Posted: August 6th, 2022

Exploring Traumatic Influences

 A critical aspect of supporting young children and families is your  understanding of the varied ways traumatic influences impact children’s  identities and their development. What might surprise you is that the  ways in which you view trauma, much like your other views, have also  been shaped in various ways by societal bias. This week you were asked  to review a sampling of articles focused on a variety of different  categories of trauma. These articles were specifically selected to  provide you with information on a range of traumatic influences while  also providing you with another lens through which to view that  particular trauma. As you engage in this week’s discussion be certain to  focus on the varied ways trauma can influence children differently, the  similarities and differences found amongst a range of traumatic  influences, and any factors of resilience that were revealed in your  readings.

Keep in mind the prompts below:

  • Aspects of this week’s readings that challenged your thinking with  regard to trauma and other disruptive life events and the ways in which  trauma impacts children’s identities and continued development. Provide  examples, including what surprised you and if relevant, what  preconceptions were dispelled.
  • The similarities and differences you found amongst the categories of traumatic influences you explored
  • Your definition of resilience and any factors of resilience you found in the articles you selected
  • Any connections you made between Quinn’s story (from “Learning from Another’s Life Story”) and this week’s reading assignments

Visit the link below:

https://bernardvanleer.org/app/uploads/2015/12/ECIF6_Culture-and-learning

Turn to page 6

Visit the link below:

http://cdn-media.waldenu.edu/2dett4d/Walden/EDUC/6357/CH/mm/audio_player/index_week7.html

The click on “Traumatic Influences.” Then click on each person’s name in the lower lefthand corner

Forum on Public Policy

1

Assessing the Consequences For Children and Families When a Parent Has A

Problem With Substance Use and Abuse: Considerations For Social Workers

and Other Helping Professionals

Dennis Kimberley, Professor, School of Social Work, Memorial University, Newfoundland , Canada

Dedicated to the memory of Margaret Cork and her forgotten children.

Introduction

“She was a crack ho who did lines on the way to birth me. I am better off where I be than back

with her, brud and dad.”
1

The intent of this paper is to contribute to scholarship, knowledge and public policy regarding

child maltreatment and parenting capacity within the context of parental substance use and

abuse. One goal is to give voice to the children who have moved to, or who are approaching, the

threshold for needing a type of protection that is neither governed by the best interest of the

parent (even by default) nor by fixation by professionals on an ideology of family preservation—

in the face of competing logical possibilities. In their best interest, many children and youth with

drug addicted parents, who present repeated risks with known harm, are now more likely to

require continuous care and a permanency plan (Brown and Hohman, 2006; Covey, 2007;

Hogan, 2007; Schmittroth, 1994).

Among the objectives of this analysis are included:

 to contribute to policy analysis and debate with respect to children’s protection
programming and practices within the context of repeated parental substance use or

abuse, which pose imminent and highly likely risks and associated valid concerns with

parental capacity and child-youth care;

 to apply child risk-need-harm assessment knowledge, gained from the qualitative review
of 50 cases from one clinical practice, that integrated assessments of parental capacity

and care issues associated with substance use, abuse and/or addictions—cases where

expert professional opinion was requested by the court and/or by children’s services;

 to explore the risk-need implications of parent capacity issues associated with co-
occurring (concurrent) disorders – addictions and mental health;

 to analyze some program implications of treating parental addiction as a form of child
maltreatment and of defining increasing numbers of children as in need of continuous out

of home care.

This policy-practice analysis relies on selected literature and on published studies and analyses

within some current and emerging contexts. Part of the analysis is informed an analysis of fifty

case files, exploring an available sample of expert assessment processes and classifications

associated with parental capacity and child-risk need—where parental capacity has been

repeatedly compromised by substance use, abuse and addictions. The analysis applied pre-

determined broad child-risk-need-harm dimensions, expanded upon within the context of

interpretations arising from the case content and findings from the literature, to enable

formulation of conclusions regarding how some drug effects, substance use and abuse, and/or

drug using lifestyle, interact with parental capacity and child risk-need-harm.

1 Statement of a young male who found himself “doing better” in continuous care and a 24/7 alternative living

arrangement. Quotes have been modified slightly and cases have been merged in order to ensure childrens’ voices

are heard and identifying information is not disclosed.

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The context of child maltreatment associated with addictions-compromised parenting
2

Since the early 1900’s social workers and cognate disciplines responsible for the protection of

children have been concerned with the impact of parental substance use and abuse: on the safety,

well being and development of children and youth; on personal and social functioning of

parent[s]; as well as on the social functioning of the family (Richmond, 1917). Of note by the

1960’s were the findings that, even when the alcoholic parent became sober, children reported

their experiences of parental and family problems and risks had not changed significantly and

had sometimes become worse (Cork, 1969, 53-56). By the 1970’s treatment policies, programs

and practices expanded to enable family therapy supports for children of alcoholics (Aubertin

and Berlinguet, 1971; Bepko, 2002).

Following from Cork (1969), by the 1980’s, those writing from an adult children of

alcoholics perspective often emphasized the long term developmental and transgenerational

damage of being raised by a parent or parents who had problems with substance abuse; family,

group and self-help supports were offered for some children (Woititz, 1990). Some addictions-

related abuse, neglect and developmental damage was sufficiently serious that by the 1990’s it

was argued that parental alcoholism and/or drug addiction, justifiably, could be judged as being a

form of child maltreatment (Briere, 1992; Covey, 2007: 142). As well, some professionals and

courts have made a best interest case that repeated patterns of addicted mothers, putting unborn

and newborn children at risk (and causing predictable developmental damage, Chapman, Tarter,

Kirisci, and Cornelius, 2007) should result in children being apprehended at birth. The counter

point is typically advocacy for the mothers and accounting for child risk in terms of structural

and situational factors that contribute to the mothers’ addiction risks, versus assuming a primary

focus on individual parental responsibility and child-centeredness. This author has revisited the

issue of repeated parental relapse to substance use, abuse and/or addictions (after personalized,

social and economic supports have been offered) as posing sufficient risk and harm, as well as a

serious violation of the rights of children to have basic needs met, and concluded that child-

centered assessments may be more and more justified in defining substance addictions-

compromised parenting as a form of child maltreatment
3
—independent of any additional

compounding risks and harm with respect to sexual, physical, or emotional abuse and

exploitation.
4

While family support and preservation have been themes of child and family practice

since the early 1900’s, and while there was a major emphasis in the 1980’s and 1990’s on family

preservation as being in a child’s best interest, largely based on the impacts of parent-child-

parent attachment and separation dynamics on child development (Daniel, Wassell and Gilligan,

2
The words addicted and addiction are hereafter applied to refer to substance use, abuse and/or life style

patterns consistent with a general addictions paradigm, rather than repeating the complete phrase in the text.
3
It is disturbing to note that DUI laws do not require officers to prove reckless driving but arguments that

children’s protection social workers must observe acts of endangerment associated with parental addiction may be

put forward (Covey, 2007,140).
4
The author notes that intervention with women who have an FASD child is critical because of the likelihood

that “successive children with FASD demonstrate even more dramatic effects”. For a comprehensive analysis of

policy and program issues regarding substance use and abuse during pregnancy see: Basford, Thorpe and Williams

(2005)

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1999), there was also a recognition that a threshold would be reached where the family

preservation goal could no longer be justified as being in the best interest of the child. Within the

context of a preference for family preservation, Steinhauer (1991) proposed applying a principle

in child placement decisions of “least harm”, but concluded that the family preservation goal

may have to be displaced by apprehension, protection, and permanency based on significant

known and expected risks and harm. Others have contributed to overcoming attachment

difficulties and risks after continuous care has had to be recommended (Archer and Hughes,

2003).

Under conditions where parental use, abuse and/or addiction to substances, and/or related

life-styles, create or exacerbate continued risk and harm, and are associated with a significant

violation of the child’s rights and related unmet needs, policy, program and practice bias in favor

of family preservation, must be challenged. Unfortunately, within the context of repeated and

continued addictions-compromised parenting, the best interest with the least harm, and the most

developmental benefit, for increasing numbers of children, is permanent out of home care—

sometimes with no contact with birth parents. In the current context, the realities of children’s

services is that child protection social workers often do not have a choice other than out of home

care, with more continuous and permanent placements being needed. From a policy-program

point of view protection and least harm options are becoming increasingly limited to placing

children—by design or default. (see for example, Barnard, 2007: 157 or Srikanthan, 2005).
5

Initially, this analysis takes a standpoint that minimizes attention to additional direct

concerns of child harm due to assessed or suspected physical abuse, sexual abuse, emotional

abuse or exploitation. As well, the recommendation to differentially assess addictions-

compromised parenting is put forward to promote child-centered evaluation of parenting

capacity that critically analyses the risks and impacts for the child that can be associated with

parent capacity concerns related to use, abuse, addiction and “addiction” lifestyle, relatively

independent of issues of poverty. Preventable poverty related to substance abuse, but not related

to non-addiction disability, illness, or parenting deficits in care and parenting knowledge or

skills, is among the main contributors to risk and harm. Within the context of this analysis, the

threshold for risk, harm and clinical significance is based on the standpoint of what the parent’s

substance use, abuse, addictions and related lifestyle imply if assessments focus on assistance

and special care needs and rights of children under the age of eighteen years (United Nations,

1989), versus parental rights.6

As one researcher concluded:

“It is perhaps ironic that in all the crowded attention on the parent with the drug

problem…there was very little discussion among the practitioners of the

5
While the author favors attempting family preservation in many instances, one study (Pidcock and Fischer,

1998)which hypothesized that children of parents in recovery would evidence significantly less addictive behavior

than those whose parents were not in recovery, failed to support the hypothesis. Also, addictions-compromised

mothers involved with children’s protection were found to be more likely to exhibit unsatisfactory discharges from

treatment than were substance abusing mothers not involved with children’s services (Hohman, Shillington and

Baxter, 2003).
6
Notwithstanding the exclusion of physical abuse, sexual abuse, emotional abuse and child exploitation from

the main thrust of the author’s analysis, it is recognized that all of these added risk-harm factors have been found to

be more highly correlated with, and exacerbated by, parental addictions and related lifestyles (Briere, 1992; Covey,

2007: 150; Kroll and Taylor, 2003).

Forum on Public Policy

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children’s perspectives. For the most part their needs were assumed, and

considered to be best met through supporting the parent. This might be an

explicable dynamic, especially where children are very young, but it creates a

dangerous invisibility and reinforces their vulnerability.” (Barnard, 2007, p.150.)

The position in this analysis is that parental assessments must become more child-centered and

the voices of children must assume primacy.

Professionals’ assumptions about child care and parenting knowledge and skills deficits

may be misapplied when parenting deficits are more associated with addictions-compromised

parenting. For example, it may not be uncommon to have addicted parents who have adequate

education, adequate resources and/or “good enough” knowledge and skills with respect to child

development and child risk-need. Child risk-need issues may not be significantly related to skills

and knowledge deficits and problems regarding ability for care and parenting, as they are, for

example, related to parental distraction and self-centered motivation -sometimes framed within

the context of narcissism associated with addictions (Flores, 2004; Forrest, 1994). Providing

parent training services may have little relevance and/or few impacts with respect to risk-harm

reduction, or improved well-being for the children of

addictions-compromised parents.

The following addictions-compromised parent capacity assessment dimensions may increase

effectiveness in estimating child risks and needs:

 the relatively direct impacts of substance use and abuse on parenting and the parent-

child-parent relationship (e.g. the increased risks of parental aggression with some drug

use patterns);

 the impacts of substance using lifestyle on parenting and the parent-child-parent

relationship (e.g. the child having to self-protect from impaired strangers in her home);

 the impacts of parental narcissism that compromises child centered care and parenting

(e.g. parental expression of empathy in the interest of manipulating the child); addictions-

compromised attachment and bond (e.g. the child receiving repeated double-bind

messages such as, “I love you with my life, …. leave me alone.”);

 and parent-centered motivation displacing child centered motivated parenting and care

(e.g. an impaired parent playing an adult movie so he/she and the six year old child can

have some “quality time” watching a movie together at 1a.m.).

What is important is that parenting capacity issues, directly related to addictions-

compromised parenting, must be addressed; these are seldom developed and refined in

standardized child or parenting assessments. For example, in the case above, the parent

reported staying home with the child and watching movies; without more depth of

exploration and analysis, a social worker risks concluding that the parent was being

responsibly attentive, was reinforcing attachment and was adequately supervising the child.

This example reinforces the necessity for child-centered observations of children and risk,

including in interaction with addictions-compromised parents, including independent

interviews with the children, to whom addictions-compromised parents have access, or have

care and parenting responsibilities.

Forum on Public Policy

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Current policies and practices that promote parent effectiveness training and parent

capacity building (e.g. Cipani, 1999), in case of addictions-compromised parenting, may be

trying to change the wrong dimensions of parenting capacity such as the less complex area of

parenting knowledge and skills. Parent training practices may actually exacerbate the problems

and risks for children. An example is the case where a parent is cued to children’s protection

expectations regarding meals and nutrition and then presents an “illusion of change” that appears

as compliance while not acting in the spirit of the child-centered interests. In some cases parents

purchased and stored quality nutrition, yet the children did not have regular meals or receive the

food with needed regularity. The food may even be found to be well organized for display when

a follow up protection assessment is undertaken (one clue is an abundance of out of date food).

Goal displacement was common with parents whose patterns of addiction continue. For example,

some parents did not reason that obtaining, organizing, placing on the table for possible

consumption, and displaying food, was not their primary change goal with respect to child care

and the demonstration of improved parent capacity.

As well, from a child-centered perspective, parent training might mean active parent

coaching (in real time interaction with their children) from a social worker or behavior

management specialist, in order to manage a child who is disruptive and defiant (two of the

patterns associated with children’s coping with a mentally ill or addicted parent). It should be

recognized, though, that from the child’s perspective the impact on him or her is that of blaming

the child for the parent’s failure in recovery; by default, the child is given the responsibility to

change his or her behaviour, while the parent may change nothing. In short, typical programs for

parent training, as applied to addictions-compromised parenting capacity, are often be

misapplied, at best, and may add to risk and harm, at worst.

In the experience of the author, assessing and changing the parent-child-parent

relationship in terms of care and parent capacity could require much more complex and extended

in vivo observation and therapy inputs, observing the real time care and parenting as part of an

in-depth biopsychosocial assessment, as well as undertaking parental and family therapy and

coaching in real time—much beyond behavior management training for child and parent. For

addiction-compromised parents observed in vivo
7
with their children, informed by some

independent direct observations and interviews of some of the children, risk control and harm

management, as well as demonstrating strengths in meeting the needs of the children, required

much effort and commitment by parents to change and sustain change. Unfortunately for the

children, half of the assessment observations were made under conditions where parental energy

was directed to substances and the related addiction life-styles. Some parents were so impaired

cognitively and behaviourally while being observed for assessment and services planning, that

alternate care givers had to assume child-care and parenting responsibilities during access. In the

experience of the author, confidence levels in the parenting capacity and child risk-need

7
In most cases the author and other professionals associated with the parent capacity assessments observed the

parent(s) with their children, and some children on their own, for eight to twenty hours over four to seven

observation periods. The professionals came to have more confidence in these observations and judgments of

problems, risks, harm, strengths and need, than they did from parent interviews in clinic, or from observing and

interviewing children in a “less natural” controlled clinical setting.

Forum on Public Policy

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assessments were increased with multiple direct observations over eight or more hours –

preferably over two or more weeks.

Parent’s relative lack of sustained success, in parental education and/or counselling-

therapy programs, associated with repeated return to parental use of a current range of disabling

substances such as cocaine, “crack”, methamphetamine, oxycodones, and ecstacy, cannot give

justice, policy, program and practice professionals much confidence in the relative likelihood of

successful family preservation in the best interest of child safety, meeting childrens’ needs, and

supporting normative biopsychosocial development. Even when highly drug involved parents

claim, with conviction, that their love for their children is paramount, and when they

vociferously “contemplate” child-centered change and promise sustained motivation, and even

when they have been given repeated “last chances” by children’s protection services and/or the

justice system, the likelihood of relapse and return to child risk and harm, most often, is greater

than is the likelihood of them sustaining action in the best interest of the child.
8
After successive

broken promises and parental failures, the “forgotten children”, then more skeptical of their wish

for a “cured” parent, would not have much confidence in effective and sustained parental

change; as one twelve year old stated to the learned protection and justice professionals, whom

she believed had not protected her and her sister well: “So which last chance is the last chance; I

thought the last chance was the last chance.” Child-centered parenting capacity assessments

could make protection, continuous care and permanency plan thresholds more effective in

controlling risk, reducing harm, ameliorating impacts, meeting developmental needs and

increasing well-being of children.
9

For those social workers who are responsible for foster care and adoptions placements, a

policy, program and practice movement towards planning for more continuous out of home care,

as a permanent plan for children and youth, would likely result in much apprehension and fear.
10

For foster parents and for those adopting highly damaged children and youth, the feeling is often

one of being overwhelmed and wishing to do more. Such intense feelings are often associated

with professionals being aware that older children, children with developmental deficits (e.g.

FASD) due to personal and family history, and those with addicted parents, would be at high risk

in terms of both adoption failures and foster family failures. One the other hand, with more

resources put in place to control risks (e.g. professionally supervised parental access) or to

ameliorate harm (e.g. therapeutic foster care), fostering may provide care and parenting with

relatively helpful outcomes (Dozier and Rutter, 2008); similarly, financial and service-supported

adoptions, for children at high risk, may be relatively successful. For some children even

8
Learning and ability to transfer information from a drugged state to an undrugged state (“dissociation”,

McKim, 2007, 37) may impair parents’ abilities to transfer parent capacity learning from an undrugged state to a

drugged state and vice versa.
9
Social justice demands that the well-being of children must be framed in such a way that parent-centered

expectations for the child’s resilience, adaptation and coping do not become a compromising substitute for child-

centered well-being.
10

Some foster care social workers expressed concern about finding sufficient placements able to help children

who brought with them complex issues of addictions-compromised parenting – especially when the child defined the

parent as non-abusive. Some adoption social workers were concerned with the added complexities of finding

placements for children that were exposed to addictions-compromised parenting – especially when the child may

have ingested drugs or have been exposed to hazardous chemicals.

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alternate semi-independent, or independent, supported living arrangements provide more hope,

less harm, and less risk than do further attempts at family preservation. In applying all of these

placement options, the author has come to have confidence in an integrated “therapeutic foster

care” or “therapeutically supported adoption” type of model.

The literature suggests that therapeutic foster care has beneficial results in the best

interest of the child, albeit while being more costly than traditional foster care (Crosson-Tower,

2008). In the author’s clinical experience, a less costly version of therapeutic foster care, also

becomes an option with children at additional risk due to life experiences with, care from, and

parenting from, substance using-abusing parents.
11

Specifically, part of service planning may put

supports in place for traditional foster care families, or traditional adoptive families, that fully

integrates long term individual and family therapy, some of which may be undertaken in the

home. The policy, program and practice case being made here is for therapeutically supported

foster care and adoptive placements with integrated foster parent/adoptive parent development,

timely support, psychosocial education and in vivo integrated therapy with foster parents and

adoptive parents coached in assuming some roles as “surrogate therapists”—thus helping to

maintain and enhance strengths and treatment effect. The less ideal option is alternate and semi-

independent living arrangements, with multiple child-youth care-givers providing age-stage

appropriate and continuous support. Integrated therapy for the child and professional coaching

for paraprofessional care givers may simulate a therapeutic foster care model.

Use, Misuse and Addiction—A Child-Centered Perspective

The risks and impacts of substance use, misuse and abuse, and the presence of hazardous

materials in living spaces, have serious implications for the safety and developmental needs of

children, the personal and social functioning of parents, as well as on the social functioning of

their families. The nature of the effects of some drugs and the addicted parent’s lifestyle may

increase risks for children and their families. For example, methamphetamine, cocaine and crack

cocaine use, and other stimulants such as amphetamine may be associated with irritability,

agitation and aggression,and antisocial behavior [McKim, 2007] as well as impaired parental

patience, which has posed additional risks for physical and emotional abuse [Barnard, 2007].

Heroin abuse and sedative-hypnotics misuse may be associated with impaired capacity for

parental alertness, attention and supervision, but may be followed by irritability; benzodiazapines

are associated with confusion. Ecstacy, the love drug (methylenedioxymethamphetamine) is

associated with intoxication, increased libido and enhanced sexual pleasure and eroticization

[McKim, 2007] and has put children at risk for exposure to explicit sex and eroticization or, at

worst, sex abuse and sexual exploitation (see for example Famularo, Kinscherff and Fenton,

1992). The risks of exposure to family violence are exacerbated in families where substance use

and abuse is a compounding factor (Potter-Efron, Potter-Efron and Carruth, 1990; Barnard,

2007). In short, each drug, as used in moderate and high levels, and as associated with tolerance,

11

The author distinguishes between care and parenting in that a parent may provide food, shelter, clothing and

personal care while not providing adequate supervision, direction, coaching, safety, and optimal age-stage controls.

As well, with addicted and mentally disordered parents it is important to differentially assess child care and

parenting activities that are acted out in the best interest of the parent – a narcissistic approach to parenting.

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8

withdrawal, and dependence, presents its own risks vis a vis addictions-compromised personal

and social functioning—including parenting.

The distinction between use, misuse and abuse, or addiction to substances, most often

becomes moot when considering risks, impacts and children’s needs for care, parenting and

protection. Applying causal theories, such as parental disinhibition due to substance use and

abuse, or an expectation effect associated with drug effects (Walsh, MacMillan and Jamieson,

2003; Fromme, D’Amico and Katz, 1999), may help refine assessments, but do not mediate risks

and harm to the child. Without attending to risks posed by parents’ friends and acquaintances, a

parent might be on a relapse prevention program that supports what is defined as safe controlled

use, or may be on a harm reduction program that supports what is defined as use with some

known impacts, but with predictably less harm to the parent. The child-centered assessment issue

is that even low to moderate levels of substance use may contribute to child risks, harm, unmet

needs and developmental damage. For example, even two standard drinks of beverage alcohol

(King and Byars, 2004), let alone the single use of a drug like ecstacy, (Jansen and Theron,

2006) may disinhibit parental sexual behavior in the presence of a child; a predictable, imminent

and serious risk is premature sexualization and eroticization
12

A parent may put a child at risk

irrespective of the parent not consuming drugs while parenting; for example the child may

consume prescription or street drugs left within reach, or the child may be given a drug (often

non-prescribed prescription drugs) in the interest of the parents’ needs to control the child or to

induce somnolence, or the child may be exposed to other adults or youth who pose risks

associated with use and abuse of substances or related life-style issues. As well, a parent’s

behavior and cognitive functioning are most likely impacted by drug tolerance, emotional

dependence, “hangover” and/or withdrawal; chronic exposure to drug mediated parenting is

associated with risks, harm and developmental problems for the child. For the child, parental use,

moderate use, misuse, excessive use, dependence and addictions all present avoidable risks in

addictions-compromised parents.

The analysis below addresses issues associated with children’s protection cases, or cases

where children’s protection should have been notified, where there was a high level of parental

abuse of street drugs, prescription medications and/or alcohol, and associated lifestyle—with

some cases meeting criteria for dual, concurrent, or otherwise labeled as co-occurring mental

health and addiction problems – considered to be a high risk and difficult to treat with sustained

success (Centre for Addiction and Mental Health, 2001). Many parents meet criteria for being

alcohol or drug dependent (American Psychiatric Association (2000) and fit the patterns

associated with a general addictions paradigm (Doweiko, 2008); others fit concurrent or dual

disorder criteria (Kimberley and Osmond, 2003; Centre for Addiction and Mental Health, 2003).

12

The author distinguishes between premature adult range sexualized behaviour and actions, which may be

expressed by the child without having sexual feelings, sensations, or motives (e.g. when a child is forced to fondle

her brother for a porn movie), and premature eroticization, which involves the child having sexual feelings and

sensations, sometimes without ostensibly related sexual actions (e.g. observed in children who have observed adult

sex movies or live sex acts, at a young age). At another extreme, the author has observed expressions of deviant

sexual acts by children such as bestiality, possibly associated with exposure to adult videos, or the fusion of sex acts

and physical aggression, by children who have been directly exposed to sexual assault. Such cases have involved

addicted or co-morbid parents and/or surrogate care givers.

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Either are likely to be high risk clinically, are not likely to sustain personal and child centered

change needed to ensure child safety, well being and normative range development.

Notwithstanding the above, from a child-centered perspective, high risk parent’s who are

now abstinent, parents who are using substances at low levels, parents who abuse, parents who

are addicted, or parents who live an addicted lifestyle, may all pose considerable risk and harm

for the child. Assuming that parental progress in control of substance use and abuse significantly

reduces risk and harm to the child, and/or results in parenting and care that is in the best interest

of the child, is a dangerous assumption. Current parental abstinence or low levels of use are not a

sufficient rational for returning children to parental care.

The likelihood is increasing that more children will need to be placed in continuous care,

with little hope of family preservation, is becoming a reality. Beyond the social costs, levels of

risk and personal and family difficulty are making costs of support, protection and care of great

concern. As well, the changing face of families involved with children’s protection, it appears,

include more persons with (or having had) adequate to significant education and resources—

often presenting children’s protection with new layers of legal and political complexity.
13

Assessing risks, needs and harm to children in an addictions context

Within the context of significant and repeated parental abuse of substances, the analysis below is

based on selected research and practice related literature and a review of a limited clinical

sample of cases in one service which has provided case consultation to children’s services and

expert opinion to the courts. Parenting capacity, correlated parenting assessment concerns and

exemplars of child-risk need issues are integrated into each child assessment dimension, thus

supporting a child centered and child relevant parenting assessment and plan.
14

The need to belong

The need to belong to someone or with someone who is a care giver typically does not appear on

a list of common human needs [although it is referred to in the United Nations Convention on the

Rights of the Child, including the right to a name.]. At times the need to belong is enmeshed

conceptually with cultural, ethnic, racial, familial and social identity, and personal identity. The

author is making the case that even when children have a sense of cultural, ethnic, familial and

social identity, they may lack a sense of where they belong and to whom they belong. Children

of high risk parents who have a high level of involvement with drugs and the substance abuse

lifestyle may be left with various extended family members, friends and neighbors, and have a

13

Even those parents who meet the minimal criteria for good enough parenting, but who repeatedly return to

repeated high risk, are not likely to sustain their motivation, attention and actions expected with good enough

parenting. Some children have reported that their parents “fooled the judge and the counsellors” for a few days, then

returned to drug parties within hours of “winning me back” in court. When a newborn half-brother was returned to a

drug involved mother, in the interest of mother-infant-mother bonding, the pre-teen, concerned for her new half-

brother said: “she couldn’t take care of us, what makes them think she can take care of him.”
14

The position taken in this analysis is that parent centered parenting capacity assessment criteria often

disadvantage the child(ren). For example, as part of a court order, an addicted parent may be assessed as needing a

parenting course; in many cases such courses teach knowledge and skills, often already possessed by the addicted

parent. The case plan for, or parental compliance in, completing a parent training program, would result in no

verifiable reduction or control in child risk or harm associated with addictions-compromised parenting.

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10

sense that they belong to no one (e.g. A child was left with a neighbor who was a stranger and

the parent never returned to claim the child—a form of abandonment; other children have been

“forgotten” in shopping malls.).

Even when apprehended and placed, the child’s level of biopsychosocial difficulty may

be such that he/she must placed in 24/7 “alternate living arrangements” that do not model a

family care environment. In extreme cases children may be “sold”, sometimes before birth

(sometimes to pay for drugs) or given to others in informal “adoption” arrangements. The sense

of not belonging with, or to, a parent or care giver is associated with high insecurity, distrust of

adults and threats to attachment and bond and a stable and integrated identity. With high risk

addictions-compromised parents, children who do not have a sense of belonging may never have

this need met; their coping strategies may result in them being relatively independent, adultified,

and the “resilience poster child”, but efforts at family preservation, in these cases, may actually

exacerbate the risks and long term developmental damage. Repeated failures to protect may

contribute to premature school leaving and the child “running”.

In addition to the above, in addictions-compromised parent assessments, direct observations

have included parents:

 missing planned and agreed upon access with their child(ren);

 arranging to attend to adults and adult matters during access visits;

 expressing emotional and intended commitment and then not following through;

 playing in parallel activity with a child, when the child is trying to be interactive;

 competing with a child for success in play and/or social tasks;

 competing with the child for the attention of the parent supervisor-coach;

 showing up to access while being under the influence of substances and/or impaired, or

evidencing significant withdrawal symptoms;

 falling asleep during access with the child, often associated with addictions and life style

choices;

 evidencing very little bond with the child and avoiding the child’s attempts to bond.

Issues of physical, emotional or sexual abuse, maltreatment or exploitation, would compound

problems associated with the need to belong. A stable placement with adequate supports (e.g. an

in vivo therapeutic environment) may give the child a sense of belonging and a sense of

continuity as well as more secure structure in her/his life.
15

The need for security and safety

Independent of more general concerns with maltreatment, abuse, exploitation and neglect, while

it is not uncommon that children in need of protection experience insecurity and threats to safety,

the children of high risk substance abusers may experience a range of risks and harm that are

linked to the substance use-abuse and the substance abusing life-style (Covey, 2007; Peleg-Oren

and Teichman, 2006). One major problem is children who have been exposed to hazardous

15

As part of differential assessment, the social worker must consider the logical possibility that a parent’s

demonstrated efforts to give the child a sense of belonging may be associated with the child being a source of social

assistance income and/or exploitation income, that may be used to support parental addiction.

