Borenstein et al., 2009).
Sensitivity analysis. Additionally, a sensitivity analysis was performed to determine
whether the inclusion of both cross-sectional and longitudinal study designs impacted the findings.
Results Characteristics of Included Studies
A total of 12 publications met our inclusion criteria, published between 1997 and 2013. Publications with overlapping samples were treated as a single study (Punamäki, Qouta, & El Sarraj, 1997a; Punamäki, Qouta, & El Sarraj, 1997b; Punamäki, Qouta, & El Sarraj, 2001). As a result, present meta-analysis contains of 10 independent samples and 20 reported effects sizes in a range between -.29 and .18. Three publications have a longitudinal study design, which takes in account the developmental aspect of the association between war exposure and parental warmth by measuring over a period of time. Sample sizes varied between 86 and 3,462 participants. The total sample size involved 13,347 independent
participants. The majority of participants experienced high level of war exposure according to our categorization (79%). Three independent publications with high war exposure reported displacement, accounting for less than 8% of the families in this meta-analysis. Most
participants are originally from a Middle Eastern country, specifically from Palestine (79.2%) and Israel (9.5%). Other participants are from North Ireland (5,2%) and Croatia (6.1%). Participating children have a mean age of 14.6 years and both genders are evenly represented (49.5% boys). If a child’s mean age was not reported, the exact mean of the child age range was selected in order to calculate the mean age. Publications are mainly about preadolescents and adolescents, because less than 7.9% of the participating children is 12 years or younger. The characteristics of the included studies are shown in Table 1.
Preliminary Results
Publication bias. Visual inspection of the funnel plot in Figure 2 showed a slightly
asymmetrical plot. Adversely, Egger’s method showed a non-significant intercept and therefore revealed funnel plot symmetry and eliminated the publication bias (t = 1.06, p = .29).
Heterogeneity. The likelihood ratio test found significant variance at the within study
level (χ2(1) = 6.7653, p < .001) and the between study level (χ2(1) = 3.6285, p = .03). This indicates a heterogeneous effect and means that the differences between the effect sizes in both levels are not due to chance. About 20% of the variance was explained by differences in effect sizes within studies (level 2), and about 72% of the variance was explained by
differences in effect sizes between studies (level 3). The remaining 8% of the variance accounted for the sampling variance (random sampling error) (level 1).
Multilevel Random Effects Model
Results of the multilevel meta-analysis show no overall significant association
between war exposure and parental warmth (r = -.07, 95% CI [-0.151, 0.014], p = .10) (Table 2; Figure 3). This reflects that co-exposure from families to war-related traumatic events is not associated with their parental warmth. The estimated results of the included publications about the association between war exposure and parental warmth are shown together with the overall results in a forest plot.
Sensitivity analysis. To make sure that the results were not biased by study design, I
conducted a sensitivity analysis. The association between traumatic events and parental warmth was tested with only the cross-sectional study designs included. A significant result was found, indicating that the nature of the study design had an effect on the findings (r = -.06, 95% CI [-0.108, -0.021], p = .01, k = 8, including 15 effect sizes). If data was only acquired with a cross-sectional study design, an association was found between war exposure
and parental warmth, compared to when the data was acquired with both cross-sectional and longitudinal designs.
Moderator Analysis
The country of origin did not moderate the association between war exposure and parental warmth (Table 2). Neither coming from a European country (β = -.12, p = .13), or Middle Eastern country (β = .07, p = .43), did interact with the association between war exposure and parental warmth.
Discussion
This meta-analysis aimed at understanding whether more war exposure is associated with less parental warmth in war-affected families. The results showed no significant association, and this result was maintained even after considering the country of origin as a moderating variable. This indicates that parents might still be able to provide their children sensitive and responsive parenting behavior after being co-exposed to traumatic events. Furthermore, moderator analysis showed that parents coming from European or Middle Eastern countries did not influence the association between war exposure and parental warmth.
Although the hypothesis was not confirmed, the lack of association between war exposure and parental warmth provides important information as it hints at the possibility that parental warmth may be a fundamental parental characteristic that remains intact regardless of war exposure. This finding builds on previous research of Abbott (2009), showing an
increased value of family togetherness after families experienced the traumatic event of losing a child. Families responded with spending more time together and communicate more with each other, indicating that they continued showing warm parenting behavior.
