Student #: 7907634
Word count: 2049
The Impact of Parent Psychopathology and Parenting Behaviors on the Mental Health of
Children in Refugees Families Settled in Canada
Background
The past decade has seen more persons displaced from their home than any other time in
history, with at least 100 million people forcibly displaced, out of which, 40% are estimated to
be children 17 or younger (United Nations High Commissioner for Refugees, 2020). Canada is
one of the leading countries in refugee resettlement, ranking first among 26 countries in 2019,
when it accepted 30,082 asylum claimants (United Nations High Commissioner for Refugees,
2020). However, resettled refugees continue to be at a disproportional risk of mental health
problems post-migration (Steel et al., 2009). Although pre-migration exposure to violence and
other traumatic events has been extensively studied (Scharpf et al., 2020), emerging research
indicates that post-migration stressors also play an important role on mental health outcomes
(Fazel et al., 2012; Steel et al., 2009). For example, a review by Hadfield, Ostrowski and Ungar
(2017) on the mental health of settled Syrian refugee children settled in Canada found them to
be at higher risk of mental disorders, and that risk factors included both pre- and post- arrival
factors. One prominent post-migration risk factor for children is parenting mental health (Scharpf
et al., 2020), but the environmental pathways through which parental mental health problems
come to be imbedded in children’s mental health remain understudied in refugee populations.
Here, I propose a longitudinal study investigating the impact of parental psychopathology on
child mental health, with parenting as a potential mediating mechanism of this relationship.
The most commonly studied mental disorder in the context of refugee populations is posttraumatic stress disorder (PTSD). PTSD is a psychological disorder that can develop after a
person is exposed to a traumatic event such as “actual or threatened death, serious injury, or
sexual violence” (APA, 2013, p. 271). This severe stress reaction can develop as a result of
experiencing a traumatic event directly, by witnessing it, or by the event occurring to a close
loved one. PTSD tends to be highly impairing to a person’s life, with symptoms including
intrusive thoughts, memories, or dreams about the traumatic event, or feeling as though the
traumatic event is re-occurring. The person also experiences psychological distress and/or
physiological reactions to cues related to the traumatic event, and avoidance of this triggering
stimuli is common. To be considered PTSD, these symptoms must persist for longer than a
month after the traumatic experience (APA, 2013).
Although there is high variability in reports of PTSD of displaced adults, a systematic
review by Steel and colleagues (2009) found an estimated prevalence rate of 30% for both PTSD
and depression. Up to five years after migration, increased rates of PTSD and depression
persisted, and the incidence of anxiety disorders increased over time, suggesting trauma inducing
experiences create a susceptibility to internalizing disorders (Bogic et al., 2015). Not
surprisingly, increased psychopathology is also evidenced in child refugees. Blackmore and
colleagues (2020) estimate that refugee children and adolescents have high rates of PTSD
(approximately 23%), and increased prevalence of depression (14%), anxiety (16%), and ADHD
(9%), when compared to Western-born children. Interestingly, this review found no evidence for
elevated rates of ODD in refugee children, even though ODD and ADHD are highly comorbid
(APA, 2013) and that both adult (Hinton et al., 2009) and child (Elsayed et al., 2019) refugees
tend to experience greater anger on average. Despite the heterogeneity of refugee populations,
several environmental factors have been consistently found to be protective of (for example
longer period of schooling prior to displacement, family cohesion, acculturation) or to put
children at risk for (for example exposure to violence, longer stay at a refugee camp, perceived
discrimination) mental disorders (Scharpf et al., 2020). Another helpful divides of risk factors are
by timeline of experience (were these present before, during, or after settling in the host
country?) and the socio-ecological level of the factor (is it something about the individual, the
family system, the community they moved in, or the structure of the new society? Scharpf et al.,
2020).
The most investigated risk factor pre-migration in refugee populations is exposure to
violence and other war-related traumatic events (Fazel et al., 2012). Other risk factors include
risks of detention and length of stay at a refugee camp. However, an emerging body of literature
has started focusing on the factors perpetuating psychopathology after arrival to the host country
(Fazel et al., 2012; Giacco et al., 2018; Hynie, 2018; Scharpf et al., 2020; Walker et al., 2009).
Factors that negatively influence the mental health of refugee adults include low income, unsafe
neighbourhoods, inadequate housing, lower language skills, difficulties finding employment, and
social isolation (Hynie, 2018). Similar post-immigration risk factors affect children (Fazel et al.,
2012; Hadfield et al., 2017), although the added parental-related risks take the forefront as one of
the most important factors, including parental mental health problems, negative parenting
behaviors and parental abuse (Scharpf et al., 2020). For parents who have recently moved to
Canada, combining these daily stressors with past trauma experiences might increase refugee
parent’s allostatic load to levels where it impairs their parenting skills.
Even if the child did not experience traumatic events firsthand, or if they did not develop
PTSD or other psychopathology from it, parental PTSD can still have a negative effect on child
outcomes. Children without a history of trauma exposure but with a parent suffering from PTSD
have an elevated rate of mental health problems, even when controlling for other environmental
risks (Leen-Feldner et al., 2013). Importantly, whereas Scharpf and colleagues (2020) identify
parental psychopathology and negative parenting behaviors as independent risk factos, LeenFeldner and colleagues (2013) argue that maladaptive parenting behaviors are a pathway of
vulnerability between parental mental health problems and child mental health outcomes. This is
consistent with the literature on non-refugee parents struggling with mental health. For example,
maternal depression has been shown to negatively influence child outcomes (Goodman et al.,
2011), a finding that appears consistent across most psychiatric disorders (Apter et al., 2017).