Forum on Public Policy

11

substances (chemicals of abuse) in the womb and at birth (Schmittroth, 1994)—with special risks

for those children experiencing drug effects at birth. Lack of parental attention, care and

supervision (Barnard, 2007; Hogan, 2007) can take on new meaning when parents are so

impaired that they do not know the whereabouts of their three year old, for four days. Physical

environmental threats such as “needles”, broken bottles, and drugs within reach, present clear

and imminent dangers. The child’s physical environments may pose a HAZMAT risk for

children and safety professionals (e.g. a “crystal meth” lab, see Swetlow, 2003). Additionally,

some drugs may compound the risk of physical violence against a child (e.g. “meth”; “coke”;

“Oxy’s”) (see for example Covey, 2007: 150) or risks of sexual maltreatment of a child (e.g.

ecstacy). Parents’ drug abusing peers may pose many child protection risks. The drug abusing

lifestyle may be associated with substances and relationships that expose the children to the

immediate threat of being in the presence of violence—let alone the know developmental harm

related to such exposure (Potter-Efron , Potter-Efron, and Carruth, B.,1990). With high risk

abusers, it is difficult to arrive at a level of confidence in parenting-care change that is child

relevant, that would be sustained and control risk.

An additional risk, by default, is that if a child improves in care, the courts may judge that

the improved stability and well being of the child is sufficient to give the parent “another

chance”. Improvements in a child’s mood or actions in care, or even in the home with 24/7

parent coaching, often have no association with related improvements in the parent with respect

to care, parenting, risk reduction or harm amelioration. Besides giving parents multiple “last”

chances, children may cue the social workers that the parent has not changed and that risks are

still present.
16

Cases and addictions-compromised parenting assessments reviewed, and the literature

suggest giving attention

to:

 parental impairment, child centered attention and child supervision by the parent, even

under conditions where the parent-child contact is being supervised by another adult;

 parental agitation, irritability, threat and/or verbal or physical aggression towards a child,

even while being observed;

 parents giving the child an excess of negative attention or punishment based on parental

needs, paradoxically at times to impress the parent coach or access supervisor;

 parental sexualization or eroticization of some aspect of activities with the child(ren),

sometimes related to active drug use and impairment, independent of other valid concerns

about sexual abuse or sexual exploitation;

 parents “accidentally” giving unsafe persons access to the child during the child’s access

visit with the parent -even an adult who may have access prohibited;

 parents significantly misjudging the safety of the environment or the level of hazard to

which the child is exposed, even while being observed;

 parents exposing the child to physical or verbal violence in adult to adult exchanges,

during access or parental supervision;

16

In one case a thirteen year old child, doing well in foster care, requested to be present at the decision

conference to “prove” that her parent had not “really changed”; the parent failed the child’s test and the child got her

wish of having her and her sister remain in care.

Forum on Public Policy

12

 parents not complying with children’s protection directions (in case plans or in real time

directives) regarding physical, emotional and developmental safety, security and well

being, even when the parent has supervised custody.
17

One failure in judicial decision rules for a child protection service plan, that is not in the

child’s best interest, is using the child’s progress as a basis to, by default, risk his or her

regression in the interest of meeting the parents’ needs for access, under conditions where the

parent has not demonstrated adequate child-centered and safety-security relevant progress.

The need for stability and continuity

Children with high risk parents often experience unstable life experiences and significant

breaches of continuity associated with substance abuse. One source of rapid and dramatic

destabilization is when the child’s parent(s) are sent to prison (e.g. on drug related offenses).

(See for example, Srikanthan, 2005) More common instability is associated with long periods in

extended and repeated temporary care while a parent is “on a binge”, in withdrawal, or in

“rehab”. Terms of parental access may cause further instability and discontinuity when there is a

conflict associated with contact and access, or where the parent defaults on a promised “visit.”

One of the decision rules in many protection jurisdictions is to place a child with an

approved extended family member or known family friend, as opposed to in a stranger foster

home. Relative foster care may reinforce some of the risk dynamics such as permitting a risky

parent to have unauthorized and unsupervised access. By the time some children are offered

stranger foster care, their biopsychosocial problems are so pervasive (e.g. FASD compounded

with PTSD) that risks of foster care failure are increased and risks of adoptive placement failure

are increased. There is some evidence that a therapeutic foster care plan, or a therapeutically

supported adoption, may enable more amelioration of impact, but such practices may not be

supported, broadly and on a sufficiently continuous basis, in policies and programs, as they

imply additional costs for a system that is largely reactive.

Related addictions-compromised parenting assessments observed suggest giving attention

to:

 parent functional capacity to sustain stable actions and patterns associated with optimal

child care and child centered parenting;
18

 parent functional capacity for good judgement and actions to create child-centered

stability and continuity that is in the child’s best interest, as opposed to a narcissistic

agenda by the parent;

 parent risks in explicitly or surreptitiously misbehaving or destabilizing out of home

placements, or the daycare or school environment;

17

One differential assessment dynamic that is important to consider is a parent making parentified demands of

an age-stage inappropriate child, such as sending the nine year old to get the baby some milk at 1 a.m., based on

parental reasoning that the parentified child has proved able in the past. The link between parentification and

addiction and mental health-compromised parenting is strong.
18

One differential assessment consideration is in situations where the parent is creating stability and security

because the parent needs the child in her his life for social support and/or economic gain.

Forum on Public Policy

13

 not succumbing to parent agendas in breaking continuity for the child when out of home

placements are so child centered that they do not permit the birth parent much

opportunity for manipulation and control masquerading as “inclusive care.”

One case on which the author consulted was particularly dramatic. The child had stabilized

and progressed and in foster care, benefitting from continuous care from the ages six to eight at

the time of observation. The foster mother had the task of monitoring telephone contact between

the child and either birth parent. The telephone contact was encouraged, even when the child was

“not in the mood”, theoretically in the interest of attachment and bond, identity formation and

family inclusion. After one such telephone contact the child became very unstable—emotionally

and behaviourally. The foster mother was confused because she had heard nothing in the

telephone exchange that would make her suspicious. What was discovered in assessment was

that the parent had strategically targeted the foster home for disruption, likely hoping to get the

child to declare that she wished to return to her birth home. It appeared that the birth parent

strategically “caused” the destabilization by telling the child that he was petting a family pet—

the named pet had died years earlier. The foster parent was guided in taking ameliorative and

supportive action that would reinforce treatment effect for the child (a modified treatment foster

care model).

In short, in the face of repeated addictions-compromised parenting, the child’s need for

stability and continuity in a child-centered manner must take presidence over the parent’s need to

continue as parent.

The need for attachment and bond

The assumption made by most children’s protection, justice, addictions and mental health

professionals is that one of the foundations of healthy and normative biopsychosocial

development is an adequate attachment and bond to serve the mental health and developmental

needs of the child (Davies, 2004). There is considerable indication that parents with addiction

and mental health problems have deficits in enabling an infant or young child to attach and bond

sufficiently to meet the developmental needs of the child (Flores, 2004). When parents are

heavily into substance use and abuse and/or an addictions lifestyle, there is likely very little

energy put into enabling and retaining healthy attachment and bond that is child centered. At

later stages of the parents’ development of dependence and addictions, often interacting with the

parentification of the child, there may be an unhealthy trauma bond that is developed between

the parent and the child. The children need to have a healthy social bond supported, hopefully

one that has sufficient continuity to enable more normative development.

In considering parent capacity, assessments should examine the following. Some children

report a double bind message from the parent that is reflected in the following depiction:

“Mom/Dad wants to be closer to you; go away and stop bothering me”. In observing access, care

and parenting it is important to look for indications that the parent has problems with attachment

and with enabling the child to attach and sustain attachment. In assessments it is important to

distinguish those times when a parent is enabling attachment because a child needs a social bond,

care, security, versus the narcissistic counterpoint (Forrest, 1994) that the parent needs the

Forum on Public Policy

14

feeling of bond with her/his child and expects the child to be there for him or her. The risk of

significant developmental problems, including reactive attachment disorder, for the children of

high risk parents, is evident in some of the patterns of attachment, detachment or failure to attach

that are observed and reported. There is some evidence that attachment problems may be

overcome through enabling the child to attach to an alternate effective caregiver such as a foster

parent (Howes, 1999). The position of this author is that therapeutically integrated foster care or

supported adoption increases the chance of the child achieving and sustaining more optimal

growth and development, including attachment – with due consideration to the child’s potential.
19

Need for positive and instructive attention and affection

There are indications that children respond to parental direction when balanced with affection

and positive attention (Suchman, Rounsaville, DeCoste and Luthar, 2007). Children brought into

care often experience much negative attention and directives (coaching); parenting may not be

associated with child-centered affection. It is not uncommon for the addicted parent, as observed

in assessments, to express or look for affection when it is the parent needs such expression.

Associated with the issues of the quality of attention and affection, the high risk parent

often has pervasive problems with respect to self-control and then complains that they can’t

parent, as expected by children’s protection, because their child is “out of control”, “never

cooperates” and “was always that way”. The parent then feels vindicated (often supported by

default in court decisions) when his/her child is placed in a youth corrections facility or is

referred to a children’s mental health center
20

. Addicted parents, often, have much first-hand

experience with social exchange based relationships and may barter affection and positive

attention needed by their child, on a conditional basis. Foster parents, adoptive parents and

therapists, who are trying to successful integrate the child into a more promising social unit,

often must address issues such as: instructive attention being defined as negative attention and

the child wishing to “escape” structure and control; the child not knowing how to received

positive attention and affection and to process their meanings in a healthy fashion; the child

interpreting being spoken to by an adult as an indication that the child has failed in some fashion.

In short, it is important to understand care and parenting based on the child’s experience

in life as lived, not life as reported by the parent. With younger children, direct observation of

them and interacting with the child in play may be a source of hypotheses regarding the quality

19

In differential assessment, aside from the issues of trauma bond, it is important to the assessor to be sensitive

to illusions of healthy attachment based on a parent’s actions to get the child to meet the parent’s need for bond. One

marker that the author has found useful in assessment, is when the parent becomes angry with the child because

mom/dad “needs a hug/kiss/cuddle”, and the child has not responded or complied; yet when the child is trying to

attach, based on child-centered initiative, the parent may be unattentive, unaware or rejecting – sometimes

compounded by substance induced impairment. Another dimension that is important to differentiate is parental use

of what this author has labeled “strategic empathy” for parent centered purposes, with a child who needs positive

attention.
20

This author has seen cases where a parent has insisted that her/his child see one mental health professional

after another until a diagnosis is discovered and confirmed, not within the sense of Munchausen’s Syndrome, but in

the sense that if the child has a now “proven” mental disorder, then a thesis of parental deficits may be replace with

the cognitive script that: “I knew this all along; I am a good parent with an impossible child”.

Forum on Public Policy

15

of parental attention the child has experienced. Within this context, the child’s interpretation of

the quality and quantity of parental attention must be factored into the assessments.

Need for freedom from preventable maltreatment and trauma

While the author has focussed on impacts of parental addictions independent of other forms of

child maltreatment, abuse, exploitation and related trauma, the literature and research has many

examples of findings that parental use and abuse of substances, addictions and related life styles

are associated with a child’s increased risk of death, sex abuse, physical abuse, neglect and

various levels of exploitation from parentification to sexual exploitation. Children may be faced

with a double disadvantage and sets of risks in that they experience the direct effects of parental

addictions as well as associated risks of other forms of maltreatment (see for example Wolock

and Magura, 1996). While family preservation theory was built largely on the assumption that

neglected children would have less harm if they did not go into continuous care and thus

benefitted from family preservation plans, children who are repeatedly abused and/or put at

repeated risk for maltreatment, may be sacrificed on the alter of family preservation.

Need to not be increasingly resilient in the interest of parents

Application of resilience theory is often paradoxical in that children and youth, who have

suffered maltreatment and developmental damage associated with a life with addictions-

compromised parenting, often demonstrate much ability to adjust, adapt and cope (Ungar, 2005).

Their strengths are often framed being associated with resilience. Yet, in their silent awareness,

or shared thoughts in confidence with counselors, many do not define themselves as resilient;

they define themselves as fragile. The metaphor used by some is that of the tough outer shell but

with anxiety provoking cracks. The paradox is that the children’s apparent strength may be used

by “the system” to justify giving their parents yet another chance. When the child’s resilience

finally fails and the child ends up in mental health services, addictions services or youth

detention, accounts seldom point to the system’s responsibility or to parental responsibility but to

the child (now a youth) taking responsibility for his/her actions, attitudes and feelings. As one

child queried, “How come I am responsible for what I did but mom and dad were never

responsible for what they did to me, it was always blamed on the booze or the drugs”. When

another youth (aged 14) was complimented by professionals on her strength and resilience, the

wise teen retorted, “My resilience runs thin”. In assessments it is important to explore the child’s

paradoxical perspective on strengths and resilience as the voice of the child often expresses

nuances of anxiety and fragility that imply risk, need and harm that requires amelioration. In

short, the great strength of resilience may be experienced as a troubling weakness and be self-

defined, by the child, as a fraudulent presentation of self.

Conclusion

As parental use, abuse, addictions and substance abuse lifestyles become more intractable, and

have more repeated and lasting damage on children and youth, society must come to define

parental addictions that are chronic and/or repeated as a form of child maltreatment. As parenting

capacity is increasingly compromised by parental addictions and/or related life-style, and as

Forum on Public Policy

16

developmental risks increase, addictions and children’s services, as well as the justice, education

and mental health systems, are faced with the growing reality of parents defaulting on care and

parenting responsibilities. Child centered risk-need and parenting assessments, which include

significant in vivo observations, must address how the effects of the chemicals themselves,

addictions-compromised parenting and and/ or
21

addictions lifestyle, independent of any other

child maltreatment and developmental issues, should be addressed in policy, program and

practices in the best interest of children
22

.

Variations of in vivo therapeutic foster care, even

within 24/7 alternate care or adoptions, present one avenue for amelioration of harm, control of

risk, and support for more normative child-youth development. As one male child in an

alternative living arrangement offered: “I tried it again back there. I’m doing better with my four

mothers; they all take care of me” . But, his statement is not as poignant as the plea of a six year

old in a letter to the judge:

“Dear Judge, please don’t send me and my sister back to mommy and daddy.

They can fool you. They don’t change.”

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The author wishes to acknowledge the contributions of Louise Osmond, M.S.W., RSW and Meghan Hillier, R.A. in

the preparation of this paper.

Published by the Forum on Public Policy

Copyright © The Forum on Public Policy. All Rights Reserved. 2009.

O R I G I N A L C O N T R I B U T I O N

Adverse life events, area socioeconomic disadvantage,
and psychopathology and resilience in young children:
the importance of risk factors’ accumulation
and protective factors’ specificity

Eirini Flouri • Nikos Tzavidis • Constantinos Kallis

Received: 6 March 2009 / Accepted: 21 September 2009 / Published online: 10 October 2009

� Springer-Verlag 2009

Abstract Few studies on resilience in young children

model risk appropriately and test theory-led hypotheses

about its moderation. This study addressed both issues. Our

hypothesis was that for preschool children’s emotional/

behavioral adjustment in the face of contextual risk pro-

tective factors should be located in the cognitive domain.

Data were from the first two sweeps of the UK’s Millen-

nium Cohort Study. The final study sample was 4,748

three-year-old children clustered in 1,549 Lower layer

Super Output Areas in nine strata. Contextual risk was

measured at both area (with the Index of Multiple Depri-

vation) and family (with proximal and distal adverse life

events experienced) level. Moderator variables were par-

enting, verbal and non-verbal ability, developmental

milestones, and temperament. Multivariate multilevel

models—that allowed for correlated residuals at both

individual and area level—and univariate multilevel mod-

els estimated risk effects on specific and broad psychopa-

thology. At baseline, proximal family risk, distal family

risk and area risk were all associated with broad psy-

chopathology, although the most parsimonious was the

proximal family risk model. The area risk/broad psycho-

pathology association remained significant even after

family risk was controlled but not after family level

socioeconomic disadvantage was controlled. The cumula-

tive family risk was more parsimonious than the specific

family risks model. Non-verbal ability moderated the effect

of proximal family risk on conduct and emotional prob-

lems, and developmental milestones moderated the effect

of proximal family risk on conduct problems. The findings

highlight the importance of modeling contextual risk

appropriately and of locating in the cognitive domain

factors that buffer its effect on young children’s

adjustment.

Keywords Hierarchical data � MCS � Multilevel models �
Multivariate multilevel models � Psychopathology �
Resilience � Strengths and Difficulties Questionnaire

Introduction

In the classic approach to cumulative contextual risk in

child psychiatry [1], organismic characteristics as well as

proximal and distal qualities of the environment are mod-

eled collectively. For each environmental construct, a

dichotomous classification of risk exposure is determined,

typically by a statistical cut off (e.g., greater than one

standard deviation above the mean, upper quartile, etc.) or

on the basis of a conceptual categorization (e.g., being

below the poverty line). Cumulative risk is then calculated

by a simple summation of the multiple risk categories.

These risk categories are usually not weighted. In this

approach, therefore, risk is viewed as an accumulation of

stressors, and the number of risks that children experience

carries more gravity than the experience of any particular

E. Flouri (&)
Department of Psychology and Human Development,

Institute of Education, University of London,

25 Woburn Square, London WC1H 0AA, UK

e-mail: e.flouri@ioe.ac.uk

N. Tzavidis

Social Statistics and Centre for Census and Survey Research,

University of Manchester, Manchester, UK

e-mail: nikos.tzavidis@manchester.ac.uk

C. Kallis

London School of Hygiene and Tropical Medicine,

University of London, London, UK

e-mail: Constantinos.Kallis@lshtm.ac.uk

123

Eur Child Adolesc Psychiatry (2010) 19:535–546

DOI 10.1007/s00787-009-0068-x

risk. Indeed, cumulative risk indexes have been noted for

their potential to capture the natural covariation of risk

factors. For example, physical risk factors, such as poor

housing quality, noise and pollution are strongly interre-

lated as are psychosocial risk parameters such as family

turmoil and violence [2]. Furthermore, aggregate variables

of risk are more stable than any individual measure, and

there is increased power to detect effects because errors of

measurement decrease as scores are summed and degrees

of freedom are preserved [3]. Cumulative risk measures are

consistently found to explain more variance in children’s

outcomes than single factors [4–7].

Despite this, few studies [8] have examined the rela-

tionship between multiple risk exposure and young chil-

dren’s psychopathology using a cumulative risk approach.

In fact, even studies with school-aged children have yet to

deal with several issues with respect to the modeling of

cumulative risk. First, studies have yet to establish con-

vincingly the effect of the timing of cumulative contextual

risk on psychopathology [4, 9, 10]. Second, with few

exceptions [4, 11–14], studies do not examine the func-

tional form of cumulative contextual risk’s effect on psy-

chopathology. There is evidence for a linear effect whereby

increments in risk factors have a steady, additive impact on

mental health problems in school-aged children [5].

However, as few researchers actually report whether their

investigations included appropriate tests for nonlinear

patterns of cumulative risk, this ignores the possibility of a

nonlinear relationship that might manifest itself as an

acceleration [14] or a leveling-off [13] of problems at a

critical level of risk. Third, despite the renewed interest in

neighborhood effects on children’s development [15], only

few studies [16] compare family and neighborhood risk.

Fourth, although it is possible that the effect of one type or

one level of risk on psychopathology is conditional upon

the value of another, interactions between types and levels

of risk on child psychopathology are not usually studied.

Fifth and finally, with few exceptions [4, 8, 17, 18], most

studies do not examine factors that protect from negative

outcomes in children exposed to cumulative contextual

risk. The dearth of such research is unfortunate as various

protective factors have been identified as moderating the

impact of specific contextual risk. These factors are

grouped under two domains, namely, individual attributes

and connections to competent and caring adults in the

family and the community [19, 20].

Moderation of risk

To the best of our knowledge, the only study modeling the

moderation of cumulative contextual risk in preschool

children’s emotional and behavioral adjustment [8] found

that low vagal tone during tasks protected from the effect

of multiple risks, and concluded that this is because low

vagal tone during tasks may reflect regulatory capacities

that allow children to engage with learning opportunities.

This suggests that children’s advanced cognitive develop-

ment may be the factor that moderates the effect of con-

textual risk on emotional and behavioral outcomes.

Although previous research has certainly located in the

cognitive domain protective factors for school-aged chil-

dren’s emotional and behavioral adjustment in the face of

cumulative contextual risk [4, 18], studies have yet to

establish the importance of cognitive protective factors for

preschool children’s adjustment in the face of cumulative

contextual risk or test the hypothesis that for preschool

children’s adjustment in the face of cumulative contextual

risk factors promoting resilience should be located in the

cognitive rather than the biological or the social domain.

This study was undertaken to meet this aim, i.e., to test

that for preschool children’s adjustment in the face of

cumulative contextual risk factors promoting resilience

should be located in the cognitive domain. In doing so, it

also extended in several ways prior work on the role of

contextual risk in child psychopathology. First, it used

items from a well-validated measure of multiple family

risks. However, since only a selection of the original items

could be used, it also tested appropriately for the effect or

risk accumulation and risk specificity when modeling the

effect of family risk on child psychopathology. Second, it

measured both distal and proximal family risk to test for

the effect of the timing of risk on psychopathology. Third,

it measured area risk and compared area with family risk

effects. Fourth, it searched for an appropriate functional

form of both area and family risk’s effect on psychopa-

thology. Fifth and finally, it tested for the presence of

interaction effects between proximal, distal and area risk

on

psychopathology.

Method

Participants and procedure

Data were obtained from the first two sweeps of the

Millennium Cohort Study (MCS), a longitudinal survey

drawing its sample from all live births in the UK over a

period of 12 months, beginning on 1 September 2000 in

England and Wales, and 3 months later in Scotland and

Northern Ireland. The sample was drawn slightly later in

Scotland and Northern Ireland so as not to coincide with

other surveys being carried out on families with babies in

these areas at the same time. Sweep 1 took place when the

children were aged 9 months, and Sweep 2 took place when

the children were around 3 years. The sample design

536 Eur Child Adolesc Psychiatry (2010) 19:535–546

123

allowed for disproportionate representation of families liv-

ing in areas of child poverty in Northern Ireland, Scotland

and Wales and in areas with high ethnic minority

populations in England. In all there were nine strata: Eng-

land-advantaged, England-disadvantaged, England-ethnic,

Wales-advantaged, Wales-disadvantaged, Scotland-advan-

taged, Scotland-disadvantaged, Northern Ireland-advan-

taged, and Northern Ireland-disadvantaged. Data on child

psychopathology were collected at Sweep 2 from the main

respondent. Although the MCS is a study of 19,244 children,

there were complete data on broad psychopathology for a

total of 9,736 children clustered in Lower layer Super Output

Areas (LSOAs). LSOAs are built from groups of Output

Areas (typically 4–6), and are constrained by the boundaries

of the Standard Table wards used for 2001 Census outputs.

They have, on average, 1,500 residents. For example, there

are 175,434 Output Areas and 34,378 LSOAs in England

and Wales. In this study, LSOAs, rather than the electoral

wards on which the MCS survey design was built, were used

to get smaller ‘neighborhoods’ and more up-to-date eco-

logical correlates. For one child, there was no information on

the LSOA at Sweep 2 and, therefore, this case was removed

from our analysis.

Measures

Area contextual risk was measured with the Index of

Multiple Deprivation (IMD), a weighted area level aggre-

gation of specific dimensions of deprivation. The dimen-

sions of deprivation used to construct the English IMD

2004, for instance, were (1) income deprivation, (2)

employment deprivation, (3) health deprivation and dis-

ability, (4) education, skills and training deprivation, (5)

barriers to housing and services, (6) living environment

deprivation and (7) crime [21]. As the various UK coun-

tries’ indices of multiple deprivation are not comparable,

IMD ranks were used, which for the purposes of this study

were standardized. As discussed above, the geography we

worked with was at LSOA level and the IMD score was

measured at LSOA level. Many families changed LSOAs

between Sweeps 1 and 2 (of the 19,244 cohort members,

52.4% did not change LSOA between Sweeps 1 and 2, 44%

did, and for 3.6% there was missing information about

LSOA at Sweep 1), but most remained within the same

LSOA. The IMD scores at Sweeps 1 and 2 were highly

correlated (the correlation between the IMD ranks at

Sweeps 1 and 2 was 0.911), and we, therefore, used IMD at

Sweep 1 in all our analyses.

Distal (birth to Sweep 1) and proximal (Sweep 1 to

Sweep 2) family contextual risk was measured with a

subset of Tiet et al.’s [18] Adverse Life Events Scale. This

scale is composed of 25 possible events for which children

had little or no control over and is a modification of the

Life Events Checklist (LEC) [22–24], a psychometrically

valid [22] measure of exposure to potentially traumatic

events developed at the National Center for Posttraumatic

Stress Disorder (PTSD) to facilitate the diagnosis of

PTSD. The self-report version of the Adverse Life Events

Scale has been used with children as young as 9 years

[25], and measures exposure to adverse life events at both

family (e.g., ‘negative change in parents’ financial situa-

tion’), and child (e.g., ‘got seriously ill or injured’, ‘lost a

close friend’) levels. In view of this study’s research aims

the version of the scale used comprised items which (a)

measured only family level risk, (b) were developmentally

appropriate, (c) could be reconstructed from the MCS

data, and (d) measured both distal and proximal risk. In

all, information about eight adverse life events was

available both between birth and Sweep 1 (‘distal family

risk’) and between Sweeps 1 and 2 (‘proximal family

risk’) in MCS. The eight events corresponded to the fol-

lowing Adverse Life Events Scale items: ‘family member

died’, ‘family member was seriously injured’, ‘negative

change in parents’ financial situation’, ‘family member

had mental/emotional problem’, ‘family moved’, ‘got a

new brother or sister’, ‘one of the parents went to jail’, and

‘parents separated’. In contrast to the high correlation in

IMD scores at Sweeps 1 and 2, the correlation between

family risk at Sweep 1 and family risk at Sweep 2 was

0.201.

Broad and specific psychopathology was assessed with

the main caregiver’s report of the Strengths and Difficulties

Questionnaire (SDQ), a 25-item 3-point (ranging from 0 to

2) scale measuring four difficulties (hyperactivity, emo-

tional symptoms, conduct problems, and peer problems), as

well as prosocial behavior [26, 27]. Each subscale has five

items. A total difficulties (broad psychopathology) scale is

calculated by summing the scores for hyperactivity, emo-

tional symptoms, conduct problems and peer

problems

(http://www.sdqinfo.com). The SDQ has both good test–

retest reliability [28] and excellent concurrent and dis-

criminant validity [29, 30].

The child level covariates were age and sex, and the

family level covariates, all measured at Sweep 1, were

family structure, maternal psychological distress, and, to

index family’s socioeconomic status, maternal social class

and qualifications. Maternal psychological distress was

measured with nine items from the Malaise Inventory [31],

a psychometrically valid [32] measure of depressed mood.

Maternal social class, measured with the National Statistics

Socio-economic Classification (NS-SEC), ranged from 1

(‘high managerial’/‘professional’) to 7 (‘routine’). Moth-

ers’ highest qualifications were grouped into six major

categories, ranging from 1 to 6 (‘level 5’, i.e., first/higher

degree), roughly equivalent to National Vocational Quali-

fication (NVQ) levels.

Eur Child Adolesc Psychiatry (2010) 19:535–546 537

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http://www.sdqinfo.com

The moderator variables examined were developmental

milestones, temperament and parenting, all assessed in

Sweep 1 by the main respondent, and verbal and non-

verbal ability, measured in Sweep 2. Developmental mile-

stones are a set of functional skills or age-specific tasks that

most children can do at a certain age range. In the MCS

developmental milestones assessing communicative ges-

tures as well as fine and gross motor coordination typical

for a 9-month-old child were measured with 12 3-point

scales from the Denver Developmental Screening Test

[33], the most popular tool to screen for potential devel-

opmental problems. A high score on the test indicated

developmental delay. Temperament or individual differ-

ences in reactivity and self-regulation that are assumed to

have a relatively enduring, biological basis, was measured

in the MCS with items selected from the Carey Infant

Temperament Scale [34, 35], used also in the Avon Lon-

gitudinal Study of Parents and Children (ALSPAC) and the

National Longitudinal Survey of Youth. The items inclu-

ded in the MCS measured three dimensions of tempera-

ment, namely mood (measured with five items such as ‘is

pleasant’), adaptability (measured with five items such as

‘is rarely or almost never wary of strangers’) and regularity

(measured with four items such as ‘gets sleepy at about the

same time’). Parenting was measured with four 5-point

scales, originally derived from the European Longitudinal

Study of Pregnancy and Childhood, and used in other UK

longitudinal studies (such as the ALSPAC), assessing to

what extent the main respondent agreed that ‘it is important

to develop a regular pattern of feeding and sleeping with a

baby’, ‘babies need to be stimulated if they are to develop

well’, ‘talking, even to a young baby, is important’, and

‘cuddling a baby is very important’. The four-item scale for

the whole MCS at Sweep 1 yielded a Cronbach’s alpha of

0.67, with a high scale score indicating negligent parenting.

Finally, verbal and non-verbal ability were measured with

the naming vocabulary subtest of the British Ability Scales

(BAS) and with the School Readiness Composite (SRC) of

the Revised Bracken Basic Concept Scale, respectively.

The BAS Naming Vocabulary subtest measures children’s

expressive language skills, and the SRC measures ‘readi-

ness’ for formal education. Both assessments were indi-

vidually administered in Sweep 2 by survey team members

in computer-assisted interviews. The BAS Naming

Vocabulary subtest is part of a cognitive test battery

designed for children aged 3–17 [36]. Children are asked to

name a series of pictures of everyday items. There are 36

items in total, and the assessment is terminated if five

successive items are answered incorrectly. In the MCS, the

test was not administered to children who did not speak

English. The SRC comprises six subtests of the Revised

Bracken Basic Concept Scale measuring children’s

knowledge of those ‘readiness’ concepts that parents and

teachers traditionally teach children in preparation for

formal education [37]. The test has been designed for

children in the age range of 2.5–7 years and 11 months.

The six subtests of the SRC comprise the assessment of

children’s basic concepts of colors, letters, numbers/

counting, sizes, comparisons and shapes.

