Acceptability and Preliminary Outcomes of a Parenting Intervention for Syrian Refugees

Abstract

Purpose:

Forced displacement may increase the risk of child maltreatment and mental health problems among children and caregivers. This study assessed the acceptability and preliminary outcomes of a parenting intervention to prevent child maltreatment and improve parental and child mental health among Syrian refugees in Lebanon.

Method:

292 parents and 88 children participated in a structured assessment before and after a group-based parenting intervention implemented by an international nongovernmental organization serving refugee and vulnerable Lebanese communities.

Results:

Paired sample t tests showed significant reductions in harsh punishment and rejecting parenting behavior and significant improvements in measures of parental and child mental health from pre- to postintervention. On average, parents completed 7.7 of 10 sessions.

Discussion:

Preliminary results suggest that the parenting intervention was acceptable to refugee parents and may show promise in reducing child maltreatment and improving parental and child mental health in a humanitarian setting.

Keywords

refugees child abuse mental health parenting interventions program evaluation

In 2018, approximately 70.8 million individuals worldwide were forcibly displaced due to armed conflict, persecution, or human rights violations (United Nations High Commissioner for Refugees [UNHCR], 2019). Children below 18 years of age constituted half of the refugee population (UNHCR, 2019). Forcibly displaced children experience a host of challenges to their physical, cognitive, and psychosocial development and well-being, including exposure to war-related trauma and deprivation of basic needs and access to education (Murphy et al., 2017; Reed et al., 2012). While positive parenting—warm, nurturing, and responsive parenting behaviors and interactions—can help to buffer negative effects on children’s well-being, caregivers struggling to cope with the stressors of war and displacement can also be a source of risk (Tol et al., 2013). Research with conflict-affected populations in Lebanon (Sim, Bowes, & Gardner, 2018), Northern Uganda (Saile et al., 2014), and Sri Lanka (Catani et al., 2008) suggests that caregivers’ own exposure to war and subsequent mental health problems (e.g., depressive and post-traumatic stress symptoms) are associated with an increase in child maltreatment, which in turn elevate the risk of child mental health problems. In addition to the mental health effects on the parenting behavior of war-affected caregivers, qualitative studies with Syrian refugees highlight the structural barriers (e.g., restrictions on refugees’ freedom of movement) that impinge on opportunities for positive caregiver–child interactions (Akesson & Sousa, 2019; Sim, Fazel, et al., 2018).

A recent meta-analysis and meta-synthesis of 38 quantitative and 10 qualitative studies found compelling evidence of the transgenerational effects of war (Eltanamly et al., 2021). Results showed that more war-exposed parents exhibited less warmth and more harshness toward their children, which in turn mediated the association between war exposure and child mental health. The nature of war experiences also influenced parenting behavior, with parents showing more harshness, hostility, and inconsistency and less warmth in highly insecure settings. Furthermore, research with refugee families who have been permanently resettled in a safe country suggests that the effects of war can persist for years after exposure. For example, a population-based prospective cohort study of refugees permanently resettled in Australia found that caregivers’ trauma history and postmigration difficulties were associated with greater harsh parenting and in turn higher levels of child mental health problems (Bryant et al., 2018). Given the potentially severe and long-term consequences for children’s psychosocial development and well-being, interventions to reduce child maltreatment and promote positive parenting in humanitarian settings are urgently needed (Shonkoff et al., 2012).

Aim of the Study

The overall aim of the current study is to report the acceptability and preliminary outcomes of a group-based parenting intervention to reduce the risk of child maltreatment among Syrian refugees in Lebanon. Parenting interventions have a well-established evidence base in high-income countries, and there is increasing evidence that they are feasible and effective at reducing harsh parenting and improving child mental health in low- and middle-income countries (LMICs) as well (Knerr et al., 2013; Pedersen et al., 2019). However, research on parenting interventions in acute humanitarian contexts such as the Syrian refugee crisis remains limited, with few programs specifically designed to address the complex interplay of factors influencing parenting in times of war (Murphy et al., 2017). Recent exceptions include two pilot randomized controlled trials (RCT) of parenting interventions with war-affected caregivers in the West Bank and Lebanon, with the former reporting improvements in parenting, family functioning, and child psychosocial difficulties and the latter finding positive impacts on parental stress and discipline practices (El-Khani et al., 2020; Ponguta et al., 2020). In addition, a small feasibility study with Syrian refugee families in Turkey found that an integrated mental health and parenting skills intervention showed promise in improving parenting efficacy and skills, and child behavior problems and post-traumatic stress symptoms (El-Khani et al., 2018).

The current study contributes to this nascent literature on parenting interventions in acute humanitarian settings by assessing the acceptability and preliminary outcomes of a parenting intervention specifically designed for caregivers affected by the Syrian conflict. The Families Make the Difference program has been widely disseminated in Lebanon, Jordan, and Syria since 2014 as part of a broader response to the Syrian crisis but had not yet undergone an external evaluation (International Rescue Committee [IRC], 2016a). In this study, acceptability was assessed by participant attendance and retention in the intervention, and outcomes were assessed using a single-sample, multiinformant, pre-/posttest design. The primary study outcome was reduction in child maltreatment, as defined by harsh or violent discipline and parental rejection. Given previous research linking harsh parenting to child psychosocial problems via poor parental mental health and lack of social support, we included as secondary outcomes child emotional and behavioral difficulties, caregiver symptoms of post-traumatic stress and generalized distress, and caregivers’ access to social support (Panter-Brick et al., 2014; Sim et al., 2019). We hypothesized the following:
Hypothesis 1: Participants in the parenting intervention and their children will report a significant decrease in harsh punishment and parental rejection at posttest.

Hypothesis 2: Participants in the parenting intervention and their children will report a significant decrease in child emotional and behavioral difficulties at posttest.

Hypothesis 3: Participants in the parenting intervention will report a significant decrease in caregiver symptoms of post-traumatic stress and generalized distress at posttest.

Hypothesis 4: Participants in the parenting intervention will report a significant increase in perceived social support at posttest.

Method

Study Setting

The war in Syria has resulted in a displacement crisis of unprecedented scale, accounting for the largest refugee population globally (UNHCR, 2019). Approximately 6.3 million Syrians are refugees in other countries, of which 40% are under the age of 12 years (Sirin & Rogers-Sirin, 2015). The current study was conducted in four regions of Lebanon with a large presence of Syrian refugees: Akkar, Arsal, Hermel, and Tripoli. Lebanon hosts the highest number of refugees per capita in the world, with one in six people living as a refugee (UNHCR, 2019). Available data suggest that Syrian refugee children in Lebanon experience high levels of violence in the home: A representative household survey of registered Syrian refugees found that 78% of children are subjected to harsh physical or verbal discipline, including yelling and shouting (54%); spanking (31%); slapping on the hand, arm, or leg (28%); and shaking (19%; UNHCR et al., 2017). Assessments of mental health among Syrian refugees in the Middle East region also suggest high levels of psychological distress among both adults and children, with one study finding that almost half of a random sample of Syrian refugees aged 14–45 years in Lebanon had three or more post-traumatic stress symptoms (Aoun et al., 2018). Similarly, a school-based survey of 1,000 Syrian refugee children in Lebanon and Jordan found that 45.6% had symptoms meeting criteria for post-traumatic stress disorder (PTSD; Khamis, 2019).

Families Make the Difference intervention

The parenting intervention, Families Make the Difference, is a group-based, 10-session, manualized program developed by the IRC in 2014 to address the specific challenges of families displaced by the war in Syria (IRC, 2016b). Content for the intervention was adapted by the IRC from a parenting program that had previously undergone a randomized evaluation in a postconflict setting (Puffer et al., 2015). Additional content was adapted from teaching recovery techniques, a manualized intervention based on trauma-focused-cognitive behavioral therapy, developed by the Children and War Foundation (Yule et al., 2013). In response to a needs assessment conducted with internally displaced families in Northwest Syria, in which caregivers identified linkages between parental stress, child abuse and neglect, and child psychosocial problems, the Families Make the Difference program includes specific sessions on coping with parental stress and addressing children’s psychosocial needs as shown in Table 1 (IRC, 2013).

Table 1.
Content of Families Make the Difference Program.

Session Topic Objective

1 Introduction to the program Introduce the foundational principles of nurturing and positive parenting.

2 Understanding parental stress Identify caregivers’ psychosocial and emotional needs, understand the impact of parental stress on children’s well-being, and identify positive stress management techniques.