However, families may also experience parental emotional and behavioral
Broberg, 2003; Scheeringa & Zeanah, 2001). Previous research among veterans confirm these findings, as veterans reported difficulties in resuming their parental role in the family and reconnect with the family members after deployment, what might decrease parental warmth (Creech et al., 2014; Marsanic et al., 2014; Sayers, Farrow, Ross, & Oslin, 2009; Solomon et al., 2010; Solomon, Debby-Aharon, Zerach, & Horesh, 2011; Willerton, Schwarz,
Wadsworth, & Oglesby, 2011). However, war-affected families may not face situations of family reintegration. Moreover it should be questioned if it is possible to compare traumatic experiences of veterans with war-affected families, who are civilians and are inactive and without a choice exposed to organized violence.
The way families cope with traumatic events can be conceptualized by the family stress theory, emphasizing that the meaning families give to a situation determine their possible adaptation or deteriorating after experiencing a traumatic event (Boss, Bryant, & Mancini, 2017). As with pain, trauma is an internal phenomenon and individual perceptions of trauma may differ (Abbott, 2009; Friedman & Jaranson, 1994; Kimhi, Eshel, Zysberg, & Hantman, 2010). This suggest that it is possible that levels of parental warmth may partly be driven by people’s perception of the traumatic event they experienced (Lazarus & Folkman, 1984). For example, mothers who have been raped in the presence of their children, showed damaged mental representations about her parental role of being a caring mother who can provide safety for her child, and therefore showed less emotional and behavioral availability what might reduce parental warmth. On the other hand, families who lost a child experienced an increased appreciation of their relationship and togetherness (Abbott, 2009). One possible explanation is that traumatic events – such as the death of a family member – make families realize how precious their relationship is, while other traumatic events – such as being raped in the presence of your child – make people feel guilty about engaging others into traumatic
events. This indicates that people’s perception of the traumatic event may possibly influence whether one show closeness or avoidant behavior.
It must be considered that parental warmth may depend on different traumatic events that families experienced and in the light of their related individual perceptions. For example, families who lost a child reported intense grief. As a result, they used memorializing as a coping strategy, what made them look for things that reminded them of their loved ones (Abbott, 2009). Contrary to these possible grief responses, comorbid disorders of grief such as post-traumatic stress symptoms, may result in avoiding situations and people that remind parents of the traumatic event (Jong & van Schaik, 1994). Parents suffering from comorbid disorders of grief are less likely to monitor the child’s needs and symptoms correctly, and therefore may decrease parental warmth (Scheeringa & Zeanah, 2001). An explanatory framework for the perception of a traumatic event can be offered by a person’s ideology. People may use their perception of the utility of the war and their determination to continue the war, to give meaning to the traumatic event (Punamäki, 1987; Abbott, 2009). Seeing the loss of your child as a sacrifice for the greater good, or as a pointless event may possibly affect parental behavior differently (Abbott, 2009). To conclude, this shows that generalizing traumatic events on their global context of war might be insufficient, given that trauma experiences may refer to subjective individual perceptions.
Generalization of war-related traumatic events may provide an explanation for the lack of a significant association in the present meta-analysis. Extensive analyses of the
publications included in this meta-analysis showed systematical differences in measuring and calculating war exposure. This illustrates that valuable insights may have been lost by
generalizing different traumatic events as one variable. Since the sample size consisted of different types of war exposure and therefore different individual perceptions, this may have neutralized the results and caused the lack of significant association in the overall effect.
Furthermore, this also may explain the lack of association in the moderator effect, because there can be considerable variations within people’s perception who live in the same country or share the same culture (Abbott, 2009).
Another possible explanation for the lack of a significant association may refer to some people’s personalities that remained unchanged or even positively changed following trauma. Tedeschi and Calhoun (1996) referred to this as posttraumatic growth and described that people’s prewar functioning may allow perception of benefits. For example, people who are agreeable may find others more supportive towards them following trauma. Since social support is a protective factor against the development of PTSD, their personality might help remaining parental warmth (Brewin, Andrews, & Valentine, 2000). Furthermore, personal changes due to traumatic events may possibly lead to increased psychological functioning and personal development Aldwin, Levenson & Spiro III, 1994). Positive personality
development may even increase linear. Thus, the more traumatic events one experienced, the more positive personality developments are reported, what might help remaining levels of parental warmth.