Models

The structure of the MSC data with children clustered

within LSOAs dictates the use of statistical models that

appropriately account for the nested structure. One class of

statistical models that provide valid inferences in the case

of hierarchical data is multilevel random effects models

[38]. To be consistent with the hierarchical structure of the

MCS data, we describe multilevel models using a two-level

structure under which children are clustered within LSOAs

at Sweep 2. The simplest two-level model for total diffi-

culties is a random intercepts model described by

yij ¼ xTij b þ uj þ eij; i ¼ 1; . . .; n; j ¼ 1; . . .; d ð1Þ

where yij is the response variable (total difficulties) for

child i in LSOA j, xij denotes a set of explanatory variables

that can be defined at child, family and LSOA level, uj
denotes a vector of random effects associated with LSOA j

and eijk denotes the level 1 (child level) residual term.
As information for each child was available for each of

the five SDQ subscales, allowing for a different model for

each SDQ subscale may provide a deeper insight. How-

ever, it is possible that responses to the different SDQ

subscales are correlated. To account for the existence of

correlation in each child’s responses, we fitted multivariate

response multilevel models that allowed for the error terms

of the different models to be correlated. Let us denote by i

the subscript referring to the child, by j the subscript

referring to the LSOA, and by l the subscript denoting a

specific SDQ subscale. The multivariate response multi-

level model is then defined as

yijl ¼ xTijlbl þ ujl þ eijl; i ¼ 1; . . .; n; j ¼ 1; . . .; d;
l ¼ 1; . . .; 5

ð2Þ

where eijl * N(0, Re) with Re denoting the variance
covariance matrix between the level 1 error terms and

ujl * N(0, Ru) with Ru denoting the variance covariance
matrix between the level 2 error terms. Modeling specific

psychopathologies in a multivariate way offers a more

flexible modeling framework as it can accommodate dif-

ferent covariates for the different SDQ subscales as well as

allow for the correlation between unobserved factors

affecting the scores on the different SDQ subscales at

different hierarchical levels. When compared with a single

multilevel model for broad psychopathology, a multivariate

538 Eur Child Adolesc Psychiatry (2010) 19:535–546

123

multilevel model offers an additional advantage with

respect to the handling of missing data. In particular, when

modeling broad psychopathology, a missing value in one of

the items comprising total difficulties on the SDQ results in

a missing total difficulties value. This is not the case with

multivariate models, since missing values in some of the

SDQ subscales do not result in the omission of the corre-

sponding unit from the analysis. In this way, the estimates

obtained from the multivariate multilevel model are

efficient.

The complex survey design of the MCS was accounted

for by conditioning on the design variables, i.e., the vari-

ables used in designing the MCS survey. Therefore, in the

models described below, stratification was accounted for

by including a set of dummy variables representing the

nine strata of the MCS, whereas clustering was accounted

for by running multilevel models. The models assumed that

data were missing at random (MAR) [38].

Results

We used STATA version 10 and MLwiN to run random

intercepts models (see Table 1 for a model summary),

described by (1), allowing the constant to vary at level 2,

i.e., LSOA at Sweep 2. We first estimated an empty

model for total difficulties in the 9,735 children with valid

data on total difficulties. This model included only the

design variables to adjust for the effects of stratification.

The two-level empty model showed that the average total

difficulties score as reflected in the intercept was 8.219

(SE = 0.102). The child level variance component (level

1 variance) was 23.367 (SE = 0.353), and the variance

due to differences in LSOAs was 0.850 (SE = 0.166).

This suggests a significant between LSOA variation.

Using the two variance components to partition the var-

iance across levels we found that the intra-cluster corre-

lation coefficient was 0.035. This suggests that controlling

only for stratification 3.5% of the variance in total diffi-

culties scores was attributable to the area level. Therefore,

although small the intra-cluster correlation justified the

use of hierarchical modeling. We first investigated the

contextual risk/total difficulties association by running

three baseline models, one with proximal family risk, one

with distal family risk and one with area risk. Area risk

(b = -0.938, SE = 0.083), distal family risk (b = 0.852,

SE = 0.060), and proximal family risk (b = 0.715,

SE = 0.043) were all related to total difficulties. As

expected, the amount of variance due to differences in

areas explained in this model when area risk was added to

Table 1 Model summary
(broad psychopathology)

a
The design variables used

were the MCS strata defined by

country (England, Scotland,

Wales and Northern Ireland)

and disadvantage status

according to the Child Poverty

Index (CPI). For England, there

was an additional stratum, i.e.

ethnic minority indicating wards

which, in the 1991 Census of

Population, had an ethnic

minority indicator of at least

30%. In other words, at least

30% of their total population

fell into the categories ‘Black’

or ‘Asian’

Models Specification

Model 1 Design variables
a

Model 2 Model 1 ? area random effect

Model 3.1 Model 2 ? proximal family risk

Model 3.2 Model 2 ? distal family risk

Model 3.3 Model 2 ? area risk

Model 4 Model 2 ? area risk ? measures of family risk (proximal and distal family risk)

Model 5 Model 4 ? family level fixed effects (family structure, mother’s qualifications,

mother’s social class and mother’s psychological distress)

Model 6 Model 5 ? child level fixed effects (gender, age) ? moderator variables (mood,

regularity, adaptability, non-verbal ability, verbal ability, developmental delay,

negligent parenting)

Model 7.1 Model 6 ? quadratic effect for area risk

Model 7.2 Model 6 ? quadratic effect for distal family risk

Model 7.3 Model 6 ? quadratic effect for proximal family risk

Model 8.1 Model 6 ? interaction between proximal family risk and distal family risk

Model 8.2 Model 6 ? interaction between proximal family risk and area risk

Model 8.3 Model 6 ? interaction between distal family risk and area risk

Model 9.1 Model 6 ? interaction between proximal family risk and mood

Model 9.2 Model 6 ? interaction between proximal family risk and regularity

Model 9.3 Model 6 ? interaction between proximal family risk and adaptability

Model 9.4 Model 6 ? interaction between proximal family risk and non-verbal ability

Model 9.5 Model 6 ? interaction between proximal family risk and verbal ability

Model 9.6 Model 6 ? interaction between proximal family risk and developmental delay

Model 9.7 Model 6 ? interaction between proximal family risk and parenting

Eur Child Adolesc Psychiatry (2010) 19:535–546 539

123

the empty model was reduced (0.697, SE = 0.152). To

compare the goodness of fit of these three baseline

models, we used an appropriate statistic that takes into

account that the models are not nested. Using the

Bayesian Information Criterion (BIC), a function of the

likelihood, the number of observations and the number of

free parameters of each model [39], we found that the

most parsimonious model was the proximal family risk

model. The association of area risk, distal family risk and

proximal family risk with total difficulties remained sig-

nificant even when all three risk variables were entered in

the same model. The amount of variance due to differ-

ences in areas explained in this model was further

reduced (0.606, SE = 0.140), but was still significant.

This suggests that although child psychopathology scores

differed by area partly because of differences in area level

socioeconomic disadvantage, even with area socioeco-

nomic disadvantage adjusted there was still area level

variance that remained unexplained.

In the next step, the family level variables of family

structure, and mother’s qualifications, social class and

psychological distress were added. With these variables in

the model, the effect of area risk on total difficulties

became nonsignificant. The amount of variance in total

psychopathology scores due to differences in area

explained in the model became nonsignificant (0.090,

SE = 0.093). Taken together, these two findings suggest

that both the area differences in total difficulties and the

effect of area risk on total difficulties operated via family

characteristics. The effect of distal and proximal family

risk, on the other hand, remained significant (b = 0.238,

SE = 0.065, and b = 0.376, SE = 0.044, respectively)

suggesting that family contextual risk predicts child psy-

chopathology directly and independently of family struc-

ture, socioeconomic status or maternal psychopathology.

Next, the full model (Model 6) was introduced. This

added the child level control variables and the proposed

moderators. The final study sample obtained after omitting

cases with missing values on both broad psychopathology

and all its predictors was 4,748 children clustered in 1,549

LSOAs. The number of children per LSOA ranged from 1

to 41, with an average of 3.1 children per LSOA. The

distribution of the 4,748 children in the nine MCS strata in

Sweep 2 was as follows: England-advantaged: 1,847;

England-disadvantaged: 884; England-ethnic: 139; Wales-

advantaged: 319; Wales-disadvantaged: 421; Scotland-

advantaged: 434; Scotland-disadvantaged: 264; Northern

Ireland-advantaged: 220, and Northern Ireland-disadvan-

taged: 220. As can be seen in Table 2, although negligent

parenting was marginally significant, all the child level

moderator variables were statistically significant in pre-

dicting broad psychopathology. In this final model, the

child level variance component (level 1 variance) was

16.409 (SE = 0.359), and the variance due to differences

in LSOAs was 0.203 (SE = 0.133).

As explained above, the initial MCS sample is 19,244

children. Of these, 9,736 had information about broad

psychopathology, our main response variable, and of these,

4,748 children were the final study sample. As expected,

these 4,748 children differed from the 14,496 children not

included in the final study sample in most of the study

variables. In particular, with regards to differences in

Sweep 1 variables, compared with their counterparts those

in the final study sample tended to live in less disadvan-

taged areas, in intact families, and with mothers who were

less negligent, less distressed, more educated and of higher

social class. With regards to differences in Sweep 2 vari-

ables, compared with their counterparts those in the study

sample tended to present with less broad psychopathology,

be female, have easier temperament, higher verbal and

non-verbal cognitive ability, and have less developmental

delay (all differences were statistically significant at

P \ 0.001; results available from the authors). However,
there was no difference between the two groups in age or in

number of either proximal or distal family adverse life

events experienced.

Comparing cumulative and specific family risk

specifications

We could not compare the proximal cumulative risk

specification with the proximal specific risk specification

as one item of the proximal Adverse Life Events Scale

(‘one of the parents went to jail’) was dropped due to

collinearity. However, the comparison of the distal

cumulative with the distal specific risk specification

showed that, after applying a Bonferroni correction

(alpha of 0.05/8 adverse events = 0.00625), none of the

eight specific distal risks were significantly associated

with broad psychopathology. The only distal risk item

approaching significance was ‘negative change in parents’

financial situation’ (b = 0.421, SE = 0.158). As the BIC

for the cumulative risk model (27,176.89) was lower than

that for the specific risk model (27,216.41), we concluded

that the cumulative risk model specification should be

preferred, and therefore this risk specification was used for

the remaining analysis.

Investigating the appropriate functional

form of contextual risk’s effect and testing

for moderator effects

We further investigated the appropriate functional form of

contextual risk’s effect on broad psychopathology by

introducing quadratic terms for contextual risk separately

in the full model (Model 6). None of the three quadratic

540 Eur Child Adolesc Psychiatry (2010) 19:535–546

123

terms for area, distal family, and proximal family risk were

significant. We also tested if the effect of one type of risk

was conditional upon the value of another. We entered

these two-way interactions between distal, proximal and

area risk variables separately in the full model, but neither

interaction term was significant. This suggests that the

effect of proximal family risk on broad psychopathology

did not depend on the level of distal risk, and that area risk

did not moderate the effect of either proximal or distal risk

on broad psychopathology.

Table 2 Broad psychopathology

Predictors Model 2 Model 4 Model 6

Coeff. SE Coeff. SE Coeff. SE

Constant 8.219 0.102 7.250 0.174 13.749 1.371

Stratum (Ref: England-advantaged)

England-disadvantaged 1.927 0.170 0.849 0.186 0.315 0.208

England-ethnic 2.732 0.289 1.983 0.294 0.630 0.405

Wales-advantaged -0.155 0.257 -1.609 0.289 -0.528 0.321

Wales-disadvantaged 1.276 0.224 -0.406 0.266 0.021 0.302

Scotland-advantaged -0.357 0.234 21.595 0.257 -0.178 0.281

Scotland-disadvantaged 1.115 0.268 -0.403 0.293 0.188 0.334

Northern Ireland-advantaged 20.715 0.286 22.142 0.318 20.844 0.360

Northern Ireland-disadvantaged 1.194 0.260 -0.435 0.298 20.854 0.360

Standardized IMD rank 20.776 0.081 -0.039 0.095

Proximal adverse life events 0.581 0.044 0.394 0.054

Distal adverse life events 0.666 0.061 0.308 0.079

Family structure (Ref: two natural parents)

Natural mother only 0.260 0.208

Other -0.959 1.828

Mother’s NS-SEC (Ref: high managerial/professional)

Low managerial/professional -0.047 0.229

Intermediate 0.098 0.259

Small emp and self-employed 20.824 0.361

Low supervisory and technical 0.517 0.336

Semi routine 0.728 0.275

Routine 0.553 0.310

Mother’s highest qualifications (Ref: level 5)

Level 4 -0.426 0.306

Level 3 0.372 0.330

A/AS Level 0.345 0.333

Level 2 0.920 0.314

Level 1 1.623 0.364

Mother’s psychological distress 0.472 0.040

Girl 20.755 0.121

Age 0.669 0.327

Mood 20.153 0.019

Regularity 20.134 0.023

Adaptability 20.123 0.018

Non-verbal ability 20.038 0.006

Verbal ability 20.072 0.017

Developmental delay 0.049 0.025

Negligent parenting 0.073 0.042

Between area variability (ru
2
) 0.849 0.155 0.606 0.133 0.171 0.135

Within area variability (re
2
) 23.367 0.351 22.379 0.335 16.317 0.357

Eur Child Adolesc Psychiatry (2010) 19:535–546 541

123

We finally explored if parenting, verbal and non-verbal

ability, developmental milestones, and mood, regularity

and adaptability moderate the association between con-

textual risk and young children’s broad psychopathology.

As proximal risk was the type of risk more strongly asso-

ciated with child psychopathology both at baseline and in

the full model, interaction terms with proximal family risk

and each of the proposed moderators were calculated and

entered separately in the full model (Model 6). None of the

interaction terms were significant, however, suggesting that

the effect of proximal risk on broad psychopathology was

not buffered either by child’s easy temperament or

advanced development, or by involved parenting. Table 2

presents the results of Model 6 and of the intermediate

models (Models 2 and 4) that were of particular substantive

significance.

Multivariate response models

We fitted multivariate response multilevel models descri-

bed by [8] that allowed the error terms of the different

models to be correlated and that included random area

(LSOA) effects. These multivariate response two level

models were effectively treated in MLwiN as three level

models, i.e., with the responses as the additional lower

level.

First, we ran an empty multivariate response multilevel

model (Model 10). This model included only the design

variables to adjust for the effects of stratification. The

variance partition coefficients obtained showed that 1% of

the total variation in prosocial behavior, 2% of the total

variation in emotional symptoms, 2% of the total variation

in conduct problems, 2% of the total variation in hyper-

activity, and 2% of the total variation in peer problems

were due to between LSOA variation.

We started our analysis by fitting three baseline models.

The first model examined the effect of proximal family

risk, which was significant in predicting scores in all five

SDQ subscales. The second model examined the effect of

distal risk, which was also significant in predicting scores

in all five SDQ subscales. The third model examined the

effect of area risk, which also had a significant, albeit

weaker, effect on the four difficulties and a nonsignificant

effect on prosocial behavior. The effect of proximal, distal

and area risk on all four difficulties remained significant

even when all risk variables were entered simultaneously

(Model 13). However, the effect of distal risk on prosocial

behavior became nonsignificant after adjusting for proxi-

mal and area risk suggesting that the effect of distal risk on

prosocial behavior was via its impact on proximal risk.

Subsequently, we introduced the full model (Model 14).

This added to the model including the design variables and

the three risk variables all the family- and child level fixed

effects, and all the moderator variables. The sample size in

this full model was 28,672.
1

In this model, the effect of

proximal risk on prosocial behavior became nonsignificant,

as did the effect of area risk on all four difficulties.

Although the effect of proximal risk remained significant

on all four difficulties, the effect of distal risk was signif-

icant only on hyperactivity and conduct problems.

Inspection of the between area and between children var-

iance covariance matrices (Table 3) from the various

models showed the covariances between the SDQ sub-

scales at area level became less significant as we controlled

for background characteristics. The covariances between

the SDQ subscales at child level, however, remained sig-

nificant even after controlling for a range of background

characteristics in this final model (Model 14), which jus-

tifies the use of a multivariate model.

Next, we tested if the effect of one type of risk was

conditional upon the value of another. We calculated two-

way interactions between distal, proximal and area risk

variables and entered these separately in the full model,

but none of these interaction terms was significant. This

suggests that the effect of proximal family risk on specific

psychopathology did not depend on the level of distal

risk, and that area risk did not moderate the effect of

either proximal or distal risk on any specific child

psychopathology.

Finally, we explored if parenting, verbal and non-verbal

ability, developmental milestones, and mood, regularity
and adaptability moderate the association between con-

textual risk and young children’s specific psychopathology.

As proximal risk was the type of risk more strongly asso-
ciated with child psychopathology both at baseline and in
the full model, interaction terms with proximal family risk

and each of the proposed moderators were calculated

and entered separately in the full model. The interaction

between proximal family risk and developmental

milestones predicted conduct problems (b = -0.017,

SE = 0.008), and the interaction between proximal family

risk and non-verbal ability predicted both conduct prob-

lems (b = -0.002, SE = 0.001) and emotional

symptoms

(b = -0.002, SE = 0.001), but no other interaction effects

were significant. These effects remained significant even

when both interaction terms were entered in the same

model (Model 17). These findings suggest that delayed

development buffered the effect of proximal risk on con-

duct problems, and non-verbal ability buffered the effect

of proximal risk on both emotional symptoms and con-

duct problems. Although developmental delay was not

1
This was the total number of observations in the multivariate

(specific psychopathology) model. The number of observations for

each SDQ outcome was as follows: Prosocial behavior: 5,719;

Emotional symptoms: 5,966; Conduct problems: 5,954; Hyperactiv-

ity: 5,689, and Peer problems: 5,344.

542 Eur Child Adolesc Psychiatry (2010) 19:535–546

123

significantly associated with any externalizing psychopa-

thology (although it was positively associated with emo-

tional symptoms and peer problems and negatively

associated with prosocial behavior) in the full model

(Model 14), it buffered the effect of proximal adverse life

events on conduct problems. Similarly, although non-ver-

bal ability was not significantly associated with any

internalizing psychopathology (although it was positively

related to prosocial behavior and negatively related to both

conduct problems and hyperactivity) in the full model

(Model 14), it buffered the effect of proximal risk on

conduct problems but also on emotional symptoms.

Table 4 shows the model summary for specific psychopa-

thology, and Table 5 shows the results of Model 17.

Table 3 Child level and area level covariance matrices between the five SDQ subscales estimated by fitting multivariate models (Models 10, 13,
and 14)

Prosocial Emotional Conduct Hyperactivity Peer

Model 10

Between area variance covariance matrix

Prosocial 0.021 (0.011)

Emotional -0.011 (0.007) 0.042 (0.008)

Conduct -0.018 (0.010) 0.050 (0.009) 0.088 (0.017)

Hyperactivity -0.018 (0.011) 0.048 (0.010) 0.080 (0.016) 0.090 (0.022)

Peer -0.009 (0.007) 0.039 (0.007) 0.051 (0.010) 0.047 (0.011) 0.043 (0.010)

Between children variance covariance matrix

Prosocial 3.302 (0.043)

Emotional -0.209 (0.024) 1.938 (0.025)

Conduct -1.246 (0.036) 0.757 (0.026) 3.937 (0.050)

Hyperactivity -1.249 (0.041) 0.715 (0.031) 2.173 (0.047) 5.202 (0.069)

Peer -0.759 (0.027) 0.611 (0.020) 0.719 (0.029) 0.745 (0.033) 2.105 (0.029)

Model 13

Between area variance covariance matrix

Prosocial 0.022 (0.011)

Emotional -0.013 (0.007) 0.032 (0.008)

Conduct -0.023 (0.009) 0.031 (0.008) 0.054 (0.015)

Hyperactivity -0.023 (0.011) 0.033 (0.009) 0.053 (0.014) 0.068 (0.002)

Peer -0.011 (0.007) 0.028 (0.006) 0.029 (0.008) 0.029 (0.010) 0.031 (0.009)

Between children variance covariance matrix

Prosocial 3.299 (0.043)

Emotional -0.200 (0.024) 1.915 (0.024)

Conduct -1.223 (0.035) 0.700 (0.026) 3.799 (0.048)

Hyperactivity -1.228 (0.041) 0.663 (0.030) 2.043 (0.045) 5.079 (0.067)

Peer -0.750 (0.027) 0.587 (0.020) 0.665 (0.028) 0.697 (0.033) 2.081 (0.028)

Model 14

Between area variance covariance matrix

Prosocial 0.005 (0.017)

Emotional -0.005 (0.009) 0.008 (0.009)

Conduct -0.006 (0.014) 0.015 (0.01) 0.029 (0.02)

Hyperactivity -0.004 (0.016) 0.029 (0.012) 0.011 (0.018) 0.024 (0.027)

Peer -0.011 (0.011) 0.007 (0.008) 0.003 (0.011) -0.003 (0.013) 0.023 (0.013)

Between children variance covariance matrix

Prosocial 2.848 (0.056)

Emotional -0.093 (0.029) 1.468 (0.028)

Conduct -0.949 (0.043) 0.375 (0.029) 2.992 (0.058)

Hyperactivity -0.871 (0.051) 0.358 (0.036) 1.478 (0.054) 4.304 (0.085)

Peer -0.500 (0.033) 0.384 (0.023) 0.361 (0.033) 0.387 (0.04) 1.668 (0.034)

Eur Child Adolesc Psychiatry (2010) 19:535–546 543

123

Discussion

This study was carried out to test the hypothesis that for

preschool children’s behavioral and emotional adjustment

in the face of contextual risk, factors promoting resilience

should be located in the cognitive domain. Indeed, this

study showed that neither parenting nor temperament

buffered the effect of contextual risk on young children’s

emotional and behavioral adjustment. However, non-verbal

ability moderated the effect of cumulative proximal risk on

both emotional symptoms and conduct problems.

In testing this hypothesis, we measured and modeled

contextual risk appropriately and we, therefore, also

extended in several ways prior work on contextual risk

effects on children’s behavioral and emotional adjustment.

First, assessing with well-validated measures family con-

textual risk, we showed that, although the number of family

adversities experienced in the child’s first year (distal

family risk) did predict broad and externalizing psycho-

pathology, the number of proximal (i.e., in the second and

third year) family adversities (proximal family risk) pre-

dicted both broad and externalizing but also internalizing

psychopathology. Second, we showed that the most parsi-

monious model was the model that included cumulative

rather than specific family risk. Taken together, these

findings highlight the importance of proximal family risk in

predicting both broad and specific psychopathology, and

the importance of considering family risk accumulation

rather than specificity in predicting psychopathology in

young children. Third, we showed that although the effect

of area and the effect of area level contextual risk were

significant on broad psychopathology even after distal and

proximal family risk were controlled for, they became

nonsignificant after adjusting for maternal socioeconomic

status and mental health. This finding suggests that the

effect of area and the effect of area risk on child psycho-

pathology operate via family characteristics. The effect of

distal and proximal family risk, on the other hand,

remained significant after adjusting for these maternal

characteristics suggesting that family contextual risk pre-

dicts child psychopathology directly and independently,

and not because it is associated with parental psychopa-

thology or social class. In other words, the effect of family

contextual risk on child psychopathology transcends social

origins and genetic predispositions. Fourth and finally, by

testing for the functional form of the effect of both area and

family risk and for the interaction between the various

types and levels of risk, we joined the few other researchers

[4, 11–14] that have tested for ‘threshold’ models of mul-

tiple risk. Ours, however, was the first study to test such

effects on young children’s psychopathology.

Of course, the study’s limitations should also be

acknowledged. For example, the children of the final study

sample were clearly more privileged than those not inclu-

ded in the final study sample. However, in our modelling

framework data were treated under the MAR assumption.

Table 4 Model summary
(specific psychopathology)

Models Specification

Model 10 Design variables

Model 11 Model 10 ? area random effect

Model 12.1 Model 11 ? proximal family risk

Model 12.2 Model 11 ? distal family risk

Model 12.3 Model 11 ? area risk

Model 13 Model 11 ? area risk ? measures of family risk (proximal and distal family risk)

Model 14 Model 13 ? family level fixed effects (family structure, mother’s qualifications,

mother’s social class, mother’s psychological distress) ? child level fixed effects

(age, gender) ? moderator variables (mood, regularity, adaptability, non-verbal

ability, verbal ability, developmental delay, negligent parenting)

Model 15.1 Model 14 ? interaction between proximal family risk and distal family risk

Model 15.2 Model 14 ? interaction between proximal family risk and area risk

Model 15.3 Model 14 ? interaction between distal family risk and area risk

Model 16.1 Model 14 ? interaction between proximal family risk and mood

Model 16.2 Model 14 ? interaction between proximal family risk and regularity

Model 16.3 Model 14 ? interaction between proximal family risk and adaptability

Model 16.4 Model 14 ? interaction between proximal family risk and non-verbal ability

Model 16.5 Model 14 ? interaction between proximal family risk and verbal ability

Model 16.6 Model 14 ? interaction between proximal family risk and developmental delay

Model 16.7 Model 14 ? interaction between proximal family risk and parenting

Model 17 Model 14 ? interaction between proximal family risk and developmental

delay ? interaction between proximal family risk and non-verbal ability

544 Eur Child Adolesc Psychiatry (2010) 19:535–546

123

Our study findings have important implications for the

study of both contextual risk and resilience as they suggest

that, even among young children, contextual factors that

impede adjustment are proximal rather than distal, and

should be modeled cumulatively and located in the family

rather than the area, and, importantly for the study of

resilience, that factors that promote adjustment in the face

of such contextual risk should be located among individual

Table 5 Specific psychopathology (Model 17)

Predictors Prosocial

behavior

Coeff. (SE)

Emotional

symptoms
Coeff. (SE)

Conduct

problems
Coeff. (SE)

Hyperactivity

Coeff. (SE)

Peer problems

Coeff. (SE)

Constant 6.633 (0.558) 2.306 (0.401) 3.789 (0.573) 3.989 (0.698) 2.870 (0.445)

Stratum (Ref: England-advantaged)

England-disadvantaged -0.050 (0.076) -0.032 (0.054) 0.017 (0.078) 0.078 (0.094) 0.181 (0.063)

England-ethnic 0.375 (0.139) 0.128 (0.099) 0.038 (0.146) 0.076 (0.176) 0.259 (0.117)

Wales-advantaged 0.033 (0.118) -0.046 (0.084) -0.213 (0.122) 0.118 (0.146) -0.134 (0.097)

Wales-disadvantaged 0.177 (0.109) -0.044 (0.079) 0.154 (0.114) 0.237 (0.136) -0.082 (0.091)

Scotland-advantaged -0.037 (0.105) -0.058 (0.074) -0.042 (0.108) -0.042 (0.129) -0.067 (0.086)

Scotland-disadvantaged -0.194 (0.123) -0.079 (0.088) 0.141 (0.128) 0.139 (0.153) 0.062 (0.101)

Northern Ireland-advantaged 0.024 (0.134) -0.036 (0.094) -0.232 (0.136) -0.197 (0.164) -0.187 (0.108)

Northern Ireland-disadvantaged 0.154 (0.133) -0.085 (0.094) -0.134 (0.137) -0.408 (0.164) -0.082 (0.108)

Standardized IMD rank -0.037 (0.035) -0.012 (0.025) -0.028 (0.036) 0.077 (0.043) -0.033 (0.029)

Proximal adverse life events -0.071 (0.147) 0.171 (0.105) 0.511 (0.149) 0.134 (0.181) 0.073 (0.118)

Distal adverse life events 0.025 (0.030) 0.031 (0.021) 0.096 (0.030) 0.132 (0.037) 0.035 (0.024)

Family structure (Ref: two natural parents)

Natural mother only 0.079 (0.077) 0.079 (0.054) 0.170 (0.078) 0.110 (0.095) 0.082 (0.061)

Other -0.092 (0.060) -0.131 (0.459) -0.745 (0.617) -1.340 (0.833) 0.425 (0.525)

Mother’s NS-SEC (Ref: high managerial/professional)

Low managerial/professional 0.002 (0.088) -0.065 (0.062) -0.064 (0.089) 0.120 (0.108) 0.039 (0.070)

Intermediate 0.015 (0.099) -0.136 (0.069) 0.069 (0.099) 0.280 (0.121) -0.082 (0.078)

Small emp and self-employed 0.109 (0.138) -0.159 (0.097) -0.243 (0.138) -0.173 (0.168) -0.035 (0.109)

Low supervisory and technical 0.123 (0.126) -0.123 (0.089) 0.056 (0.127) 0.445 (0.156) 0.174 (0.100)

Semi routine -0.107 (0.104) -0.037 (0.073) 0.347 (0.104) 0.332 (0.128) 0.082 (0.083)

Routine 0.017 (0.116) 0.001 (0.082) 0.173 (0.117) 0.276 (0.142) 0.173 (0.092)

Mother’s highest qualifications (Ref: level 5)

Level 4 -0.100 (0.115) -0.050 (0.081) -0.096 (0.117) -0.035 (0.140) -0.120 (0.094)

Level 3 -0.048 (0.124) -0.004 (0.088) 0.010 (0.126) 0.345 (0.152) 0.067 (0.101)

A/AS Level -0.108 (0.125) 0.022 (0.088) -0.058 (0.127) 0.272 (0.153) 0.056 (0.102)

Level 2 -0.111 (0.117) 0.096 (0.083) 0.170 (0.119) 0.495 (0.143) 0.141 (0.096)

Level 1 -0.092 (0.134) 0.311 (0.095) 0.400 (0.136) 0.722 (0.165) 0.229 (0.110)

Mother’s psychological distress -0.032 (0.014) 0.085 (0.010) 0.158 (0.015) 0.159 (0.018) 0.064 (0.012)

Girl 0.306 (0.045) -0.009 (0.032) -0.143 (0.046) -0.505 (0.056) -0.152 (0.036)

Age 0.051 (0.121) 0.109 (0.088) 0.013 (0.124) 0.580 (0.152) -0.066 (0.097)

Mood 0.064 (0.007) -0.025 (0.005) -0.053 (0.007) -0.051 (0.009) -0.017 (0.006)

Regularity 0.003 (0.008) -0.019 (0.006) -0.031 (0.009) -0.043 (0.010) -0.035 (0.007)

Adaptability 0.017 (0.007) -0.050 (0.005) -0.020 (0.007) -0.015 (0.008) -0.039 (0.005)

Non-verbal ability 0.009 (0.003) -0.000 (0.002) -0.011 (0.003) -0.016 (0.004) -0.002 (0.003)

Verbal ability 0.021 (0.007) -0.016 (0.005) -0.014 (0.007) -0.033 (0.008) -0.020 (0.005)

Developmental delay -0.076 (0.015) 0.023 (0.011) 0.029 (0.015) 0.009 (0.019) 0.026 (0.012)

Negligent parenting -0.095 (0.015) 0.005 (0.011) 0.015 (0.015) 0.035 (0.019) 0.028 (0.012)

Proximal adverse life events by developmental delay 0.004 (0.008) -0.004 (0.005) -0.017 (0.008) 0.004 (0.010) -0.002 (0.006)

Proximal adverse life events by non-verbal ability -0.001 (0.001) -0.002 (0.001) -0.002 (0.001) -0.002 (0.002) 0.001 (0.001)

Eur Child Adolesc Psychiatry (2010) 19:535–546 545

123

attributes pertaining specifically to cognitive strengths.