3 Coping and healing strategies for caregivers Identify and share participants’ own coping and healing strategies.

4 The impact of parenting Understand the key concepts of brain development and the impact of toxic stress.

5 Empathy and positive behavior Introduce and practice the four steps of empathy.

6 Communicating with children Understand the key principles of effective communication with children.

7 Nurturing all children Introduce and practice positive reinforcement techniques (e.g., praise) and nonviolent discipline techniques (e.g., rule setting, ignoring).

8 Understanding children’s psychosocial needs Understand the psychosocial impact of trauma and adversity on children and identify mental health symptoms of children affected by crisis.

9 Providing psychosocial support to children Identify and practice techniques to provide psychosocial support to children affected by crisis and identify severe mental health problems and make appropriate referrals if necessary.

10 Moving forward Recap key concepts and celebrate achievements.

The IRC began implementation of the Families Make the Difference intervention for refugee and host communities in Lebanon in 2014. The intervention was delivered by local IRC staff and refugee volunteers, the majority of whom had secondary or some university-level education. Training for facilitators consisted of a minimum of 10 days on the program curriculum, as well as more general psychoeducation on early childhood development, positive discipline, and the effects of toxic stress. In addition, facilitators received training on the core facilitation techniques used in the program, including skills practice through role-plays, peer-to-peer learning through collaborative group work, and critical reflection. Facilitators also participated in regular one-on-one supervision meetings with IRC capacity building staff throughout intervention delivery.

The intervention was delivered either in community centers or individual tents in informal tented settlements where refugees resided. On average, there were 15–20 participants in each group, with sessions cofacilitated by one IRC staff and one refugee volunteer. Participants did not receive monetary or material incentives with the exception of transportation to the program site where necessary, basic refreshments, and childcare.

Participant Recruitment

Participants were recruited by local IRC staff through community and school outreach visits and referrals from IRC case management staff, other nongovernmental agencies, and community members. Study inclusion criteria for adult participants included being of Syrian origin, being the primary caregiver of at least one child aged 2–12 years, and enrollment in the parenting intervention. Individuals who had previously participated in the intervention were excluded from the study. If the individual met the inclusion criteria, IRC staff followed informed consent procedures to obtain verbal consent, then registered the name, age, and gender of all children in the household aged between 2 and 12 years. Children aged 8–12 years were also enrolled into the study if parental consent and child assent were given. If the caregiver had more than one child aged 8–12 years in the household, one was randomly selected to participate in the study. If there were no children in the eligible age range, then one child aged 2–7 was randomly selected from the household register to serve as the index child (i.e., the child about whom the caregiver reported) and only the caregiver participated in the study.

Data Collection

Participant recruitment and collection of pre- and postintervention data were conducted on a rolling basis from August 2016 to June 2017 by local IRC staff trained in research ethics and survey administration. Figure 1 shows the flow of participants through the study. Of the 714 caregivers assessed for inclusion in the study, 10 declined to participate and a further 120 did not have a child in the eligible age range, leaving 584 caregivers eligible for inclusion. Due to human resource constraints, it was not possible to survey all eligible individuals. Instead, the lead author randomly selected a subsample of caregivers (n = 383) to participate in the study. Of this sample, 292 caregivers and 88 children aged 8–12 years participated in the pretest survey, with the remainder excluded because of inadequate staffing, caregiver unavailability, or caregivers’ past participation in the parenting intervention. At posttest, 254 caregivers and 73 children were assessed, with the remainder lost to follow-up due to caregiver unavailability. The study retention rate for individuals who provided data at pretest was 85.3% or caregivers and 75% for children. In addition, five caregivers and seven children who were not assessed at pretest provided posttest data.

Figure 1.
Flow of participants. Note. ^aDid not have child in the eligible age range (n = 120); did not consent (n = 10). ^bNot assessed due to caregiver unavailability or lack of human resources (n = 77); caregiver had previously participated in the parenting program (n = 14). ^cChildren in the eligible age range (8–12 years). ^dCould not locate; caregiver or child was unavailable. ^eIncludes posttest data from five caregivers and seven children who were not assessed at pretest.

Enumerators administered the surveys to participants and recorded their responses on tablets using the application Open Data Kit (2020). When asked about parenting practices, child participants were instructed to respond in reference to the participating caregiver only. In order to aid comprehension of survey items, visual aids such as cartoons and picture-based response ratings were used. The majority of interviews were conducted in the participant’s home or the local IRC office. In addition to the pre- and postintervention data, program facilitators collected participant attendance data at each session of the parenting intervention. However, due to data collection and entry error, attendance data were available for only 271 of the 292 participants.

Outcome Measures

We conducted a review of existing measures to identify and select outcome measures that have been validated with similar populations or in similar contexts (e.g., refugee populations in other countries; Arabic-speaking immigrants) or successfully administered in multicountry studies including different social and cultural groups. In order to avoid ad hoc translations of the measures, Arabic versions were obtained either from the original developers of the instrument or from researchers who have previously validated the Arabic translation. An exception was the Modified Medical Outcomes Study Social Support Survey, which did not have an existing Arabic translation. In this case, IRC staff fluent in Arabic and English conducted a translation and back-translation of the measure. The entire battery of measures underwent an extensive process of field-testing with interviewers and members of the study population, with minor clarifications made to the translations until the field team reached consensus on accuracy and comprehensibility of all the items.

Child maltreatment

Discipline Module, Multiple Indicator Cluster Survey (MICS; United Nations Children’s Fund, 2020)

Eight items from the MICS Discipline Module were used to assess frequency of harsh physical and verbal punishment in the past 30 days (e.g., “shouted, yelled, or screamed at him or her”). The MICS is routinely implemented in over 100 countries, and the Discipline Module is administered as part of an annual representative household survey of registered Syrian refugees in Lebanon (UNHCR et al., 2017). In the study sample, Cronbach’s α was .78 for parent report and .82 for child report.

Parental Acceptance Rejection Questionnaire (PARQ; short version; Rohner & Khaleque, 2008)

The PARQ examines four areas of parental behavior—warmth/affection, hostility/aggression, indifference/neglect, and undifferentiated rejection—and has demonstrated good psychometric properties in a range of countries (Putnick et al., 2015). A meta-analysis of data from 51 studies found that the PARQ demonstrated at least acceptable internal consistency in all groups as well as convergent and discriminant validity (Khaleque & Rohner, 2002). This study used the parent and child 24-item short version and reverse-coded positive items to achieve an overall measure of parental rejection (e.g., “I hurt my child’s feelings”). The Cronbach’s α was .79 for parent report and .82 for child report.

Child psychosocial problems

Strengths and Difficulties Questionnaire (SDQ; Goodman, 1997#x0029;

The SDQ is a widely used measure of children’s emotional and behavioral difficulties, and an Arabic version has been validated for use in epidemiological and clinical studies (Alyahri & Goodman, 2006). It consists of 25 items and five subscales: Emotional Symptoms, Conduct Problems, Hyperactivity-Inattention, Peer Problems, and Prosocial Behavior (e.g., “often loses temper”). A total difficulties score is calculated by adding the scores from the first four subscales. A review of 48 studies concluded that the parent-reported total difficulties score demonstrated acceptable internal consistency and good test–retest reliability (Stone et al., 2010). In the current study, the parent-reported total difficulties score demonstrated acceptable internal consistency (Cronbach’s α = .69).

Screen for Child Anxiety-Related Emotional Disorders (SCARED; Birmaher et al., 1997)

The SCARED was used to assess child-reported anxiety symptoms. It consists of 41 items and five factors that parallel the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) classification of anxiety disorders: general anxiety disorder, separation anxiety disorder, panic disorder, and social phobia (e.g., “when I feel frightened, it is hard to breathe”). The SCARED has shown high internal consistency (α = .90), test–retest reliability (r = .86), and good discriminant validity with a suggested cutoff score of 25 to indicate clinical levels of anxiety symptoms (Birmaher et al., 1999). The Arabic version of the SCARED demonstrated satisfactory psychometric properties in a clinical sample of children in Lebanon (Hariz et al., 2013). In the current study, Cronbach’s α was .89.

