Multiple Traumas,Maternal Depression,Mother–Child Relationship,Social Support,and Young Children’s Behavioral Problems

Abstract

This study examined whether maternal depression, mother–child relationships, and maternal perceived social support mediate the associations between child’s exposure to multiple traumatic events and behavioral problems. We recruited a representative sample of 904 Israeli (Jewish and Arab) mothers and their 2- to 6-year-old children. Data collection was conducted through structured face-to-face interviews with the mothers between July and November 2011. All measures were completed by the mothers. We used the child’s and mother’s exposure to political violence questionnaires, Child Behavior Checklist (CBCL), a short version of the Parental Acceptance–Rejection Questionnaire (PARQ), the Center for Epidemiologic Studies Depression Scale (CES-D), and the Medical Outcomes Study (MOS) Social Support Survey. The research study model was tested using path analysis. The model showed a very good fit to the data, suggesting that maternal rejection, maternal depression, and social support play an important role in child’s behavioral problems in the context of multiple traumatic events. Higher levels of maternal rejection were significantly associated with greater children behavior problems. Maternal rejection mediated the associations between maternal depressive symptoms and child’s behavioral problems. Maternal perceived social support mediated the associations between child’s exposure to multiple traumatic events and child’s behavioral problems; child’s exposure to multiple traumatic events was associated with lower levels of maternal perceived social support. In turn, lower levels of perceived social support were associated with higher levels of behavioral problems. In conclusion, in accordance with the “social stress framework,” social support has a mediation role in the association between exposure to traumatic events and child’s behavioral problems. Thus, enhancing social support to mothers to young children in the context of multiple traumatic events is essential for children resiliency.

Keywords

mental health and violence support seeking sexual assault war cultural contexts intergenerational transmission of trauma mother-child relationships

Introduction

Exposure to multiple acts of political violence such as war and terrorism has adverse effects on children (Dubow et al., 2012) including posttraumatic stress symptoms (PTS), aggression, and other behavioral problems (Pat-Horenczyk et al., 2013). Evidence suggests that children’s mental health in the first 5 years of life can be affected by traumatic stressors including domestic violence, political violence, and war (Laor, Wolmer, Spirman, & Wiener, 2003). Children’s exposure to traumatic events is associated not only with PTS but also with broader developmental impairment including deficiencies in biological, emotional, social, and cognitive functioning and development (Alisic, Jongmans, van Wesel, & Kleber, 2011). Yet, a direct link between exposure to political violence and child distress has not been established. Several risk and protective factors have been found to moderate or mediate these associations, including social support (Dimitry, 2012), ethnicity (Dwairy et al., 2010), and parental characteristics, practices, and distress (Lieberman & Van Horn, 2009; Slone, Shechner, & Farah, 2012). In the aftermath of politically violent events, the mother–child relationship is considered essential to child posttraumatic adaptation (Al-Sabah et al., 2015). The present study examined the indirect paths associating child’s exposure to multiple traumatic events and his or her behavioral problems. Specifically, it tested whether maternal depression, mother–child relationships, and maternal perceived social support mediate the associations between child’s exposure to multiple traumatic events and behavioral problems.

Maternal Acceptance–Rejection and Child Behavioral Problems

One type of conceptualization for mother–child relationships is maternal acceptance–rejection. “Maternal Acceptance–Rejection” is a widely studied concept derived from Rohner, Khaleque, Riaz, et al., (2005) parental acceptance–rejection theory (Rohner, Khaleque, & Cournoyer, 2005). This theory states that parental acceptance–rejection is a bipolar dimension of parental warmth, with parental acceptance at the positive end of the continuum and parental rejection at the negative end. Parental acceptance includes love, affection, care, and nurturance expressed by parents toward their offspring. Parental rejection includes absence of warmth, love, and affection expressed by parents toward their children. The findings indicating that parental rejection has negative effects on children are universal (Rohner & Khaleque, 2002). They are consistent across race, ethnicity, and geographic location. The negative effects include depression and depressed affect and behavioral problems, including conduct disorders, externalizing behaviors/delinquency, and substance abuse (Rohner, Khaleque, Riaz, et al., 2005). Parental rejection is crucial in early childhood, when personality dispositions are formed and children build mental representations of themselves, the world, and human relationships (Rohner & Britner, 2002). Children who experience parental rejection may develop negative mental representations of themselves and the world, perceive hostility where there is none and feel worthless even in the face of strong information to the contrary (Rohner & Britner, 2002; Rohner, Khaleque, Riaz, et al., 2005).

The importance of parental acceptance–rejection, herby parental rejection, in child adjustment suggests that it might also serve as a mediator between child’s exposure to multiple traumatic events and psychological distress. Specifically, child’s exposure to trauma may decrease parental rejection, which in turn may be related inversely to child distress, meaning will decrease distress (mediation effect). Research indicates that parental rejection can partially or completely mediate the relationship between structural family variables (i.e., father’s absence, divorce, family size, socioeconomic status, and parental unemployment) and child behavior problems (Rohner & Britner, 2002). Nonetheless, to the best of our knowledge, the mediating effect of parental rejection in the association between exposure to multiple traumatic events and child behavioral problems has not yet been examined.

Maternal Perceived Social Support and Child Behavioral Problems

Social support to children and adolescents from family, friends, schools, and neighborhoods is considered a powerful protective factor in the context of exposure to political violence (Dubow, Huesmann, & Boxer, 2009). In this context, perceived high social support is associated with less psychological distress (Dimitry, 2012). For example, a longitudinal study conducted among adolescents in south Israel, an area that was highly exposed to rocket attacks, found evidence for a consistent, moderation effect of perceived social support from family members. At high levels of family support, there was no effect of exposure to rocket attacks on adolescents’ depression while at low levels of family support there was a strong effect of exposure (Shahar & Henrich, 2016). Social support provided to the mothers may also play an important mediation role in the relationships between maternal depression, maternal rejection, and child behavioral problems (Min, Singer, Minnes, Kim, & Short, 2013). Mothers of young children seek support more often than do mothers of older children (Tanninen, Haggman-Laitila, & Pietila, 2009). According to the family stress model (Conger, Reuter, & Conger, 2000), stressful events (e.g., economic pressure) lead to parental emotional distress including depressive symptoms. These, in turn, disrupt parents’ effective parenting practices and are associated with children maladjustment. Moreover, the social stress framework (Pearlin, Lieberman, Menaghan, & Mullan, 1981) posits that social stressors (e.g., economic pressure), could affect parental depression and other psychological distress through diminished social support. Both models found empirical support. External stressful events were associated with lower level of support which in turn was associated with maternal depressive symptoms and ineffective parenting, meaning that social support played a mediation role (Lee, Anderson, Horowitz, & August, 2009). Thus, while according to our best knowledge the potential mediation effect of social support on maternal depressive symptoms, ineffective parenting and young children maladjustment has not been addressed before in the context of the stressor of political violence, it may well be that social support serves as a mediator between child’s exposure to multiple traumatic events including acts of political violence, maternal depression, and child behavioral problems.