Despite the interesting finding that parental warmth is not associated with war exposure, this meta-analysis has several limitations. First, the included studies mainly relied on child reports of perceived parental warmth measures. It is a common phenomenon that members of the same family report differently about the quality of their relationship (Barber, 1999). In addition, children tend to have less positive opinions about parental functioning than parents (Schwarz, Barton-Henry, & Pruzinsky, 1985). This variation between their individual frames of reference may have affected the results. Second, despite the extensive literature research through electronic databases and the extended literature search by contacting experts in the field, only a few publications dealing with war-related traumatic events and parental warmth in civilian co-exposed families were available. Although the number of participants in
the included studies have enough power, the low number of available publications for the present meta-analysis may have limited the power of the study (Heiman, 2002). The third limitation is that the available publications frequently used a cross-sectional study design, while a longitudinal study design is more effective (Heiman, 2002). The reason to use a cross-sectional design may be caused by difficulties to keep in touch with participants, and it is understandable that a war context makes this even more difficult. Since almost all available publications used a cross-sectional design, we decided to include both cross-sectional and longitudinal study designs in present meta-analysis.
Among the strengths of this study is first the investigation of co-exposure of war-related traumatic events in families. The increasing number of families living in war-affected areas makes it important to focus on the co-exposure of traumatic events among civilian families. A second strength is that a sensitivity analysis was performed to show if the outcomes are biased by including different study designs. Although a longitudinal study design is supposed to be more effective than a cross-sectional study design, the findings of the sensitivity analysis showed a significant association if only cross-sectional study designs were included. This finding points at the possibility that the association between war exposure and parental warmth may fade over time. However, this finding should be interpreted with caution since only three included publications used a longitudinal study design. Another possible explanation for this finding could also be that the reliability of people’s memory decreased if a lot of time has passed after the traumatic event. Especially in case of a traumatic event, people may try to repress their feelings and experiences. Besides, the findings may have been confounded by any additional variable that the participant experienced during the study. Third, the use of an advanced multilevel design made it possible to include multiple effect sizes out of the same study. Finally, attention was paid to a possible publication bias by
statistically testing for funnel plot asymmetry. These strengths increase the representativeness of the findings.
To the best of my knowledge, this is the first conducted quantitative meta-analysis about the direct association between related traumatic events and parental warmth in war-affected families. The findings suggest that there is no association between traumatic events and parental warmth. An alternative approach for further research is to focus more on the individual perception of war exposure and the association on parental warmth, for example in the form of perceived stress. In addition, future research should utilize more longitudinal research designs, where the long-term effects of war exposure on parental warmth can be assessed. The use of a longitudinal design may contribute to a better understanding of the association between war exposure and parental warmth and provide a more comprehensive perspective on the needs of war exposed families during and after the war, while not longer living in war-affected areas. However, the changing of generations should of course always be taking into account. It may also be required to have more insight on multiple informants and therefore include parallel measures of both reports of parents and their children on traumatic events and parental warmth. Additionally, observational research may gain valuable insights. Yet, I understand that this is difficult in a war context.
Conclusion
The importance of focusing on war-affected families relates to the influences of co-exposure of traumatic events. The present meta-analysis showed no association between war-related traumatic events and parental warmth in war-affected families and the association was also independent of country of origin. Although co-exposure to traumatic events may increase the value of family closeness or lead to post-traumatic growth, generalization of war-related traumatic events in the light of elimination of individual perceptions, provides a possible explanation for the lack of significant findings. The findings highlight the importance of
further research on both parent and child reports on war exposure and parental warmth, with attention to individual perceptions of the traumatic event. Longitudinal research designs can help to understand this association and clarify the needs of war-affected families during and after exposure to war-related traumatic events.
References
References marked with an asterisk indicate studies included in the meta-analysis.
Abbott, A. D. (2009). Violent death: A qualitative study of Israeli and Palestinian families. Journal of Loss and Trauma, 14, 117-128. doi: 10.1080/15325020802540462
Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Erlbaum.
Ainsworth, M. D. S., & Bowlby, J. (1991). An ethological approach to personality
development. American Psychologist, 46, 331-341. doi: 10.1037/0003-066X.46.4.333 *Al-Krenawi, A., & Graham, J. R. (2012). The impact of political violence on psychosocial functioning of individuals and families: The case of Palestinian adolescents. Child and Adolescent Mental Health, 17, 14-22. doi: 10.1111/j.1475-3588.2011.00600.x
*Al-Krenawi, A., Graham, J. R., & Kanat-Maymon, Y. (2009). Analysis of trauma exposure, symptomatology and functioning in Jewish Israeli and Palestinian adolescents. British Journal of Psychiatry, 195, 427-432. doi: 10.1192/bjp.bp.108.050393
*Al-Krenawi, A., Graham, J. R., & Sehwail, M. A. (2007). Tomorrow's players under occupation: An analysis of the association of political violence with psychological functioning and domestic violence, among Palestinian youth. American Journal of Orthopsychiatry, 77, 427-433. doi: 0.1037/0002-9432.77.3.427
Aldwin, C. M., Levenson, M. R., & Spiro III, A. (1994). Vulnerability and resilience to combat exposure: Can stress have lifelong effects? Psychology and Aging, 9, 34-44. doi: 10.1037/0882-7974.9.1.34
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: American Psychiatric Press.