Short Mood and Feelings Questionnaire (SMFQ; Messer et al., 1995)

The 13-item version of the Mood and Feelings Questionnaire was used to assess child-reported depressive symptoms. Using a 3-point scale, children were asked to indicate the degree to which they endorsed a series of statements about how they have been feeling and acting in the past 2 weeks (e.g., “I felt miserable or unhappy”). Previous studies have shown high internal consistency and satisfactory 1 week test–retest reliability for the full version of the MFQ (Sund et al., 2001), and an Arabic version demonstrated good psychometric properties in a clinical sample in Lebanon (Tavitian et al., 2014). A cutoff score of 8 for the SMFQ has been proposed to indicate clinical levels of depressive symptoms (Angold et al., 1995). In this study, the SMFQ demonstrated acceptable internal consistency with a Cronbach’s α of .74.

Parental mental health

Depression Anxiety and Stress Scale (DASS-21; Lovibond & Lovibond, 1995)

The 21-item version of the DASS was used to assess parents’ generalized distress. It consists of seven items for each subscale of Depression, Anxiety, and Stress (e.g., “I felt I was close to panic”), and respondents use a 4-point severity/frequency scale to report the extent to which they experienced each state in the past week. This study used the Arabic version of DASS-21, which demonstrated satisfactory psychometric properties in a sample of Arabic-speaking immigrants in Australia (Moussa et al., 2016). Internal consistency was excellent with a Cronbach’s α of .91.

PTSD Checklist—Civilian Version (Weathers et al., 1993)

The PTSD Checklist was used to assess parents’ symptoms of post-traumatic stress in the past month. It comprises 17 items that ask respondents to indicate how much they have been bothered by a particular symptom using a 5-point Likert-type scale (e.g., “In the past 30 days, how much were you bothered by feeling irritable or having angry outbursts?”). Previous studies have found good 1 week test–retest reliability (r = .88; Ruggiero et al., 2003). The Cronbach’s α for this sample was .89.

Mother’s perceived social support

Modified Medical Outcomes Study Social Support Survey (mMOS-SS; Sherbourne & Stewart, 1991)

The eight-item modified version of the Medical Outcomes Study Social Support Survey was used to assess parents’ perceived social support in two domains: emotional and instrumental support (e.g., “If you need it, how often is someone available to help you if you were sick in bed?”). The mMOS-SS demonstrated excellent psychometric properties similar to those of the original 19-item measure in a sample of female patients in the United States (Moser et al., 2012). In this study, Cronbach’s α was .89.

Data Analysis

The statistical software package IBM SPSS Statistics 25 was used to conduct data analysis. To examine the change in outcome variable scores from pre- to postintervention, we conducted a series of paired t tests of pre-/postdata pooled from the four data collection sites. We adopted an intention-to-treat approach, meaning that all pre- and posttest data were included in the analysis regardless of program attendance or dropout. Multiple imputation was conducted in SPSS to account for missing data, including missing pretest data for the five caregivers and seven children from whom only posttest data were collected. Multiple imputation used fully conditional specification with predictive mean matching and included all pre- and posttest items to improve estimation. Analyses used pooled data from five imputed data sets. In order to assess the potential impact of missing data, we also conducted a complete case analysis and found no differences in statistical significance or outcomes. Results from the complete case analysis are available in Table 2.

Table 2.
Pre- and Posttest Results Using Complete Case Analysis.

Outcome Respondent Pretest Posttest Difference 95% Confidence Interval t Effect Size (Cohen’s d)

M (SD) M (SD) M (SD)

Child maltreatment

Harsh punishment Parent (n = 249) 9.55 (5.73) 5.06 (4.51) 4.49 (6.34) [3.70, 5.28] 11.18*** .71

Child (n = 66) 5.86 (5.48) 4.08 (5.52) 1.79 (6.68) [0.15, 3.43] 2.18* .27

Parental rejection Parent (n = 235) 20.71 (8.58) 13.92 (7.77) 6.80 (10.35) [5.47, 8.13] 10.07* .66

Child (n = 59) 18.08 (9.43) 13.20 (9.16) 4.88 (11.23) [1.95, 7.81] 3.34 .43

Child psychosocial problems

Total difficulties score Parent (n = 225) 16.67 (5.37) 12.50 (5.49) 4.17 (5.86) [3.40, 4.94] 10.66* .71

Depression Child (n = 63) 7.33 (4.40) 4.38 (4.37) 2.95 (4.29) [1.87, 4.03] 5.46* .69

Anxiety Child (n = 54) 29.67 (13.24) 21.30 (16.04) 8.37 (15.30) [4.19, 12.55] 4.02* .55

Parental mental health

Generalized distress Parent (n = 234) 31.83 (12.84) 20.31 (13.47) 11.52 (14.37) [9.67, 13.37] 12.26* .80

Post-traumatic stress Parent (n = 238) 33.92 (12.25) 25.36 (13.17) 8.56 (15.41) [6.60, 10.53] 8.58* .56

Perceived social support Parent (n = 247) 15.52 (7.77) 17.92 (7.34) 2.40 (9.17) [3.55, 1.25] −4.11* .26

p < .05. p < .01. p < .001.

Ethical and Safety Considerations

Study procedures were designed with special consideration of the vulnerable status of refugees in Lebanon. Informed consent procedures emphasized that participation in the study was voluntary and not linked to receiving assistance from the IRC or any other organization. Caregivers were also informed that participation in the intervention was not tied to participation in the study (i.e., all caregivers were invited to participate in the parenting intervention regardless of their eligibility for or inclusion in the study). As part of the informed consent process, both caregivers and children were advised that their responses would be kept confidential unless there was a risk of harm (e.g., disclosure of self-harm or child abuse), in which case staff would be mandated to report to the IRC case management team. To safeguard the children participating in the study, enumerators received an automated alert if the caregiver or child participant endorsed the survey item, “Hit child over and over again as hard as you could” in the past 30 days. Approximately 15% of caregivers and children endorsed this item at pretest. In addition to participation in the parenting intervention, these families were referred to IRC’s case management staff who followed up with the family to assess and address any child protection concerns. Enumerators were also trained on how to manage potential adverse events such as participant distress, and a protocol was developed to specify procedures for referral to case management services in the event of disclosure of child maltreatment or intimate partner violence. Finally, enumerators offered participants a list of local health and psychosocial support services at the conclusion of the interview. The study protocol was reviewed by the IRC and approved by the University of Oxford’s Central University Research Ethics Committee.

Results

Sample Characteristics

Table 3 reports the sample characteristics of caregiver and child participants who completed and did not complete the posttest. In total, 292 caregivers and 88 children provided pretest data. Of these, 43 caregivers and 22 children did not complete the posttest (i.e., noncompleters). Caregiver noncompleters reported higher levels of parental rejection and lower perceived social support than completers, although the magnitude of the difference was extremely small (Hedges’ g of .02 and .08, respectively). Child noncompleters reported higher levels of parental rejection (Hedges’ g = .34) and anxiety (Hedges’ g = .56) than completers. There were no significant differences in any other demographic or pretest characteristics between completers and noncompleters. The mean age of parents was 31.8 years (SD = 8.16) ranging from 19 to 56 years, and the majority (52.9%) had some secondary education. All caregivers were the biological mother of the index child with the exception of one biological father. Over 90% of participants were married, and of those 95% were living with their spouse in the same household. The average number of household members was 5.8 (SD = 2.00), and the average number of children under 18 years in the household was 3.4 (SD = 1.50). Almost half of the participants (47.3%) had arrived in Lebanon in the previous 2–3 years. While about 90% of participants were registered with the UNHCR, approximately a third did not have a legal permit for residing in Lebanon. Over half (56.5%) of the sample lived in informal tented settlements, and the vast majority (93.1%) reported lack of food or money to buy food in the 30 days prior to the pretest survey. On average, parents reported experiencing 7.2 war-related traumatic events (SD = 3.49). When asked if it was necessary to physically punish their child in order to bring them up properly, 16.1% of parents agreed with the statement at pretest.

Table 3.
Sample Characteristics of Parent and Child Participants Grouped by Completion and Noncompletion of Posttest.