Maternal Depression and Child Behavioral Problems

In addition to maternal rejection, the link between a child’s exposure to multiple traumas and his or her behavioral problems may be associated directly or indirectly with maternal depression. Maternal depression has been found to be a risk factor of child behavioral problems (Choe, Olson, & Sameroff, 2013). Maternal depression is associated with child internalizing and externalizing behavioral problems, especially in early childhood (Cho, Kim, Lim, Lee, & Shin, 2015). Maternal practices have been identified as one mechanism for this association. Depression may undermine the development of an accepting relationship with the child (Lovejoy, Graczyk, O’Hare, & Neuman, 2000). Mothers with depression tend to be less responsive to their child’s needs, resent their parental duties and use harsh and inconsistent parenting techniques (Wickramaratne, Weissman, Pilowsky, & Rush, 2010). Harsh, inconsistent and rejecting parenting is a risk factor of maladaptive behaviors and functioning (Sethi, Mischel, Aber, Shoda, & Rodriguez, 2000). Maternal rejection that includes shaming, induction of guilt, criticism of the child, and love withdrawal are associated with child behavioral problems (Scanlon & Epkins, 2015). In addition, maternal own exposure to multiple traumatic events may exacerbate her psychological distress including higher level of depressive symptoms (Johnson et al., 2009) and may be associated with child’s behavioral problems even more than his own exposure to such events (Lieberman & Van Horn, 2009, 2013). Thus, maternal depression may mediate, at least partially, the associations between her own and her child exposure to multiple traumatic events, her perceived social support and child’s behavior problems. Maternal depression may also be associated with child behavioral problems either directly or through the mediation of maternal rejection.

Contextual Confounders in the Associations Between Child Exposure to Multiple Traumas and Child Behavioral Problems

The associations between child’s exposure to multiple traumas and behavioral problems may be confounded by several factors, including child’s gender and ethnicity. Regarding gender differences, research has indicated that girls have higher levels of internalizing behavior problems than boys (Fanti & Henrich, 2010). However, these gender differences in internalizing behavior problems usually begin to show up only during late childhood/early adolescence (Sterba, Prinstein, & Cox, 2007). Gender differences in externalizing behavior problems are inconclusive. Boys have been reported to show more externalizing problems than girls (Sterba et al., 2007), while no gender differences were found in other studies (Silver, Measelle, Armstrong, & Essex, 2010). We will control for gender effects in the multivariate analyses.

Ethnicity

Within the borders of Israel, the Israeli Arabs are the largest minority group, comprising 20.7% of the total population (Central Bureau of Statistics, July, 2015; publication no. 2015/7). Arabs and Jews in Israel have different sociodemographic backgrounds, cultures, religions, and sources of support (Somer, Maguen, Or-Chen, & Litz, 2009). Arab Israelis’ socioeconomic status is lower than that of Jewish Israelis, and they suffer more discrimination than their Jewish counterparts (Hall et al., 2010). Moreover, they may experience a conflict between their Israeli citizenship and their Arab-Palestinian identity, which may affect the way they perceive acts of political violence against Israel (Shamir & Shikaki, 2002). Consequently, their psychological distress resulting from exposure to acts of political violence is frequently greater than that of Israeli Jews (Slone & Shoshani, 2014). Like previous studies conducted in Israel in the context of political violence (Hall et al., 2010; Schiff et al., 2012), we will control for ethnicity in the multivariate analyses.

In summary, this study examined the conceptual model presented in Figure 1 among a representative sample of 904 Israeli Arab and Israeli Jewish mothers of young children (2-6 years). Hypotheses were as follows:

Hypothesis 1 (H1): Child’s exposure to multiple traumatic events will be associated directly with child behavioral problems. Higher levels of exposure will be associated with higher levels of behavioral problems.

Hypothesis 2 (H2): Maternal rejection, depressive symptoms, and (lower level of) perceived social support will be associated with higher level of child’s behavioral problems.

Hypothesis 3 (H3): Maternal rejection will mediate the associations between child’s exposure to multiple traumatic events and behavioral problems. Child’s exposure will be associated with lower level of maternal rejection which in turn will be associated with lower level of behavioral problems.

Hypothesis 4 (H4): Maternal depressive symptoms and perceived social support will mediate the associations between child’s exposure to multiple traumatic events and behavioral problems. Child’s exposure will be associated with greater maternal depressive symptoms and with lower level of perceived support, which in turn will be associated with higher level of behavioral problems.

Hypothesis 5 (H5): Maternal depressive symptoms will mediate the associations between her own exposure to multiple traumatic events, perceived social support and child behavioral problems.

Figure 1.

Research model.

Method

Participants and Procedure

We recruited a representative sample of 904 Israeli mothers and their 2- to 6-year-old children who lived in the sampled household (the “study child”). Maternal mean age was 33.97 (SD = 5.78) Most of the mothers were married (91.0%). More than one third (35.7%) of the mothers had two children and 53.3% of the mothers had at least three children. Child’s mean age was 3.90 (SD = 1.21). Of the total number of children, 52.9% were males.

We used a cross-sectional design. Sample recruitment and structured face-to-face interviews of the mothers in Hebrew (for the Jewish mothers) or Arabic (for the Arab mothers) were conducted by experienced interviewers who were trained and supervised by the institute in charge on the data collection. The data were collected between July and November 2011. The study was approved by the authors’ university ethics committee.