Almqvist, K., & Broberg, A. G. (2003). Young children traumatized by organized violence together with their mothers – The critical effects of damaged internal representations.
Attachment & Human Development, 5, 367-380. doi: 10.1080/14616730310001633447
Assink, M., & Wibbelink, C. J. M. (2016). Fitting three-level meta-analytic models in R: A step-by-step tutorial. The Quantitative Methods for Psychology, 12, 154-174. doi: 10.20982/tqmp.12.3.p154
*Barber, B. K. (1999). Political violence, family relations, and Palestinian youth functioning. Journal of Adolescent Research, 14, 206-230. doi: 10.1177/0743558499142004 Basu, B., & Dutta, N. (2010). Psychological changes of children surviving terrorist shock in Indian Kashmir. Journal of Child Neurology, 25, 1331-1334. doi:
10.1177/0883073810362925
Baumrind, D. (2005). Patterns of parental authority and adolescent autonomy. In E. L. Grigorenko (Ed.), New directions for child and adolescent development (pp. 61-69). doi: 10.1002/cd.128
Berndt, T. J. (1979). Developmental changes in conformity to peers and parents. Developmental Psychology, 15, 608-616. doi: 10.1037/0012-1649.15.6.608 Blankers, E. (2013). A new generation: How refugee trauma affects parenting and child development (Doctoral dissertation). Retrieved from https://dspace.library.uu.nl/ Bodenmann, G., Ledermann, T., & Bradbury, T. N. (2007). Stress, sex, and satisfaction in marriage. Personal Relationships, 14, 551-569. doi: 10.1111/j.1475-
6811.2007.00171.x
Boss, P., & Bryant, C. M., & Mancini, J. A. (2017). Family stress management: A contextual approach (3rd Ed.). Los Angeles, CA: Sage.
Bowlby, J. (1971). Attachment and loss (Vol. 1). Harmondsworth, England: Penguin.
Borenstein, M., Hedges, L. V., Higgins, J. P. T., & Rothstein, H. R. (2009). Introduction to Meta-Analysis. Hoboken, NJ: John Wiley & Sons.
Brewin, C. R., Andrews, B. A., & Valentine, J. D. (2000). Meta-analysis of risk factors for posttraumatic stress disorder in trauma-exposed adults. Journal of Consulting and Clinical Psychology, 68, 748-766. doi: 10.1037//0022-006X.68.5.748
Creech, S. K., Hadley, W., & Borsari, B. (2014). The impact of military deployment and reintegration on children and parenting: A systematic review. Professional Psychology, Research & Practice, 45, 452-464. doi: 10.1037/a0035055
*Cummings, E. M., Schermerhorn, A. C., Merrilees, C. E., GoekeMorey, M. C., Shirlow, P., & Cairns, E. (2010). Political violence and child adjustment in Northern Ireland: Testing pathways in a social-ecological model including single-and two-parent families. Developmental Psychology, 46, 827-841. doi: 0.1037/a0019668.