Characteristics Completers^a Noncompleters^b Total Participants at Pretest^c F Statistic (p Value)

Demographics

Parent age, M (SD) 31.69 (8.06) 32.58 (8.79) 31.82 (8.16) 0.05 (.83)

Highest level of parent education, M (SD) 2.71 (1.06) 2.74 (1.16) 2.71 (1.07) 0.05 (.83)

Days lacking food or money to buy food, M (SD) 14.21 (7.82) 11.09 (7.71) 13.75 (7.86) 0.05 (.83)

Parent exposure to war-related traumatic events, M (SD) 7.27 (3.46) 6.74 (3.66) 7.19 (3.49) 0.70 (.40)

Belief in the need for physical punishment, % endorsed (SD) 16.9 (0.38) 11.6 (0.32) 16.1 (0.37) 3.33 (.07)

Index child age, M (SD) 7.47 (3.21) 7.28 (3.38) 7.45 (3.23) 0.40 (.53)

Index child sex, % female (SD) 46.20 (0.50) 48.80 (0.51) 46.60 (0.50) 0.20 (.65)

Child respondent age, M (SD) 9.64 (1.34) 10.14 (1.67) 9.76 (1.44) 2.55 (.11)

Child respondent sex, % female (SD) 51.50 (0.50) 50.00 (0.51) 51.10 (0.50) 0.02 (.89)

Child maltreatment

Parent report: Harsh punishment, M (SD) 9.55 (5.73) 8.84 (6.22) 9.45 (5.80) 0.02 (.88)

Parent report: Parental rejection, M (SD) 20.71 (8.56) 20.88 (11.45) 20.73 (9.02) 7.61 (.01)

Child report: Harsh punishment, M (SD) 5.86 (5.48) 8.09 (7.02) 6.42 (5.94) 3.14 (.08)

Child report: Parental rejection, M (SD) 17.90 (9.35) 21.57 (14.45) 18.84 (10.90) 6.22 (.02)

Child psychosocial problems

Parent report: Total difficulties score, M (SD) 16.62 (5.38) 16.15 (6.20) 16.55 (5.50) 0.68 (.41)

Child report: Depression, M (SD) 7.33 (4.40) 8.71 (3.61) 7.68 (4.24) 0.45 (.51)

Child report: Anxiety, M (SD) 29.70 (13.10) 36.43 (7.68) 31.04 (10.90) 5.77 (.02)

Parental mental health

Parent report: Generalized distress, M (SD) 31.78 (12.84) 34.05 (15.14) 32.10 (13.18) 3.67 (.06)

Parent report: Post-traumatic stress, M (SD) 33.88 (12.21) 30.55 (14.65) 33.38 (12.63) 2.18 (.14)

Parent report: Perceived social support, M (SD) 15.52 (7.77) 14.90 (9.48) 15.43 (8.03) 7.71 (.01)

^a Completers refer to n = 254 parents and n = 66 children who completed the posttest. ^b Noncompleters refer to n = 43 parents and n = 22 children who did not complete the posttest. ^c Total number of parents who were assessed at pretest = 292; total number of children who were assessed at pretest = 88.

The mean age of the index children (i.e., the child about whom caregivers responded to questions about parenting practices and child psychosocial problems) was 7.5 years (SD = 3.23) and just under half were female. Approximately 72% of school-aged children (i.e., 4 years and above) were attending school at the time of the pretest, and 5.8% of index children aged 4 years and above had performed paid work in the 30 days prior to the pretest. A subsample of 88 index children aged 8–12 years directly participated in the study. The mean age of this subsample of children was 9.8 years (SD = 1.44) and just over half (51.1%) were female. The majority (88.6%) were attending school at the time of the pretest, and 5.7% had performed paid work in the 30 days prior to the pretest interview.

Program Attendance and Retention

Attendance data were available for 271 of the 292 parents enrolled in the study. On average, parents attended 7.7 of a total of 10 sessions of the intervention. Approximately a fifth (21.0%) of the participants completed all 10 sessions, and three quarters (75.6%) completed seven or more sessions of the intervention. While attendance and retention is the only one indicator of acceptability, the high level of sustained participation suggests that the program was acceptable to caregivers.

Study Outcomes

Table 4 presents the mean pre- and posttest scores, standard errors, t-statistic, and p value for each outcome variable as reported by parents (n = 292) and/or children (n = 88). There were significant improvements in all parent- and child-reported outcomes from pre- to posttest, including after applying a Bonferroni correction for multiple comparisons (0.05/10).

Table 4.
Pre- and Posttest Results From Parent and Child Self-Reported Measures.

Outcome Respondent Pretest Posttest Difference 95% Confidence Interval t Effect Size (Cohen’s d)

M (SE) M (SE) M (SE)

Child maltreatment

Harsh punishment Parent 9.48 (0.34) 5.85 (0.33) 3.63 (0.43) [2.79, 4.47] 8.53* .54

Child 6.52 (0.59) 4.19 (0.51) 2.32 (0.69) [0.96, 3.68] 3.35 .35

Parental rejection Parent 20.86 (0.52) 15.12 (0.50) 5.74 (0.66) [4.44, 7.04] 8.70* .52

Child 18.72 (1.08) 13.41 (0.81) 5.31 (1.20) [2.96, 7.65] 4.44* .46

Child psychosocial problems

Total difficulties score Parent 16.66 (0.32) 13.26 (0.34) 3.40 (0.39) [2.63, 4.16] 8.76* .55

Depression Child 7.82 (0.43) 4.87 (0.42) 2.95 (0.45) [2.06, 3.83] 6.51* .69

Anxiety Child 32.65 (1.24) 23.45 (1.36) 9.19 (1.43) [6.39, 12.00] 6.43* .67

Parental mental health

Generalized distress Parent 32.69 (0.77) 22.01 (0.76) 10.68 (0.85) [9.01, 12.35] 12.56* .74

Post-traumatic stress Parent 33.66 (0.73) 26.34 (0.77) 7.32 (0.93) [5.50, 9.15] 7.89* .47

Perceived social support Parent 15.43 (0.47) 17.57 (0.43) 2.14 (0.57) [3.25, 1.03] −3.78* .23

Note. Results based on the analyses of pooled caregiver (n = 292) and child (n = 88) data from five multiply imputed data sets.

p < .05. p < .01. p < .001.

For the primary outcome of child maltreatment, we hypothesized that both parents and children would report a significant decrease in harsh punishment and parental rejection after participation in the parenting intervention (Hypothesis 1). Results from the paired sample t tests supported the hypothesis, with significant reductions in parent-reported use of harsh punishment (mean difference = 3.63, 95% confidence interval (CI) = [2.79, 4.47], p < .001) with a medium effect size of d = .54, as well as child-reported experience of harsh punishment (mean difference = 2.32, 95% CI [0.96, 3.68], p < .01) with a smaller effect size of d = .35. Parents also reported a significant decrease in rejecting parenting behavior (mean difference = 5.74, 95% CI [4.44, 7.04], p < .001) with a medium effect size of d = .52, as did children (mean difference = 5.31, 95% CI [2.96, 7.65], p < .001, d = .46).

For the secondary outcome of children’s emotional and behavioral difficulties, we hypothesized that parents would report a decrease in their children’s psychosocial problems as measured by the SDQ total difficulties score, while children would report a decrease in depression and anxiety symptoms at posttest (Hypothesis 2). Results supported the hypothesis, with parents reporting a significant reduction in their children’s SDQ total difficulties score (mean difference = 3.40, 95% CI [2.63, 4.16], p < .001) with a medium effect size (d = .55). Children reported significant reductions in their symptoms of depression (mean difference = 2.95, 95% CI [2.06, 3.83], p = <.001) and anxiety (mean difference = 9.19, 95% CI [6.39, 12.00], p < .001), with effect sizes of d = .69 and d = .67, respectively.

Finally, for the outcome of parental mental health and social support, we hypothesized that parents would report a significant reduction in symptoms of generalized distress and post-traumatic stress (Hypothesis 3) and a significant increase in perceived social support (Hypothesis 4) after participation in the parenting intervention. Results from the analyses supported both hypotheses, with parents reporting a large decrease in symptoms of generalized distress (mean difference = 10.68, 95% CI [9.01, 12.35], p < .001, d = .74) and a smaller decrease in symptoms of post-traumatic stress (mean difference = 7.32, 95% CI [5.50, 9.15], p < .001, d = .47) at posttest. Parents also reported a significant but small increase in perceived social support (mean difference = 2.14, 95% CI [3.25, 1.03], p <.001, d = .23).

These results should be interpreted with caution given the lack of a control group and validated norms for this population. However, preliminary findings indicate potentially clinically significant reductions in child and parental mental health symptoms from pre- to postintervention that merit further investigation. For example, the mean total difficulties score on the parent-reported SDQ went from 16.66 at pretest to 13.26 at posttest. Using the cutoff score of 16/17 based on a national epidemiological study in the UK (Goodman, 2001), this suggests a potentially clinically significant reduction in children’s emotional and behavioral problems.