Measures

Demographic information

This study included child’s gender and mother and child’s age and ethnicity.

Child’s exposure to multiple traumatic events

Mother’s report on child’s exposure to political violence was based on Pat-Horenczyk et al. scale (Pat-Horenczyk, Schiff, & Doppelt, 2006). The six items describe various forms of exposure to political violence, which include terrorist attacks, missile attacks, and war. Participants were asked whether the child was exposed (not at all, once, or more than once) to those forms of exposure. Cronbach’s alpha was .61, low as expected, as there are no expectations that children will be exposed to all types of acts of political violence. Tukey’s test for nonadditivity was significant (p < .001) suggesting there is a statistically significant interaction between the items of this scale. No corrections were made.

Mothers’ reports on their children’s exposure to other traumatic events (unrelated to political violence) were scored by the 12-item Traumatic Events Screening Inventory (TESI; Ghosh-Ippen et al., 2002). They include a serious accident at home, or outside home, and being physically hurt by hitting, pushing, and so on. The cumulative exposure to traumatic events was calculated counting the number of all traumatic events the child had experienced (political and other events).

Child behavioral problems

The mothers completed the Child Behavior Checklist (CBCL) for preschool (1.5-5) children (Achenbach & Rescorla, 2000). This measure includes 99 items that are rated on a scale of 0 to 2 (0 = not at all, 1 = sometimes, 2 = yes), yielding seven subscales and a total problem scale. Calculation of the scale from the items was done using the ASEBA RTS software (ASEBA). For this study, we used the total problems scale. Cronbach’s alpha was .93.

Maternal acceptance–rejection

The short version of the Parental Acceptance–Rejection Questionnaire (PARQ; Rohner & Khaleque, 2005) was completed by the mothers to assess maternal rejection of the study child. The scale consists of 24 items, constructed especially for parental report. Each item has a 4-point scale (1 = almost never true; 4 = almost always true). The responses are summed to a total score, which can range from 24 to 96. Higher scores indicate greater rejection. Cronbach’s alpha was .76.

Maternal exposure to multiple traumatic events

Mothers reported on their exposure to political violence based on Pat-Horenczyk et al.’s scale (Pat-Horenczyk et al., 2006). The eight items describe various forms of exposure to political violence, which include terrorist attacks, missile attacks, and war on a yes/no scale (Cronbach’s α = .72). Mothers also reported on other types of trauma (e.g., car accidents and domestic violence (Cronbach’s α = .51). The levels of reliability are similar to previous studies in the same context (Schiff & Pat-Horenczyk, 2014; Schiff et al., 2012) and are reasonable given that in community samples most adult individuals will report experiencing one traumatic event (Greenberg, Brooks, & Dunn, 2015). Thus, it is not expected that the mother would have been exposed to a wide variety of traumatic events. The cumulative exposure to traumatic events was calculated counting the number of all traumatic events (political and other events) the mother had experienced. Tukey’s test for nonadditivity was significant (p < .001) suggesting there is a statistically significant interaction between the items of this scale. No corrections were made.

Maternal depressive symptoms

Mothers’ self-report of depressive symptoms was assessed by the Center for Epidemiological Studies Depression Scale (CES-D; Radloff, 1977). The CES-D is a 20-item self-report scale that measures symptoms of depression in nonclinical populations on a 4-point scale (0-3). The responses are summed to a total score, which can range from 0 to 60 forming a scale of depressive symptoms. Cronbach’s alpha in the present study was .91.

Maternal perceived social support

Mothers completed the Medical Outcomes Study (MOS) Social Support Survey (Sherbourne & Stewart, 1991). The scale includes 20 items that pertain to several aspects of support and also yields an overall social support index. Each item is reported on a 5-point scale (1 = none of the time; 5 = all of the time). Cronbach’s alpha for the total scale was .96. We used the total scale by summing all 20 items from the scale which can range from 20 to 100.

Data Analyses

The research hypotheses and model were examined using path analysis. We tested the indirect effects using bootstrapping confidence intervals. The advantage of this approach is discussed by Hayes (2009). Analyses were conducted based on EQS 6.1 software (Bentler, 2006). The specific way in which bootstrapped indirect effects is calculated in EQS is explained by Shrout and Bolger (Shrout & Bolger, 2002).

Results

Distribution of Mothers and Children Traumatic Experience and Psychological Distress

Mothers’ exposure to acts of political violence was high; 37.2% had seen, heard, or felt a shock or tremor during a rocket or terrorist attack; 37.8% lived in rocket attacks or war zones; 11.4% have moved to another residential area because of the war or threat of rockets, for at least a week; 10.5% of the mothers report that the home or other property such as vehicles, shop, and so forth of someone they knew was hit by a falling rocket or other politically violent incident. Six percent (6.1%) reported spending more than 24 consecutive hours in a shelter or safe room, and 5.6% reported that a very close person to them was injured or killed in rocket or terrorist attacks.

The rate of child’s exposure to acts of political violence is also high, considering the extreme youth of the children. Nearly seven percent (6.9%) reported that their child had seen, heard, or felt a shock or tremor during a rocket or terrorist attack, and 5.3% have moved to another residential area because of the war or threat of rockets, for at least a week. As for child’s exposure to trauma other than political violence, more than 16% (16.2%) of the children had been physically hurt by being hit, pushed, choked, bitten, shaken, burned, or otherwise at some point in their life; 11.6% of the children had gone through a serious, life-threatening medical procedure, or had been hospitalized overnight.

Behavioral problems and psychological distress

Almost 4% (3.7%) of the boys and 3.4% of the girls had total behavioral problems at borderline or clinical range (t > 62 for boys; t > 60 for girls); 22.1% of the mothers report depressive symptoms at the clinical level (scores above 16). Means and standard deviations of all study variables are presented on Table 1 along with the correlation matrix.

Table 1.

M (SD) and Pearson Correlations Matrix of All Study Variables.