Dekel, R., & Goldblatt, H. (2008). Is there intergenerational transmission of trauma? The case of combat veterans’ children. American Journal of Orthopsychiatry, 78, 281–289. doi:10.1037/a0013955
Dybdahl, R. (2001). Children and mothers in war: an outcome study of a psychosocial intervention program. Child Development, 72, 1214-1230. doi: 10.1111/1467- 8624.00343
Egger, M., Smith, D. G., Schneider, M., & Minder, C. (1997). Bias in meta-analysis detected by a simple, graphical test. BMJ, 315, 629–634. doi: 10.1136/bmj.315.7109.629 Elder, G. H., & Clipp, E. C. (1989). Combat experience and emotional health: Impairment and resilience in later life. Journal of Personality, 57, 311-341. doi: 10.1111/j.1467- 6494.1989.tb00485.x
Elsass, P. (2001). Individual and collective traumatic memories: A qualitative study of post- traumatic stress disorder symptoms in two latin american localities. Transcultural Psychiatry, 38, 306-316. doi: 10.1177/136346150103800302
Feldman, R., & Vengrober, A. (2011). Posttraumatic stress disorder in infants and young children exposed to war-related trauma. Journal of American Academy of Child & Adolescent Psychiatry, 50, 645-658. doi: 10.1016/j.jaac.2011.03.001
Fontana, A., & Rosenheck, R. (1998). Psychological benefits and liabilities of traumatic exposure in the war zone. Journal of Traumatic Stress, 11, 485-503. doi:
10.1023/A:1024452612412
Frazier, P., Greer, C., Gabrielsen, S., Tennen, H., Park, C., & Tomich, P. (2013). The relation between trauma exposure and prosocial behavior. Psychological Trauma: Theory, Research, Practice, and Policy, 5, 286-294. doi: 10.1037/a0027255
Friedman, M., & Jaranson, J. (1994). The applicability of the posttraumatic stress disorder concept to refugees. In A. J. Marsella, T. Bornemann, S. Ekblad, & J. Orley (Eds.), Amidst peril and pain: The mental health and well-being of the world's refugees (pp. 207-227). Washington, DC: American Psychological Association. doi:
10.1037/10147-010
Goff, B. S. N., Reisbig, A. M. J., Bole, A., Scheer, T., Hayes, E., Archuleta, K. L., … Smith, D. B. (2006). The effects of trauma on intimate relationships: A qualitative study with clinical couples. American Journal of Orthopsychiatry, 76, 451-460. doi:
10.1037/0002-9432.76.4.451
Goldberg, S., Benoit, D., Blokland, K., & Madigan, S. (2003). Atypical maternal behavior, maternal representations, and infant disorganized attachment. Development and Psychopathology, 15, 239-257. doi: 10.1017/S0954579403000130
*Grgic, M., Vidovic, V., Soldo-Butkovic, S., & Koic, O. (2005). Depression and perceived family functioning in Croatian displaced children. Drustvena Istrazivanja, 14, 597- 608.
Harwood, I. (2006). Head start is too late: Integrating and applying infant observation studies, and attachment, trauma, and neurobiological research to groups with pregnant and new mothers. International Journal of Group Psychotherapy, 56, 5-28. doi:
10.1521/ijgp.2006.56.1.5
Heiman, G. W. (2002). Research methods in psychology (3th ed.). Boston, MA: Houghton Mifflin Company.
Hinkle, D. E., Wiersma, W., & Jurs, S. G. (2003). Applied statistics for the behavioral sciences (5th ed.). Belmont, CA: Wadsworth cengage learning.
Hinton, D. E., & Lewis-Fernández, R. (2011). The cross-cultural validity of posttraumatic stress disorder: Implications for DSM-5. Depression and Anxiety, 28, 783-801. doi: 10.1002/da.20753
Jong, J. T. V. M., & van Schaik, M. M. (1994). Culturele en religieuze aspecten van rouw- en traumaverwerking naar aanleiding van de Bijlmerramp. Tijdschrift voor Psychiatrie, 36, 291-304.
*Kerestes, G. (2006). Children's aggressive and prosocial behavior in relation to war exposure: Testing the role of perceived parenting and child's gender. International Journal of Behavioral Development, 30, 227-239. doi: 10.1177/0165025406066756 Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of General Psychiatry, 52, 1048-1060. doi: 10.1001/archpsyc.1995.03950240066012
*Kimhi, S., Eshel, Y., Zysberg, L., & Hantman, S. (2010). Sense of danger and family support as mediators of adolescents' distress and recovery in the aftermath of war. Journal of Loss & Trauma, 15, 351-369. doi:10.1080/15325024.2010.491769 Koren-Karie, N., Oppenheim, D., & Getzler-Yosef, R. (2004). Mothers who were severely abused during childhood and their children talk about emotions: Co-construction of narratives in light of maternal trauma. Infant Mental Health Journal, 25, 300-317. doi: 10.1002/imhj.20007
Kraemer, H. C., Morgan, G. A., Leech, N. L., Gliner, J. A., Vaske, J. J., & Harmon, R. J. (2003). Measures of clinical significance. Journal of the American Academy of Child and Adolescent Psychiatry, 42, 1524-1529. doi:10.1097/00004583-200312000-00022 Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York, NY: Springer Publishing Company.
Lieberman, A. F. (2004). Traumatic stress and quality of attachment: Reality and
internalization in disorders of infant mental health. Infant Mental Health Journal, 25, 336-351. doi: 10.1002/imhj.20009
Lipsey, M., & Wilson, D. (2001). Practical meta-analysis. Thousand Oaks, CA: Sage. Macksoud, M. (2000). Helping children cope with the stresses of war: a manual for parents and teachers. New York, NY: United Nations Children’s Fund Programme
Pubications.