Discussion and Applications to Practice

Results from this pre-/postevaluation suggest that the Families Make the Difference intervention was acceptable to participants (as indicated by high levels of program attendance and retention) and may hold promise for reducing child maltreatment and improving child and parental mental health among displaced Syrian families in Lebanon. Pre- and posttest results and anecdotal feedback from program providers and participants did not reveal any indication of harm or other unintended effects arising from participation in the intervention. While there is now an accumulating evidence base on the feasibility and effectiveness of parenting interventions to reduce child maltreatment and improve child psychosocial outcomes in nonconflict and postconflict LMICs, evidence from acute humanitarian settings characterized by ongoing insecurity remains scarce. Results from the current study have two important practical implications for the prevention of child maltreatment and mental health problems in refugee settings. First, structured parenting interventions can be successfully implemented and evaluated in the context of routine service delivery by trained nonspecialist staff. Second, such interventions have the potential to be successfully integrated into programming by humanitarian organizations to reach war-affected families at scale. As the need for child protection and mental health treatment far exceeds available services in conflict settings, this study and other recently published evaluations (Janowski et al., 2020) highlight parenting interventions as a promising strategy for addressing the psychosocial consequences of the unprecedented levels of global displacement seen around the world today.

Participant attendance in the program was high (average of 7.7 of 10 sessions completed) and comparable to similar parenting interventions in other high-risk, low-resource settings where average attendance ranged from 50% to 81% of sessions (Puffer et al., 2017; Shenderovich et al., 2018). The high level of participant attendance suggests that the intervention was acceptable to caregivers and further indicates that sustained parent engagement in a structured, multisession intervention is feasible even in acute humanitarian settings where families are living under current threat. Studies in similarly volatile settings are few but also indicate that war-affected caregivers can be successfully retained over multiple weeks of an intervention. For example, an RCT of a psychosocial and parenting intervention in Northern Democratic Republic of Congo (n = 159) reported an average attendance rate of 84% for caregivers over eight sessions (O’Callaghan et al., 2014).

While conclusions are limited by the nonexperimental study design, preliminary outcome data suggest promising reductions in harsh punishment and rejecting parenting behavior reported by both parents and children. These results are consistent with trials of parenting interventions in other conflict and nonconflict-affected LMICs, which report positive impacts on reducing harsh discipline and dysfunctional parenting practices (Cluver et al., 2018; El-Khani et al., 2020; Oveisi et al., 2010; Puffer et al., 2015). Furthermore, this study found significant reductions in parent and child-reported emotional and behavioral problems, further supporting findings from a systematic review that parenting and family interventions can improve the mental health of children in LMICs (Pedersen et al., 2019). Given that children did not participate directly in the intervention, the child-reported reductions in symptoms of depression and anxiety from pre- to posttest may point to improved parenting as a mediator of intervention effects on child mental health. However, it is also possible that some of the children in the sample participated directly in other interventions (e.g., life skills training) offered by the IRC or other humanitarian organizations, which may have contributed—among other unmeasured variables—to the decrease in child mental health problems at posttest. A more rigorous randomized design with data from multiple time points and informants is necessary to assess potential mediating effects of parenting behavior and parental mental health.

Finally, study results suggest that parents experienced a reduction in symptoms of generalized distress as well as post-traumatic stress after participating in the parenting intervention. The evidence on the impact of parenting interventions on parental mental health is mixed, with some evaluations in high- as well as LMICs finding short-term improvements in parental mental health (Barlow et al., 2014; Cluver et al., 2018), while a meta-analysis of individual participant data from the Incredible Years parenting program (n = 1,390) showed no effect on parental depression (Leijten et al., 2018). In this study, the parent-reported improvements in their mental health may be due in part to the intervention’s explicit focus on caregivers’ psychosocial needs and coping strategies in a context of ongoing insecurity, threat, and deprivation. Anecdotal feedback from parents also suggests that the increase in social support through participation in the intervention, and the empathy and solidarity demonstrated by program facilitators, contributed to improvements in parental mental health. Pre- and posttest results are consistent with this feedback, with parents reporting a significant increase in perceived social support after participating in the intervention. Extant research with Syrian refugees and other conflict-affected populations suggest an important association between parental mental health, child maltreatment, and children’s psychosocial difficulties (Bryant et al., 2018; Panter-Brick et al., 2014; Sim, Bowes, & Gardner, 2018). While preliminary, results from this study highlight the potential for family-focused interventions to have positive intergenerational effects on the mental health and well-being of refugee children and their caregivers, even in conditions of ongoing threat and adversity.

Strengths of the study include the inclusion of child reports (albeit only from a subsample of older children), which allowed for some triangulation with parent-reported data. The study also benefited from partnership with a large nongovernmental organization that was implementing and scaling up delivery of the parenting intervention to refugee and vulnerable host communities across Lebanon and the Middle East region. The study was thus able to recruit a large sample of caregivers across four diverse regions of Lebanon with significant refugee presence. The main limitation of the study is its nonexperimental design, which precludes attribution of results to the intervention. There was significant attrition in survey response from recruitment to pretest (23.8%), and from pre- to posttest for both parents (14.7%) and children (25%), which may have contributed to response bias. Comparison of completers (participants who completed the posttest) and noncompleters (participants who did not complete the posttest) revealed differences in some parenting and mental health variables at pretest, which may have differentially influenced study outcomes. In addition, the measures used in the study were all self-reports and vulnerable to social desirability bias and have not been validated with the study population. However, most of the measures had been previously validated with other Arabic-speaking populations in the region, and reliability data suggest that the measures performed adequately in the current study. Future research would benefit from efforts to assess the psychometric performance (e.g., test–retest reliability, construct, and content validity) of parenting and mental health measures, as well as direct observation methods, among the Syrian refugee population. As the sample was composed almost exclusively of biological mothers, results cannot be generalized to fathers and other types of caregivers. Finally, the lack of data on other aspects of implementation beyond participant attendance and retention (e.g., facilitators and barriers to uptake and engagement, intervention fidelity) is a limitation in assessing the overall acceptability and feasibility of the intervention. An important next step would be to conduct a randomized feasibility trial to assess intervention engagement, fidelity, and quality and inform the design of a future definitive RCT (Eldridge et al., 2016). In addition, embedding qualitative methods such as individual and group interviews in future evaluations would add useful insights into the acceptability and effectiveness of the intervention as experienced by caregivers.

This study assessed the acceptability and preliminary outcomes of the Families Make the Difference parenting intervention for Syrian refugees in Lebanon. High levels of attendance and retention indicate that a structured, group-based parenting intervention is acceptable to Syrian refugee caregivers living in a context of ongoing displacement. Caregiver and child-reported reductions in child maltreatment, child psychosocial problems, and caregiver mental health symptoms further suggest that the intervention may hold promise for preventing violence against children and addressing the significant mental health burden among refugee populations. While there is a critical need for further research on the implementation and effectiveness of parenting interventions in humanitarian settings, preliminary results from this study contribute to emerging evidence of the potential for family-based approaches to prevent violence against children and mitigate the intergenerational effects of war.

Directions for future research include a randomized feasibility trial with a multiinformant, longitudinal design to examine factors influencing implementation outcomes, evaluate implementation, assess intervention effects across multiple time points, and investigate potential mediators. Future research should also include specific focus on the challenges of and strategies for involving male caregivers in the parenting intervention and assessment of potential gender-differentiated intervention effects.

Session	Topic	Objective
1	Introduction to the program	Introduce the foundational principles of nurturing and positive parenting.
2	Understanding parental stress	Identify caregivers’ psychosocial and emotional needs, understand the impact of parental stress on children’s well-being, and identify positive stress management techniques.
3	Coping and healing strategies for caregivers	Identify and share participants’ own coping and healing strategies.
4	The impact of parenting	Understand the key concepts of brain development and the impact of toxic stress.
5	Empathy and positive behavior	Introduce and practice the four steps of empathy.
6	Communicating with children	Understand the key principles of effective communication with children.
7	Nurturing all children	Introduce and practice positive reinforcement techniques (e.g., praise) and nonviolent discipline techniques (e.g., rule setting, ignoring).
8	Understanding children’s psychosocial needs	Understand the psychosocial impact of trauma and adversity on children and identify mental health symptoms of children affected by crisis.
9	Providing psychosocial support to children	Identify and practice techniques to provide psychosocial support to children affected by crisis and identify severe mental health problems and make appropriate referrals if necessary.
10	Moving forward	Recap key concepts and celebrate achievements.