	M (SD)	1	2	3	4	5	6	7
1. Maternal depressive symptoms	10.56 (10.12)
2. Maternal rejection	33.90 (8.37)	.302***
3. Mother’s social support	73.33 (15.43)	−.479***	−.337***
4. Child’s exposure	0.74 (1.31)	.172***	−.052	−.140***
5. Mother’s exposure	1.73 (2.03)	.039	−.029	−.060	.252***
6. Child’s gender (female)	NA	−.004	.054	.039	−.093**	.007
7. Child’s behavior problems	44.66 (9.59)	.223***	.285***	−.332***	.124***	.097**	−.090**
8. Ethnicity (Jewish)	NA	.003	−.426***	.324***	.207***	−.105**	−.013	−.314***

Note. NA = not applicable.

p<.01, ***p < .001.

Associations Between Study Variables

Table 2 presents the correlation matrix of all study variables. It shows that child’s exposure to multiple traumatic events was mildly associated with child behavioral problems. Maternal rejection, maternal depressive symptoms as well as maternal perceived low social support were all associated with child behavioral problems. Jewish ethnicity was associated with less maternal rejection, greater perceived support, and lower level of child behavior problems compared with Arab ethnicity.

Table 2.

Direct Effects (N = 852).

Dependent Variable	Predictor	B	β	SE	Z	Significance	R ²
Maternal depressive symptoms							.26
	Mother’s social support	−.34	−.52	.02	−16.29	p < .001
	Child’s exposure	.48	.06	.24	1.97	p = .057
	Mother’s exposure	.04	.01	.15	.27	p = .385
	Ethnicity (Jewish)	3.92	.16	.81	4.86	p < .001
Maternal rejection							.29
	Maternal depressive symptoms	.21	.27	.03	7.93	p < .001
	Mother’s social support	−.04	−.08	.02	−2.29	p = .029
	Child’s exposure	−.02	.00	.19	−.12	p = .396
	Mother’s exposure	−.33	−.09	.12	−2.83	p = .007
	Ethnicity (Jewish)	−7.90	−.41	.63	−12.47	p < .001
Mother’s perceived social support							.15
	Child’s exposure	−2.63	−.23	.39	−6.75	p < .001
	Mother’s exposure	.27	.04	.25	1.09	p = .220
	Ethnicity (Jewish)	14.13	.38	1.23	11.45	p < .001
Child’s exposure							.04
	Ethnicity (Jewish)	.67	.21	.11	6.17	p < .001
Mother’s exposure							.01
	Ethnicity (Jewish)	−.52	−.11	.17	−3.08	p = .003
Child’s behavior problems							.21
	Maternal depressive symptoms	.09	.10	.04	2.60	p = .014
	Maternal rejection	.14	.11	.04	3.16	p = .003
	Mother’s social support	−.09	−.15	.02	−3.81	p < .001
	Child’s exposure	.98	.14	.23	4.24	p < .001
	Child’s gender (Female)	−1.55	−.08	.59	−2.63	p = .013
	Ethnicity (Jewish)	−5.79	−.25	.86	−6.73	p < .001

Examining the Research Model and Hypotheses

The model showed a very good fit to the data. Fit indices appear at the bottom of Figure 2. The statistically significant paths are presented in Figure 2. Table 2 presents all direct effects. It shows that child’s exposure to multiple traumatic events was directly associated with behavioral problems, supporting H1. Maternal rejection, depressive symptoms, and perceived social support were associated with child behavioral problems supporting H2. Maternal depressive symptoms were associated with greater maternal rejection of her child. As for the correlations between the control variables in the model, mothers’ exposure to multiple traumatic events was associated with child’s exposure to multiple traumatic events (r = .28, Z = 7.93, p < .001). Child’s gender (female) was negatively associated with child’s exposure to multiple traumatic events (r = −.09, Z = 2.84, p = .007).

Figure 2.

Path analysis.

Indirect paths

Bootstrapping confidence intervals analyses show that only three indirect effects were significant. Maternal rejection mediated the associations between maternal depressive symptoms and child behavioral problems (bootstrapping low and high Confidence Interval 0.01, 0.06). Maternal perceived social support mediated the associations between child’s exposure to multiple traumatic events and behavioral problems (bootstrapping low and high Confidence Interval 0.01, 0.06); greater exposure was associated with less support, which in turn was associated with a higher level of child behavioral problems, supporting part of H4. Finally, maternal depressive symptoms mediated the associations between maternal perceived social support and child behavioral problems; a lower level of support was associated with higher levels of depressive symptoms, which in turn was associated with higher levels of child behavioral problems (bootstrapping low and high confidence interval [−0.09, −0.01]), supporting part of H5. Contrary to our hypotheses (H3 and part of H4), neither maternal rejection nor maternal depressive symptoms mediated the associations between child’s exposure to multiple traumatic events and behavioral problems.

Discussion

The aim of the present study was to examine whether maternal depression, mother–child relationships, and maternal perceived social support mediate the associations between child’s exposure to multiple traumatic events and behavioral problems. First, we found a direct path between child’s exposure to traumatic events and his or her behavioral problems. Thus, similar to previous research, our study demonstrates the heavy toll of exposure to political violence and other traumatic events as early as in early childhood (Chemtob et al., 2010; Feldman & Vengrober, 2011). Second, maternal rejection mediated the associations between maternal depression and child behavioral problems, suggesting that mother–child relationships and mother’s psychological distress in the aftermath of traumatic events are important mitigating factors in child distress (Scheeringa & Zeanah, 2001). Studies examining the mediation role of maternal rejection in the associations between maternal depression and child behavioral problems in early childhood are scarce. More commonly, the mediation role of maternal rejection in the associations between maternal depression and child behavioral problems have focused on adolescents (Brenning, Soenens, Braet, & Bal, 2012). Thus, the study findings serve as an additional empirical support for PART theory. Unlike our hypothesis, child’s exposure to multiple traumas was not directly associated with maternal rejection, and maternal rejection did not mediated the associations between exposure and child’s behavioral problems. The lack of the direct associations between exposure and maternal rejection and the lack of mediation effect of maternal rejection may be explained by the different context this study was conducted compared with a previous one. Specifically, one study that we found revealed that exposure to stressful events is associated with maternal rejection (Barbot, Crossman, Hunter, Grigorenko, & Luthar, 2014) focused on stressful events related to parenthood. In the present study, the stressful events were mostly unrelated to the maternal role. Hence, while maternal or child stress related to parenthood may have a direct impact on maternal acceptance–rejection, the associations between traumatic events experienced by the child and maternal rejection of her child are not direct and are passed through maternal stress reactions such as depressive symptoms. Thus, it is the parental stress reactions, demonstrated in the present study through mothers’ depressive symptoms that are linked indirectly with child’s behavioral problems rather than the mere exposure to multiple traumatic events (Samuelson, Wilson, Padrón, Lee, & Gavron, 2017).