Macksoud, M. S., & Aber, J. L. (1996). The war experiences and psychosocial development of children in Lebanon. Child Development, 67, 70-88. doi: 10.2307/1131687
Magwaza, A. S. (1999). Assumptive world of traumatized south African adults. The Journal of Social Psychology, 139, 622-630. doi: 10.1080/00224549909598422
Markus, H.R., & Kitayama, S. (1991). Culture and self implications for cognition, emotion, and motivation. Psychological Review, 98, 224-253. doi: 10.1037/0033-295X.98.2.224
Marsanic, V. B., Margetic, B. A., Jukic, V., Matko, V., & Grgic, V. (2014). Self-reported emotional and behavioral symptoms, parentadolescent bonding and family functioning in clinically referred adolescent offspring of Croatian PTSD war veterans. European Child & Adolescent Psychiatry, 23, 295-306. doi: 10.1007/s00787-013-0462-2 Mullen, M. K., & Yi, S. (1995). The cultural context of talk about the past: Implications for the development of autobiographical memory. Cognitive Development, 10, 407-419.
doi: 10.1016/0885-2014(95)90004-7
Norris, A. E., & Aroian, K. J. (2008). Avoidance symptoms and assessment of posttraumatic stress disorder in arab immigrant women. Journal of Trauma and Stress, 21, 471-478. doi: 10.1002/jts.20363
*Palosaari, E., Punamaki, R.L., Qouta, S., & Diab, M. (2013). Intergenerational effects of war trauma among Palestinian families mediated via psychological maltreatment. Child Abuse & Neglect, 37, 955-968. doi: 10.1016/j.chiabu.2013.04.006
Panaccione, V. F., & Wahler, R. G. (1986). Child behavior, maternal depression, and social coercion as factors in the quality of child care. Journal of Abnormal Child Psychology, 14, 263-278. doi: 10.1007/BF00915445
Peterson, R. A., & Brown, S. P. (2005). On the use of beta coefficients in meta-analysis. The Journal of Applied Psychology, 90, 175-181. doi: 10.1037/0021-9010.90.1.175 Punamäki, R-L. (1987). The attitudes and emotional life of Israeli and Palestinian Children (Research report number 32). Tampere, Finland: Tampere Peace Research Institute. *Punamäki, R-L., Qouta, S., & El Sarraj, E. E. (1997a). Relationships between traumatic events, children's gender, and political activity, and perceptions of parenting styles. Internal Journal of Behavior Development, 21, 91-110. doi:
10.1080/016502597385009
children’s psychological adjustment: the roles of perceived parenting and the children’s own resources and activity. Child development, 64, 718-728. doi: 10.2307/1132121
*Punamäki, R-L., Qouta, S., & El Sarraj, E. (2001). Resiliency factors predicting psychological adjustment after political violence among Palestinian children. International Journal of Behavioral Development, 25, 256-267. doi:
10.1080/01650250042000294
R Core Team (2017). Foreign: Read Data Stored by 'Minitab', 'S', 'SAS', 'SPSS', 'Stata', 'Systat', 'Weka', 'dBase'. R package version 0.8-70. Retrieved from https://CRAN.R- project.org/package=foreign
R Core Team (2018). R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. Retrieved from http://www.R-project.org. Raboteg-Saric, Z., Zuzul, M., & Kerestes, G. (1994). War and children's aggressive and prosocial behaviour. European Journal of Personality, 8, 201-212. doi:
10.1002/per.2410080305
Rosenthal, R. (1979). The file drawer problem and tolerance for null results. Psychological Bulletin, 86, 638-641. doi: 10.1037/0033-2909.86.3.638
Ruscio, A. M., Weathers, F. W., King, L. A., & King, D. W. (2002). Male war-zone veterans’ perceived relationships with their children: The importance of emotional numbing. Journal of Traumatic Stress, 15, 351-357. doi: 10.1023/A:1020125006371
Samper, R. E., Taft, C. T., King, D. W., & King, L. A. (2004). Posttraumatic stress disorder symptoms and parenting satisfaction among a national sample of male Vietnam veterans. Journal of Traumatic Stress, 17, 311-315. doi:
10.1023/B:JOTS.0000038479.30903.ed
by conflict [Blog post]. Retrieved from https://www.savethechildren.net/article/one- six-children-globally-living-areas-impacted-conflict