Outcome	Respondent	Pretest	Posttest	Difference	95% Confidence Interval	t	Effect Size (Cohen’s d)
Child maltreatment
Harsh punishment	Parent (n = 249)	9.55 (5.73)	5.06 (4.51)	4.49 (6.34)	[3.70, 5.28]	11.18***	.71
Child (n = 66)	5.86 (5.48)	4.08 (5.52)	1.79 (6.68)	[0.15, 3.43]	2.18*	.27
Parental rejection	Parent (n = 235)	20.71 (8.58)	13.92 (7.77)	6.80 (10.35)	[5.47, 8.13]	10.07***	.66
Child (n = 59)	18.08 (9.43)	13.20 (9.16)	4.88 (11.23)	[1.95, 7.81]	3.34**	.43
Child psychosocial problems
Total difficulties score	Parent (n = 225)	16.67 (5.37)	12.50 (5.49)	4.17 (5.86)	[3.40, 4.94]	10.66***	.71
Depression	Child (n = 63)	7.33 (4.40)	4.38 (4.37)	2.95 (4.29)	[1.87, 4.03]	5.46***	.69
Anxiety	Child (n = 54)	29.67 (13.24)	21.30 (16.04)	8.37 (15.30)	[4.19, 12.55]	4.02***	.55
Parental mental health
Generalized distress	Parent (n = 234)	31.83 (12.84)	20.31 (13.47)	11.52 (14.37)	[9.67, 13.37]	12.26***	.80
Post-traumatic stress	Parent (n = 238)	33.92 (12.25)	25.36 (13.17)	8.56 (15.41)	[6.60, 10.53]	8.58***	.56
Perceived social support	Parent (n = 247)	15.52 (7.77)	17.92 (7.34)	2.40 (9.17)	[3.55, 1.25]	−4.11***	.26

Characteristics	Completers^a	Noncompleters^b	Total Participants at Pretest^c	F Statistic (p Value)
Demographics
Parent age, M (SD)	31.69 (8.06)	32.58 (8.79)	31.82 (8.16)	0.05 (.83)
Highest level of parent education, M (SD)	2.71 (1.06)	2.74 (1.16)	2.71 (1.07)	0.05 (.83)
Days lacking food or money to buy food, M (SD)	14.21 (7.82)	11.09 (7.71)	13.75 (7.86)	0.05 (.83)
Parent exposure to war-related traumatic events, M (SD)	7.27 (3.46)	6.74 (3.66)	7.19 (3.49)	0.70 (.40)
Belief in the need for physical punishment, % endorsed (SD)	16.9 (0.38)	11.6 (0.32)	16.1 (0.37)	3.33 (.07)
Index child age, M (SD)	7.47 (3.21)	7.28 (3.38)	7.45 (3.23)	0.40 (.53)
Index child sex, % female (SD)	46.20 (0.50)	48.80 (0.51)	46.60 (0.50)	0.20 (.65)
Child respondent age, M (SD)	9.64 (1.34)	10.14 (1.67)	9.76 (1.44)	2.55 (.11)
Child respondent sex, % female (SD)	51.50 (0.50)	50.00 (0.51)	51.10 (0.50)	0.02 (.89)
Child maltreatment
Parent report: Harsh punishment, M (SD)	9.55 (5.73)	8.84 (6.22)	9.45 (5.80)	0.02 (.88)
Parent report: Parental rejection, M (SD)	20.71 (8.56)	20.88 (11.45)	20.73 (9.02)	7.61 (.01)
Child report: Harsh punishment, M (SD)	5.86 (5.48)	8.09 (7.02)	6.42 (5.94)	3.14 (.08)
Child report: Parental rejection, M (SD)	17.90 (9.35)	21.57 (14.45)	18.84 (10.90)	6.22 (.02)
Child psychosocial problems
Parent report: Total difficulties score, M (SD)	16.62 (5.38)	16.15 (6.20)	16.55 (5.50)	0.68 (.41)
Child report: Depression, M (SD)	7.33 (4.40)	8.71 (3.61)	7.68 (4.24)	0.45 (.51)
Child report: Anxiety, M (SD)	29.70 (13.10)	36.43 (7.68)	31.04 (10.90)	5.77 (.02)
Parental mental health
Parent report: Generalized distress, M (SD)	31.78 (12.84)	34.05 (15.14)	32.10 (13.18)	3.67 (.06)
Parent report: Post-traumatic stress, M (SD)	33.88 (12.21)	30.55 (14.65)	33.38 (12.63)	2.18 (.14)
Parent report: Perceived social support, M (SD)	15.52 (7.77)	14.90 (9.48)	15.43 (8.03)	7.71 (.01)

Outcome	Respondent	Pretest	Posttest	Difference	95% Confidence Interval	t	Effect Size (Cohen’s d)
Child maltreatment
Harsh punishment	Parent	9.48 (0.34)	5.85 (0.33)	3.63 (0.43)	[2.79, 4.47]	8.53***	.54
Child	6.52 (0.59)	4.19 (0.51)	2.32 (0.69)	[0.96, 3.68]	3.35**	.35
Parental rejection	Parent	20.86 (0.52)	15.12 (0.50)	5.74 (0.66)	[4.44, 7.04]	8.70***	.52
Child	18.72 (1.08)	13.41 (0.81)	5.31 (1.20)	[2.96, 7.65]	4.44***	.46
Child psychosocial problems
Total difficulties score	Parent	16.66 (0.32)	13.26 (0.34)	3.40 (0.39)	[2.63, 4.16]	8.76***	.55
Depression	Child	7.82 (0.43)	4.87 (0.42)	2.95 (0.45)	[2.06, 3.83]	6.51***	.69
Anxiety	Child	32.65 (1.24)	23.45 (1.36)	9.19 (1.43)	[6.39, 12.00]	6.43***	.67
Parental mental health
Generalized distress	Parent	32.69 (0.77)	22.01 (0.76)	10.68 (0.85)	[9.01, 12.35]	12.56***	.74
Post-traumatic stress	Parent	33.66 (0.73)	26.34 (0.77)	7.32 (0.93)	[5.50, 9.15]	7.89***	.47
Perceived social support	Parent	15.43 (0.47)	17.57 (0.43)	2.14 (0.57)	[3.25, 1.03]	−3.78***	.23

Footnotes

Authors’ Note

Amanda L. Sim is now at the Department of Psychiatry and Behavioural Neurosciences, Offord Centre for Child Studies, McMaster University, Hamilton, Ontario, Canada.

Acknowledgments

The authors would like to express their gratitude to the families who participated in this study and to the staff at the International Rescue Committee in Lebanon.

Declaration of Conflicting Interests

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

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was generously supported by the UNICEF Lebanon Country Office.

ORCID iD

Amanda L. Sim

References

Akesson

Sousa

(2019). Parental suffering and resilience among recently displaced Syrian refugees in Lebanon. Journal of Child and Family Studies, 29, 1264–1273.

Alyahri

Goodman

(2006). Validation of the Arabic strengths and difficulties questionnaire and the development and well-being assessment. Eastern Mediterranean Health Journal, 12(2), 9.

Angold

Costello

E. J.

Messer

S. C.

Pickles

Winder

Silver

(1995). Development of a short questionnaire for use in epidemiological studies of depression in children and adolescents. International Journal of Methods in Psychiatric Research, 5, 237–249.

Aoun

Joundi

El Gerges

(2018). Post-traumatic stress disorder symptoms and associated risk factors: A cross-sectional study among Syrian refugees. British Journal of Medical Practitioners, 11(1), a1106.

Barlow

Smailagic

Huband

Roloff

Bennett

(2014). Group-based parent training programmes for improving parental psychosocial health. Cochrane Database of Systematic Reviews, 2014(5), Art. No.: CD002020. https://doi.org/10.1002/14651858.CD002020.pub4

Birmaher

Brent

D. A.

Chiappetta

Bridge

Monga

Baugher

(1999). Psychometric properties of the screen for child anxiety related emotional disorders (SCARED): A replication study. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1230–1236.

Birmaher

Khetarpal

Brent

Cully

Balach

Kaufman

McKenzie Neer

(1997). The screen for child anxiety related emotional disorders (SCARED): Scale construction and psychometric characteristics. Journal of the American Academy of Child & Adolescent Psychiatry, 36(4), 545–553.

Bryant

R. A.

Edwards

Creamer

O’Donnell

Forbes

Felmingham

K. L.

Silove

Steel

Nickerson

McFarlane

A. C.

Hooff

M. V.

Hadzi-Pavlovic

(2018). The effect of post-traumatic stress disorder on refugees’ parenting and their children’s mental health: A cohort study. The Lancet Public Health, 3(5), e249–e258.