Future studies should test this as well as the generalise-

ability of these findings in older child samples as the

adverse characteristics of a neighborhood might impact

differently upon the psychopathology of older children.

Acknowledgments This program of research was supported by a
grant from the British Academy to the first two authors. The authors

are grateful to Jon Johnson, Rachel Rosenberg, and Tina Roberts for

their help with the construction of the dataset.

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WAMT1092-67711545-083XJournal of Aggression, Maltreatment & Trauma, Vol. 19, No. 2, January 2010: pp. 0–0Journal of Aggression, Maltreatment & Trauma

LITERATURE REVIEW

Childhood Emotional Maltreatment and Later
Intimate Relationships: Themes
from the Empirical Literature

Emotional Maltreatment and Intimate RelationshipsN. Dodge Reyome

NANCY DODGE REYOME
State University of New York at Potsdam, Potsdam, New York, USA

Within the last three decades, researchers have begun to investigate
the long-term consequences of childhood emotional maltreatment
on interpersonal and intrapersonal functioning. These investiga-
tions have led to the realization that survivors of childhood emo-
tional maltreatment suffer from myriad psychological and social
difficulties. These difficulties influence the quality and nature of
intimate relationships formed by emotional abuse survivors. The
empirical literature looking at the effect of childhood emotional
maltreatment on intimate relationships is summarized and dis-
cussed. Implications of the current body of research for future
research and clinical practice are addressed.

KEYWORDS child abuse, emotional maltreatment, intimate
relationships, relational problems

Emotional maltreatment is a commonly occurring form of child maltreatment.
In a recent comprehensive national telephone survey conducted in the
United States, 2,030 children and adolescents were asked questions regard-
ing the types of victimization they had experienced. Finkelhor, Ormrod,
Turner, and Hamby (2005) found that of the different forms of child mal-
treatment assessed, psychological and emotional forms of maltreatment
were the most frequently reported by the children and youth surveyed.

Submitted 13 October 2009; revised 6 December 2009; accepted 7 December 2009.
Address correspondence to Nancy Dodge Reyome, Psychology Department, State University

of New York at Potsdam, Potsdam, NY 13676. E-mail: dodgenm@potsdam.edu

Emotional Maltreatment and Intimate Relationships 225

Scher, Forde, McQuaid, and Stein (2004) found similar results after conduct-
ing a telephone survey of 967 men and women in a major metropolitan area
in Tennessee. In their study, emotional abuse was one of the most common
forms of childhood trauma reported by the adult participants. Although
emotional maltreatment has been recognized and documented as a com-
monly occurring form of childhood maltreatment, research on the short- and
long-term effects has lagged behind other forms of child maltreatment.

Garbarino, Eckenrode, and Bolger (1997) considered emotional maltreat-
ment to be “an elusive crime.” In their estimation, it is too often overlooked,
difficult to demonstrate, and is clearly not studied as frequently as other
forms of maltreatment. Emotional maltreatment is comprised of parental
behaviors that often ignore a child’s emotional and psychological needs
(Garbarino et al., 1997; Hart & Brassard, 1987; McGee & Wolfe, 1991).
These actions might involve isolation, rejection, exploitation, terrorization,
or outright neglect of the child who is the target of these parental actions.
Glaser (2002) proposed a framework comprised of five categories to encom-
pass parental behaviors that constitute emotional maltreatment: (a) emotional
unavailability, unresponsiveness, and neglect; (b) negative attributions or
misattributions to the child; (c) developmentally inappropriate or inconsis-
tent interactions with the child; (d) failure to recognize or acknowledge the
child’s individuality and psychological boundary; and (e) failing to promote
the child’s social adaptation. As with other forms of maltreatment, an iso-
lated incident of emotional maltreatment is not thought to have lasting
developmental implications, however, a repeated and chronic pattern of
exposure to psychologically and emotionally abusive actions is considered
to be especially deleterious to the growing child’s psychological, social, and
emotional well-being (Hart & Brassard, 1987; McGee & Wolfe, 1991; Teicher,
Samson, Polcari, & McGreenery, 2006).

Harter (1998) argued that child abuse in general and emotionally abu-
sive parenting in particular has a harmful effect on the child’s emerging
sense of self. She explains that child abuse leads to multiple self-system
impairments including impairments in self-awareness, agency, self-continuity,
and self-coherence. According to Harter, children who experience child
abuse struggle with low self-esteem and a “profound sense of inner badness,”
which often leads the child to engage in behavior that is not congruent with
the true self. Harter pointed out that guilt, depression, shame, and anger are
among the negative emotional problems experienced by abused children.

Consistent with Harter’s concerns, a childhood history of emotional
maltreatment has been linked with myriad psychosocial problems. Repeat-
edly, empirical investigations have discovered that survivors of childhood
emotional abuse suffer from both internalizing and externalizing symptoms.
A childhood history of emotional maltreatment has been found to be associ-
ated with low self-worth, anxiety, depression, anger, dissociation, somatization,
heightened self-criticism, and intense feelings of shame (Briere & Runtz,

226 N. Dodge Reyome

1988; Chapman et al., 2004; Dodge Reyome, Ward, & Witkiewitz, 2010; Kim &
Cicchetti, 2006; Sachs-Ericsson, Verona, Joiner, & Preacher, 2006; Schneider,
Rosa, Graham, & Zielinski, 2005; Showers, Ziegler-Hill, & Limke, 2006; Spertus,
Yehuda, Wong, Halligan, & Seremetis, 2003; Teicher et al., 2006; Uhrlass &
Gibb, 2007; Webb, Heisler, Call, Chickering, & Colburn, 2007). Given the
psychological and emotional problems reported by survivors of emotional
maltreatment, it is not surprising that research indicates that individuals with
childhood histories of emotional maltreatment often report suffering from
eating disorders, substance abuse, and posttraumatic stress disorder (Moran,
Vuchinich, & Hall, 2004; Schneider, Baumrind, & Kimberling, 2007; Witkiewitz &
Dodge Reyome, 2000).

These early impairments in self-development and the resulting psycho-
social aftereffects often translate into poor interpersonal relationships as the
individual grows and develops (Berzenski & Yates, 2010; Dodge Reyome
et al., 2010; Riggs, 2010; Taussig & Culhane, 2010). In fact, the experience
of any form of maltreatment has been shown to set off a vulnerability
toward poor peer relationships. In an early influential study of maltreated
toddlers’ social interactions with other toddlers and adults, George and Main
(1979) found that the young maltreated children in their study were more
likely to verbally and physically assault peers and adults than the children
who had not experienced maltreatment. These researchers also found that
the maltreated toddlers were more likely to respond to positive social inter-
actions with avoidance or a mixture of approach-avoidance behaviors. By
the preschool and elementary school years, maltreated children have been
found to be rated as more disliked, more physically and verbally aggressive,
and more socially withdrawn than nonmaltreated children (Anthonysamy &
Zimmer-Gembeck, 2007; Bolger & Patterson, 2001; Darwish, Esquivel, Houtz, &
Alfonso, 2001; Shonk & Cicchetti, 2001). Duncan (1999) found that children
who have experienced parental maltreatment are not only more likely to
bully others, but are also likely to be the victims of peer bullying. Although
these studies did not focus exclusively on emotional maltreatment, researchers
have identified similar developmental outcomes regarding peer relationships in
emotionally maltreated children (Egeland, 2009).

Although many studies have documented the long-term effects of physical
and sexual abuse (or childhood maltreatment in general) on peer and intimate
relationships, the emerging literature has only begun to examine the nature and
quality of intimate relationships for adolescents and adults who have a history
of childhood emotional maltreatment. This article intends to review the current
literature that has been published on the long-term consequences of childhood
emotional maltreatment for intimate relationships in adolescence and adult-
hood. The studies considered in the review fall into three areas or themes of
relationship functioning and difficulties: (a) intimacy and relationship quality,
(b) codependency, and (c) intimate partner violence. This review is not
intended to be exhaustive of the published literature in each area, but is meant

Emotional Maltreatment and Intimate Relationships 227

to be illustrative of the current state of knowledge regarding this expanding
topic of inquiry in the field of child maltreatment. Following this review, sug-
gestions are made for future research on the connection between childhood
emotional maltreatment and relationship functioning. Brief remarks on the
practice implications of these research findings are made as well.

As mentioned previously, emotional maltreatment can include a multitude
of emotionally abusive and neglectful behaviors and because of this, it has
been not been clearly defined in the literature and researchers often use differ-
ent criteria in defining emotional maltreatment across studies. Due to the lack of
consistency in the research, this review uses a broad definition for emotional
maltreatment and considers a range of studies to summarize the research that
has been conducted on this specific area of study. To provide clarification of
what emotionally abusive behaviors are being classified as emotional maltreat-
ment in each study, the assessment tool used to measure emotional mal-
treatment is presented for each study reviewed. Finally, because emotional
maltreatment and psychological maltreatment are terms that are both used to
describe the emotional abusive behaviors that are intended to be captured in
this review, they are both considered to be interchangeable in this article.

CHILDHOOD EMOTIONAL MALTREATMENT, INTIMACY,
AND RELATIONSHIP QUALITY

Given the chronic nature of emotional maltreatment and the effect this form
of trauma has on self-development and psychosocial well-being, researchers
have sought to understand the influence of childhood emotional maltreat-
ment on beliefs about relationships, relationship quality, and satisfaction.
Repeatedly, investigators have arrived at the conclusion that a history of
childhood emotional maltreatment is strongly associated with serious diffi-
culties in interpersonal relationships in adolescence and adulthood.

Childhood psychological maltreatment has been found to be signifi-
cantly associated with lower relationship quality, greater fear of intimacy,
and distance in interpersonal relationships. Davis, Petretic-Jackson, and
Ting (2001) conducted a study looking at the impact of various child
abuse experiences on functioning in partner relationships. Davis and his
colleagues measured psychological maltreatment using a scale that
incorporated Briere and Runtz’s (1990) Scale of Psychological Maltreat-
ment and items reflecting Hart and Brassard’s (1987) definition of psy-
chological abuse. In this study, a childhood history of psychological
maltreatment accounted for more variance in predicting quality of cur-
rent interpersonal relationships than either a history of childhood sexual
abuse or physical abuse. Of the child abuse variables measured in their
study, only a history of psychological abuse or multiple abuse experiences
were related to a greater fear of intimacy (see Paradis & Boucher, 2010).

228 N. Dodge Reyome

Similarly, Drapeau and Perry (2004) looked at how different forms of
childhood trauma influence adult relationship patterns. These researchers
used vignettes to elicit narratives concerning wishes, needs, motivations,
and intentions in interpersonal relationships. Childhood trauma history was
measured using a modified version of the Traumatic Antecedents Interview
Scale (Herman, Perry, & Van der Kolk, 1989). They found that those partici-
pants with a history of verbal abuse during childhood reported “more desire
to be distant from others” than those who had not experienced trauma.
They also experienced others as “less strong,” and they were more likely to
react by “not being open” in interpersonal interactions. Those with a history
of emotional neglect had “less desire to avoid conflicts” and “more of a wish
to be distant from others” than those who had not experienced trauma. In a
study looking at the long-term effects of parental physical abuse, verbal
abuse (as measured by Straus’s [1979] Conflict Tactics Scale), and emotional
neglect (as measured by Parker’s [1979] Caring Subscale of the Parental
Bonding Instrument), Loos and Alexander (1997) found that undergraduates
who reported a history of emotional neglect had the highest rates of loneli-
ness and social isolation in their sample. The researchers underscore this
finding by pointing out that the association between parental emotional
neglect and high rates of loneliness and social isolation among their college
student sample was the strongest relationship uncovered in their research.
Finally, in a community sample, Mullen, Martin, Anderson, Romans, and
Herbison (1996) found emotional abuse survivors, as determined by scores
on Parker’s (1979) Parental Bonding Instrument, were more likely to report
their current partner as uncaring and overintrusive and more frequently
reported marital dissolution than a nonabused comparison group.

The extent to which a childhood history of emotional maltreatment is
recognized and acknowledged also appears to be associated with the quality
of later intimate relationships. Varia and Abidin (1999) discovered that psy-
chological maltreatment survivors who minimize their maltreatment history
report higher quality relationships than those who actively acknowledge
their abuse history. Using the Psychological Maltreatment Scale (Briere &
Runtz, 1988), they identified three groups of participants in their study:
those who had no history of psychological abuse (nonabused), those who
reported a history of psychological abuse and acknowledged the abuse
(acknowledgers), and those who reported a history of psychological abuse
experiences but did not label themselves as psychologically abused as a
child (minimizers). They found the acknowledgers had the lowest quality of
adult relationships and the nonabused group had the highest quality rela-
tionships. The minimizers fell in between these two groups on measures of
relationship quality. Acknowledgers reported less spousal support and more
spousal conflict than either of the other two groups and were least likely to
report having securely attached adult relationships. Interestingly, minimizers
tended to report higher levels of overall maternal care than acknowledgers

Emotional Maltreatment and Intimate Relationships 229

and the researchers reported that it was possible that this level of maternal
care moderated the effects of childhood emotional and psychological mal-
treatment on the quality of adult interpersonal relationships.

Related to the findings that individuals with a childhood history of
emotional maltreatment report lower quality relationships marred by loneli-
ness, isolation, and mistrust, survivors of childhood emotional maltreatment
also report higher rates of interpersonal conflict in intimate relationships
than individuals without a history of emotional maltreatment. Using the psy-
chological abuse scale from the Computer Assisted Maltreatment Inventory
(DiLillo et al., 2006), Messman-Moore and Coates (2007) found that a child-
hood history of psychological abuse was directly correlated with adult inter-
personal conflict. They also discovered that the relationship between a history
of childhood emotional abuse and adult interpersonal conflict is mediated
by an individual’s beliefs about the self and interpersonal relationships.
Messman-Moore and Coates referred to these beliefs as early maladaptive
schemas. According to these researchers, the early maladaptive schemas, which
guide the interpersonal relationships of psychological abuse survivors, involve
mistrust, abandonment, deprivation, and defectiveness (see Riggs, 2010, for a
discussion of the development of internal working models in emotional abuse
survivors). In their research, they found that the relationship between child-
hood history of psychological abuse and adult interpersonal conflict was fully
mediated by the mistrust or abuse and abandonment schema and partially
mediated by the defectiveness or shame schema. The demonstration of media-
tion indicates that certain rigid interpersonal beliefs about the self in relation to
others accounted for the connection between a childhood history of psycholog-
ical maltreatment and interpersonal conflict in adulthood.

As time unfolds, the interpersonal difficulties of childhood emotional
abuse survivors can impact marital relationship quality and satisfaction. Belt
and Abidin (1996) looked at quality of parenting history and the nature of
childhood abuse experiences in a sample of married couples with children.
In this study, verbal abuse was measured using a verbal maltreatment scale
adapted from Berger and Knutson (1984) and Briere and Runtz (1988). Belt
and Abidin discovered that the quality of family-of-origin functioning and
childhood abuse experiences (physical and sexual maltreatment were also
measured) were more consistently associated with the quality of the marital
relationship for women than men. For men, neither the quality of childhood
parenting nor the extent of childhood abuse predicted the depth or the
level of supportiveness of their current marital relationship. The extent of
childhood care was a significant predictor of the depth of women’s marital
relationships. Also for women, verbal abuse during childhood significantly
predicted conflict in the marital relationship.

In a recent prospective study that also considered gender differences in
childhood maltreatment and marital functioning, DiLillo et al. (2009) assessed
marital functioning at three points over a 2-year period in 202 recently

230 N. Dodge Reyome

married couples. They measured childhood history of psychological maltreat-
ment using the Computer Assisted Maltreatment Inventory (DiLillo et al.,
2006) and the Childhood Trauma Questionnaire (Bernstein & Fink, 1998). In
contrast to Belt and Abidin (1996), DiLillo and his colleagues found that a
history of childhood psychological abuse was related to lower marital satis-
faction at the first point of measurement for husbands but not for wives.
Husbands with histories of psychological maltreatment had declining marital
satisfaction throughout the study. Overall, these researchers found that
husbands with psychological maltreatment histories reported far more prob-
lems with marital relationships than did wives with similar histories.

Finally, Perry, DiLillo, and Peugh (2007) investigated the role of psycholog-
ical difficulties as possible mediators of the relationship between childhood his-
tory of psychological maltreatment and marital satisfaction in a sample of newly
married couples. The Childhood Trauma Questionnaire was employed in this
study to measure both history of emotional abuse and history of emotional
neglect (Bernstein & Fink, 1998). As with previous studies, Perry et al. (2007)
found a significant negative association between having a history of childhood
emotional maltreatment and marital satisfaction for the entire sample. Further-
more, for the entire sample of male and female participants, these researchers
found the association between a childhood history of emotional abuse and
emotional neglect and marital satisfaction and quality was completely mediated
by psychological distress, hostility, and depression (see Riggs & Kaminski, 2010,
for a discussion of the connection between childhood emotional abuse and
depression). When looking at gender differences in mediation, Perry et al.
found the association between childhood emotional abuse and marital quality
in males was mediated by psychological distress and paranoia. In females,
psychological distress, hostility, and obsessive-compulsive tendencies served to
mediate the relationship between childhood emotional abuse and emotional
neglect and marital satisfaction and quality.

In summary, childhood emotional abuse survivors report a greater fear
of intimacy, a need for interpersonal distance in relationships, and a general
lack of trust in others. At the same time, they report feeling lonely, discon-
nected, and socially isolated. Many individuals who have experienced emo-
tional abuse during childhood possess maladaptive beliefs about themselves
and others (e.g., “other people can’t be trusted”) that negatively influence
their interpersonal relationships. A history of childhood emotional abuse
tends to be related to lower quality marital relationships, lower marital satis-
faction, and marital dissolution. A few researchers have found that there are
gender differences in the impact of childhood emotional maltreatment on
marital relationships, however, these findings are mixed and warrant further
investigation. Finally, there is emerging evidence that particular psychological
and social variables such as psychological distress and depression can account
for the connection between childhood emotional abuse and the quality of
later relationships.

Emotional Maltreatment and Intimate Relationships 231

CHILDHOOD EMOTIONAL MALTREATMENT
AND CODEPENDENCY

The literature linking childhood emotional maltreatment with codependency in
later relationships is conceptually similar to the Messman-Moore and Coates
(2007) study that found maladaptive schemas of self-sacrifice and mistrust
underlie the connection between childhood emotional maltreatment and
later relationship problems. Noriega, Ramos, Medina-Mora, and Villa (2008)
referred to codependency as a “relational problem” characterized by a ten-
dency to remain within stressful, abusive, and unhealthy relationships.
Codependents tend to engage in self-sacrificing, self-defeating, controlling,
and rigid behavior in an attempt to control and change their partner (Dear,
Roberts, & Lange, 2005; Dodge Reyome & Ward, 2007; Dodge Reyome et al.,
2010). Originally, codependency was believed to emerge from a family con-
text of substance abuse, especially alcoholism (Beattie, 1987; Mellody,
Miller, & Miller, 1989). As investigations into the link between substance
abuse and codependency progressed and only a weak relationship between
familial substance abuse and codependency emerged, researchers broad-
ened their focus to look at the influence of different family and parenting
environments and the influence of other forms of childhood trauma on the
development of codependent tendencies in intimate relationships. Eventually,
investigators began to consider child abuse and neglect history as a possible
precursor of codependency in adulthood.

Early studies examining the link between childhood abuse history and
codependency focused on physical and sexual abuse. These studies are
mixed in regard to whether or not there is a relationship between childhood
physical abuse or sexual abuse and codependency in adulthood. For
instance, in a study looking at the relationship between different forms of
childhood trauma, Irwin (1995) found that codependency in adulthood was
not predicted by either childhood sexual abuse or physical abuse. Similarly,
Cullen and Carr (1999) found that individuals labeled as high codependency
were no more likely to have childhood histories of physical abuse or sexual
abuse than those in the low codependency group. However, F. Parker,
Faulk, and LoBello (2003) did find a positive association between codepen-
dency and both childhood physical abuse and sexual abuse.

Unlike physical abuse and sexual abuse, researchers have consistently
found a direct relationship between childhood emotional abuse and code-
pendency in late adolescence and adulthood. Carson and Baker (1994)
were perhaps the earliest researchers to report on the strong connection
between emotional and psychological forms of abuse and codependency.
They found that individuals in their sample with histories of emotional
abuse tended to score high in codependency. Although Cullen and Carr
(1999) focused their study on other forms of maltreatment, they did note
that family environments that lacked warmth and appropriate emotional

232 N. Dodge Reyome

expression tended to be associated with codependency. Investigations into
parenting styles and practices and codependency tend to support this overall
conclusion that emotional maltreatment is linked with codependency. Crothers
and Warren (1996) found that codependency was positively associated with
coercive, controlling, and nonnurturing forms of parenting. Related to this
finding, Fischer and Crawford (1992) found paternal authoritarian parenting
was linked with high codependency scores.

Dodge Reyome and Ward (2007) conducted a comprehensive study to
investigate the link between childhood abuse history and codependency by
looking at all five major forms of childhood maltreatment and looking at the
association of each form with codependency. Childhood abuse history was
measured using the Childhood Trauma Questionnaire (Bernstein et al., 1994),
which has emotional abuse and emotional neglect subscales. Additionally,
childhood psychological maltreatment was assessed using the Psychological
Maltreatment Inventory (Engels & Moisan, 1994). They found that although
all forms of child abuse and neglect measured in the study were significantly
positively associated with codependency, the most robust relationships were
between emotional abuse and emotional neglect and codependency (see
Dodge Reyome et al., 2010, for further exploration of the link between child-
hood emotional maltreatment and codependency). In a sample of young
women seeking primary health care in Mexico, Noriega et al. (2008) found
that women who reported a history of familial emotional maltreatment
(measured by a three-item scale) were more than two times more likely to
be codependent than other young women without a childhood history of
emotional abuse and neglect. Interestingly, in this same study, neither child-
hood physical nor sexual abuse was found to be significantly associated
with codependence in this sample of young women.

In summary, for some time, researchers and theoreticians believed that
family-of-origin alcohol and substance abuse was the primary familial context
of codependency in adult relationships. However, investigations looking at
the relationship between exposure to substance and alcohol abuse and
codependency found only a weak association. Studies looking at other forms
of childhood trauma and codependency in adulthood have consistently
found a moderate to strong relationship between childhood emotional mal-
treatment and codependency. Further research is needed to look at explan-
atory mechanisms for the connection between emotional maltreatment and
codependency.

CHILDHOOD EMOTIONAL MALTREATMENT AND INTIMATE
PARTNER VIOLENCE

Initially, researchers looking at the association between child maltreatment
and intimate partner violence focused on a history of physical child abuse

Emotional Maltreatment and Intimate Relationships 233

or witnessing domestic violence as possible antecedents of relationship vio-
lence in adulthood (Rich, Gidycz, Warkentin, Loh, & Weiland, 2005). Some
investigators also linked child sexual abuse with a high likelihood of sexual
victimization in adult relationships (Arata & Lindman, 2002). Only recently
have researchers turned their attention to the role of childhood emotional
maltreatment in the experience of intimate violence in partner relation-
ships during late adolescence and adulthood (see Berzenki & Yates, 2010;
Zurbriggen, Gobin, & Freyd, 2010).

Childhood emotional maltreatment has been found to be associated
with intimate partner violence in marital relationships. In an early study
looking at childhood emotional maltreatment among battered married women,
Cascardi, O’Leary, Lawrence, and Schlee (1995) compared three groups of
women on a variety of psychosocial and family history measures. Child
abuse history including childhood history of emotional abuse was measured
using the Child Abuse Assessment (Neidig, 1989). Cascardi et al. (1995) uti-
lized three groups of women in their study: abused women, unhappily married
nonabused women, and martially content women. They found that rates of
childhood physical abuse and sexual abuse did not differ significantly across
groups. However, the abused women and the unhappily married women
reported significantly higher rates of childhood emotional abuse than did
the women who were content in their marriage. Further, the abused women
reported the highest rate of childhood emotional maltreatment of all three
groups in the study.

In a telephone survey of 637 women in the Memphis, Tennessee area,
Seedat, Stein, and Ford (2005) examined the association between childhood
maltreatment history (as measured by the Childhood Trauma Questionnaire),
substance misuse, posttraumatic stress disorder (PTSD), suicidal behavior,
and intimate partner violence victimization. Approximately half of the
women surveyed in their study were married or cohabitating and the aver-
age age of the participants was 37 years for those who reported intimate
partner violence and 40 years for those reporting no history of intimate part-
ner violence. Using a simultaneous regression model, childhood emotional
abuse (among other variables) significantly predicted experiencing intimate
partner violence. Stepwise regression analysis revealed that childhood emo-
tional abuse along with childhood sexual abuse and low educational attainment
were the only significant predictors of intimate partner violence victimization
in their study.

Studies also indicate that a history of childhood emotional abuse is
strongly associated with dating violence. Sappington, Pharr, Tunstall, and
Rickert (1997) looked at the relationship among a history of child abuse,
dating violence, and psychological problems in a sample of 133 female
undergraduates. Verbal abuse was assessed in this study using a measure
designed by the researchers called the Experiences Questionnaire. These
researchers found that a reported history of parental verbal abuse was

234 N. Dodge Reyome

strongly associated with being forced to have sex on a date, being physi-
cally abused by a date, being verbally abused by a date, and verbally abus-
ing a date. In essence, Sappington et al. found a strong association between
having a history of parental verbal abuse and reported dating violence vic-
timization and perpetration. Similarly, in a college student sample, Rich et al.
(2005) looked at the link between childhood victimization experiences and
college-age victimization experiences, including dating violence. In this
study, verbal aggression between parent and child was measured using
Straus’s (1979) Conflict Tactics Scale. Sixty-seven percent of the college-age
women in this study reported a history of paternal verbal abuse with close
to 50% reporting severe paternal verbal abuse. Eighty percent reported
maternal verbal abuse and almost 54% of the sample reported severe verbal
abuse from their mothers. In this sample, a reported history of maternal and
paternal verbal abuse was significantly related to dating violence victimization
during late adolescence. In fact, the only forms of childhood victimization
(physical abuse and sexual abuse were also measured) that predicted expe-
riencing dating violence during adolescence were maternal and paternal
verbal abuse during childhood.

Recently, investigators have begun to look at potential mediators of the
relationship between a history of childhood emotional abuse and intimate
partner violence victimization and perpetration. As with the connection
between childhood emotional maltreatment and interpersonal conflict in
adult relationships, early maladaptive schemas have been found to be one
of the possible links explaining the association between having a history of
childhood emotional abuse and later experiencing intimate violence in ado-
lescence and adulthood. Using a sample of college males and females,
Crawford and Wright (2007) studied the relationship between childhood
emotional maltreatment and intimate partner violence and the role of early
maladaptive schemas in this connection. These researchers utilized the Life-
time Experiences Questionnaire to measure childhood emotional abuse and
childhood emotional neglect. Similar to other researchers, Crawford and
Wright found that childhood emotional maltreatment emerged as a signifi-
cant predictor of both victimization and perpetration of intimate partner
violence. In addition, they found different schemas mediated the relationship
between a history of emotional maltreatment and intimate violence victim-
ization and emotional maltreatment and intimate violence perpetration. The
schemas of mistrust, self-sacrifice, and emotional inhibition all emerged as
full mediators of the relationship between childhood emotional abuse and
intimate partner victimization. The schemas of entitlement, emotional inhibition,
and insufficient self-control emerged as partial mediators of the relationship
between the perpetration of intimate partner violence and a childhood
history of emotional abuse.

Other psychological and social mechanisms have been investigated as
possible explanatory mechanisms for the established relationship between

Emotional Maltreatment and Intimate Relationships 235

childhood emotional maltreatment and intimate partner violence. Taft,
Schumm, Marshall, Pamuzio, and Holzworth-Munroe (2008) considered PTSD
and social information processing deficits as potential mediators of the asso-
ciation between a history of childhood maltreatment and intimate partner
violence in a sample of adult couples who were married or living together.
Of the forms of childhood maltreatment (childhood exposure to parental
violence and childhood physical abuse were also measured) assessed in the
Taft et al. study, only parental rejection emerged as being significantly
related to the perpetration of physical and psychological forms of relation-
ship violence. Parental rejection in childhood, as measured by the Rejection
subscale of the EMBU (Perris, Jacobsson, Lindstrom, von Knorring, & Perris,
1980), was also strongly correlated with posttraumatic stress symptoms and
social information processing deficits. Finally, Taft et al. found the associa-
tion of parental rejection with the perpetration of intimate partner violence
was mediated by posttraumatic stress symptoms and social information pro-
cessing deficits.

In a recent study, Wekerle et al. (2009) also looked at PTSD as a mediator
of the relationship between a childhood history of emotional maltreatment
and dating violence in a sample of adolescents involved with protective
services. These researchers gathered information from 402 teenagers receiving
child protective services. Most of the teens in their sample had begun dating
and between half and two thirds reported some form of dating violence.
Two instruments were utilized to measure childhood emotional maltreatment in
this study: the Childhood Trauma Questionnaire (Bernstein et al., 1994) and
the Childhood Experiences of Victimization Questionnaire (Walsh, MacMillan,
Trocme, Jamieson, & Boyle, 2008). Similar to Taft et al. (2008), these research-
ers found childhood emotional maltreatment was a significant predictor of
PTSD symptoms and intimate partner violence. Interestingly, they found
childhood emotional abuse was a significant predictor of both perpetration
of violence and victimization in dating relationships among males. In
females, only being a victim of dating violence was significantly predicted
by a history of childhood emotional abuse. Also, posttraumatic stress symp-
toms were found to be a significant mediator of childhood emotional abuse
and dating violence perpetration in males and dating violence victimization
in females.