Lower levels of maternal perceived social support were associated with greater behavioral problems among children. Social support had also a mediating role between child’s exposure to multiple traumas and behavioral problems. These findings further confirm the important role of social support in alleviating the negative effects of exposure to multiple traumatic events, including disasters such as hurricanes (Lai, Kelley, Harrison, Thompson, & Self-Brown, 2015), and political violence (Tol et al., 2010). Our results are consistent with a meta-analysis on the risk factors of PTS among children and adolescents, which found that low levels of social support had a large and consistent effect size on children’s and adolescents’ PTS and diagnosis (Trickey, Siddaway, Meiser-Stedman, Serpell, & Field, 2012).

Based on the stress-buffering model (Cohen & Wills, 1985; Rueger, Malecki, Pyun, Aycock, & Coyle, 2016), previous studies emphasized the moderation role of social support in the context of political violence and other traumatic events (Leshem, Haj-Yahia, & Guterman, 2016; Shahar & Henrich, 2016; Vorhies Klodnick, Guterman, Haj, Yahia, & Leshem, 2014). Our study shows that social support can also serve as a mediator, as suggested by the social stress framework (Pearlin et al., 1981), not only in the context of economic pressure (Lee et al., 2009), or childhood trauma (Ammerman et al., 2013) but also in a more general context of exposure to multiple traumatic events including acts of political violence. Given the importance of social support in the context of political violence and other traumatic events, results revealing that exposure to traumatic events was associated with lower levels of maternal perceived social support are discouraging. It seems that in time of great need for support, mothers feel less supported. The lack of support may be related to the phenomenon of shared trauma, especially with regard to political violence, where all support sources may be equally affected by the same traumatic events (Dekel, 2010; Dekel, Nuttman-Shwartz, & Lavi, 2016; Koren et al., 2009) or to discrepancies between maternal perceived and actual support (Maercker & Horn, 2013).

Results show that compared with Jewish mothers, Arab mothers report more rejection toward their children. This could be explained by the harsher discipline methods often reported by Arab mothers that are not necessarily associated with child’s greater mental health problems in the collectivist culture which characterizes Israeli Arab society (Dwairy et al., 2010). Arab mothers also report less perceived social support than Jewish mothers, which might reflect their minority status and disadvantaged conditions in general (Hobfoll et al., 2008; Schiff et al., 2012). Given the importance of social support in mediating the relationships between children’s exposure to multiple traumatic events and behavioral problems found in this study, Israeli Arab children can be considered as a vulnerable group in the context of multiple traumatic events.

Limitations

This study has several limitations. First, it relies on maternal reports on her and her child’s experiences and behaviors and does not include observational methods on mother–child interaction or measures reported by children. Maternal acceptance–rejection of her child for example, might be experienced differently by her child (Rohner, Khaleque, Riaz, et al., 2005), and therefore could have formed different results. Second, paternal rejection was not investigated, and recent work in this area has pointed to its impact on early childhood development (Papadaki & Giovazolias, 2015). Third, items in the measurements of child and maternal exposure to multiple traumatic events were not additive and no corrections for the statistically significant interactions were made.

Fourth, the present study is cross-sectional in design. While maternal rejection may lead to child behavioral problems, child behavioral problems may well lead to maternal rejection and to higher levels of maternal depression. Thus, the relationships between maternal rejection, maternal distress, and child behavioral problems might be bidirectional (Barbot et al., 2014). Promising lines of research, then, would include observational methods to assess mother–child interaction in the context of exposure to multiple/continuous traumatic events and an investigation of the impact of paternal rejection on child distress. Moreover, a longitudinal design would further address the questions of mediation that were examined preliminarily in the current study, as well as the open issue of the directionality of associations between maternal rejection and mother and child distress.

Conclusion

Maternal psychological distress and social support are key factors in developing resiliency among young children exposed to multiple traumatic events. As maternal perceived social support is associated with lower levels of maternal depression, it is essential to discuss those associations with mothers to young children who are faced with political violence and other traumatic events, as well as assist mothers to approach and gain social support. In addition, professionals should work with the community on how to provide support in the context of traumatic events. This study revealed high diversity between Arab and Jewish mothers in their reported maternal acceptance–rejection and the extent of received social support. While the differences in level of maternal acceptance–rejection may reflect cultural different point of views about the best disciplinary methods for children, the lower level of perceived support is a risk factor for Arab children psychosocial adjustment as early as early childhood. Strengthening social and community support in the context of multiple trauma among minorities such as Israeli Arab mothers to young children is therefore essential and should get high priority by governmental authorities in Israel.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Author Biography

Miriam Schiff, PhD, is associate professor and Zena Harman Chair in Social Work at Paul Baerwald School of Social Work and Social Welfare, Hebrew University, Jerusalem, Israel. She is also the chair of the Teaching, Policy, and Procedures Committee at her university. Her research interests are in (a) the moderators and mediator factors explaining the associations between man-made trauma and substance use as well as mental health in general among children and adolescents and (b) translational research from academic research to the field of social work and from practice wisdom to theories and research in the areas of social work education.

Ruth Pat-Horenczyk, PhD, a clinical psychologist, is an associate professor at the Paul Baerwald School of Social Work and Social Welfare at the Hebrew University, Jerusalem. She also is the director of the child and adolescent clinical services at Herzog Hospital’s Israel Center for the Treatment of Psychotrauma, Jerusalem, Israel. Her research topics focus on risk and protective factors for childhood posttraumatic stress disorder (PTSD), preparedness and resilience, relational trauma, and posttraumatic growth. In the last few years, she has been conducting a nationwide screening project aimed at identification of posttraumatic distress among preschool and school children and developing evidence-based interventions and treatments.