Catani

Jacob

Schauer

Kohila

Neuner

(2008). Family violence, war, and natural disasters: A study of the effect of extreme stress on children’s mental health in Sri Lanka. BMC Psychiatry, 8, Article 33.

10.

Cluver

L. D.

Meinck

Steinert

J. I.

Shenderovich

Doubt

Herrero Romero

Lombard

C. J.

Redfern

Ward

C. L.

Tsoanyane

Nzima

Sibanda

Wittesaele

Stone

S. D.

Boyes

M. E.

Catanho

Lachman

J. M.

Salah

Nocuza

Gardner

(2018). Parenting for lifelong health: A pragmatic cluster randomised controlled trial of a non-commercialised parenting programme for adolescents and their families in South Africa. BMJ Global Health, 3(1), e000539.

11.

Eldridge

S. M.

Chan

C. L.

Campbell

M. J.

Bond

C. M.

Hopewell

Thabane

Lancaster

G. A.

(2016). CONSORT 2010 statement: Extension to randomised pilot and feasibility trials. BMJ, i5239. https://doi.org/10.1136/bmj.i5239

12.

El-Khani

Cartwright

Ang

Henshaw

Tanveer

Calam

(2018). Testing the feasibility of delivering and evaluating a child mental health recovery program enhanced with additional parenting sessions for families displaced by the Syrian conflict: A pilot study. Peace and Conflict: Journal of Peace Psychology, 24(2), 188–200.

13.

El-Khani

Maalouf

Baker

D. A.

Zahra

Noubani

Cartwright

(2020). Caregiving for children through conflict and displacement: A pilot study testing the feasibility of delivering and evaluating a light touch parenting intervention for caregivers in the West Bank. International Journal of Psychology, 55(S1), 26–39.

14.

Eltanamly

Leijten

Jak

Overbeek

(2021, March 10). Parenting in times of war: A meta-analysis and qualitative synthesis of war exposure, parenting, and child adjustment. Trauma, Violence, & Abuse, 22(1), 147–160. https://doi.org/10.1177/1524838019833001

15.

Goodman

(1997). The strengths and difficulties questionnaire: A research note. Journal of Child Psychology and Psychiatry, 38, 581–586.

16.

Goodman

(2001). Psychometric properties of the strengths and difficulties questionnaire. Journal of the American Academy of Child & Adolescent Psychiatry, 40(11), 1337–1345.

17.

Hariz

Bawab

Atwi

Tavitian

Zeinoun

Khani

Birmaher

Nahas

Maalouf

F. T.

(2013). Reliability and validity of the Arabic screen for child anxiety related emotional disorders (SCARED) in a clinical sample. Psychiatry Research, 209(2), 222–228.

18.

International Rescue Committee. (2013). Child protection and education assessment in Al Karameh camp, Idlib governorate [Unpublished report].

19.

International Rescue Committee. (2016a, October 3). Education at the international rescue committee: Early childhood development . https://www.rescue.org/resource/education-international-rescue-committee-early-childhood-development

20.

International Rescue Committee. (2016b). Parenting skills intervention trainer’s manual. http://shls.rescue.org/shls-toolkit/parenting-skills/

21.

Janowski

R. K.

Wessels

Bojo

Monday

Maloney

Achut

Oliver

Lachman

J. M.

Cluver

Ward

(2020). Transferability of evidence-based parenting programs to routine implementation in postconflict South Sudan. Research on Social Work Practice, 30(8), 858–869. https://doi.org/10.1177/1049731520932986

22.

Khaleque

Rohner

R. P.

(2002). Reliability of measures assessing the pancultural association between perceived parental acceptance-rejection and psychological adjustment: A meta-analysis of cross-cultural and intracultural studies. Journal of Cross-Cultural Psychology, 33, 87–99.

23.

Khamis

(2019). Posttraumatic stress disorder and emotion dysregulation among Syrian refugee children and adolescents resettled in Lebanon and Jordan. Child Abuse & Neglect, 89, 29–39.

24.

Knerr

Gardner

Cluver

(2013). Improving positive parenting skills and reducing harsh and abusive parenting in low- and middle-income countries: A systematic review. Prevention Science, 14(4), 352–363.

25.

Leijten

Gardner

Landau

Harris

Mann

Hutchings

Beecham

Bonin

E. M.

Scott

(2018). Research review: Harnessing the power of individual participant data in a meta-analysis of the benefits and harms of the incredible years parenting program. Journal of Child Psychology and Psychiatry, 59(2), 99–109.

26.

Lovibond

P. F.

Lovibond

S. H.

(1995). The structure of negative emotional states: Comparison of the depression anxiety stress scales (DASS) with the Beck Depression and Anxiety Inventories. Behaviour Research and Therapy, 33(3), 335–343.

27.

Messer

S. C.

Angold

Costello

E. J.

Loeber

Van Kammen

Stouthamer-Loeber

(1995). Development of a short questionnaire for use in epidemiological studies of depression in children and adolescents: Factor composition and structure across development. International Journal of Methods in Psychiatric Research, 5, 251–262.

28.

Moser

Stuck

A. E.

Silliman

R. A.

Ganz

P. A.

Clough-Gorr

K. M.

(2012). The eight-item modified medical outcomes study social support survey: Psychometric evaluation showed excellent performance. Journal of Clinical Epidemiology, 65(10), 1107–1116.

29.

Moussa

M. T.

Lovibond

Laube

Megahead

H. A.

(2016). Psychometric properties of an Arabic version of the depression anxiety stress scales (DASS). Research on Social Work Practice, 27(3), 375–386.

30.

Murphy

K. M.

Rodrigues

Costigan

Annan

(2017). Raising children in conflict: An integrative model of parenting in war. Peace and Conflict: Journal of Peace Psychology, 23(1), 46–57.

31.

O’Callaghan

Branham

Shannon

Betancourt

T. S.

Dempster

McMullen

(2014). A pilot study of a family focused, psychosocial intervention with war-exposed youth at risk of attack and abduction in north-eastern Democratic Republic of Congo. Child Abuse & Neglect, 38(7), 1197–1207.

32.

Open Data Kit. (2020). The standard for mobile data collection. https://getodk.org/

33.

Oveisi

Ardabili

H. E.

Dadds

M. R.

Majdzadeh

Mohammadkhani

Rad

J. A.

Shahrivar

(2010). Primary prevention of parent-child conflict and abuse in Iranian mothers: A randomized-controlled trial. Child Abuse & Neglect, 34(3), 206–213.

34.

Panter-Brick

Grimon

M. P.

Eggerman

(2014). Caregiver-child mental health: A prospective study in conflict and refugee settings. Journal of Child Psychology and Psychiatry, 55(4), 313–327.

35.

Pedersen

G. A.

Smallegange

Coetzee

Hartog

Turner

Jordans

M. J. D.

Brown

F. L.

(2019). A systematic review of the evidence for family and parenting interventions in low- and middle-income countries: Child and youth mental health outcomes. Journal of Child and Family Studies, 28(8), 2036–2055.

36.

Ponguta

L. A.

Issa

Aoudeh

Maalouf

Hein

S. D.

Zonderman

A. L.

Katsovich

Khoshnood

Bick

Awar

Nourallah

Householder

Moore

C. C.

Salah

Britto

P. R.

Leckman

J. F.

(2020). Effects of the mother-child education program on parenting stress and disciplinary practices among refugee and other vulnerable communities in Lebanon: A pilot randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 59(6), 727–738.

37.

Puffer

E. S.

Annan

Sim

A. L.

Salhi

Betancourt

T. S.

(2017). The impact of a family skills training intervention among Burmese migrant families in Thailand: A randomized controlled trial. PLoS One, 12(3), e0172611.

38.

Puffer

E. S.

Green

E. P.

Chase

R. M.

Sim

A. L.

Zayzay

Friis

Garcia-Rolland

Boone

(2015). Parents make the difference: A randomized-controlled trial of a parenting intervention in Liberia. Global Mental Health, 2, e15.

39.

Putnick

D. L.

Bornstein

M. H.

Lansford

J. E.

Malone

P. S.

Pastorelli

Skinner

A. T.

Sorbring

Tapanya

Tirado

L. M. U.

Zelli

Alampay

L. P.

Al-Hassan

S. M.

Bacchini

Bombi

A. S.

Chang

Deater-Deckard

Giunta

L. D.

Dodge

K. A.

Oburu

(2015). Perceived mother and father acceptance-rejection predict four unique aspects of child adjustment across nine countries. Journal of Child Psychology and Psychiatry, 56(8), 923–932.