In summary, although not as frequently studied as physical abuse,
emotional forms of child abuse have been found to be linked with intimate
partner violence in adolescent and adult populations in dating and marital
relationships. Those individuals with a history of emotional maltreatment
are far more likely than those without such a history to be involved in rela-
tionship violence perpetration and victimization. Recent studies have begun
to look at possible explanations for the link between a history of emotional
maltreatment and intimate partner violence in both dating and marital rela-
tionships. Some promising explanatory mechanisms for this connection are

236 N. Dodge Reyome

PTSD, maladaptive schemas about the self and others, and social informa-
tion processing deficits.

IMPLICATIONS FOR FUTURE RESEARCH AND CLINICAL PRACTICE

Although the research literature on the long-term consequences of child-
hood emotional maltreatment is growing, the sheer volume of studies lags
behind the amount of empirical research that has been carried out on other
forms of child maltreatment. It is especially important that child maltreat-
ment researchers continue to shine a light on the effect of childhood emo-
tional maltreatment on adolescent and adult interpersonal functioning.
Future investigations looking at aspects of adult interpersonal functioning
associated with childhood emotional maltreatment could advance this field
of inquiry by utilizing diverse samples, exploring protective factors, studying
mediators of the relationship, and employing prospective designs.

Studies looking at relationship functioning have tended to focus on female
participants and overlook male participants. This tendency has been especially
true in intimate violence studies seeking to understand the background and
psychosocial history of victims of intimate violence. The importance of con-
ducting studies that include male and female participants is exemplified by
studies where gendered relationship patterns have been uncovered. For
instance, DiLillo et al. (2009) found that husbands with a history of childhood
emotional abuse and emotional neglect reported declining marital satisfaction,
whereas wives with similar histories did not. Similarly, Wekerle et al. (2009)
found that a history of childhood emotional abuse was predictive of dating vio-
lence victimization in females and dating violence perpetration in males.

Whereas the connection between a history of childhood emotional
maltreatment and deleterious intimate relationships is clear, it is much less
clear what conditions could or do serve as protective factors in this connec-
tion. In their research, Varia and Abidin (1999) discovered that individuals
with a history of childhood psychological maltreatment who minimize their
history report higher quality relationships than individuals who have similar
histories of childhood psychological abuse who label themselves as being
childhood victims of emotional maltreatment. Besides minimizing the impor-
tance of their history of parental psychological abuse, the only other factor
Varia and Abidin could identify for ameliorating the effect of the abuse on
their adult relationships was the higher level of maternal care that the indi-
viduals who minimized their history reported receiving. It will be important
for future studies to begin to identify, explore, and understand other protec-
tive factors that soften the blow of parental emotional maltreatment on later
intimate relationships.

Researchers have begun to identify explanatory mechanisms for the
connection between a childhood history of emotional maltreatment and

Emotional Maltreatment and Intimate Relationships 237

later problems in intimate relationships. In marital relationships, Perry et al.
(2007) identified psychological distress as a mediator of the relationship
between a childhood history of emotional abuse and neglect and marital
satisfaction in males and females. Crawford and Wright (2007) found the
early maladaptive schemas of mistrust, self-sacrifice, and emotional inhibi-
tion were full mediators of the association between childhood emotional
abuse and intimate partner victimization. Both Wekerle et al. (2009) and Taft
et al. (2008) identified PTSD as a mediator of the relationship between child-
hood emotional abuse and partner violence. It is likely that other psychological
or contextual variables will be found to serve as pathways between a childhood
history of emotional abuse and relationship difficulties in adolescence and
adulthood (see Berzenski & Yates, 2010; Dodge Reyome et al., 2010).

The importance of employing prospective research designs in under-
standing the consequences of child maltreatment has been addressed in
other venues (Widom, Raphael, & DuMont, 2004). One of the greatest
advantages of using prospective, longitudinal research designs in looking at
the long-term consequences of emotional abuse is the ability to avoid recall
bias, which might artificially inflate the relationship between childhood
emotional abuse and later relationship problems. At the present time, most
of the studies looking at the relationship between childhood emotional mal-
treatment and later relationship functioning are retrospective in nature.
Short-term prospective designs have been utilized in the research literature
on the effect of childhood emotional maltreatment on intimate relationships.
For instance, DiLillo et al. (2009) looked at childhood emotional abuse and
marital functioning in newlyweds over a 2-year period. However, longer
term prospective studies have been carried out looking at the effect of other
forms of childhood maltreatment on interpersonal relationships in adoles-
cence and adulthood (Colman & Widom, 2004). Similar studies are needed
that follow individuals with a history of childhood emotional maltreatment
over longer spans of time and measure stage-salient aspects of relationship
functioning.

The findings of the current literature looking at the effect of childhood
emotional maltreatment history on later intimate relationships hold consid-
erable promise for clinical practice. Adult survivors of childhood emotional
victimization clearly have lowered opinions of themselves in relationship to
others and maladaptive beliefs and expectations of interpersonal relation-
ships. These early maladaptive schemas serve to guide their behavior in inti-
mate relationships and can result in mistrust, disconnection, and loneliness.
Therapeutic approaches that explore and rework these negative self and
relationship schemas will assist the individual in adopting new and more
constructive ways of thinking about the self and other people (see Carbone,
2010, for further exploration of therapeutic interventions). This cognitive
reworking should help the adult survivor form more meaningful, peaceful,
and connected relationships with others.

238 N. Dodge Reyome

Moreover, psychological distress and PTSD have been identified as
pathways by which a childhood history of emotional maltreatment is linked
with lower relationship satisfaction and quality as well as intimate violence
in adolescence and adulthood. Exploring and addressing these possible
avenues of relationship discord with adult survivors of emotional maltreat-
ment and providing targeted therapeutic intervention for these difficulties
should prove fruitful in assisting these individuals in finding ways to live
more productive and satisfying lives.

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Parent Alcohol Problems and Peer Bullying and Victimization:
Child Gender and Toddler Attachment Security

as Moderators

Rina D. Eiden

Research Institute on Addictions, University at Buffalo, State University of New York

Jamie M. Ostrov and Craig R. Colder

Department of Psychology, University at Buffalo, State University of New York

Kenneth E. Leonard, Ellen P. Edwards, and Toni Orrange-Torchia

Research Institute on Addictions, University at Buffalo, State University of New York

This study examined the association between parents’ alcoholism and peer bullying and
victimization in middle childhood in 162 community-recruited families (80 girls and 82
boys) with and without alcohol problems. Toddler–mother attachment was assessed at
18 months of child age, and child reports of peer bullying and victimization were
obtained in 4th grade. There was a direct association between fathers’ alcohol symptoms
and bullying of peers, as well as indirect association via toddler–mother attachment
security. Multiple group models indicated that the direct association between parents’
alcohol symptoms and bullying was significant for boys but not girls. The association
between maternal alcohol symptoms and bullying was significant for secure but not
insecure boys or secure=insecure girls. The association between fathers’ alcohol
symptoms and bullying was significant for insecure boys but not secure boys or
secure=insecure girls.

It is now well established that children who have parents
with alcohol problems are at increased risk for inter-
personal and behavioral problems, psychiatric distur-
bances, and substance abuse (see Zucker, Donovan,
Masten, Mattson, & Moss, 2008). Longitudinal research
has demonstrated prospective associations between
paternal alcoholism and externalizing and internalizing
behavior problems (e.g., DeLucia, Belz, & Chassin,
2001; Hussong et al., 2008), and the subsequent develop-
ment of substance use and problems (see Jacob &
Windle, 2000; Zucker et al., 2008). A few longitudinal
studies also have noted lower social competence among
girls of fathers with alcoholism at age 6 according to
self and teacher reports (Hussong, Zucker, Wong,

Fitzgerald, & Puttler, 2005), and lower social
competence among kindergarten children of fathers with
alcohol problems according to parent and teacher
reports, via lower maternal warmth (Eiden, Colder,
Edwards, & Leonard, 2009).

In middle childhood, there is a dramatic increase in
children’s social networks (Ladd & Pettit, 2002). An
important developmental task in middle childhood is
the formation of peer relationships and reciprocated
friendships (Sroufe, Egeland, & Carlson, 1999). By 10
to 12 years of age, children become more notably skilled
in using goal directed strategies to maintain peer rela-
tionships and manage conflict with peers without adult
intervention (Parker & Gottman, 1989). Children who
have problems in maintaining relationships and interact-
ing cooperatively with peers are at risk for a number of
concurrent and later problems (Parker & Asher, 1987;
Parker, Rubin, Erath, Wojslawowicz, & Buskirk, 2006).

Correspondence should be addressed to Rina D. Eiden, Research

Institute on Addictions, University at Buffalo, SUNY, Buffalo, NY

14203. E-mail: eiden@ria.buffalo.edu

Journal of Clinical Child & Adolescent Psychology, 39(3), 341–350, 2010

Copyright # Taylor & Francis Group, LLC

ISSN: 1537-4416 print=1537-4424 online

DOI: 10.1080/15374411003691768

Numerous studies of peer relations in early to middle
childhood have highlighted considerable variations in
the degree to which children are accepted by their peers
(e.g., Hymel, Rubin, Rowden, & LeMare, 1990).
Although some children are well accepted and enjoy a
great deal of popularity, others are relatively isolated
and disliked. These individual differences in peer
interactions are relatively stable across childhood and
are indispensable in the development of later social
competence (Hartup, 1983, 1996).

Two interrelated aspects of peer relations that are
critical for current and later developmental outcomes
are peer bullying and victimization by peers. Bullying is
a serious problem that has been extensively researched
in recent years (e.g., Olweus, 1995, 1996; Pepler, Jiang,
Craig, & Connolly, 2008; Smith et al., 1999; Solberg &
Olweus, 2003). Bullying is a subtype of aggression (i.e.,
intentional acts to hurt, harm, or injure; Dodge, Coie, &
Lynam, 2006) that is repeated frequently and character-
ized by an imbalance of strength or power (Olweus, 1994;
Pepler et al., 2008; Vaillancourt et al., 2008). As a specific
negative relationship context in which aggression is
displayed, bullying may manifest as verbal, physical, or
relational in nature (Crick & Grotpeter, 1995; Olweus,
1994; Pepler et al., 2008). Bullying is often conceptua-
lized along a continuum recognizing that children may
be involved in bullying behavior to differing degrees
as the perpetrator or victim, a bully-victim in which they
experience both, a bystander, or an uninvolved peer
(Espelage & Swearer, 2003). This dimensional approach
has revealed that bullying is only moderately correlated
with both general peer-directed physical and relational
aggression in past research (Pepler et al., 2008). In other
words, although all bullying involves aggression, it is
distinct from physical aggression perhaps because the
most frequent type of bullying involves verbal aggression
and teasing (Eder, 1995) and serves the goal of enhancing
peer group status (Espelage, Holt, & Henkel, 2003).
Few longitudinal studies have been conducted to assess
developmental antecedents of bullying (see Long &
Pellegrini, 2003; Pepler et al., 2008) and to our knowl-
edge no prospective studies have examined bullying in
children at risk for maladaptive trajectories like children
of parents who abuse alcohol.

Bullying is particularly relevant for children of
parents with alcoholism because evidence from two pro-
spective studies indicate that these children do not follow
a normative developmental trajectory for aggressive
behavior. For instance, children of parents with alcohol
problems are at increased risk for aggression in the
toddler and early preschool periods (Edwards, Eiden,
Colder, & Leonard, 2006a), and this risk continues into
the early school years (Loukas, Fitzgerald, Zucker, &
Von Eye, 2001; Loukas, Zucker, Fitzgerald, & Krull,
2003). As children’s social worlds become more focused

on peers in middle childhood, higher aggressive behavior
noted among children with parents who have alcohol
problems may become more focused on peers and mani-
fest as bullying. These children also have lower parent
reported social competence around kindergarten age
(Eiden, Colder, Edwards, & Leonard, 2009), and this
association seems to vary by child gender (Hussong
et al., 2005). Children, especially boys with lower social
competence, may be more likely to engage in behaviors
such as bullying in order to enhance social status among
peers (Espelage et al., 2003).

Similarly, victimization by peers increases children’s
risk for concurrent and later maladjustment (Ladd &
Kochenderfer Ladd, 2002; for reviews see Card &
Hodges, 2008; Juvonen & Graham, 2001). Some chil-
dren of parents with alcoholism may be at higher risk
for victimization because of poor social skills arising
out of poor parenting and social isolation due to par-
ents’ alcoholism. Victims of peer aggression often report
higher levels of social anxiety, depression, and loneliness
(Cunningham, 2007). However, little is known about the
association between parents’ alcoholism and children’s
aggression toward or victimization by peers, or about
factors that may mediate or moderate this association.

One potential mediator or moderator of the associ-
ation between parents’ alcohol problems and peer
bullying or victimization is the quality of parent–toddler
attachment. According to attachment theory, early
attachment patterns play a key causal role in the devel-
opment of subsequent relationships (Bowlby, 1979,
1988). Parents who are warm, responsive, and supportive
during parent–child interactions are more likely to have
securely attached children (Ainsworth & Bell, 1970).
Secure attachment to a parent not only serves as a secure
base under conditions of stress, but because of greater
emotional availability and communication, provides
opportunities for learning that carries into the peer
context (Ainsworth & Bell, 1970; Michiels, Grietens,
Onghena, & Kuppens, 2008). Insecurely attached
children may engage in greater bullying of peers as a
result of negative internal working models characterized
by anger or mistrust (Bretherton, 1985), or due to
negative attributional biases (Dodge & Newman,
1981). They may also be more likely to be victimized
by peers due to poorer emotion regulation or greater fear
in the peer context (Michiels et al., 2008). Empirical
evidence from a few studies indicates that children with
insecure attachment to their mothers were more likely
to bully their peers and experience more peer victimiza-
tion (Smith & Myron-Wilson, 1998; Troy & Sroufe,
1987). Thus, attachment security may serve as a protec-
tive factor for negative child outcomes such as peer
bullying or victimization especially under conditions of
stress or negative family experiences (Dallaire &
Weinraub, 2007; van Ijzendoorn, 1997).

342 EIDEN ET AL.

A second potential moderator of the association
between parents’ alcohol problems and peer bullying
or victimization by peers is child gender. Sons of fathers
with alcohol problems are more likely to be aggressive
and to not display the normative declines in aggressive
behavior in the preschool or early childhood period
(Edwards, Eiden, Colder, et al., 2006). However, other
studies have noted that girls of fathers with alcohol pro-
blems, but not boys, have lower social competence in
the early school years (Hussong et al., 2005). The attach-
ment literature also indicates some evidence for further
interactive effects such that insecurely attached boys,
but not girls, may be at risk for externalizing behaviors
including peer aggression (Lewis, Feiring, McGuffog, &
Jaskir, 1984; McCartney, Owen, Booth, Clarke-Stewart,
& Vandell, 2004). Other studies indicate that girls
with insecure attachment may exhibit higher levels of
externalizing behaviors and be more likely to engage
in bullying (Munson, McMahon, & Spieker, 2001).

Based on this literature, we hypothesized that
children of parents who have problems with alcohol
would be more likely to engage in bullying of their peers
and experience more frequent victimization. Attachment
security was expected to mediate or moderate the asso-
ciation between parents’ alcoholism and bullying=
victimization. We expected that parents’ alcohol symp-
toms would predict higher toddler–mother insecurity,
which in turn would be a significant predictor of peer
bullying and victimization. In other words, toddler–
mother attachment security would be one pathway
explaining the association between alcohol problems
and peer bullying and victimization. A secure attach-
ment relationship with the mother (who in most families
is the primary caregiver and, for most families in
this sample, the nonabusing parent), may also have a
protective effect, so that under condition of risk such
as fathers’ alcoholism, children who had a secure
mother–toddler relationship may have positive internal
working models of self and other and engage in less
bullying and experience less victimization by peers.
The association between fathers’ alcoholism and peer
bullying and victimization may also be moderated by
child gender. Boys of fathers who have problems with
alcohol may be more likely to engage in bullying of
peers. We did not have specific hypotheses regarding
gender moderation for peer victimization, but conduc-
ted analyses to examine this issue.

METHOD

Participants

The sample consisted of 227 families (111 girls, 116
boys) participating in an ongoing longitudinal
study. Families were classified into two groups at

recruitment: the group consisting of parents with no or
few current alcohol problems (n ¼ 102, 51% boys), and
the group of families with at least one parent who
abused alcohol (n ¼ 125). Within the alcoholic group,
102 families had one parent (in 93% of families, this
was the father) who met criteria for alcohol abuse or
dependence, whereas the other parent was light drinking
or abstaining (52% boys). In the remaining 23 families,
both parents met diagnostic criteria for alcohol abuse
(52% boys). These classifications were based on parental
self-reports at 12 months of child age.

As would be expected of any longitudinal study
involving multiple family members, there were incom-
plete data for some participants at one or more of the
assessment points included in this study. Of the 227
families, all provided data at 12 months, 220 mother
and toddlers had attachment data at 18 months, and
162 children provided data on peer bullying and victimi-
zation at fourth grade (9–10 years of child age). There
were no significant differences between the 227 families
with complete data compared to those with missing data
on alcohol diagnosis (48% of families with missing data
were in the alcohol group), or child gender distribution
(52% of families with missing data had boys). There was
no significant association between attachment security
(secure=insecure) and missing status at fourth grade.

The majority of the parents in the study were Cauca-
sian (94% of mothers and 87% of fathers) with a smaller
percentage of African Americans (5% of mothers, 7% of
fathers). Although parental education ranged from less
than high school degree to master’s degree, about half
the mothers (57%) and fathers (55%) had received some
post–high school education or had a college degree.
Annual family income ranged from $4,000 to $95,000
(M ¼ $41,824, SD ¼ $19,423). At the first assessment,
mothers were residing with the biological father of the
infant in the study. Most of the parents were married
to each other (88%). At recruitment, mothers’ age
ranged from 19 to 40 (M ¼ 30.4, SD ¼ 4.58). Fathers’
age ranged from 21 to 58 (M ¼ 32.9, SD ¼ 6.06).

Procedure

The names and addresses of families were obtained from
the New York State birth records for Erie County.
Parents who indicated an interest in the study were
screened by telephone with regard to sociodemographic
characteristics and eligibility criteria (see Eiden,
Edwards, & Leonard, 2007, for procedural details).
Parents were primary caregivers and cohabiting since
the infant’s birth, and women who reported drinking
moderate to heavy amounts of alcohol during preg-
nancy were excluded from the study in order to control
for potential fetal alcohol effects. During the phone
screen, mothers were administered the Family History

PARENT ALCOHOL & BULLYING VICTIMIZATION 343

Research Diagnostic Criteria for alcoholism with regard
to their partners’ drinking (Andreasen, Rice, Endicott,
Reich, & Coryell, 1986) and fathers were screened with
regard to their alcohol use. Because we had a large pool
of families potentially eligible for the nonalcoholic
group, alcoholic and nonalcoholic families were
matched on race=ethnicity, maternal education, child
gender, parity, and marital status.

Families visited the laboratory at six different child
ages (12, 18, 24, 36 months, kindergarten [5–6 years of
child age], and fourth grade [9–10 years of child age]).
The study was approved by the University at Buffalo
Social Science Institutional Review Board. Informed
written consents were obtained from both parents and
child assents were obtained in fourth grade. Extensive
observational assessments with both parents and
children were conducted at each age. This paper
focuses on 12 month alcohol data, fourth-grade peer
bullying and victimization data, and attachment data
obtained from observational assessments at 18 months
of child age. Families were compensated for their
time in the form of gift cards, toys, and monetary
compensation.

Measures

Parental alcohol use. The University of Michigan
Composite International Diagnostic Interview adapted
to a self-report questionnaire (Anthony, Warner, &
Kessler, 1994) was used to assess alcohol abuse and
dependence at 12 and 18 months. In addition to the
screening criteria, Diagnostic and Statistical Manual
of Mental Disorders (4th ed. [DSM–IV]; American
Psychiatric Association, 1994) criteria for alcohol abuse
and dependence diagnoses for current alcohol problems
(in the past year at 12 months) were used to assign final
diagnostic group status. The continuous measures of
maternal and paternal alcohol abuse and dependence
symptoms assessed at 12 months were used in further
analyses.

Mother-toddler attachment. The Ainsworth
Strange Situation paradigm (Ainsworth & Wittig,
1969), a 21-min videotaped, structured laboratory
separation-reunion procedure was used to examine
mother–toddler attachment at 18 months. The pro-
cedure consists of eight 3-min episodes that occur in a
fixed order and are designed to include increasing levels
of stress in the infant so as to activate the attachment
system. In each episode, the infant’s behavior is rated
along six dimensions using 7-point scales. The ratings
are used to classify the infants into three major cate-
gories: secure, insecure-avoidant, and insecure-resistant.
In addition to these three classifications, the coding

scheme has been extended to include an additional
pattern that is especially prevalent in high-risk infants,
the disorganized (D) pattern (Main & Solomon, 1990).
The D classification is considered to be an insecure pat-
tern with behaviors representing a collapse of organized
behavior in response to stress of separation, resulting
from fear or apprehension in the parent’s presence
(Carlson, 1998). This may be exhibited in a variety of
ways. Two major behavioral themes are contradictory
behavior patterns or direct indices of fear, freezing,
apprehension, or disassociation in the parent’s presence.
Because the D classification does not represent an
organized strategy for maintaining access to the care-
giver, an alternative, best-fitting classification of secure,
avoidant, or resistant is assigned as well, although in
several cases, coding of this alternative classification is
extremely difficult.

The fifth author and two research assistants who were
blind to group status were responsible for coding all the
Strange Situations, with consultation on difficult to code
tapes provided by the first author. The first author was
originally trained in coding Strange Situations by
Douglas Teti, with training on D coding provided by
Dante Cicchetti and follow-up training by Alan Sroufe
and Elizabeth Carlson. The fifth author was trained by
Alan Sroufe and Elizabeth Carlson. Individual dyads
used for reliability were selected randomly and included
all four classifications. The mean interrater reliability
on 15% of the sample using Pearson’s r was .76 on
the Strange Situation rating scales and .81 for the
Disorganization scale score. Interrater agreement on
the four attachment classifications was 93% (Cohen’s
j ¼ .86). Due to power concerns, only the secure=
insecure classifications were used in further analyses.
Results on predictors of attachment classifications have
been reported previously (see Eiden, Edwards, &
Leonard, 2002).

Peer bullying and victimization. The Revised
Bully=Victim Questionnaire (Olweus, 1994) was used
to measure peer aggression using child self-reports. This
is a widely used measure that assesses bullying toward
peers and experiences of being victimized by peers.
Children were provided with a definition of bullying
and victimization and asked to report the frequency
and severity of bullying others and being victimized by
others in the last 2 months. Bullying behavior and
victimization (nine items in each scale) were measured
on 5-point scales, ranging from 0 (not at all) to 4 (several
times a week). The sum of the two sets of items (bullying
others and victimization) were used as measures of
bullying and victimization. The measure has well estab-
lished validity in large-scale studies across different
schools, with significant associations on the ‘‘bullying

344 EIDEN ET AL.

others’’ and ‘‘victimization’’ subscales with peer ratings
on similar items (Olweus, 1997), with peer nominations
(Olweus, 1991), and with measures of antisocial
behavior and other measures of aggressive behavior
(see Bendixen & Olweus, 1999). Moreover, positive
and significant associations have been found between
the BVQ and teacher ratings and diary reports of bully-
ing (Pellegrini & Bartini, 2000). Internal consistencies
for this measure have been acceptable in the past (e.g.,
.76 for bullying and .78 for victimization, Pellegrini &
Long, 2002). In the current study, the internal consisten-
cies of the two measures were as follows: Cronbach’s
a ¼ .67 for the bully scale, and .66 for the victimization
scale. Given the extensive use of these measures and
appropriate internal consistency in the past (see Card &
Hodges, 2008) these lower than conventional levels of
reliability were deemed acceptable, but some caution
should be exercised in interpreting the findings. The
scores on bullying and victimization were skewed
and transformed using square root transformations
before further analyses and reached acceptable levels
of skew (i.e., <3; Kline, 2005). For the descriptive infor- mation presented for bullying and victimization, the nontransformed means and standard deviations are reported.

Data Analytic Approach

Structural equations modeling (SEM) was used to test
all hypotheses. All SEM analyses were conducted using
Mplus (Version 4.0; Muthen & Muthen, 1998–2006).
Full-information maximum likelihood estimation proce-
dures were used and standardized parameter estimates
are presented. Multiple group analyses were used to
examine moderation by gender and moderation by
attachment security and gender. These models were
tested by comparing fully unconstrained with fully
constrained models. The Dv2 was used as an omnibus
test of differences across groups. Given a significant
Dv2, we examined the modification indices to locate
group differences in path coefficients.

RESULTS

Demographic and Descriptive Information

Descriptive and demographic information were first
examined for each group of families. By the
fourth-grade assessment, 16% of the biological fathers
were not living with their families. Of these, 12% were
in the alcoholic group, and 4% were in the nonalcoholic
group. Chi-square analyses revealed that this difference
was not statistically significant (p > .05). All of the
children who completed assessments at fourth-grade

had regular contact (at least once a week) with their
biological fathers and there were no group differences
with regards to how much time fathers or mothers spent
with their children. Overall, 27 fathers (13%) and 23
mothers (11%) had been in treatment for alcohol
problems at some point since recruitment and the
fourth-grade assessment, 14 fathers (7%) and 11 mothers
(5%) had been in treatment for drug-related problems
and 24 fathers (11%) and 38 mothers (18%) had been
in treatment for psychological problems. One-way
analysis of variance tests revealed that there were no
significant group differences in mothers’ education,
fathers’ education, total family income, fathers’ work
hours, or mothers’ work hours. Descriptive information
regarding group differences on parents’ alcohol con-
sumption and alcohol problems is presented in Table 1.
There were no associations between child gender and
attachment classifications, or between child gender and
parents’ alcohol symptoms. The child bullying and victi-
mization scales were correlated at r ¼ .31, p < .001, for the sample as a whole. The correlation between bullying and victimization was significantly higher among chil- dren in the nonalcoholic group (r ¼ .52) than for chil- dren in the alcoholic group (r ¼ .23), z ¼ 2.07, p < .05.

Main Analyses

We first examined the fit of the overall conceptual
model, with maternal and paternal alcohol abuse=
dependence symptoms at 12 months as the predictors,
toddler attachment security with mother at 18 months
as the intervening variable, and mean ratings of bullying
and victimization by peers as the outcome measures.
This model included paths from the two predictors to
the mediator, and paths from the mediator to the two

TABLE 1

Group Differences in Alcohol Consumption, at Recruitment, Peer

Bullying, and Victimization Scales

Nonalcoholica Alcoholicb

Variable M SD M SD g2

Paternal QFI .20a .28 1.31b 1.16 .25

Paternal Binge .36a .58 2.97b 1.93 .39

Paternal Alcohol Symptoms .16a .46 9.43b 15.50 .12

Maternal QFI .06a .10 .20b .29 .07

Maternal Binge .20a .45 .90b 1.04 .13

Maternal Alcohol Symptoms .05a .20 1.03b 2.40 .06

Peer Bullying .08a .18 .18b .28 .03

Peer Victimization .27 .33 .37 .34 .02

Note. Means with different subscripts were significantly different

from each other. QFI ¼ Quantity-Frequency Index.
an ¼ 59.
bn ¼ 103.

PARENT ALCOHOL & BULLYING VICTIMIZATION 345

outcome variables. The model also included a covari-
ance between the two alcohol measures and a covariance
between the residuals of bullying and victimization.
Goodness of fit indices revealed that the model did not
fit the data well, v2(4, N ¼ 227) ¼ 16.23, p ¼ .003, com-
parative fit index (CFI) ¼ .53, root mean square error
of approximation [RMSEA] ¼ .11. We next added direct
paths from paternal and maternal alcohol symptoms to
mean ratings of bullying. Results indicated a significant
improvement in model fit, Dv2(2, N ¼ 227) ¼ 13.59,
p < .01. This final overall model fit the data well, v2(2, N ¼ 227) ¼ 2.64, p ¼ .27, CFI ¼ .98, RMSEA ¼ .038. Higher paternal alcohol symptom at 12 months was associated with toddler–mother insecurity at 18 months. Toddler–mother insecurity at 18 months predicted greater bullying of peers in fourth grade. There was also a significant direct path from fathers’ alcohol symptoms at 12 months to peer bullying at fourth grade (see Figure 1). Maternal alcohol symptoms were not related to attachment insecurity or directly to peer bullying. Addition of other direct paths from parents’ alcohol symptoms to victimization did not improve the fit of the model. Attachment security was not a significant predictor of peer victimization.

In the next step, we used multiple group analysis to
examine if child gender moderated the association

between alcohol group status and peer bullying and
victimization. We first examined fit indices for a fully
unconstrained model for boys and girls and compared
this unconstrained model with a fully constrained
model. These two nested models were significantly
different from each other, Dv2(8, N ¼ 227) ¼ 28.91,
p < .01. Modification indices indicated that the direct paths from paternal to maternal alcohol symptoms to peer bullying, the path from paternal alcohol symptoms to attachment security, and the path from attachment security to peer bullying should be freely estimated for boys and girls. In the final multiple group model these four paths were freely estimated and all other paths were constrained. This model fit the data well, v2(6) ¼ 3.21, p ¼ .78, CFI ¼ .99, RMSEA ¼ .001. The significant para- meter estimates for this final model for boys are depicted in Figure 2. As depicted in the figure, both maternal and paternal alcohol problems at 12 months were directly associated with peer bullying and victimization at fourth grade. Paternal alcohol problem was associated with higher attachment insecurity, which in turn predicted greater bullying in fourth grade. None of the parameter estimates were significant for girls.