Yuval Ziv has an MA in psychology and organizational sociology at Hebrew University, where he worked in the Educational Research Lab. He is the data analyst at the Herzog Hospital’s Israel Center for the Treatment of Psychotrauma, Jerusalem, Israel, as well as a consultant to a variety of local NGOs and individual social science researchers on multilevel multivariate statistical analyses.

Danny Brom, PhD, certified clinical psychologist, is an adjunct associate professor at the Paul Baerwald School of Social Work and Social Welfare, Hebrew University, Jerusalem, Israel. He is the founding director of the Israel Center for the Treatment of Psychotrauma of Herzog Hospital in Jerusalem, and is also the initiator and former chairman of the Israel Trauma Coalition. His focus is on the fields of prevention acute stress reactions, and treating people affected by mass trauma, community resilience, health and mental health care to increase the capacity of Israeli society to cope with the ongoing existential threat.

References

Achenbach

T. M.

Rescorla

(2000). Manual for the ASEBA preschool forms & profiles. Burlington: University of Vermont Press.

Alisic

Jongmans

M. J.

van Wesel

Kleber

R. J.

(2011). Building child trauma theory from longitudinal studies: A meta-analysis. Clinical Psychology Review, 31, 736-747. doi:10.1016/j.cpr.2011.03.001

Al-Sabah

Legerski

J. P.

Layne

C. M.

Isakson

Katalinski

Pasalic

. . . Pynoos

R. S.

(2015). Adolescent adjustment, caregiver-adolescent relationships, and outlook towards the future in the long-term aftermath of the Bosnian war. Journal of Child & Adolescent Trauma, 8, 45-60. doi:10.1007/s40653-014-0035-7

Ammerman

R. T.

Shenk

C. E.

Teeters

A. R.

Noll

J. G.

Putnam

F. W.

van Ginkel

J. B.

(2013). Multiple mediation of trauma and parenting stress in mothers in home visiting. Infant Mental Health Journal, 34, 234-241. doi:10.1002/imhj.21383

Barbot

Crossman

Hunter

S. R.

Grigorenko

E. L.

Luthar

S. S.

(2014). Reciprocal influences between maternal parenting and child adjustment in a high-risk population: A 5-year cross-lagged analysis of bidirectional effects. American Journal of Orthopsychiatry, 84, 567-580. doi:10.1037/ort0000012

Bentler

P. M.

(2006). EQS 6 structural equations program manual. Encino, CA: Multivariate Software.

Brenning

Soenens

Braet

Bal

(2012). The role of parenting and mother-adolescent attachment in the intergenerational similarity of internalizing symptoms. Journal of Youth and Adolescence, 41, 802-816. doi:10.1007/s10964-011-9740-9

Chemtob

C. M.

Nomura

Rajendran

Yehuda

Schwartz

Abramovitz

(2010). Impact of maternal posttraumatic stress disorder and depression following exposure to the September 11 attacks on preschool children’s behavior. Child Development, 81, 1129-1141. doi:10.1111/j.1467-8624.2010.01458.x

Cho

S.-M.

Kim

E. J.

Lim

K.-Y.

Lee

J.-W.

Shin

Y.-M.

(2015). The effects of maternal depression on child mental health problems based on gender of the child. Community Mental Health Journal, 51, 354-358. doi:10.1007/s10597-014-9824-6

10.

Choe

D. E.

Olson

S. L.

Sameroff

A. J.

(2013). Effects of early maternal distress and parenting on the development of children’s self-regulation and externalizing behavior. Development and Psychopathology, 25, 437-453. doi:10.1017/S0954579412001162

11.

Cohen

Wills

T. A.

(1985). Stress, social support, and the buffering hypothesis. Psychological Bulletin, 98, 310-357.

12.

Conger

K. J.

Reuter

M. A.

Conger

R. D.

(2000). The role of economic pressure in the lives of parents and their adolescents: The family stress model. In Crockett

L. J.

Silbereisen

R. J.

(Eds.), Negotiating adolescence in times of social change (pp. 201-223). Cambridge, UK: Cambridge University Press.

13.

Dekel

(2010). Mental health practitioners’ experiences during the shared trauma of the forced relocation from Gush Katif. Clinical Social Work Journal, 38, 388-396. doi:10.1007/s10615-009-0258-5

14.

Dekel

Nuttman-Shwartz

Lavi

(2016). Shared traumatic reality and boundary theory: How mental health professionals cope with the home/work conflict during continuous security threats. Journal of Couple & Relationship Therapy, 15, 121-134. doi:10.1080/15332691.2015.1068251

15.

Dimitry

(2012). A systematic review on the mental health of children and adolescents in areas of armed conflict in the Middle East. Child: Care, Health and Development, 38, 153-161. doi:10.1111/j.1365-2214.2011.01246.x

16.

Dubow

E. F.

Huesmann

L. R.

Boxer

(2009). A social-cognitive-ecological framework for understanding the impact of exposure to persistent ethnic-political violence on children’s psychosocial adjustment. Clinical Child and Family Psychology Review, 12, 113-126. doi:10.1007/s10567-009-0050-7

17.

Dubow

E. F.

Huesmann

L. R.

Boxer

Landau

Dvir

Shikaki

Ginges

(2012). Exposure to political conflict and violence and posttraumatic stress in Middle East youth: protective factors. Journal of Clinical Child & Adolescent Psychology, 41, 402-416. doi:10.1080/15374416.2012.684274

18.

Dwairy

Achoui

Filus

Nia

P. R.

Martina Casullo

Vohra

(2010). Parenting, mental health and culture: A fifth cross-cultural research on parenting and psychological adjustment of children. Journal of Child and Family Studies, 19, 36-41. doi:10.1007/s10826-009-9340-4

19.

Fanti

K. A.

Henrich

C. C.

(2010). Trajectories of pure and co-occurring internalizing and externalizing problems from age 2 to age 12: Findings from the national institute of child health and human development study of early child care. Developmental Psychology, 46, 1159-1175. doi:10.1037/a0020659

20.