40.

Reed

R. V.

Fazel

Jones

Panter-Brick

Stein

(2012). Mental health of displaced and refugee children resettled in low-income and middle-income countries: Risk and protective factors. The Lancet, 379(9812), 250–265.

41.

Rohner

R. P.

Khaleque

(2008). Handbook for the study of parental acceptance and rejection. Rohner Research.

42.

Ruggiero

K. J.

Del Ben

Scotti

J. R.

Rabalais

A. E.

(2003). Psychometric properties of the PTSD checklist—Civilian version. Journal of Traumatic Stress, 16(5), 495–502.

43.

Saile

Ertle

Neuner

Catani

(2014). Does war contribute to family violence against children? Findings from a two-generational multi-informant study in Northern Uganda. Child Abuse & Neglect, 38(1), 135–146.

44.

Shenderovich

Eisner

Cluver

Doubt

Berezin

Majokweni

Murray

A. L.

(2018). What affects attendance and engagement in a parenting program in South Africa? Prevention Science, 19(7), 977–986.

45.

Sherbourne

C. D.

Stewart

A. L.

(1991). The MOS social support survey. Social Science & Medicine, 32(6), 705–714.

46.

Shonkoff

J. P.

Garner

A. S.

, The Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, and Section on Developmental and Behavioral Pediatrics, Siegel

B. S.

Dobbins

M. I.

Earls

M. F.

McGuinn

Pascoe

Wood

D. L.

High

P. C.

Donoghue

Fussell

J. J.

Gleason

M. M.

Jaudes

P. K.

Jones

V. F.

Rubin

D. M.

Schulte

E. E.

Macias

M. M.

Bridgemohan

Fussell

J.…

Wegner

L. M.

(2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232–e246.

47.

Sim

Bowes

Gardner

(2018). Modeling the effects of war exposure and daily stressors on maternal mental health, parenting, and child psychosocial adjustment: A cross-sectional study with Syrian refugees in Lebanon. Global Mental Health, 5, e40.

48.

Sim

Bowes

Gardner

(2019). The promotive effects of social support for parental resilience in a refugee context: A cross-sectional study with Syrian mothers in Lebanon. Prevention Science, 20(5), 674–683.

49.

Sim

Fazel

Bowes

Gardner

(2018). Pathways linking war and displacement to parenting and child adjustment: A qualitative study with Syrian refugees in Lebanon. Social Science & Medicine, 200, 19–26.

50.

Sirin

S. R.

Rogers-Sirin

(2015). Educational and mental health needs of Syrian refugee children. Migration Policy Institute.

51.

Stone

L. L.

Otten

Engels

R. C. M. E.

Vermulst

A. A.

Janssens

J. M. A. M.

(2010). Psychometric properties of the parent and teacher versions of the Strengths and Difficulties Questionnaire for 4- to 12-year-olds: A review. Clinical Child and Family Psychology Review, 13, 254–274.

52.

Sund

Larsson

Wichstrøm

(2001). Depressive symptoms among young Norwegian adolescents as measured by the mood and feelings questionnaire (MFQ). European Child & Adolescent Psychiatry, 10, 222–229.

53.

Tavitian

Atwi

Bawab

Hariz

Zeinoun

Khani

Maalouf

F. T.

(2014). The Arabic mood and feelings questionnaire: Psychometrics and validity in a clinical sample. Child Psychiatry & Human Development, 45(3), 361–368.

54.

Tol

W. A.

Song

Jordans

M. J. D.

(2013). Annual research review: Resilience and mental health in children and adolescents living in areas of armed conflict—A systematic review of findings in low- and middle-income countries. Journal of Child Psychology and Psychiatry, 54(4), 445–460.

55.

United Nations Children’s Fund. (2020). Multiple indicator cluster surveys. http://mics.unicef.org/surveys

56.

United Nations High Commissioner for Refugees. (2019, June 19). Global trends: Forced displacement in 2018. https://www.unhcr.org/globaltrends2018/

57.

United Nations High Commissioner for Refugees, United Nations Children’s Fund, & World Food Programme. (2017, December 15). Vulnerability assessment of Syrian refugees in Lebanon—VASyR 2017. https://data2.unhcr.org/en/documents/details/61312

58.

Weathers

F. W.

Litz

B. T.

Herman

D. S.

Huska

J. A.

Keane

T. M.

(1993). The PTSD checklist (PCL): Reliability, validity, and diagnostic utility [Paper presentation]. Annual Convention of the International Society for Traumatic Stress Studies, San Antonio, Texas.

59.

Yule

Dyregrov

Raundalen

Smith

(2013). Children and war: The work of the children and war foundation. European Journal of Psychotraumatology, 4(1), 18424.

Outcome	Respondent	Pretest	Posttest	Difference	95% Confidence Interval	t	Effect Size (Cohen’s d)
Outcome	Respondent	M (SD)	M (SD)	M (SD)	95% Confidence Interval	t	Effect Size (Cohen’s d)
Child maltreatment
Harsh punishment	Parent (n = 249)	9.55 (5.73)	5.06 (4.51)	4.49 (6.34)	[3.70, 5.28]	11.18***	.71
Harsh punishment	Child (n = 66)	5.86 (5.48)	4.08 (5.52)	1.79 (6.68)	[0.15, 3.43]	2.18*	.27
Parental rejection	Parent (n = 235)	20.71 (8.58)	13.92 (7.77)	6.80 (10.35)	[5.47, 8.13]	10.07***	.66
Parental rejection	Child (n = 59)	18.08 (9.43)	13.20 (9.16)	4.88 (11.23)	[1.95, 7.81]	3.34**	.43
Child psychosocial problems
Total difficulties score	Parent (n = 225)	16.67 (5.37)	12.50 (5.49)	4.17 (5.86)	[3.40, 4.94]	10.66***	.71
Depression	Child (n = 63)	7.33 (4.40)	4.38 (4.37)	2.95 (4.29)	[1.87, 4.03]	5.46***	.69
Anxiety	Child (n = 54)	29.67 (13.24)	21.30 (16.04)	8.37 (15.30)	[4.19, 12.55]	4.02***	.55
Parental mental health
Generalized distress	Parent (n = 234)	31.83 (12.84)	20.31 (13.47)	11.52 (14.37)	[9.67, 13.37]	12.26***	.80
Post-traumatic stress	Parent (n = 238)	33.92 (12.25)	25.36 (13.17)	8.56 (15.41)	[6.60, 10.53]	8.58***	.56
Perceived social support	Parent (n = 247)	15.52 (7.77)	17.92 (7.34)	2.40 (9.17)	[3.55, 1.25]	−4.11***	.26

Outcome	Respondent	Pretest	Posttest	Difference	95% Confidence Interval	t	Effect Size (Cohen’s d)
Outcome	Respondent	M (SE)	M (SE)	M (SE)	95% Confidence Interval	t	Effect Size (Cohen’s d)
Child maltreatment
Harsh punishment	Parent	9.48 (0.34)	5.85 (0.33)	3.63 (0.43)	[2.79, 4.47]	8.53***	.54
Harsh punishment	Child	6.52 (0.59)	4.19 (0.51)	2.32 (0.69)	[0.96, 3.68]	3.35**	.35
Parental rejection	Parent	20.86 (0.52)	15.12 (0.50)	5.74 (0.66)	[4.44, 7.04]	8.70***	.52
Parental rejection	Child	18.72 (1.08)	13.41 (0.81)	5.31 (1.20)	[2.96, 7.65]	4.44***	.46
Child psychosocial problems
Total difficulties score	Parent	16.66 (0.32)	13.26 (0.34)	3.40 (0.39)	[2.63, 4.16]	8.76***	.55
Depression	Child	7.82 (0.43)	4.87 (0.42)	2.95 (0.45)	[2.06, 3.83]	6.51***	.69
Anxiety	Child	32.65 (1.24)	23.45 (1.36)	9.19 (1.43)	[6.39, 12.00]	6.43***	.67
Parental mental health
Generalized distress	Parent	32.69 (0.77)	22.01 (0.76)	10.68 (0.85)	[9.01, 12.35]	12.56***	.74
Post-traumatic stress	Parent	33.66 (0.73)	26.34 (0.77)	7.32 (0.93)	[5.50, 9.15]	7.89***	.47
Perceived social support	Parent	15.43 (0.47)	17.57 (0.43)	2.14 (0.57)	[3.25, 1.03]	−3.78***	.23