Multiple group analyses with the two attachment
security groups for boys and girls were conducted next
to examine if the association between parents’ alcohol

FIGURE 1 Overall path model for peer bullying and victimization. Note. The model included paths from maternal and paternal alcohol problems

to peer victimization, a path from maternal alcohol problems to bullying, and a path from attachment security to peer victimization. These paths

were nonsignificant and are not depicted in the model for ease of presentation. �p < .05. ��p < .01.

FIGURE 2 Path model for peer bullying and victimization for boys. Note. The model included paths from maternal and paternal alcohol problems

to peer victimization, and a path from attachment security to peer victimization. These paths were non-significant and are not depicted in the model

for ease of presentation. þp < .10. �p < .05. ��p < .01.

346 EIDEN ET AL.

problems and peer bullying differed as a function of
child gender and attachment security. As before, a fully
unconstrained model was compared to a fully con-
strained model and the chi-square difference test was
used as an omnibus test of differences across groups.
This model included parents’ alcohol problems as pre-
dictors and child bullying as the outcome measure. As
before, the model also included the covariance between
fathers’ and mothers’ alcohol symptoms. The fully con-
strained model was significantly different from the fully
constrained model, Dv2(9) ¼ 20.59, p < .05, indicating that the association between parents’ alcohol symptoms and peer bullying was significantly different across the four groups. Modification indices suggested that the two paths from parental alcohol problems to peer bully- ing should be freely estimated for secure and insecure boys, but not girls. Thus, these two paths and the covariance were freely estimated for the two groups of boys, but not girls. This final multiple group model fit the data well, v2(5) ¼ 2.16, p ¼ .54, CFI ¼ .99, RMSEA ¼ .001. There was a significant association between maternal alcohol symptoms and peer bullying for secure boys (B ¼ .33, p < .05), but not for insecure boys (B ¼ .19, p > .05). There was also a significant
association between paternal alcohol symptoms and
peer bullying for insecure boys (B ¼ .61, p < .05) but not for secure boys (B ¼ .18, p > .05).

DISCUSSION

Results partially supported our hypothesized model
indicating direct and indirect associations via toddler–
mother attachment security between paternal alcohol
problems and peer bullying. We also hypothesized that
sons of parents with alcohol problems and children with
insecure attachment to their mothers would be at higher
risk for peer bullying. Results generally supported these
hypotheses. Among boys, both paternal and maternal
alcohol problems directly predicted peer bullying.
Paternal alcohol problems also indirectly predicted
bullying via security of attachment. These results are
supportive of previous studies indicating that sons of
parents with alcohol problems are at higher risk for
externalizing behavior problems in general (Loukas
et al., 2001), and display a non-normative trajectory
for aggressive behavior more specifically (Edwards,
Edien, Colder, et al., 2006). The current results indicate
that this risk may spillover into peer relationships as
well, with boys of parents with alcohol problems
displaying higher rates of bullying toward peers.

In addition to child gender, security of attachment
with mother was a significant moderator of risk for peer
bullying among boys. The association between paternal
alcohol problems and peer bullying was significant for

boys who had an insecure attachment relationship with
their mothers, whereas the association between maternal
alcohol problems and peer bullying was significant
among boys with a secure attachment relationship with
their mothers. The results indicate that in the presence of
maternal psychopathology, security of attachment with
the mother may be associated with increased risk. In
other words, having a secure relationship with a prob-
lematic parent may be associated with negative conse-
quences and not confer protection from adversity. Our
findings regarding the association between paternal
alcohol problems and peer bullying for insecure, but
not secure boys, are consistent with the extant attach-
ment theory. Results indicate that sons of fathers with
alcohol problems who have an insecure attachment to
their mothers continue to have relationship problems
in middle childhood in the peer domain. The continuity
between early parent–child attachment patterns and
future peer relationship problems has been well docu-
mented (see Sroufe et al., 1999) but the present findings
extend this literature in novel ways. There have been no
previous studies examining the role of attachment secur-
ity in moderating the association between parents’
alcoholism and children’s peer relationships. However,
results from a previous study indicated that secure
mother–toddler attachment moderated the association
between fathers’ alcoholism and children’s externalizing
behavior problems in the preschool period (Edwards,
Eiden, & Leonard, 2006). To the extent that externaliz-
ing behavior problems is one predictor of greater peer
bullying, the current results extend these previous find-
ings developmentally to middle childhood. This may
also explain the stronger association between bullying
and victimization among children of nonalcoholic
parents compared to children with alcoholic parents.
Children with parents who have alcohol problems may
be more likely to cope with the stress of their parent’s
alcoholism by acting out and using aggressive behaviors,
or by social withdrawal. Future studies may well
examine these specific patterns of behavior in the
school setting.

Contrary to expectations, there were no direct
or indirect associations between parental alcohol
problems and peer victimization. A paucity of research
exists exploring the developmental antecedents of peer
victimization among typically developing children and
even less literature is available for understanding how
early risk factors may set children on a maladaptive
trajectory toward peer victimization in later develop-
mental periods (see Card & Hodges, 2008). Specifically,
few studies have examined risk for victimization by
peers among children of parents with alcohol problems.
It is possible that other factors not included in this study
such as family aggression may predict peer victimiza-
tion. Future studies may examine this issue more closely.

PARENT ALCOHOL & BULLYING VICTIMIZATION 347

Similarly, unlike results with peer bullying, attach-
ment security did not moderate the relationship between
alcohol group status and peer victimization. Previous
studies on predictors of peer victimization have noted
that there is a great deal of heterogeneity among
children who are victimized frequently by peers and
there are significant differences in length of peer victimi-
zation (Kochenderfer Ladd & Ladd, 2001). Others have
noted that aspects of parenting that are gender-atypical,
such as coercive parenting for girls, and overprotective
parenting for boys may predict victimization because
they hamper the acquisition of social competencies that
are gender typical (Perry, Hodges, & Egan, 2001). Thus,
aspects of parenting other than attachment per se may
have moderated the association between alcohol group
status and peer victimization. Moreover, future studies
of high-risk children with repeated measures over time
may be better able to examine the issue of duration of
peer victimization. Chronic victimization over longer
periods of development may have different antecedents
and consequences than peer harassment at a particular
point in time.

Unlike the results with victimization, there were
significant and direct associations between parents’
alcohol problems and bullying of peers. Greater risk
for bullying of peers in middle childhood may be one
pathway to later problems documented among children
of parents with alcohol problems. Given that bullying in
an at-risk population (i.e., maltreated children; Shields
& Cicchetti, 2001) is associated with emotion regulation
problems, future research should examine the develop-
mental correlates and sequelae of experiences with bully-
ing among children of with parents who have alcohol
problems. Typically developing children that engage
in bullying also are prone to hostile attribution biases
or interpreting the intent of a perpetrator as hostile
in an ambiguous provocation situation (Camodeca,
Goossens, Schuengel, & Terwogt, 2003). In addition,
adolescents who experience bullying or victimization
are at risk for depression, suicidal ideation, and suicide
attempts compared to those not involved and those
engaged in both bullying and victimization are at the
greatest risk of these problems (Graham, Bellmore, &
Mize, 2006; Hawker & Boulton, 2000). Understanding
the antecedents and potential maladaptive outcomes
for both typically developing children and those at
increased risk could facilitate greater focus on possible
developmental mechanisms that could inform effective
prevention and intervention efforts.

Although the findings from our study fill an impor-
tant gap in the literature, there are several significant
limitations as well. First, our measures of bullying and
victimization were based on child self-report alone.
Previous studies of children of parents with alcohol
problems using different methods of measuring social

competence indicate that results vary by reporter
(Hussong et al., 2005). In addition, the bullying and vic-
timization measure did not explicitly measure relational
forms of bullying (see Pepler et al., 2008). Girls display
relational aggression as their primary form of aggression
(see Putallaz et al., 2007) and thus, this issue may have
impacted the findings with respect to the lack of associa-
tions among girls. A second limitation is that due to the
nature of the design, the role of maternal alcohol
problems cannot be examined independent of fathers’
alcohol problems. Not only was this sample restricted
with regard to maternal alcohol problems because one
exclusion criteria was maternal alcohol consumption
during pregnancy, but it was also limited because the
number of mothers with postnatal alcohol problems
was relatively small. However, it is important to note
that in the majority of families with alcohol problems,
maternal alcohol problems exist in the context of
paternal alcohol problems. In other words, women with
alcohol problems are more likely to have partners with
alcohol problems than vice versa (Roberts & Leonard,
1997). Finally, these results may not be generalizable
to families of single mothers who separated from or
never lived with a partner who had alcohol problems.
One eligibility requirement at the time of recruitment
when the child was 12 months old was that biological
parents had been living together since the child’s birth.
This was important so we could examine the effects of
fathers’ alcoholism on family functioning, parenting,
and child development. However, this limits generaliz-
ability of our findings to families who were intact when
the child was 1 year old.

Implications for Research, Policy, and Practice

In spite of these limitations, the current study adds to
the literature on parental alcoholism with its use of a
longitudinal design beginning in infancy, examination
of the role of toddler attachment security in moderating
risk, and its focus on peer bullying and victimization
during middle childhood. The findings that child gender
and attachment security moderate risk for peer bullying
and victimization are important as they suggests that
intervention efforts targeted at improving the quality
of relationship with the mother may have significant
implications for peer relationships in middle childhood,
particularly for boys of parents with alcohol problems.
Furthermore, the findings indicate the potential cascad-
ing effects and costs of early risk of exposure to parental
alcoholism and highlight the continued need to support
public health efforts at increasing access to substance
abuse and mental health treatment services for care-
givers of young children. The results also suggest that
timing these interventions for the toddler period may
be most beneficial.

348 EIDEN ET AL.

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O R I G I N A L P A P E R

Parental Combat Injury and Early Child Development:
A Conceptual Model for Differentiating Effects of Visible
and Invisible Injuries

Lisa A. Gorman • Hiram E. Fitzgerald • Adrian J. Blow

Published online: 26 November 2009
� Springer Science+Business Media, LLC 2009

Abstract The injuries (physical and emotional) sustained by service members during
combat influence all members of a family system. This review used a systemic framework

to conceptualize the direct and indirect effects of a service member’s injury on family

functioning, with a specific focus on young children. Using a meta-ethnographic approach

to synthesize the health research literature from a variety of disciplines, this review makes

relevant linkages to health care professionals working with injured veterans. Studies were

included that examined how family functioning (psychological and physical) is impacted

by parental illness; parental injury; and posttraumatic stress disorder. The synthesis of

literature led to the development of a heuristic model that illustrates both direct and

indirect effects of parental injury on family functioning and the development of young

children. It further illustrates the contextual factors or moderating variables that buffer

detrimental effects and promote family resilience. This model can be a foundation for

future research, intervention, and policy.

Keywords Parental combat injury � Trauma � Children

The Iraq and Afghan conflicts have produced an estimated 20,000 children of America’s

military force who have a parent with a combat related injury [1]. This number does not

include the effects of posttraumatic stress disorder (PTSD) or milder forms of brain injury.

PTSD, traumatic brain injury (TBI), and depression are the most common forms of

affective and cognitive impairment identified among approximately 30% of returning

veterans [2]. Hoge et al. [3] reported that 15% of service members returning from Iraq and

L. A. Gorman (&) � H. E. Fitzgerald
University Outreach and Engagement, Michigan State University, 22 Kellogg Center, East Lansing,
MI 4882, USA
e-mail: gormanL1@msu.edu

H. E. Fitzgerald
Department of Psychology, Michigan State University, East Lansing, MI, USA

A. J. Blow
Department of Family and Child Ecology, Michigan State University, East Lansing, MI, USA

123

Psychiatr Q (2010) 81:1–21
DOI 10.1007/s11126-009-9116-4

Afghanistan have suffered a mild TBI that involved either a loss of consciousness or

altered mental status. The fifth report of the Mental Health Advisory Team [4] indicates

that service members with multiple deployments are at a higher risk for PTSD and other

mental health concerns. These numbers suggest that a relatively large number of returning

veterans have either a physical or an emotional injury. Of note is that nearly half of the

active duty Army have dependent children, 27% of whom are under age three [5], meaning

that many injured service members are returning home to households that include a very

young child. In the National Guard and Reserve alone, there are 106,000 children ages

birth-three. Additionally, there are 90,000 babies born each year to active duty service

members [6]. The number of injured service members returning home to families

emphasizes the need to understand the long-term implications of parental injury on early

child development, and to identify buffers to the negative effects of these injuries.

The purpose of this article is to present a conceptual framework for studying the effects

of both visible and invisible injuries on individual and family dynamics, in order to

understand more fully the kinds of supportive services needed to reduce risk to very young

children in families traumatized by injuries. Because the early life course trajectory is

shaped ‘‘largely [by] the result of the infant’s relational world of family, community, and

life context’’ [7, p. 176] the impact of parental injury can negatively affect relationships

within the family system, including relationships that impact infants and toddlers who are

the most vulnerable members of that system. The effects of parental combat injury on early

child development continue to be understudied [8–10], despite mounting evidence for the

intergenerational transmission of trauma [11–14]. Consequently, there is a need for a

conceptual framework to guide this work; a conceptual framework that encompasses the

systemic components of the veteran’s life space including all of the factors that encompass

direct and indirect effects of parent difficulties on the child’s social, emotional, intellectual,

and physical well-being.

Theoretical Approach: A Systemic Model

The family has been described as ‘‘a unity of interacting personalities’’ [15], in short, as a

dynamic system of relationships. Thus, the relationship pathways between parents, and

parents and children, are both direct and indirect (mediated or moderated). Direct effects

include the range of direct parent-to-child interactions. For example, the nature of the

injury may affect the parent’s ability to maintain daily parenting routines like picking up,

feeding, or bathing the child. Indirect effects include those mediated through a parent, for

example, the demands of caring for the injured veteran may leave the other parent drained

and unable to be attuned to the needs of the child. Further, there are adjunctive system

impacts on the family system. The injury may cause the veteran to spend extended time

away from the child interacting with rehabilitation services influencing the parent’s ability

to develop or maintain secure attachment relationships. Hence, the system meant to support

the service member’s recovery may in this way directly undermine his or her ability to

parent if family functioning is not considered in treatment planning. Additionally, if the

culture of the military prevents the injured service member from receiving needed care for

invisible wounds [16], the cultural context has indirectly affected child outcomes by

impeding the soldier’s self-care, reintegration into the family, commitment to family well-

being, and parenting abilities. Potential pathways through which parental combat injury

might influence family functioning and early child development are illustrated in Fig. 1.

2 Psychiatr Q (2010) 81:1–21

123

In Fig. 1, we illustrate the mediating effect that family functioning has on early child

development. The critical interactions for infant mental health and development include

the primary caregiver [17], parental figures, grandparents, and siblings [18]. We will later

use the Process Model of Family Functioning [19] to organize and discuss family processes

which contribute to healthy family functioning. The Process Model includes seven con-

structs: task accomplishment, role performance, communication, affective expression,
involvement, control, and values and norms [19, p. 192] that are reflected in the parent
child relationship and contribute to development across time. We will propose that parental

combat injury has a direct and deleterious effect on dimensions of family functioning

including those aspects of family functioning that promote resilience in the face of illness

and injury.

Conceptualizing Differential Impacts of Visible and Invisible Injuries on Child

Development

Injuries sustained in combat may be visible or invisible to the child. Children can more

easily understand the effects of an injury when they can visually see the bandages, loss of

limb, scarring, or prosthetic. However, injuries like TBI, PTSD, or depression remain

invisible to the child. Symptoms are both more difficult to associate with the invisible

injury and are more readily internalized by the child as they attempt to read and control

their parent’s mood. For example, the child might read the parent’s anger as a result of his/

her running through the house rather than the deficit in the parent’s attention associated

with TBI. The child might attribute experienced rejection from his/her parent to his/her

own self-worth rather than to PTSD symptoms of avoidance or emotional numbing.

Methodological Approach to the Literature Review

We used a meta-ethnographic approach [20] to synthesize the literature on parental injury

and illness. The existing body of literature demonstrating the direct impact of a service

member’s injury upon the development of his/her young child is scarce [1, 21], as is the

literature demonstrating the efficacy of inclusion of children in evidence based family

Family
Functioning

Contextual
Factors

Parental
Combat
Injury

Individual and
Dyadic
Factors

Early Child
Development

Invisible
Injury

Visible
Injury

Fig. 1 A conceptual model of parental combat injury: direct and indirect effects on early child development

Psychiatr Q (2010) 81:1–21 3

123

treatment [22]. Therefore, the review draws upon other bodies of literature relevant to

professionals working with injured service members and their families. Studies were

included that examined the impact of parental illness on family functioning (cancer, HIV/

AIDS, affective disorders); psychological and family adjustment following a TBI; impact

on family function following other parental injury (farm injury, burns, and spinal cord

injury); and PTSD and family adjustment. Relevant studies of child development, life

course perspective, attachment theory, family process, family functioning, resilience and

posttraumatic growth were also included. Excluded were studies of sibling illness or injury

(require different family coping) and studies of parental death (grieving process for injury

is uniquely different than grieving parental death) [23]. Key phrases, ideas, and concepts

were recorded to compare how studies were related to each other. As themes began to

emerge in the synthesis, new bodies of literature emerged that added to the knowledge base

for how infant and toddler development are influenced by parental injury.

The organizational structure of the review reflects the nature of parental combat injury,

the individual and family processes following injury, and associations with early child

development. The review also considers the indirect effects on early child development by

looking at paths where injury impinges on dyadic relationships, social supports, and family

functioning, which then affects child outcomes. Finally, the review looks at extra-familial

systems, such as health care and community support that buffer the effects of parental

combat injury on family functioning and the young child’s early development.

Conceptual Model

Parental Combat Injury: Visible Versus Invisible

The nature of the injury has far-reaching implications for how the service member will

interact with all levels of systems including how he/she is received in the larger societal

system. The nature of the injury determines the course of treatment, but also patterns of

interaction in the family, family function and adjustment, the parent–child relationship, and

ultimately child development outcomes. Though injuries may be classified as visible or

invisible, the complexity involved in quantifying the biological, psychological, and social

consequences over time make it difficult to ascertain parental injury as exclusively one or

the other.

Invisible injuries are those that cannot readily be identified by non-professionals and
have no obvious physical impairment. PTSD, TBI, and depression are the most common

forms of invisible injury among returning veterans [2]. PTSD is a factor of combat trauma

with a relationship to variables such as the intensity and duration of the combat experience,

an ability/inability to control one’s environment, and witnessing the death of an important

comrade [24, 25]. TBI is the loss of brain function due to an open or closed wound to the

head and subsequent biochemical events in the brain [26]. Invisible, injuries like PTSD and

TBI are associated with increased somatic symptoms, increased health care visits, and

more work absenteeism [27].

Invisible wounds can be a source of heightened stress as the injured may be unaware

how his/her personality and interactions with family have changed [28]. In addition, the

family may not be aware of the injury or they may attribute personality changes to other

factors. Invisible wounds are most difficult for children to understand [29] and can be very

draining for both the person with the injury and the family [30]. Invisible parental injury is

further complicated by the stigma associated with psychological changes and mental health

4 Psychiatr Q (2010) 81:1–21

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care [16, 29]. ‘‘Disapproval of their unproductiveness’’ is an example of larger societal

values which denigrate persons with invisible injuries [30, p. 595]. Social stigma may

interfere with needed care and further isolates the family from critical social support.

Visible injuries are defined in War Psychiatry as those disabling and disfiguring injuries
which can be readily observed by others. Visible injuries include burns, eye injury or

blindness, major amputation, facial disfigurement, spinal cord injury, and paralysis [31].

According to Weinstein, the demands of multiple surgeries and painful rehabilitation are

often followed by emotional stress and worry as the service member begins to understand

the physical and social limitations of the injury. A review of the psychological effects of

severe burn injuries [32] suggests that anxiety and depression are prevalent in the first year

following injury, but may subside with time. Visible injuries also result in the service

member experiencing physical limitations, altered body image, lowered self-esteem, social

stigmatization, and changes in personal relationships [31].

Visible injuries can represent a significant change in the service member’s way of life

and employment [32, 33]. Those who sustain disabling and disfiguring injuries may also

experience psychological disorders such as PTSD, depression, anxiety, or combinations of

these and other mental health issues [32, 34, 35]. Injury severity has been strongly asso-

ciated with symptoms of PTSD and depression within the first year post injury [34].

Direct Effects of Parental Combat Injury on Early Child Development

The direct effect of parental combat injury is largely associated with physical constraints

placed on the relationship between the injured parent and the child. Relationships among

family members are social and interpersonal constructions. Whereas the developmental

processes driving the organization of social relationships (e.g., attachment) are robust, the

socially constructed contents of such relationships are fragile, particularly in the formative

stages of organization. Constructed within the general attachment motivational system

[36], relationships can be challenged by the extended separations from the parental/

attachment figure/s that come with treatments such as hospitalizations, surgeries, doctor’s

visits, and rehabilitation that involve one and often both parents. This is just one of the

ways in which the injury disrupts primary bonding leading to a loss of stable object

relations [36].

Affective expression is an important part of parent–child interactions and includes time,

intensity, and content of expressed feelings and can be positive or negative [19]. Emo-

tional/psychological injuries directly influence affective expression. For example, PTSD

symptoms include heightened reactivity and emotional numbing [12, 37], and TBI

symptoms include anger and aggression [38, 39]—all of which may interfere with the

injured service member’s ability to express positive affection to his/her child [37, 40] and

add to the fragile nature of parent–child relationship building.

Indirect Effects of Parental Combat Injury on Early Child Development

When parental combat injury alters the parent’s attunement to the child’s needs, the child’s

emotional, social, and physical development suffers. If developmental issues are not

attended to, the child is at risk for disorganized attachment, psychological distress, the

inability to regulate emotions, behavior problems, developmental delays, and poorer health

and well-being. Cumulative risk during developmental years is a significant public health

concern.

Psychiatr Q (2010) 81:1–21 5

123

The kind of risk associated with parental combat injury and early child development is

largely based on evidence related to the known context of parental influences on children

rather than empirical data specific to families involved in Operation Enduring Freedom

(OEF) and Operation Iraqi Freedom (OIF) combat endeavors. Developmental risk factors

associated with parental injury and illness are attachment problems [41–45]; brain

development [46]; emotion dysregulation [47–49]; cognitive, emotional, or developmental

delays [9, 28, 46]; psychological problems [50]; behavioral problems [51–56]; and health

concerns [54, 56–60].

Attachment

Optimal physiological and psychosocial development occurs in the context of a quality

attachment relationship and the development of a secure base between a child and par-

ent(s). Early attachment relationship disruption place children with an increased vulnera-

bility to the development of psychiatric difficulties [42, 45]. Secure attachments are formed

within the context of a caregiver’s availability and attentive responses to the needs of the

child [61, 62].

Parental injury can affect the child’s attachment to both parents. Parental injury is a life

event which potentially disrupts responsive parenting leaving one or both parents physi-

cally present but psychologically absent [63]. Studies show that some emotional challenges

which co-occur with parental injury such as depression, marital conflict, and economic

stress interfere with establishing a secure attachment between parent and child [41, 43, 44].

The caregiver’s availability and responsiveness to the child has an effect on the child’s

attachment style and long-term vulnerabilities. A combination of a disorganized attach-

ment style and parental psychosocial problems predict aggressive-hostile behavior in the

preschool child [50], while a hostile or anxious attachment style may make the child prone

to anxiety-related disorders [64]. If the injured parent has undergone significant psycho-

logical changes, the child may experience him/her as ‘‘alienating’’ or ‘‘abandoning’’ [28].

Alienation experiences occur for the child if the parent acts in disturbing and unfamiliar

ways; abandonment when the parent is present but unresponsive and inaccessible.

Brain Development

The National Scientific Council on the Developing Child [46] reviewed numerous studies

showing how the child’s early environment and experiences interact with genes to deter-

mine the architecture of the developing brain. Environmental impoverishment occurring

during periods of sensitive brain development leads to detrimental effects on long-term

abilities and learning. Further, ‘‘toxic stress’’ (chronic adversity) not only has detrimental

effects on brain architecture but on the chemical and physiological systems as well. The

interconnections taking place in the central nervous system are ‘‘wired’’ and become

embedded in the architecture of the brain. Delays in brain development affect the child’s

future brain functioning including emotion regulation, academic performance, behavior,

mental health, and ability to function.

There is some evidence that invisible wounds place children at greater risk than visible

wounds. A comparison of children with medically ill, non-ill, and affective disordered

parents had the following results. Children with medically ill parents scored between

affectively disordered parents and non-ill parents in regard to academic and behavior

problems [65, 66]. Children with affective disordered parents faired considerably worse

than the other two groups in relation to academic and psychological function. Reasons for

6 Psychiatr Q (2010) 81:1–21

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this are thought to be because a small child can more easily link changed behavior with

physical injuries compared to invisible injuries like PTSD where there is no apparent

tangible cause for symptoms such as reexperiencing and hyperarousal. Zeanah [67]

explains that parental triggers of trauma are not evident to the young child, and in essence,

the sources of these frightening experiences are ‘‘invisible’’ and ‘‘inaccessible’’ to the child

(p. 527).

Psychological Distress

The offspring of an injured service member may be more vulnerable to subsequent trauma

or psychological difficulty. Children growing up in homes with a depressed parent are at

increased risk for depression themselves as they become over-involved in reading and

managing the parent’s emotional state [68, 69]. Children traumatized by family violence

may themselves develop symptoms of PTSD [70, 71], as are children reared in households

with substance abusing parents, particularly when substance abuse is comorbid with other

forms of psychopathology such as antisocial behavior and aggression [72].

It is difficult to generalize a causal relationship between parental injury and psycho-

logical distress of the child in families where there are multiple stressors. For example,

Annunziato et al. [73] examined the effects of maternal chronic illness on the child’s

wellbeing, comparing both ill and non-ill single parent households. This study showed that

distress and aggravation in parenting were associated with poorer child outcomes but not

the maternal chronic illness directly. However, children with an ill parent had presented for

mental health consultation more often than children in the control group.

A parent’s injury may have an impact on the psychological health of his/her offspring

beyond the early developmental years. Solomon et al. [13] looked at combat-related PTSD

among second-generation Holocaust survivors. Among Israeli soldiers with identified

combat stress reaction, those whose parents survived the Holocaust reported higher rates of

PTSD at the 3 year follow-up suggesting consequences for mental health concerns may be

passed onto the next generation. For example, Rosenheck and Fontanna [74] showed the

offspring’s tendency toward violence was associated with parental abusive violence 10–

15 years after their father’s Vietnam experience.

Emotion Regulation

Infancy and early childhood is the time when one learns to understand, experience, and

manage emotion [75]. The security and confidence of the child in relationship with the

parent/attachment figure is a principal resource for emotion regulation [64, 76–78]. The

young child is dependent on the parent for emotional support. In one study of preschoolers

and their mothers, reciprocal emotion regulation was evident with each influencing the

other [79, 80]. This reciprocal emotional regulation is characteristic of close relationships

throughout life [81].

When the parent–child relationship is troubled, the young child is at risk for affective

dysregulation [48], which leads to behaviors such as a dampened emotional response in

relationships, a lack of curiosity or interest in his/her surroundings, gaze avoidance, anger,

and a disorganized response to separation [71]. Abuse and neglect from the caregiver may

result in psychosocial and emotional problems such as insecure attachment style and the

inability to modulate aggression [82–84]. Abusive parent–child interactions leave young

children at risk for conduct problems [85, 86] and replicating cycles of abuse [87, 88].

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Behavior Problems

The parent’s injury, including both visible and invisible wounds, can manifest in emotional

and behavioral problems for children. Parental PTSD and level of combat experience

among Vietnam veterans predicted internalizing and externalizing behavior problems in

their children [51]. Jordan et al. [53] found that children had more behavior problems if the

veteran parent had a PTSD diagnosis compared to other veterans. Hostility and violence

among children was positively associated with parental PTSD symptoms [52].

Pessar et al. [55] studied families where one parent had incurred a brain injury. Ninety

percent of families in the study reported problematic behavior change in the children

following parental injury. Physical illness and chronic pain of parents have also been

associated with poorer social skills and behavior problems in school [54, 56].

Physiological Health

The review of Armistead, Klein, and Forehand [57] tentatively proposed an association

between dimensions of parental physical illness and child functioning. The Adverse

Childhood Experiences (ACE) study looked at childhood maltreatment and family dys-

function among 17,000 participants. The ACE study showed that as the number of adverse

childhood experiences increases, so do the number of health risks later in adult life

including early death [89].

Hyatt and Allen [59] found that when the parents were unable to provide for their own

personal care, the timely immunization of their infants and toddlers was significantly

lower. Maternal depression may place the infant at risk for poorer nutrition and conse-

quently retarded growth and development [90]. Also, somatic symptoms in children have a

direct relationship with pain intensity and emotional distress of their parent [54, 56, 60]

with higher degrees of physical impairment in the parent indicative of earlier somatization

in the child [58].

Effects of Parent Combat Injury on Family Functioning

Task Accomplishment

Task accomplishments are central in organizing the family in relation to parental injury

and reflect the family’s ability to adapt to the injury of the parent while continuing to meet

the developmental needs of all family members. Successful coping strategies and the

ability to maintain routines for the child are examples of how task accomplishment

mediates the effects of parental injury on early child development.

Karlovits and McColl [91] use a qualitative approach to explore how brain injured

adults reintegrate into the community; they identified two key coping strategies. First, the

perception-focused coping strategy refers to the ability to change the meaning of a stressful

event. Second, coping occurs by avoiding situations thus enabling individuals to distance

themselves from events that have a high probability of triggering or exacerbating a

problem. These kinds of coping strategies were found to be a protective factor in dyadic

adjustment following a brain injury [92]. Because individual and family growth takes place

across the family life cycle [93], successful coping is not a one time event but a process

that will develop as the family adapts to the injury. Parents can provide comfort and

security for children by establishing and maintaining routines [94]. Placing boundaries in

this way around the normal routines of the family will protect the family and will prevent

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all things related to the injury from taking over [29]. Once the family has passed the crisis

phase of the injury, boundaries and routines provide opportunities for self-care, commu-

nication, and activities that are not saturated with the injury.