Perhaps because the large number of parallel stressors that refugee children face, the
mediation of these variables has not been studied as extensively in the literature with this
population, although research on this topic is emerging (Bryant et al., 2018; Flanagan et al.,
2020). In particular, Flanagan and colleagues (2020) point out that most research investigating
intergenerational transmission of trauma lack a nuanced explanation of how it is transmitted.
Expanding on the same theoretical mediation proposed by Leen-Feldner and colleagues (2013), a
review by Flanagan and colleagues (2020) recently summarized the findings for the
intergenerational transmission of trauma in refugee families with children without a history of
direct trauma exposure. Their findings suggest that parental exposure to trauma affected child
mental health indirectly, with insecure attachment and maladaptive parenting styles being the
most salient mechanisms. Thus, evidence appears to suggest that one of the most impactful
mechanism of mental illness transmission from refugee parents to their children post-migration is
through parenting variables.
Finally, I review a study that closely informs our proposed study design, namely the research
on settled asylum claimants and refugees in Australia conducted by Bryant and colleagues
(2018). Within the larger Building a New Life in Australia (BNLA) project, the researchers
collected data from 395 caregivers, reporting on 639 children. Across three time points roughly 3
years apart (a year between each) they assessed caregiver’s PTSD symptoms, dimensions of
warm and harsh parenting and, at the third wave of the study, child psychological difficulties.
Their analysis supported the hypothesis that increased parental PTSD symptomatology results in
heightened child psychopathology, and that this relationship is mediated by harsh parenting, as
characterized by negativity, use of physical discipline, and rigid enforcement of rules.
Although the study undertaken by Bryant and colleagues (2018) has several strengths such
as large sample size and longitudinal design, there remain some unanswered questions. First,
they focused on parental PTSD, while several types of pathology result in negative child
outcomes (Apter et al., 2017), and refugee parents are at higher risk of psychopathology beyond
PTSD (Buhmann, 2014). Second, in families with several children, they explicitly chose older
children (aged 11-17 at wave 3). Although this benefitted their analysis as the older cohort of
children was able to provide self-report responses, it might reduce the strength of the study by
potentially excluding differing pathology in younger children. Child outcomes were only
measured at time 3, so we are unable to know the influence of ongoing parental psychopathology
of children at different time points, and we are unable to account for the effects of spontaneous
recovery that sometimes occur in individuals with PTSD or depression (Buhmann, 2014). Lastly,
literature reviews suggest that refugee children are more likely to have a mental disorder during
the first 2 years of settlement (Blackmore et al., 2020). Measuring mental health outcomes at
year 3 might be missing some of this variation (children may have acculturated faster than their
parents, lending additional protective factors against the effects of parental mental illness).
Hypothesis
My research study intends to expand on the results obtained by Bryant and colleagues
(2018) in a Canadian context. I aim to form a fuller picture of child psychopathology during
refugee’s first three years post-migration, the amount of risk contributed by parental mental
disorders, and whether other psychopathology (beyond PTSD) follow the same mediation
trajectory. Thus, I seek to answer the following questions:
1. Are there similar trends of mental health outcomes in refugee children re-settled in
Australia and Canada? We expect to see similar trends, as these are both high-income
Western countries with similar refugee policies (Fazel et al., 2012)
2. Does general parent psychopathology result in more negative parenting behaviors
3. Does general parent psychopathology result in more child internalizing and externalizing
problems during early and middle childhood?
4. Do negative parenting behaviors mediate the relationship between parent
psychopathology and child outcomes?
Methods
Longitudinal data will be collected from landed refugees across key urban centers in Canada
at 3 times points: immediately after settlement (within the first 3 months of arriving to Canada,
Wave 1), at a year and a half after settlement (Wave 2), and at 3 years of settlement (Wave 3).
Only family units with at least one dependant aged between 4 and 10 years at the time of landing
will be considered for inclusion in the study. The principal or secondary applicant in the family
unit will be contacted and offered to participate with translation services available in their first
language and emphasizing that there are no penalties involved if they choose not to participate.
Translation support will be provided at each city cohort assessed in commonly spoken languages
of refugees who come to Canada (Arabic, Burmese, Swahili, Tigrinya, and Kurdish). At each
time point, data will be collected on the parent’s general psychopathology, parenting behavior,
and child internalizing and externalizing behaviors. Demographic information will be collected,
including country or origin, first language, English or French Benchmark, single parent status,
and parent and child gender and age. Continuous recruitment of families arriving to Canada will
take place from Jan 2021 – Jan 2022, with a target of recruiting 600 parent-child dyads.
For parental psychopathology, I will use the DSM–5 self-rated Level 1 cross-cutting
symptom measure (Narrow et al., 2013), a brief, self- or informant- rated measure that includes
symptoms relevant across different psychiatric domains and has been validated in prior research
(Bravo et al., 2018). Further, I will use the Harvard Trauma Questionnaire and the Hopkins
Symptom Checklist-25 to measure PTSD symptoms and depression/anxiety symptoms,
respectively (Mollica 2004), measures that have shown reliability across linguistic groups (Wind
et al., 2017). Parenting practices will be assessed through the Parenting Young Children
(PARYC) measure, which includes three dimensions: supporting positive behavior, setting
limits, and proactive parenting (McEachern et al., 2012). General child psychopathology will be
measured through the Child Behavior Checklist (CBCL; Achenbach, 1999).
Analytic plan
I will use a path analysis to assess the temporal pattern of associations between the
independent variables, namely general psychopathology, PTSD, depression and anxiety
symptoms, and the three components of PARYC measured independently, to the main variable
of CBC scores at waves 2 and 3 of the questionnaires. I will control for single parent status
child’s gender and age, country of origin, and first language.
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