Sayers, S. L., Farrow, V. A., Ross, J., & Oslin, D. W. (2009). Family problems among recently returned military veterans referred for a mental health evaluation. Journal of Clinical Psychiatry, 70, 163–170. doi: 10.4088/JCP.07m03863
Schechter, D. S., Willheim, E., Hinojosa, C., Scholfield-Kleinman, K., Turner, J. B. McCaw, J. … Myers, M. M. (2010). Subjective and objective measures of parent-child
relationship dysfunction, child separation distress, and joint attention. Psychiatry, 73, 130-144. doi: 10.1521/psyc.2010.73.2.130
Scheeringa, M. S., & Zeanah, C. H. (2001). A relational perspective on PTSD in early childhood. Journal of Traumatic Stress, 14, 799-815. doi: 10.1023/A:1013002507972 Schuengel, C., van IJzendoorn, H. M., Bakermans-Kranenburg, M. J., & Blom, M. (1996). Frightening maternal behaviour, unresolved loss, and disorganized infant attachment: A pilot-study. Journal of Reproductive and Infant Psychology, 16, 277-283. doi: 10.1080/02646839808404575
Schwarz, J. C., Barton-Henry, M. L., & Pruzinsky, T. (1985). Assessing child-rearing behaviors: a comparison of ratings made by mother, father, child, and sibling on the CRPBI. Child Development, 56, 462-479. doi: 10.2307/1129734
Shalev, A. Y. (2002). Acute stress reactions in adults. Society of Biological Psychiatry, 51, 532-543. doi: 10.1016/S0006-3223(02)01335-5
Slade, A. (2005). Parental reflective functioning: An introduction. Attachment & Human Development, 7, 269-281. doi: 10.1080/14616730500245906
Slone, M., & Mann, S. (2016). Effects of war, terrorism and armed conflict on young children: a systematic review. Child Psychiatry Human Development, 47, 950-965. doi: 10.1007/s10578-016-0626-7
Slone, M., & Shoshani, A. (2017). Children affected by war and armed conflict: parental protective factors and resistance to mental health symptoms. Frontiers in Psychology, 8, 1-11. doi: 10.3389/fpsyg.2017.01397
Snijders, T. & Bosker, R. (2012). Multilevel analysis: An introduction to basic and advanced multilevel modeling. Thousand Oaks, CA: Sage.
Solomon, Z., Debby-Aharon, S., Zerach, G., & Horesh, D. (2011). Marital adjustment,
parental functioning, and emotional sharing in war veterans. Journal of Family Issues, 32, 127-147. doi: 10.1177/0192513X10379203
Steel, Z., Chey, T., Silove, D., Marnane, C., Bryant, R. A., & van Ommeren, M. (2009). Association of torture and other potentially traumatic events with mental health
outcomes among populations exposed to mass conflict and displacement: A systematic review and meta-analysis. JAMA, 302, 537-549. doi: 10.1001/jama.2009.1132
Steffen, S. L., & Fothergill, A. (2009). 9/11 Volunteerism: A pathway to personal healing and community engagement. The Social Science Journal, 46, 29-46. doi:
10.1016/j.soscij.2008.12.005
Tabachnick, B. G., & Fidell, L. S. (2013). Using multivariate statistics (6th ed.). London, England: Pearson.
Tedeschi, R. G., & Calhoun, L. G. (1996). The posttraumatic growth inventory: Measuring the positive legacy of trauma. Journal of Traumatic Stress, 9, 455-471. doi:
10.1002/jts.2490090305
Tedeschi, R. G. & Calhoun, L. G. (2004). Posttraumatic Growth: Conceptual Foundations and Empirical Evidence. Psychological Inquiry, 15, 1-18. doi:
10.1207/s15327965pli1501_01
UN Commission on Human Rights, Forced evictions. Retrieved from United Nations Human Rights website: https://www.ohchr.org/en/Issues/Housing/Pages/ForcedEvictions.aspx
Viechtbauer, W. (2010). Conducting meta-analyses in R with the metafor package. Journal of Statistical Software, 36, 1-48. Retrieved from: http://www.jstatsoft.org/v36/i03/
Weine, S. M., Muzurovic, N., Kulauzovic, Y., Besic, S., Lezic, A., Mujagic,
A., … Pavkovic, I. (2004). Family consequences and refugee trauma. Family Process, 43, 147–160. doi: 10.1111/j.1545-5300.2004.04302002.x
Wibbelink, C., & Assink, M. (2015). Handleiding voor het uitvoeren van een drie-level meta- analyse in R. Amsterdam: Afdeling Forensische Orthopedagogiek, Universiteit van Amsterdam.