Role Performance

The nature and extent of the injury determines how the service members adapt to new roles

in multiple environments: the ability to maintain their Military Occupational Specialties;

the ability to provide for their family; whether they become recipient of caregiving; and

their ability to perform valued parenting tasks. Invisible wounds like PTSD directly affect

general health risk and increase somatic symptoms resulting in more sick days, and more

days of work missed [27]. These changes all affect the service members’ functioning role

within the family.

Significant role changes often take place for other family members as well, and these

changes represent significant ‘‘caregiver burden’’ [95]. The non-injured parent balances

previous family and work responsibilities with the recovery and/or continuous care of the

injured service member [28]. Rolland [29] suggests that the demands of caring for the ill or

injured parent diminish family resources and the ability of the family to stay on task in

relation to the life cycle (p. 250). Shared responsibility for parenting should be discussed if

real limitations prevent the injured parent from participating is some parenting roles.

Addressing traditional gender roles may open new spaces for both parents to maintain

balance and contribute significantly to the development of their child/ren.

Parents and children are empowered when the injury is framed as a family issue. The

whole family shares in adapting to the psychosocial impact of the injury rather than placing

blame or responsibility on the injured [29]. Age appropriate tasks may help the child/ren

feel as though they are contributing positively to the family. This is illustrated in a case of a

six year old girl appearing to ‘‘enjoy the closeness and her ability to help her mother’’ who

had lost use of her arm [96, p. 376]. Adolescent children of disabled parents assume more

responsibility compared with children of non-disabled parents [97]. This may be viewed as

parentification or a dynamic that emerges from disorganization in family process.

Assuming that developmentally appropriate tasks are assumed by children and they are

able to maintain their childhood, an alternative view is building resilience by teaching

children how to become a team that faces challenges, uses creative problem solving, and

overcomes barriers.

Communication

Communication contributes positively to family functioning when there is mutual under-

standing among family members and the message sent is congruent with the message

received [19]. However, communication problems are common among injured service

members and their families [98, 99].

Communicating with the child is an important part of family functioning that can buffer

negative effects of parental injury. Even though the parents themselves may be struggling

with the effects of the injury, the child still needs to make sense of what the injury will

mean for his/her life. The parent may struggle with how much information to share with

the children [8, 96]. Like other factors of parental injury, communication around parental

injury is not a one time event but a process that develops over time. A central factor is

providing an emotionally safe environment where the young child knows it is acceptable to

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ask questions. The kinds of questions asked by a 3 year old at the time of injury will be

very different from the questions he/she will ask 10–15 years later.

Age appropriate acknowledgement of the parent’s injury by family members will

support the child’s intuitive sense that something is wrong. Dale and Altschuler [8]

demonstrated that children as young as three are very aware of parental illness. Rolland’s

case presentation (1999, p. 257) demonstrates how a 5 year old daughter’s well-being was

impacted by projected worry and fears associated with parental illness kept secret. Not only

should the child be told about parental injury, they should be prepared for sights, sounds

and smells when visiting their parent at the hospital [96, 100]. Rauch et al. [100] suggest

having a trusted adult (other than the spouse) available for each child. The intent is so the

child/ren can visit their parent in the hospital as little or as long as they are comfortable

without cutting short the visit of the non-injured parent.

Affective Expression

The young child also has feelings surrounding the parent’s injury. Duvdevany et al. [97]

ascertained that both positive and negative feelings exist toward parents in and experi-

mental group of school aged children of disabled parents and a control group of school

aged children with non-disabled parents. However, the children of disabled parents

expressed more positive and ambivalent feelings and fewer negative and indifferent

feelings than children of non-disabled parents [97]. Affective expression, within the

context of healthy family functioning, is an environment that provides safety for children

to express a broad range of experienced emotion. The goal is to help that young child to

articulate and regulate their emotions. A study of children with a depressed parent revealed

that emotional fluidity (the ability to express experienced emotion concerning their
affectively ill parents) was an important factor in promoting resilience [101].

Involvement

Injury to the service member may result in psychological changes which have a direct

impact on patterns of interaction and involvement within the family. Emotional and social

alienation, depression, and anxiety are common in the course of chronic and severe PTSD

suffering veterans [102]. The caregiver (often the non-injured parent) may even begin to

experience PTSD-like symptoms or secondary traumatization [95]. The burden of caring

for a spouse with PTSD [103, 104], TBI [105], and depression [106] negatively impacts the

caregiver’s psychological well-being leaving both parents less responsive and emotionally

involved with their child/ren.

Involvement following parental injury requires the maintenance of the parent–child

relationships with the injured and non-injured parent. The literature consistently supports

the need for children to maintain a relationship with both parents. The parent–child rela-

tionship may take on new meaning as well as functional and relational changes. This is an

important protective factor for long-term development of the children regardless of the

changing dynamics of the family. Because combat injury is associated with marital dis-

ruption (and in some cases dissolution), the divorce and remarriage literature may be

especially useful. Following divorce, child outcomes are better when the child is able to

maintain a relationship with both parents [107–110]. Even when a parent has perpetrated

violence against the child or the other parent, the child does not simply forget their

existence because they are no longer living together [88]. As long as protective measures

are taken to prevent further revictimization of the child [111], conjoint parent–child

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therapy can focus on attachment issues, planning for a nonviolent future, managing con-

flict, and adjusting to new family configurations [88].

Control

Control is the family process that allows the family to maintain their environment and have

influence over one another [19]. The combat injury may have caused some unexpected and

unwanted behaviors as seen with behavior control among TBI patients [28]. Further, the

severity of aggressive behavior among injured veterans has been associated with severity

of PTSD symptoms [112].

Values and Norms

Values and norms reflect priorities that are important to the family within a larger societal

framework [19]. Values and norms shape the ‘‘family schema’’ which in turn influences

how families may interpret combat injury and attempt to deal with it [113, 114]. Hence, the

family beliefs, values, goals, and perceptions of themselves in the context of their com-

munity may influence whether the family views the injury as manageable.

Stebbins and Pakenharm [115] studied the beliefs of spouses and parents who were

caretakers of a brain injured individual. They found cognitive interpretation of the injury to

play a major role in their own psychological readjustment, suggesting irrational schemas

contribute to poorer outcomes for the caretaker. Stebbins and Pakenharm [115] found

worrying explained the greatest variance in adjustment of the caretaker. Problem avoidance

or pretending that the injury did not happen is also related to lower psychological health of

the caregiver [115, 116].

A consistent theme in family adaptation is the family’s ability to make sense of their

experience [94]. Meaning reconstruction around the injury, role changes, and loss of

personal and familial dreams is central in the process of healing [117]. The family has to

mourn the loss of the person before the injury in order to accept subsequent limitations post

injury [30]. Kosciulek [113] observed that ‘‘positive reappraisal’’ or redefining the meaning

of the stressful event of brain injury, leads to successful family adaptation.

Studies of posttraumatic growth [118, 119] show positive individual changes among

individuals following a traumatic experience. The stressful event provides the individual

with an opportunity to evaluate, reorder priorities, and live with a deepened appreciation of

life. Change may provide the emergence of new opportunities, spiritual growth, closer

personal relationships, the ability to face future challenges, and a greater capacity to show

compassion to others.

Dyadic Factors Moderating the Effects of a Combat Injury on Family Functioning

and Child Development

The child’s development takes place in relationship with his/her parents. Figure 1 illus-

trates dyadic factors as moderating variables. Since the dyadic relationship has a direct

effect on family functioning, parental injury affecting dyadic adjustment indirectly affects

child development. The dyadic relationship can either buffer or exasperate the deleterious

effects of parental injury on family functioning and early child development. This section

summarizes the known effects of parental injury on dyadic adjustment.

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Marital Adjustment and Divorce

The literature suggests poorer outcomes for the couple relationship compared to non-

injured veterans. A number of studies show a significant association between PTSD and

couple relationship problems [53, 98, 120]. The strain of invisible injuries like PTSD and

TBI cause various levels of relationship disintegration. Marital disruption and divorce is

higher among couples where one partner suffers from PTSD and TBI compared to similar

cohorts without a diagnosis [28, 53, 120–122]. Divorced service members returning from

Iraq and Afghanistan reported higher levels of depression [123] which is often comorbid

with PTSD, TBI, chronic pain associated with physical injury, and caregiver burden.

Kessler et al. [124] show an association between depressive symptoms and risk for divorce.

Veterans with a combat injury are at increased risk for divorce, and even when the family

remains intact, subsequent family stress may cause the children to live in fear of family

disintegration [23].

Intimate Partner Violence

Studies reveal some association between invisible combat injury and intimate partner

violence. Aggressive behavior among individuals with PTSD along with loss of impulse

control associated with TBI place injured service members at risk for perpetrating violence

against their intimate partners [38, 39, 53, 125, 126]. Marsh and Martinovich [127] found

that among men receiving treatment for intimate-partner violence, the rate of TBI is higher

than in the general population. Further, there is some association between violence and

more caregiver burden [128].

The known effects of family violence on child development underscore the importance

of the dyadic relationship as a moderating variable. Parental combat injury that precipitates

intimate partner violence has a deleterious effect on early child development. The fol-

lowing risk factors are present when the child is exposed to family violence, either as a

victim of physical abuse or in witnessing physical violence perpetrated from one parent

onto the other: psychosomatic disorders, anxiety, fears, sleep disruption, excessive crying,

and school problems [129–132]. Dutton [87] contends that experiencing violence, shaming,

and insecure attachment contribute to intergenerational patterns of abuse.

Dyadic factors are important moderators when considering the effects of parental injury

on family functioning and early child development. Though parental divorce will certainly

have an effect on the youngest family member, contextual factors must be considered

before determining the causal relationship and developmental outcomes. Marital disruption

drains the emotional and physical resources of already stressed families leaving little

energy for attunement to the needs of the developing child. Infants and toddlers are

especially vulnerable to parental divorce and family disruption [133, 134]. In the general

population, studies show that parental divorce is the source of vulnerability for some

children and resilience for others [133–139]. In cases when intimate partner violence is

present within the dyadic relationship, divorce has the potential to protect the young child

from witnessing violence and further trauma.

Contextual Factors Moderating the Effects on Family Functioning and Child

Development

Contextual factors moderate the effects of parental combat injury on family functioning

and early child development (Fig. 1). Contextual factors including community supports,

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the health care system, and societal values and norms all can buffer the impact of parental

injury on family functioning and early child development.

Social Support

Social support is fundamental for buffering deleterious effects of parental injury on family

functioning and early child development. The injured can easily become socially isolated

without targeted activities to facilitate reintegration into social and community life. The

development of self-esteem and feelings of having important contributions to society are

associated with social support for survivors of invisible [30] and visible injuries [32].

Social support not only predicts better adjustment for the injured, but it has a buffering

effect for the family [32] with direct effects on family functioning. Social support and the

perception of social support received are associated with less emotional distress among

caregivers [116, 140].

Social support that improves quality of life for the injured, the caregiver, and family

functioning indirectly supports early child development. Intimacy between partners and

general social support from friends and relatives are protective factors for parental stress

during the first three years of a child’s life [141]. Mothers who perceive fewer stressors

have supportive networks and are more likely to demonstrate positive interactions with

their infants [142]. Also, supportive groups of parents ‘‘who are facing or have overcome

commensurate challenges may provide a normative reference base that helps to reduce

parenting stress’’ [141, p. 954]. Social support includes both formal and informal networks

contributing to adaptation.

Continuum of Care

From critical care through rehabilitation, the service provided by the physicians and

professionals to the injured service member and his/her family make up a continuum of

care. Supportive relationships and communication between the health care professional and

the family are foundational throughout the continuum. Positive relationships are formed by

recognizing the experiences of the family, establishing trust, listening to the family, and

allowing oneself to be influenced by their story [30]. Lefebvre and associates [30] provide

a thick description in their qualitative study with TBI patients, family members, and their

health care professional. ‘‘Families appreciate being listened to by physicians and pro-

fessionals…the family is the expert on its situation of every day life…’’ [30, p. 592].
In one study, family representatives’ emotional stress, appraisal of the extent to which

their needs were being met, interpersonal appraisal of nurses and primary physician, and

the interrelationship among these variables were explored at a level one trauma center

[143]. The notification of an injury results in elevated levels of distress, symptoms char-

acteristic of acute stress disorder, and anxiety in family members [144]. During the initial

crisis, health professionals have an enormous influence over a family’s sense of compe-

tence [29, 143]. Rolland [29] describes the initial diagnosis as a ‘‘framing event’’ (p. 247).

Every interaction by the health professional, what persons are included in the conversation

as well as what is said, may be interpreted by the family as having significant meaning.

Family perception of needs met, affiliation with both physicians and bedside nurses, and

high levels of optimism among family members may be protective factors for lower levels

of emotional distress following the patient’s discharge [143]. Family members were

reassured when they felt support from physicians and professionals [30]. In contrast,

Psychiatr Q (2010) 81:1–21 13

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families viewed the professional relationships negatively when they were not recognized

for their contributions or supported in their process of adaptation [30].

Communication is a critical component in the continuum of care. Understandable and

honest information about patient medical condition builds trust and mutually respectful

relationships that help the family [29, 30]. Not only does the health care team have an

important role in communicating clear and factual information to all members of the

family in developmentally appropriate ways [94], they also have an important role in

communicating clearly as a team. Communication, intentionality, and a common purpose

contribute to teamwork among professionals [30]. Communication and continuity within

and between establishment are protective factors for the TBI patient and their family

members’ adaptation [30].

Implications for Intervention and Policy

A consistent attachment figure in the environment is a critical protective factor for young

children following parental combat injury. Urbach [28] identified quality of earlier

attachment and the availability of the other parent and supports as mediating factors

associated with parental TBI. Even when faced with abuse, children are more resilient

when they receive emotional support from another adult in their lives [145, 146].

A multisystemic, resilience-oriented approach [94] is needed to strengthen family and

community resources rather than focus on individual deficits. Considering parental

combat injury, interventions should respect individual, family, military, and community

differences. Distress experienced by families of an injured service member can be

contextualized so that family members understand their experience as normal and similar

to others with similar losses [94]. The service member should have the opportunity for

continued participation in unit debriefings so as to maintain connectedness and support

from his/her military family [147]. Challenging beliefs within society that promote

shame, blame, or guilt is a shared responsibility of family, military, and community

members [94, 148].

Further, professionals are more apt to include the family in their system of care when

they feel supported and competent in doing so. A national survey of TBI rehabilitation

staff practices revealed that 19% of participants had worked with a child relative in the

past month [149]. The staff’s perception of their ability to work with the child relative

was a significant predictor of involving children in rehabilitation. Training, resources,

and support structures to include children in rehabilitation increase the likelihood for

staff interaction with youngest members of the patient support network. The antithesis to

quality care is lack of professional resources, overload, and exhaustion among profes-

sionals [30].

Implications for Future Research

In summary, the studies available for review did not meet the conditions to make valid

causal inferences [75]. Any attempts to describe the effects of parental injury sustained
during combat upon their infant or toddler offspring is tenuous at best. Without rigorous

scientific study, it is not possible to make strong causal inferences regarding risk factors for

young children of war-injured parents. The ultimate research question to guide future

research should be ‘‘How does parental combat injury affect the offspring’s development

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and life course trajectory?’’ Some stepwise questions that might lead us to a better

understanding include: Is there an association between parental combat injury and child

development? Do different types of injuries, visible and invisible wounds, have differing or

similar effects on child development? What are the critical dimensions of the injury that

influence parent–child interactions and family functioning? What other mechanisms within

individual, parental, familial, or societal systems are negatively influencing child

development?

The known parental impact on the child’s social, emotional, intellectual, and physical

well being suggests the need for systemic interventions. While research is needed that

will provide detailed observations of child development, it may be more plausible to

conduct experiments in program evaluation rather than developmental sciences [75].

Figure 1 can be used as a model for developing systemic interventions and designing

program evaluations to meet the immediate needs of wounded warriors and their

offspring.

Conclusion

The review of literature underscores the complexity of challenges faced when a parent

is injured in combat. The service member must adapt to physical and emotional

changes, and the entire system must adapt to meet the changing needs of all family

members. Because early child development is dependent upon the parent–child rela-

tionship and family functioning, targeted efforts must be made to ensure that commu-

nities of support are aware of both risk and protective factors associated with parental

combat injury.

The nature of the invisible injury may have a direct negative impact on family func-

tioning and the quality of parent–child relationships necessary for promotion of optimal

child development. While all types of parental combat injury influence various components

of family functioning, there is some evidence that families are more resilient in relation to

visible wounds (cite) and struggle more with changes related to invisible aspects of injury,

such as irritability, rapid mood swings, emotional numbing, memory loss, and behavior

control [28, 150].

The Department of Defense (DOD) can support intervention and research inclusive of

family support systems and even the youngest family members. There is also need for the

DOD to continue efforts to reduce stigma associated with invisible injuries. Further, biases

about mental health care and pathologizing labels must be challenged in all communities.

Civilian communities must be educated on the military and combat experiences and evi-

denced-based practices that promote healing, growth, and development. The local com-

munities must be ready to receive and attend to the invisible injures, the family’s

readjustment, strengthening parent–child relationships, and the early developmental needs

of the very young. Coming Together Around Military Families (CTAMF) says: ‘‘So much

for…Oh, she’s too young to remember—she won’t be affected by what’s happening. On
the contrary, she may be affected without even knowing she’s been affected’’ (Building

Healthy Minds, Zero to Three, 2007, slide 22) [151]. The injured service member has

demonstrated their commitment to others. The legacy of our country can be affected

positively by demonstrated commitment to veterans, their health care, their family func-

tioning, and their offspring.

Psychiatr Q (2010) 81:1–21 15

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Author Biographies

Lisa A. Gorman, PhD Research Associate, University Outreach and Engagement, Michigan State
University.

Hiram E. Fitzgerald, PhD Associate Provost for University Outreach and Engagement, University
Distinguished Professor, Department of Psychology, Michigan State University.

Adrian J. Blow, PhD Assistant Professor, Department of Family and Child Ecology, Michigan State
University.

Psychiatr Q (2010) 81:1–21 21

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Mothers’ Economic Conditions and
Sources of Support in Fragile Families

Ariel Kalil and Rebecca M. Ryan

Summary
Rising rates of nonmarital childbirth in the United States have resulted in a new family type,
the fragile family. Such families, which include cohabiting couples as well as single mothers,
experience significantly higher rates of poverty and material hardship than their married coun-
terparts. Ariel Kalil and Rebecca Ryan summarize the economic challenges facing mothers in
fragile families and describe the resources, both public and private, that help them meet these
challenges.

The authors explain that the economic fragility of these families stems from both mothers’ and
fathers’ low earnings, which result from low education levels, as well as from physical, emo-
tional, and mental health problems.

Mothers in fragile families make ends meet in many ways. The authors show that various public
programs, particularly those that provide in-kind assistance, do successfully lessen economic
hardship in fragile families. Single mothers also turn to private sources of support—friends,
family, boyfriends—for cash and in-kind assistance. But though these private safety nets are
essential to many mothers’ economic survival, according to the authors, private safety nets are
not always consistent and dependable. Thus, assistance from private sources may not funda-
mentally improve mothers’ economic circumstances.

Policy makers, say Kalil and Ryan, must recognize that witli rates of nonmarital childbirth at
their current level, and potentially rising still, the fragile family is likely an enduring fixture in
tliis country. It is thus essential to strengthen policies that both support these families’ economic
self-sufficiency and alleviate their hardship during inevitable times of economic distress.

The most important first step, they say, is to strengthen the public safety net, especially such in-
kind benefits as food stamps, Medicaid, housing, and child care. A next step would be to bolster
community-based programs that can provide private financial support, such as emergency cash
assistance, child care, and food aid, when mothers cannot receive it from their own private
networks.

www.futureofchildren.org

Ariei Kaiii is a professor in the Harris Schooi of Pubiic Poiicy at the University of Ohicago. Rebecca iVI. Ryan is an assistant professor of
psychoiogy at Georgetown University.

VOL. 20 / NO. 2 / FALL 2 0 1 0 3 9

Ariel Kalil and Rebecea M. Ryan

A
S rates of nonmarital childbirth
haye increased in the United
States in the past half-century,
a new family type, the fragile
family, has emerged. Fragile

families, which are formed as the result of a
nonmarital birth, include cohabiting couples
as well as noncohabiting, or single, mothers.
Snch families eyoke public concern in part
because they are more impoyerished and
endure more material hardship than married-
parent families and haye fewer sources of
economic support. Father absence and family
instability are also cause for concern. The
economic fragility of these families stems
largely from mothers’ and fathers’ relatiyely
low skills and training, which often pose bar-
riers to higher-wage work. Fragile families
also haye almost no financial assets. In this
article, we describe the economic chal-
lenges facing mothers in fragile families and
the resources they call upon to meet these
challenges.

We begin by summarizing economic condi-
tions in fragile families using the most recent
data ayailable. Next, we suggest reasons
why mothers in fragile families face so
much poyerty and material hardship, focus-
ing especially on their liying arrangements,
employment capacities, and assets. We go
on to explain how, giyen their economic
conditions and capacities, mothers in fragile
families make ends meet in their households.
Specifically, we describe the sources of public
and priyate support ayailable to them and the
role each plays in mothers’ economic sundyal.

Economic Conditions in
Eragile Families
As Sara McLanahan has obseryed, until
recently it was unclear where along the spec-
trum of economic conditions and capabilities
the nation’s fragile families were to be found. ̂

Were these unwed U.S. parents similar
to married parents in terms of their capa-
bilities, thus resembling unwed parents in
Scandinavia, whose capabilities are generally
high? Or were they low-skilled individuals
living in what might be described as a “poor
man’s marriage”? Extensive research from
the Fragile Families and Child Wellbeing
Study (FFCWS), the ongoing study of 5,000
children in large U.S. cities, three-quarters
of whom were born to unwed parents, has
shown that U.S. unwed-couple families
fall closer to the disadvantaged end of the
spectrum.

The economic well-being of fragile families
varies somewhat by living arrangement (that
is, whether couples live together or apart),
but living arrangements do not necessarily
cause differences in economic well-being;
indeed they are equally likely to result from
them. Unwed mothers and fathers with the
highest education and earnings potential
are more likely to choose to cohabit with
one another than to choose to live apart.
Consequently, they have somewhat higher
levels of economic well-being than their
counterparts who have chosen to live apart or
who must, out of economic necessity, donble-
up with other adults. Nevertheless, even
cohabiting nnwed couples experience serious
economic hardship.

Poverty in Fragile Families
Table 1 describes the economic and demo-
graphic characteristics of the three different
types of mothers in the FFCWS. About a
quarter are married. The unmarried mothers
are divided into two groups: those in a cohab-
iting relationship with their child’s father and
those who are single, that is, not cohabiting
with the father. Because about half the moth-
ers in fragile families are cohabiting at their
child’s birth and half are not, the average

4 0 THE FUTURE OF CHILDREN

Mothers’ Economic Conditions and Sources oj Support in Fragile Families

Table 1 . Demographic and Economic Characteristics of Married, Cohabiting, and Single Mothers in
the Fragile Families Study

Percent unless otherwise indicated Relationship status

Demographic and economic characteristics Married Cohabiting Single

Demographic characteristics

Meah age (years)

Teen parent

Child with other partner

Human capital and economic characteristics

Education

Less than high school

High school or equivalent

Some college

College or higher

Mean earnings

Worked last year

Poverty status

Household income

Health and behavior

Poor/fair health

Depression

Heavy drinking

Illegal drugs

Child’s father incarcerated

29.3

3.7

1

1.7

17.8

25.5

21.1

35.7

$25,618.

86

79.3

14.0

$55,057.05

10.4

13.2

2.0

0.3

8.0

24.7

1

7.7

38.8

41.0

39.2

17.3

2.4

$11,433.78

83.4

32.5

$26,548.43

14.4

16.2

8.0
1.7

32.6

22.6

34.3

34.5

48.8

34.2

14.3

2.4

$10,764.05

79.

40

53.1

$18,662.04

17.1

15.7

7.7

3 . 1

45.2

Source: Fragile Families and Child Wellbeing Study statistics, courtesy of Sara McLanahah.

for all unmarried mothers is about halfway

between figures for each of those two groups.

As the table indicates, a defining feature of
fragile families is their high poverty rates. At
the inception of the FFCWS, 33 percent of
mothers cohabiting with the child’s father
and 53 percent of single mothers in the
sample were poor, compared with only

14

percent of married mothers. Not surprisingly,
fragile families’ average household incomes
are low. The annual household income of
cohabiting mothers in fragile families was
$26,548, and that of single mothers in the
sample was $18,662. By contrast, married
mothers’ annual household income was
$55,057.

Material Hardship in Fragile Families
Researchers have long argued that official
poverty statistics fail to capture the depth of
economic hardship faced by unwed mothers.^
Consequently, many researchers also examine
how fragile families fare along such dimen-
sions as food sufficiency, ability to pay bills,
and hardships such as having heat or electric-
ity disconnected. Julien Teitler and several
colleagues examined data from the FFCWS
during the years 1999-2001 and found that
many unwed mothers experienced some
material hardships.^ Common concerns were
not having enough income to pay bills (32
percent), not being able to pay utility bills
(25 percent), and having phone service dis-
connected (17 percent). Roughly 5 percent of
the unwed mothers reported more extreme

VOL. 20 / NO. 2 / FALL 2010 4 1

Ariel Kalil and Rebecca M. Ryan

financial difficulties such as hunger, eviction,
utility shut-offs, homelessness, or insufficient
medical care. Most important, more than half
of the unwed mothers in the sample reported
at least one type of hardship.

Why Are Fragile Families
Economically Disadvantaged?
Three primary factors shape the rates of pov-
erty and material hardship facing mothers in
fragile families: their earnings capacity, their
asset levels, and their living arrangements.

Mothers’ Eamings Capacity
Mothers in fragile families typically earn low
wages. As table 1 indicates, in the first year of
the FFCWS, both cohabiting and single
mothers earned approximately $11,000, far
less than the $26,000 married mothers
earned. These differences emerge even
though most mothers in fragile families work
extensively. Indeed, fully 80 percent of
cohabiting, single, and married mothers in
the study reported having worked in the
previous year. Melissa Radey’s more recent
analysis of mothers in the FFCWS showed
that more than half of the unmarried mothers
were employed full time three years after a
nonmarital birth and 64 percent were
employed at least part time.”* Thus, although
it is the norm for mothers in fragile families
to work, they still suffer economically
because their earnings are typically low.

Demographic Characteristics That
Limit Eamings Capacity
Unwed mothers face many barriers to higher-
wage employment, but the primary obstacle
is poor education. As table 1 shows, about
41 percent of cohabiting mothers and about
49 percent of single mothers in the FFCWS
lack a high school diploma (compared with
only 18 percent of married mothers) and
only 2.4 percent of the unwed mothers have

a college degree (compared with 36 percent
of the married mothers). Importantly, Carol
Ann MacCregor documented that between
40 and 47 percent of unwed mothers in the
FFCWS reported being in school during at
least one interview period during the first five
years of the study and that about 40 percent
of this population completed an educational
or training program of some type during
that time.^ It has not yet been established,
however, whether the returns to education
and program completion among the mothers
in the FFCWS sample have translated into
higher earnings and economic security.

It is clear that many
mothers in fragile families
will experience one or
more signiflcant barriers to
higher-wage employment.
Even when they can secure
sustained, full-time work,
mothers in fragile families
have low eamings capacity.

A second barrier to higher-wage employ-
ment typically faced by mothers in fragile
families is that they are disproportionately
young and more likely to be in their teens at
the time of their first birth. As shown in table
1, 18 percent of the cohabiting mothers in
the sample and 34 percent of single mothers
were teen parents, compared with only about
4 percent of the married mothers. Because
having a child at a young age can disrupt
educational attainment, it is not surprising
that such parents would have less success

4 2 THE FUTURE OF CHILDREN

Mothers’ Economic Conditions and Sources of Support in Fragile Families

in the labor market and experience greater
economic difficulties as a result. Moreover,
despite being relatively young, it is not
uncommon for unwed mothers in FFCWS
to have children with multiple pariners.
Table 1 shows that among mothers in fragile
families with more than one child, 39 per-
cent of cohabiting mothers and 35 percent of
single mothers had a child by another father,
compared with only 12 percent of married
mothers. Though it is not yet clear what the
implications of having children with multiple
partners are for unwed families’ economic
conditions, multipartner fertility is associated
in the FFCWS with lower levels of economic
support from family, friends, and former
partners, a dynamic we discuss further in the
next section.”

Psychosocial Characteristics That Limit
Eamings Capacity
That unmarried parents in the FFCWS
report higher rates of poor overall health,
emotional problems, and drug use than mar-
ried parents points to another explanation for
their lower earnings capacity.” For instance,
as shown in table 1, 14 percent of cohabiting
mothers are in poor or fair health, compared
with 17 percent of single mothers and 10
percent of married mothers. Similarly, about
16 percent of unwed mothers (cohabiting
and single) suffer from depression, compared
with 13 percent of their married counter-
parts. Unwed mothers are most distinct from
their married counterparts in the FFCWS
in terms of heavy drinking and use of illegal
drugs. About 8 percent of unwed mothers
(cohabiting and single) report heavy drinking,
compared with 2 percent of married mothers,
and between 2 and 3 percent of unwed moth-
ers (cohabiting and single) report using illegal
drugs, compared with 0.3 percent of married
mothers.