Feldman

Vengrober

(2011). Posttraumatic stress disorder in infants and young children exposed to war-related trauma. Journal of the American Academy of Child & Adolescent Psychiatry, 50, 645-658. doi:10.1016/j.jaac.2011.03.001

21.

Ghosh-Ippen

Ford

Racusin

Acker

Bosquet

Rogers

. . . Edwards

(2002). Trauma Events Screening Inventory-parent report revised. San Francisco, CA: The Child Trauma Research Project of the Early Trauma Network and The National Center for PTSD Dartmouth Child Trauma Research Group.

22.

Greenberg

Brooks

Dunn

(2015). Latest developments in post-traumatic stress disorder: Diagnosis and treatment. British Medical Bulletin, 114, 147-155. doi:10.1093/bmb/ldv014

23.

Hall

B. J.

Hobfoll

S. E.

Canetti

Johnson

R. J.

Palmieri

P. A.

Galea

(2010). Exploring the association between posttraumatic growth and PTSD: A national study of Jews and Arabs following the 2006 Israeli-Hezbollah War. Journal of Nervous and Mental Disease, 198, 180-186. doi:10.1097/NMD.0b013e3181d1411b

24.

Hayes

A. F.

(2009). Beyond Baron and Kenny: Statistical mediation analysis in the new millennium. Communication Monographs, 76, 408-420. doi:10.1080/03637750903310360

25.

Hobfoll

S. E.

Canetti-Nisim

Johnson

R. J.

Palmieri

P. A.

Varley

J. D.

Galea

(2008). The association of exposure, risk, and resiliency factors with PTSD among Jews and Arabs exposed to repeated acts of terrorism in Israel. Journal of Traumatic Stress, 21, 9-21. doi:10.1002/jts.20307

26.

Johnson

R. J.

Canetti

Palmieri

P. A.

Galea

Varley

Hobfoll

S. E.

(2009). A prospective study of risk and resilience factors associated with posttraumatic stress symptoms and depression symptoms among Jews and Arabs exposed to repeated acts of terrorism in Israel. Psychological Trauma-Theory Research Practice and Policy, 1, 291-311. doi:10.1037/a0017586

27.

Koren

Caspi

Leiba

Bloch

Vexler

Klein

(2009). Acute stress reactions among medical and non-medical personnel in a general hospital under missile attacks. Depression and Anxiety, 26, 123-128. doi:10.1002/da.20509

28.

Lai

B. S.

Kelley

M. L.

Harrison

K. M.

Thompson

J. E.

Self-Brown

(2015). Posttraumatic stress, anxiety, and depression symptoms among children after Hurricane Katrina: A latent profile analysis. Journal of Child and Family Studies, 24, 1262-1270. doi:10.1007/s10826-014-9934-3

29.

Laor

Wolmer

Spirman

Wiener

(2003). Facing war, terrorism, and disaster: Toward a child-oriented comprehensive emergency care system. Child and Adolescent Psychiatric Clinics of North America, 12, 343-361. doi:10.1016/S1056-4993(02)00106-2

30.

Lee

C.-Y. S.

Anderson

J. R.

Horowitz

J. L.

August

G. J

. (2009). Family income and parenting: The role of parental depression and social support. Family Relations: An Interdisciplinary Journal of Applied Family Studies, 58, 417-430. doi:10.1111/j.1741-3729.2009.00563.x

31.

Leshem

Haj-Yahia

M. M.

Guterman

N. B.

(2016). The role of family and teacher support in post-traumatic stress symptoms among Palestinian adolescents exposed to community violence. Journal of Child and Family Studies, 25, 488-502. doi:10.1007/s10826-015-0226-3

32.

Lieberman

A. F.

Van Horn

(2009). Giving voice to the unsayable: Repairing the effects of trauma in infancy and early childhood. Child and Adolescent Psychiatric Clinics of North America, 18, 707-720. doi:10.1016/j.chc.2009.02.007

33.

Lieberman

A. F.

Van Horn

(2013). Infants and young children in military families: A conceptual model for intervention. Clinical Child and Family Psychology Review, 16, 282-293. doi:10.1007/s10567-013-0140-4

34.

Lovejoy

M. C.

Graczyk

P. A.

O’Hare

Neuman

(2000). Maternal depression and parenting behavior: A meta-analytic review. Clinical Psychology Review, 20, 561-592. doi:10.1016/S0272-7358(98)00100-7

35.

Maercker

Horn

A. B.

(2013). A socio-interpersonal perspective on PTSD: The case for environments and interpersonal processes. Clinical Psychology & Psychotherapy, 20, 465-481. doi:10.1002/cpp.1805

36.

Min

M. O.

Singer

L. T.

Minnes

Kim

Short

(2013). Mediating links between maternal childhood trauma and preadolescent behavioral adjustment. Journal of Interpersonal Violence, 28, 831-851. doi:10.1177/0886260512455868

37.

Papadaki

Giovazolias

(2015). The protective role of father acceptance in the relationship between maternal rejection and bullying: A moderated-mediation model. Journal of Child and Family Studies, 24, 330-340. doi:10.1007/s10826-013-9839-6

38.

Pat-Horenczyk

Schiff

Doppelt

(2006). Maintaining routine despite ongoing exposure to terrorism: A healthy strategy for adolescents? Journal of Adolescent Health, 39, 199-205. doi:10.1016/j.jadohealth.2005.11.021

39.

Pat-Horenczyk

Ziv

Asulin-Peretz

Achituv

Cohen

Brom

(2013). Relational trauma in times of political violence: Continuous versus past traumatic stress. Peace and Conflict: Journal of Peace Psychology, 19, 125-137. doi:10.1037/a0032488

40.

Pearlin

Lieberman

M. A.

Menaghan

E. G.

Mullan

J. T.

(1981). The stress process. Journal of Health and Social Behavior, 22, 337-356.

41.

Radloff

S. L.

(1977). The CES-D scale: A self-report scale for research in the general population. Applied Psychological Measurement, 1, 385-401.

42.

Rohner

R. P.

Britner

P. A.

(2002). Worldwide mental health correlates of parental acceptance-rejection: Review of cross-cultural and intracultural evidence. Cross-Cultural Research, 36, 16-47. doi:10.1177/106939710203600102

43.