Wickham, H., François, R., Henry, L., & Müller, K. (2018). Dplyr: A grammar of data manipulation. R package version 0.7.6. Retrieved from https://CRAN.R-
project.org/package=dplyr
Willerton, E., Schwarz, R. L., Wadsworth, S. M. M., & Oglesby, M. S. (2011). Military fathers' perspectives on involvement. Journal of Family Psychology, 25, 521-530. doi:
10.1037/a0024511
Zahr, L. K. (1996). Effects of war on the behavior of Lebanese preschool children: influence of home environment and family functioning. American Journal of Orthopsychiatry, 66, 401-408. doi: 10.1037/h0080190
Table 1
Characteristics of Included Studies
Study characteristics Sample characteristics War characteristics Warmth characteristics
First author Year N #r Design Origin Child age range (M) % boy Exposure level Displacement Informant
Al-Krenawi 2007 2328 1 LONG Palestinian 12-18 (15.4) 51,6 High - Child
Al-Krenawi 2012 450 2 CROSS Palestinian 14-18 (16.3) 42,4 Medium No Child
521 Palestinian 14-18 (15.4) 42,7 Medium No Child
Al-Krenawi 2009 442 1 CROSS Israeli 14-18 (15.5) 44,9 - No Child
Barber 1999 3461 2 CROSS Palestinian 14-15 (-) 100 High No Child
3462 Palestinian 14-15 (-) 0 High No Child
Cummings 2010 700 4 CROSS Irish 8-15 (12.1) 48,3 Medium No Both
Grcic et al. 2003 121 1 CROSS Croatian 12-15 (13.7) 61,6 High Yes Child
Kerestes 2006 694 1 CROSS Croatian 12-15,3 (13.6) 53,0 Medium No Child
Kimhi 2010 820 1 CROSS Israeli 12-18 (15.0) 46,0 High Yes Child
Palosaari 2013 240 2 LONG Palestinian 10-12 (11.4) 50,0 High No Child
Palestinian 10-12 (11.4) 50,0 High No -
Punamäki 1997a 108 1 CROSS Palestinian 11-12 (-) 50,9 High Yes Child
Punamäki 1997b 108 2 CROSS Palestinian 11-12 (-) 50,9 High Yes Child
Punamäki 2001 86 2 LONG Palestinian 14-15 (14.0) 50,9 High Yes -
Note. N = number of participants; # r = number of effect sizes in publication; design = study design; origin = country of origin; child age range (M) = upper and lower ages
(mean age); % boys = percentage of boys in the sample; exposure level = level of war exposure; displacement = displacement yes/no; CROSS = cross-sectional; LONG = longitudinal; medium = experienced between 2.7 – 6.4 political life events, lived in a refugee camp, know of someone who got killed, being close to a combat situation; high = experienced > 6.5 political life events, less than 10 minutes to seek shelter, family member killed, lived under siege, seeing a dead or a mutilated body, witnessing shelling or gunfire or killing, being directly victimized by militia; both = child + mother; - = variable unspecified in study.
Table 2
Overall Result, Sensitivity Analysis, and Moderator Effect Between War Exposure and Parental Warmth
k # ES r β1 p F(df1, df2)
Overall association war exposure and parental warmth 10 20 -.07 .10
Sensitivity analysis Cross-sectional design 8 15 -.06 .01* Moderator variable Country of Origin 10 20 .43 F(1,18) = 0.65 Europe (RC) 3 6 -.12 .13 Middle East 7 14 .07 .19 .43
Note. k = number of independent studies; # ES = number of effect sizes; r = mean effect size r; β1 = estimated regression coefficient (calculated as difference
with reference category); p = p-value; F(df1, df2) = omnibus test; RC = reference category.
Figure 1. PRISMA flow chart of the selection of studies. DV = dependent variable; IV = independent variable; ES = effect size.
Records identified through database searching (n = 5148) Scree ning Incl uded Eligi bi li ty Identi ficati
on Additional records identified
through other sources (n = 29)
Records after duplicates removed (n = 3652) Records screened (n = 3652) Records excluded (n = 3512) Full-text articles assessed for eligibility
(n = 140)
Full-text articles excluded, with reasons
(n = 128)
Reasons for exclusion: No suitable DV
No suitable IV
Unable to calculate ES No reported co-exposure Child age above 18 years Studies included in
quantitative synthesis (meta-analysis)
Figure 3. Forest plot of the association between war exposure and parental warmth in the included publications. CI = confidence interval.