Rohner

R. P.

Khaleque

(2002). Parental acceptance-rejection and life-span development: A universalist perspective. Online Readings in Psychology and Culture, 6(1). doi: 10.9707/2307-0919.1055

44.

Rohner

R. P.

Khaleque

(2005). Handbook for the study of parental acceptance and rejection (4th ed.). Storrs, CT: Rohner Research Publications.

45.

Rohner

R. P.

Khaleque

Cournoyer

D. E.

(2005). Parental acceptance-rejection: Theory, methods, cross-cultural evidence, and implications. Ethos, 33, 299-334. doi:10.1525/eth.2005.33.3.299

46.

Rohner

R. P.

Khaleque

Riaz

M. N.

Khan

Sadeque

Laukkala

(2005). Agreement between children’s and mothers’ perceptions of maternal acceptance and rejection: A comparative study in Finland and Pakistan. Ethos, 33, 367-377. doi:10.1525/eth.2005.33.3.367

47.

Rueger

S. Y.

Malecki

C. K.

Pyun

Aycock

Coyle

(2016). A meta-analytic review of the association between perceived social support and depression in childhood and adolescence. Psychological Bulletin, 142, 1017-1067. doi:10.1037/bul0000058

48.

Samuelson

K. W.

Wilson

C. K.

Padrón

Lee

Gavron

(2017). Maternal PTSD and children’s adjustment: Parenting stress and emotional availability as proposed mediators. Journal of Clinical Psychology, 73, 693-706. doi:10.1002/jclp.22369

49.

Scanlon

N. M.

Epkins

C. C.

(2015). Aspects of mothers’ parenting: Independent and specific relations to children’s depression, anxiety, and social anxiety symptoms. Journal of Child and Family Studies, 24, 249-263. doi:10.1007/s10826-013-9831-1

50.

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

51.

Schiff

Pat-Horenczyk

(2014). Perceived need for psychosocial services in the context of political violence: Psychological distress among Israeli mothers with young children. Clinical Social Work Journal, 42, 346-356. doi:10.1007/s10615-013-0471-0

52.

Schiff

Pat-Horenczyk

Benbenishty

Brom

Baum

Astor

R. A.

(2012). High school students’ posttraumatic symptoms, substance abuse and involvement in violence in the aftermath of war. Social Science & Medicine, 75, 1321-1328. doi:10.1016/j.socscimed.2012.05.010

53.

Sethi

Mischel

Aber

J. L.

Shoda

Rodriguez

M. L.

(2000). The role of strategic attention deployment in development of self-regulation: Predicting preschoolers’ delay of gratification from mother-toddler interactions. Developmental Psychology, 36, 767-777. doi:10.1037//0012-1649.36.6.767

54.

Shahar

Henrich

C. C.

(2016). Perceived family social support buffers against the effects of exposure to rocket attacks on adolescent depression, aggression, and severe violence. Journal of Family Psychology, 30, 163-168. doi:10.1037/fam0000179

55.

Shamir

Shikaki

(2002). Self-serving perceptions of terrorism among Israelis and Palestinians. Political Psychology, 23, 537-557.

56.

Sherbourne

C. D.

Stewart

A. L.

(1991). The MOS social support survey. Social Science & Medicine, 32, 705-714. doi:10.1016/0277-9536(91)90150-b

57.

Shrout

P. E.

Bolger

(2002). Mediation in experimental and nonexperimental studies: New procedures and recommendations. Psychological Methods, 7, 422-445. doi:10.1037//1082-989X.7.4.422

58.

Silver

R. B.

Measelle

J. R.

Armstrong

J. M.

Essex

M. J.

(2010). The impact of parents, child care providers, teachers, and peers on early externalizing trajectories. Journal of School Psychology, 48, 555-583. doi:10.1016/j.jsp.2010.08.003

59.

Slone

Shechner

Farah

O. K.

(2012). Parenting style as a moderator of effects of political violence: Cross-cultural comparison of Israeli Jewish and Arab children. International Journal of Behavioral Development, 36, 62-70. doi:10.1177/0165025411406856

60.

Slone

Shoshani

(2014). Psychiatric effects of protracted conflict and political life events exposure among adolescents in Israel: 1998-2011. Journal of Traumatic Stress, 27, 353-360. doi:10.1002/jts.21918

61.

Somer

Maguen

Or-Chen

Litz

B. T.

(2009). Managing terror: Differences between Jews and Arabs in Israel. International Journal of Psychology, 44, 138-146. doi:10.1080/00207590701609076

62.

Sterba

S. K.

Prinstein

M. J.

Cox

M. J.

(2007). Trajectories of internalizing problems across childhood: Heterogeneity, external validity, and gender differences. Development and Psychopathology, 19, 345-366. doi:10.1017/s0954579407070174

63.

Tanninen

H. M.

Haggman-Laitila

Pietila

A. M.

(2009). Resource-enhancing psychosocial support in family situations: Needs and benefits from family members’ own perspectives. Journal of Advanced Nursing, 65, 2150-2160. doi:10.1111/j.1365-2648.2009.05080.x

64.

Tol

W. A.

Komproe

I. H.

Jordans

M. J. D.

Gross

A. L.

Susanty

Macy

R. D.

de Jong

(2010). Mediators and moderators of a psychosocial intervention for children affected by political violence. Journal of Consulting and Clinical Psychology, 78, 818-828. doi:10.1037/a0021348

65.

Trickey

Siddaway

A. P.

Meiser-Stedman

Serpell

Field

A. P.

(2012). A meta-analysis of risk factors for post-traumatic stress disorder in children and adolescents. Clinical Psychology Review, 32, 122-138. doi:10.1016/j.cpr.2011.12.001

66.

Vorhies Klodnick

Guterman

N. B.

Haj-Yahia

Leshem

. (2014). Exploring adolescent community violence exposure and posttraumatic stress cross-culturally in Israel. Journal of Community Psychology, 42, 47-60. doi:10.1002/jcop.21593

67.

Wickramaratne

Weissman

Pilowsky

Rush

A. J.

(2010). Children of depressed mothers one year after remission of maternal depression: Findings from the STAR*D-child study. International Journal of Neuropsychopharmacology, 13, 34-34.