Research by Aurora Jackson, Marta Tienda,
and Chien-Chung Huang, based on a subset
of families in the FFCWS, revealed more
specific information about the employability
and earnings capacity of motliers given their
capabilities in a variety of areas that are neces-
sary for getting and keeping higher-wage
jobs.^ A summary index of conditions likely to
limit earnings capacity included poor health,
substance abuse, experiencing domestic vio-
lence, youth, lacking a high school diploma,
having no work experience, and having three
or more children. Notably this study found
that the presence of these conditions differed
by mothers’ relationship status. Like Wendy
Sigle-Rushton and Sara McLanahan,^ they
found that single mothers in fragile families
are more likely to encounter multiple such
conditions than are cohabiting modiers:
40.8 percent of cohabiting unwed mothers
reported none of these conditions compared
with 35.2 percent of noncohabiting unwed
mothers. In fact, Jackson and her colleagues
concluded that “single mothers who are nei-
ther romantically involved with their newborn
child’s father nor cohabiting witli them have
especially precarious economic circumstances
and constitute die most fragile of all families,”

In summary, it is clear that many mothers in
fragile families will experience one or more
significant barriers to higher-wage employ-
ment. These barriers may also make it hard
to sustain a full-time year-round job. But
even when they can secure sustained, full-
time work, mothers in fragile families have
low earnings capacity. Indeed, Jackson and
colleagues’ analysis suggests that most unwed
mothers in the FFCWS would be poor even
if they worked 1,500 hours a year, and near-
poor if they worked full-time, year-round
(2,000 hours). Sigle-Rushton and McLanahan
report more specifically that only 5 percent
of unmarried mothers in the FFCWS could

VOL. 20 / NO. 2 / FALL 2010 43

Ariel Kalil and Rebecca M. Ryan

support themselves and their children at
more than twice the federal poverty level,
given their average eamings.

Asset Levels
One way for households to weather economi-
cally difficult times is to tap assets. A home is
the primary asset in American families, but
mothers with low eamings are unlikely either
to be able to accumulate assets or to purchase
a home. In the FFCWS, about 50 percent of
married-couple households live in a home that
is owned, compared with only about 11 per-
cent of cohabiting couples and less than 6 per-
cent of single-mother families.'” As Rebecca
Blank and Michael Barr report, low-income
households’ access to financial institutions is
also limited.^’

All of these factors pose a problem for moth-
ers and children in fragile families, particu-
larly because without savings or credit, it
is difficult to maintain income in challeng-
ing economic times. With unwed mothers
depending heavily on their own eamings,
their incomes will cycle more closely with the
economy. As the economy dips, their hours
of work may fall, job losses may increase, and
eamings may drop, creating greater income
shocks. Having no financial cushion also
makes unwed mothers more vulnerable to
ordinary problems such as needing to repair a
malfunctioning car. If a mother cannot repair
the car, she may lose her ability to get to work
and consequently lose her job. A job loss,
with its attendant eamings losses, could set
in motion a cascade of other problems that
wdll make it all the more difficult for her to
escape poverty. According to Blank and Barr,
policies aimed at increasing the saving rate of
low-income households could be particularly
beneficial, for access to liquid savings may be
more important in situations like these than
access to illiquid assets.’^

Living Arrangements
By definition, mothers in fragile families are
not married at the time of their child’s birth.
Though a large share of these mothers are
cohabiting wdth the child’s biological father
when the child is born, many such unions
eventually dissolve. This single status con-
tributes to high rates of poverty because if
a union dissolves (or is never formed in the
first place), mothers lose the economies of
scale that two-parent households can enjoy
(although, as noted, most two-parent unwed
households nevertheless experience seri-
ous economic hardship). Moreover, mothers
who end their cohabiting relationships often
lose some or all of the fathers’ eamings as a
source of income.

But even if all mothers in fragile families
could count on receiving a certain share of
fathers’ earnings, it is not clear that these
contributions would lift them out of poverty.
Both mothers and fathers who have children
outside of marriage are relatively economi-
cally disadvantaged. Indeed, fully 25 percent
of unmarried fathers in the FFCWS were
not working at a steady job around the time
of the child’s birth. These unmarried fathers
are also highly likely to have been incarcer-
ated at some point in their lives (see table 1),
a characteristic that is often linked with poor
employment prospects. Because fathers in
fragile families are more likely to have low
and unreliable incomes, they find it hard to
support their families, leaving mothers to
shoulder much of the breadwinning burden.’^
The article by Robert Lerman in this volume
elaborates on the conditions and capabilities
of unwed fathers in fragile families.

Living Arrangements at Birth
One of the key (and largely unexpected)
findings from the FFCWS was that many
unmarried parents were in committed or

4 4 THE FUTURE OF OHiLDREN

Mothers’ Economic Conditions and Sources of Support in Fragile Families

quasi-committed relationships at the time
their child was born. Sigle-Rushton and
McLanahan were the first to examine the
living arrangements of unmarried mothers in
the FFCWS as well as the correlates of these
arrangements.”’ They found unwed mothers
living in one of four arrangements: cohabit-
ing in a traditional “nuclear structure”—in
which only a mother, father, and children
live together; cohabiting in a “partner-plus”
structure—in which the parents live with
at least one of the baby’s grandparents or
some other adult; noncohabiting and liy-
ing alone; and noncohabiting but living with
other adults. Sigle-Rushton and McLanahan
found that just under half of the unmarried
mothers in the FFCWS were cohabiting with
their babies’ fathers at the time of birth, and
that about one-third of all unmarried moth-
ers were liying in “nuclear family arrange-
ments.” Although the nuclear arrangement
was the most common for cohabiting couples,
a substantial minority liyed in more com-
plex arrangements. Nearly 30 percent of the
cohabiting couples (15 percent of the full
sample) were liying with some other adults in
the “partner-plus” category. Only 17 percent
of the mothers were liying alone at the time
of birth, and just oyer one-third were living
outside a cohabiting union but with other
adults. In short, a relatively small share of
unwed mothers in the FFCWS sample fit the
stereotypical description of a single mother
raising her children alone.

Most surprising was the proportion of moth-
ers in romantic relationships with the father
despite being unwed and often living apart.
Indeed, more than 80 percent of unmarried
parents were romantically involved (including
those who were and were not cohabiting at
the time of the child’s birth), and an addi-
tional 8 percent characterized themselves
as “just friends.” Less than 10 percent of

mothers said they had “little or no contact”
with their child’s fatlier. These very high rates
of involvement with the child’s fatlier might
lead one to question why the mothers suffer
from such high rates of economic hardship.
One reason, as noted, is that these fathers
have relatively few resources with which to
augment mothers’ economic circumstances.
Another reason, which is explored in the
articles by Robert Lerman and by Sara
McLanahan and Audrey Beck in this volume,
is that these initial high rates of contact and
involvement with the child’s father tend to
drop off over time.

Sigle-Rushton and McLanahan found moth-
ers’ socioeconomic characteristics varied
among these living arrangements.’^ First,
women liying in less independent arrange-
ments (that is, “partner-plus” or “other-adnlt”)
were the most likely to be experiencing a first
birth and were on ayerage younger (as were
the fathers of their children). Ciyen their
more limited resources, it is not surprising
that younger mothers are less likely to be
liying independently than older motliers.
Conyersely, women who liyed alone and
women who liyed in nuclear households were
older, which may refiect people’s tendency to
moye to more independent liying arrange-
ments as they age.’** Women who were liying
with their babies’ fathers and some other
adult (that is, “partner-plus” arrangements)
were the youngest and had the least educa-
tion, most likely reflecting selection into
different liying arrangements based on
economic need.

Based on these pattems, Sigle-Rnshton and
McLanahan concluded tliat older and more
educated women are more likely to cohabit
as a nuclear family at the time of birth and
are the least likely to liye with other adults.
Similarly, women whose partners are older

VOL. 20 / NO. 2 / FALL 2010 45

Ariel Kalil and Rebecca M. Ryan

and more educated are also more likely
to be cohabiting as a nuclear family at the
time of birth. Though it would be tempt-
ing to conclude, based on tliis evidence, that
cohabitation in a nuclear arrangement con-
fers economic benefits on mothers in fragile
families, it is most likely tlie case that unwed
mothers and fathers with a higher eamings
capacity choose this type of living arrangement
(as opposed to living with otlier adults or living
alone) because of their own and their partners’
human capital and eamings capacities. Thus,
policy makers aiming to target assistance to
fragile families with the highest rates of eco-
nomic hardship might wish to focus on those
who are either “doubling up” with older adults
or living on tlieir own with their children.

Living Arrangements over Time
Another key finding from the FFCWS is that
despite professed “high hopes” for marriage,
most unmarried parents were unable to
maintain a stable union over time.'” Only 15
percent of the initially unmarried couples
were married at the time of the five-year
interview, and only 36 percent were still
romantically involved—a large decUne from
the 80 percent who were romantically
involved at the child’s birth. Among couples
who were already cohabiting at birth,

26

percent eventually married and another 26
percent maintained their unwed cohabiting
arrangement. Almost half of couples who
were cohabiting at birth, then, had ended
their romantic relationship by the five-year
survey. Other analysis of the FFCWS sample
has revealed that these families also experi-
ence high degrees of instability in living
arrangements over time.’^ The article by
McLanahan and Beck in this volume elabo-
rates on these phenomena.

These relatively low rates of movement
into marriage, high rates of relationship

dissolution, and high rates of change in liv-
ing arrangements likely play a role in tlie
economic trajectories of mothers in fragile
famihes, although the specific linkages and
the causal direction of these linkages are not
yet fully understood and likely depend on the
type of relationship that forms and dissolves.’̂

Summary
A defining feature of the families of the
unwed mothers who make up an ever-
increasing share of the U.S. population is
poverty and material hardship. Although
large numbers of mothers in fragile families
work, employment does not enable them to
escape poverty. Most have very low eamings
because they are poorly educated and have
health and emotional problems, tul of which
can make it difficult to find or keep a well-
remunerated full-time job. Mothers in fragile
families also have very few assets to help
cushion the financial blow of a job loss or an
unexpected health problem. Consequently,
such hardships are more likely to drive their
families into a downward spiral of even more
difficult economic circumstances.

The living arrangements of mothers in fragile
families may account for some of their low
household incomes but are clearly not the
predominant factor given the similarity in
household incomes between cohabiting and
single mothers. High rates of relationship
dissolution and frequent changes in living
arrangements may also play a role in the
economic conditions of mothers in fragile
families, but their relative importance has not
yet been established. The major contributor
to the economic challenges facing mothers in
fragile families is their low eamings capacity.
In the next section, we describe how these
mothers manage to make ends meet amid
these economic challenges.

4 6 THE FUTURE OF CHILDREN

Mothers’ Economic Conditions and Sources of Support in Fragile Families

Figure 1 . Fragile Families’ Income Distribution

7%

29%
19%

21%

24%

! Mother earnings

H Partner earnings

H In-kind benefits

• Other household income

H Cash benefits

Source: Qin Gao and Inwin Garfinkel, “Income Packaging amohg Unwed Fragüe Families: Variation across 20 Large U.S. Cities,” Working
Paper (School of Social Work, Columbia University, 2004).

Making Ends Meet:
Mothers’ Sources of Support
in Fragile Families
In tlieir 1997 study of low-income single
motliers, Kathryn Edin and Laura Lein
provided an answer to the question posed
above: how do motliers in fragile families
make ends meet? They found that unwed
mothers seldom survived on income from paid
work or welfare benefits alone.̂ ^ Rather, the
vast majority relied on a range of economic
supports, including cash and in-kind benefits
from public programs and help from relatives
and friends. Despite substantial economic and
policy changes since that time, Edin and Lein’s
findings still describe reality for many motli-
ers in fragile families. Although most unwed
mothers are employed, most also rely on
public programs like welfare, food stamps, and
public housing even as the numbers receiving
cash assistance have declined. Moreover, as
mothers in fragile families support children
increasingly outside tlie welfare system, many
are turning to private sources of support to
ease tlieir economic strain. In this section, we
summarize the role that each income source
and safety net plays in mothers’ lives and what

is known about how, together, tliey form frag-
ile families’ complex income packages.

Employment
With rising employinent and declining
welfare participation over the past fifteen
years, unwed mothers’ income packages
have hinged increasingly on their own eam-
ings. Thus, aldiough mothers’ eamings are
relatively low, they nevertlieless represent a
significant share of mothers’ total household
income. In ongoing work with FFCWS data,
Qin Cao and Irwin Carfinkel have parsed the
proportion of motliers’ total income package
that comes from various sources, including
own eamings, others’ earnings, and cash and
in-ldnd public benefits (see figure 1).̂ ‘ Among
tliese sources, unwed mothers’ own earn-
ings account for nearly a third of the average
household income package. Although exact
estimates vary by subgroup of unwed mothers
and income calculations, it is clear that moth-
ers’ own eamings make up an increasingly
important part of fragile families’ income.

Most mothers in fragile families also depend
on other household members to make ends
meet, which is one reason why cohabiting

VOL. 20 / NO. 2 / FALL 2010 47

Ariel Kalil and Rebecca M. Ryan

Table 2. Sources of Support for Unwed Mothers in Fragile Families

Percent

Source of support Cohabiting
Other
relationship

73

84

73

53

4 1

30

18

89

70

No
relationship

73
84
73

5 1

40
30

19

53

72

All

7 1

83

70

48

33

26

16

86

64

Earnings from regular work

Public support

WIC

Medicaid

Food stamps

TANF

Housing

Child care

Private support

Father contributions*

From family or friends

70
83

66

42

24

22

14

100

57

Source: Julien 0. Teitier, Nancy E. Reichman, and Lenna Nepomnyaschy, “Sources of Support, Child Care, and Hardship among Unwed
Mothers, 1999-2001,” Social Service Review 78, no. 1 (2004): 125-48. The survey included 1,299 cohabiting mothers, 928 mothers
in other reiationships, and 612 mothers in no relationship, totaling 2,839.
•Because of data iimitations, it was assumed that ail cohabiting mothers received father contributions.

and doubling up is so prevalent. Data from
the FFCWS suggest that on average, income
from cohabiting partners constitutes a
quarter of the total household income
package. That may be why cohabiting
mothers in fragile families report slightly
higher household incomes and somewhat
lower levels of economic hardship than single
mothers (although cohabiting mothers also
earn more money than single mothers
because of their higher levels of education),^^
Moreover, most unwed mothers in fragile
families who are not cohabiting with roman-
tic partners live with other adults who
contribute eamings to the household income,
as noted. The similarity of rates of employ-
ment across living arrangements suggests that
most unwed fathers cannot support their
families independently or that cohabiting
men (and other adults) do not contribute
enough of their income to reduce mothers’
economic burden.^^ However, mothers’
reliance on others’ earnings also indicates
that most do not shoulder the breadwinning
responsibilities alone.

Public Programs
Most mothers in fragile families also depend
on some type of cash or in-kind public benefit
to make ends meet. Using data from the
FFCWS, Julien Teitler, Nancy Reichman, and
Lenna Nepomnyaschy found that one year
after a nonmarital birth, 94 percent of the
mothers were receiving some form of public
support (see table 2 for unwed mothers’ rates
of receipt across public programs). According
to the Survey of Income and Program
Participation (SIPP), a national survey that
provides information about the income and
public program participation of individuals
and households in the United States, 44
percent of all unwed mothers, who include
never-married and divorced mothers, and 67
percent of never-married mothers partici-
pated in at least one govemment program in
2004.̂ ” Mothers’ participation varies by
specific program and by family composition,
as does the role each plays in families’ overall
income packages. In this section we review
these pattems, dividing public benefits into
cash and in-kind benefits.

4 8 THE FUTURE OF CHILDREN

Mothers’ Economic Conditions and Sources of Support in Fragile Families

Cash Assistance Programs
The most direct source of cash assistance for
low-income families is Temporary Assistance
for Needy Families (TANF), which, as part of
welfare reform in 1996, replaced a federal
entitlement to cash benefits with time-limited,
work-based assistance. Although welfare rolls
have declined overall, TANF still serves an
important economic function for many
mothers in fragile families. According to data
from the FFCWS, nearly one-third of unwed
mothers received TANF benefits during the
year following a nonmarital birth.̂ ^ Rates of
TANF participation were higher among
mothers not cohabiting with the child’s father
than among cohabiting mothers, a pattern
also found in an analysis of data from the
2001 Current Population Survey^” Still,
according to both data sources, rates of
TANF participation for cohabiting mothers
resembled those of noncohabiting unwed
mothers more than those of married mothers,
suggesting that TANF plays an important role
in the economic lives of fragile families
regardless of family structure.

Despite fragile families’ relatively high TANF
participation rates, cash payments account for
a small portion of their average income. Cao
and Carfinkel estimate that among all unwed
mothers in the FFCWS sample, income from
TANF accounted for less than 5 percent of
mothers’ total income package, with in-kind
benefits providing the lion’s share after moth-
ers’ own earnings.̂ ^ Among unwed mothers
in the sample who received TANF or food
stamps (most participants who receive TANF
also receive food stamps), employed mothers
received on average $2,500 and unemployed
mothers received approximately $3,500
from TANF in the year after their child was
born.̂ ** Lower TANF participation rates and
the low value of TANF benefits may explain
in part why unwed mothers are increasingly

dependent on other forms of cash and in-
kind public benefits.

As TANF caseloads plummeted after the
mid-1990s, the numbers of low-income
families, and unwed mothers in particular,
receiving the eamed income tax credit
(EITC) substantially increased. The EITC, a
refundable tax credit for low-income workers,
disproportionately benefits families and
single mothers. Its average value has
increased substantially, from $601 in 1990
to $1,974 in 2007.2» Because the credit is
refundable, an unwed mother whose credit
exceeds her taxes receives the difference in
cash. Because it is a tax credit, payments
increase with income up to a point, encourag-
ing low-income unwed mothers to work even
at very low-wage jobs. Janet Currie character-
izes the EITC as a crucial part of unwed
mothers’ “invisible safety net” because it
makes work pay, or at least pay more than it
otherwise would.'”‘

Because of the substantial value of the EITC
for low-income families and its widespread
use, the EITC likely constitutes a significant
portion of working mothers’ overall income
package. According to estimates from the
2001 March Current Population Survey, the
EITC represented 12 percent of net income
for those in the lowest income quintile of
unwed mothers.^’ According to Cao and
Carfinkel’s estimates, the EITC accounted
for nearly one-third of unwed mothers’
average cash benefits in the FFCWS, a
significant proportion even if cash benefits
overall accounted for a relatively small share
of the total income package.̂ ^ This finding
underscores the importance of stable work
for mothers in fragile families: losing employ-
ment today means losing not only one’s
income, but also a significant tax credit.

VOL. 20 / NO. 2 / FALL 2010 49

Ariel Kalil and Rebecea M. Ryan

In-Kind Assistance Programs
In her 2006 book. The Invisible Safety Net,
Janet Currie concludes that in-ldnd benefits
such as food stamps and Medicaid constitute
the most essential, though largely invisible,
part of the public welfare system. She argues
that in-ldnd benefits often make up the
difference between low-income families’
household earnings and what it costs to buy
family essentials like food, shelter, medical
care, and child care. For mothers in fragile
families, in-kind benefits are the most
commonly used public programs and repre-
sent the largest share of household income
from pnbhc sources, contributing as much to
mothers’ income packages as their earnings.
In Currie’s words, these programs form “a
broad-reaching and comprehensive net that
especially protects young children in low-
income families.” •’̂

The largest provider of food assistance to
low-income families is the food stamp pro-
gram, now called the Supplemental Nutrition
Assistance Program (SNAP). The yalue of
food stamps depends on household size and
income, but the allotment is typically sub-
stantial enough to deflect a family’s spend-
ing away from food to other essentials in a
meaningful way. Thus food assistance serves
a particularly important purpose in unwed
mothers’ economic support systems.

Changes in food stamp participation rates
over the past ten years indicate the program
has become a more important source of sup-
port for fragile families—and increasingly so
since the economy entered into recession in
2007.** In the FFCWS, nearly half of unwed
mothers received food stamps one year after
a nonmarital birth, with higher participa-
tion rates among noncohabiting mothers.^^
Indeed, Teitler and colleagues estimated that
unwed mothers in the FFCWS who received

food stamps and were employed receiyed
about $2,000 on ayerage in yearly benefits,
and those who were unemployed receiyed
about $2,500. The same mothers received
on average $2,500 and $3,500, respectively,
in TANF benefits, suggesting that for moth-
ers who receive either type of benefit, food
stamps represent a substantial portion of
mothers’ total in-kind benefits—less than
Medicaid and housing assistance but as much
as other sources of food assistance and more
than child care assistance.^”

Food stamps may help mothers in fragile
families by helping to keep household
consumption consistent during times of
relationship instability. According to a study
by Daphne Hernandez and Kathleen Ziol-
Cnest, nnwed mothers in the FFCWS were
more likely to enroll in the food stamp
program after exiting a cohabiting union and
more likely to leave the program after
entering a cohabiting union.^’ If food stamps
help most when they offset income lost after
a union dissolution, mothers in fragile
families may depend on them more than
otlier unwed mothers owing to their higher
levels of relationship turbulence.

The U.S. Department of Agriculture’s
Women, Infants, and Children (WIC) pro-
gram serves fewer families overall and has a
lower dollar value than food stamps, but it
may play a more important economic role for
mothers in fragile famiUes because it helps
families with young children secure foods
with high nutritional value.̂ * Perhaps for
this reason, more than 80 percent of unwed
mothers in the FFCWS reported receiving
WIC one year after the focal child’s birtli,̂ ^
compared with about half who reported
food stamp participation and 66 percent
who reported receiving Medicdd. According
to Gao and Carfinkel, WIC benefits made

5 0 THE FUTURE OF CHILDREN

Mothers’ Economic Conditions and Sources of Support in Fragile Families

For mothers in fragile
families, in-kind benefits
are the mvst commonly
used public programs and
represent the largest share of
household income from public
sources, contributing as much
to mothers’ income packages
as their earnings.

up a sizable portion of fragile families’ total
in-kind benefits, similar in proportion to
housing and food stamps. Together, WIC
and food stamps made up a larger portion of
fragile families’ in-kind benefits than housing
assistance.”*”

Janet Currie hails the expansion of publicly
funded health care coverage for low-income
children over the past fifteen years, largely
through Medicaid and tlie State Child Health
Insurance Program (SCHIP), as “a tremen-
dous success story.” Of all in-kind assistance
programs, public health insurance is by far the
most widely used among unwed mothers, with
28 percent participating in either Medicaid,
Medicare, or other public insurance in 2008.””
As with other public programs, mothers in
fragile fainilies are more likely to receive
Medicaid than are unwed mothers overall. In
the year following a nonmarital birth, 70
percent of all unwed mothers in the FFCWS
received Medicaid.”*̂ Again, as with other
programs, mothers in cohabiting relationships
were less likely to receive Medicaid than
those in noncohabiting relationships or those
with no relationship with the child’s father.

Because public health insurance covers
expenses that are by definition irregular, it is
not as clear how Medicaid affects unwed
mothers’ economic support systems. However,
a few points are clear. First, because a mother
in a fragile family no longer needs to receive
welfare to have her child covered by Medicaid,
the current public health insurance system
does not discourage work—or the income that
comes with it—the way it did before welfare
reform. Second, patterns of cycling on and off
Medicaid or SCHIP coverage, often called
“churning,” suggest that many mothers apply
for Medicaid when their child needs specific
medical services, ones she could not afford
without insurance. In this way, public hetilth
insurance allows, and thus encourages,
families to keep their incomes above tlie
poverty line, and can in many cases defray
very high medical costs for families living at
the economic margins. Assuming average
annual Medicaid payments for each eligible
household child. Cao and Carfinkel estimated
that Medicaid payments constituted the
largest single share of unwed mothers’ in-kind
benefits.

The goal of public housing assistance is to
reduce housing costs and improve housing
quality for low-income families. Because
housing often makes up a substantial portion
of the typical family’s budget, housing
assistance by definition should represent an
essential part of single mothers’ economic
support system. It also ensures that recipi-
ents’ living conditions have at least a mini-
mum standard of quality, despite public
concern over the hetüth and safety conditions
in housing projects. Housing assistance,
however, is not an entitlement, and many
poor and low-income families who want and
need housing assistance cannot get it, making
it a system that works well for those who win
assistance, but that leaves many out entirely.

VOL. 20 / NO. 2 / FALL 2010 51

Ariel Kalil and Rebecca M. Ryan

Among mothers in fragile families, housing
assistance plays a role similar to TANF
benefits. More than a quarter of all unwed
mothers in the FFCWS received some type
of housing assistance in the year after a
nonmarital birth, compared with about
one-third receiving TANF, and many who
received one form of assistance also received
the other.”̂ Thus, although most mothers in
fragile families do not receive housing
assistance or welfare, for those who do,
housing assistance constitutes a significant
proportion of their in-kind benefits. Not
surprisingly, cohabiting mothers are less
likely to receive housing assistance than
mothers who live alone, or with family,
presumably because cohabiting mothers’
higher household incomes enable more of
them to afford housing or because more of
these households are ineligible for assistance.
Thus, housing assistance, like TANF benefits,
is a particularly important source of income
for mothers who live without romantic
partners or other adults.

Of all forms of in-kind assistance, however,
child care may be the most crucial to fragile
families’ economic well-being even if its cash
value is not always as high as that of housing
or food assistance. With the new work
requirements and time limits for cash
assistance under TANF, nearly all low-income
mothers must work. Child care is expensive,
particularly for young children. Although
poor families pay less for child care than
wealthier families, they spend a larger share
of their income on it than other families (25
percent compared with 7 percent), at least
among those who pay out-of-pocket for
care.”*̂ Without public assistance to help
pay for child care, full-time employment
would be untenable for many mothers in
fragile families.

Acknowledging this dilemma, the federal
government has substantially expanded
funding for subsidized child care since put-
ting welfare reform into place. Much of the
funding flows through the Child Care and
Development Fund (CCDF), a consolida-
tion of various child care subsidy programs
for low-income families and now the federal
government’s largest child care program.”*^
Mothers can use the subsidy to pay for either
center- or home-based care, including, in
many states, care provided by relatives. The
federal government also funds Early Head
Start and Head Start, center-based inter-
ventions for poor and low-income children
from birth to age five. Finally, states such as
Oklahoma, Ceorgia, and New York now pro-
vide universal prekindergarten (UPK) pro-
grams to all children regardless of economic
status. In 2002, an estimated 13 percent of
poor families with preschoolers received
some Idnd of government help to pay for
preschool, and this percentage may under-
count children in publicly funded preschool
programs like

Covemment-funded child care helps moth-
ers in fragile families in two key ways. First, it
reduces their out-of-pocket costs for care—
costs that the vast majority could not likely
afford. Using data from the FFCWS and a
sample of mothers on a wait list for child care
subsidies, Nicole Forry found that subsidy
receipt reduced mothers’ monthly child care
costs by more than $250 and reduced the
share of household income spent on child care
by 10 to 14 percentage points.”*̂ In a study
of nine experimental evaluations of twenty-
one welfare and employment programs. Lisa
Cennetian and her colleagues found that pro-
grams offering enhanced child care assistance
prevented mothers’ child care costs from
rising even though their work hours increased,
unlike programs that did not offer enhanced

5 2 THE FUTURE OF CHiLDREN

Mothers’ Economic Conditions and Sources of Support in Fragile Families

child care assistance, and reduced child care
expenses for motliers of preschoolers,”** For
families at the economic margins, these cost
savings may make otlier child-related needs,
such as enriching children’s home leaming
environments, far more affordable.

Second, and perhaps more important, sub-
sidized child care allows mothers to work
when they might not otherwise be able to
do so. Using data from the 1999 National
Survey of American Families, David Blau
and Frdal Tekin found that child care sub-
sidies increased employment among unwed
motliers by as much as 33 percentage points
and reduced unemployment by 20 percent-
age points.””̂ Subsidies not only increase the
likelihood mothers will work but they increase
the hours worked and employment duration,
both because assistance makes care more
affordable and also because it can decrease
child care instability.̂ ” For instance, a sub-
stantial proportion of mothers in the FFCWS
report having their child care “fall through” so
that it dismpted their work schedules.^’ But,
using the same data, Nicole Forry and Sandra
Hofferth found that child care-related work
disruptions were far less likely among child
care subsidy recipients.^^ For lowering costs
of care and promoting stable employment,
subsidized child care plays an essential role in
many mothers’ economic support systems.

Despite its potential benefits, not all eligible
mothers receive child care assistance. Child
care subsidies are a block grant rather than
an entitlement, and many states can cover
only a fraction of those mothers who are
eligible.®’̂ Moreover, research suggests that
many eligible mothers do not apply for sub-
sidies because they are either unaware of the
program or unable to navigate its administra-
tive complexities, ‘̂’ These dynamics produce
the seemingly incongruous result of long

waiting lists and low take-up rates for child
care subsidies in many states. Head Start is
not a reliable alternative for many of these
mothers because it has never been funded
adequately to allow all eligible children
to participate. Universal preldndergarten
programs offer an attractive and dependable
option but serve only preschool-aged children
and are available in only a handful of states.
Consequently, mothers often turn to private
sources of child care among their friends and
family. These arrangements, often called kidi
and kin care, no doubt help mothers econom-
ically and emotionally if the arrangement is
free or low-cost and if they trust the provider
to keep their child safe. However, quality in
these arrangements is typically lower than in
center-based programs.^^ As a result, with or
without government-funded child care assis-
tance, many mothers in fragile families are
often left with few affordable, high-quality
child care options.

Private Support
Edin and Lein’s study of low-income single
mothers described how the costs of working
often outweighed the benefits. ‘̂’ Although
most mothers they interviewed could get jobs
(83 percent had some formal work experi-
ence), many had a hard time making ends
meet because costs of child care, medical
care, transportation, housing, and clothing
for work increased when they left welfare.
Overwhelmingly, those working mothers
whom Edin and Lein identified as “wage-
reliant” tumed to cohabiting relatives or
boyfriends and other relatives and friends to
provide extra cash, essentials like diapers and
food, free child care, and access to transpor-
tation. Edin and Lein see these forms of pri-
vate economic support as the “private safety
net” that mothers often need in addition to
eamings and the public safety net of welfare,
food assistance, and housing assistance.

VOL. 20 / NO. 2 / FALL 2010 53

Ariel Kalil and Rebecca M. Ryan

Although the expansion of work supportive
programs like the EITC and child care
assistance has improved the trade-off between
work and welfare for unwed mothers, private
safety nets still play a cmcial role in fragile
families’ economic survival. According to
research from the FFCWS, the vast majority
of unwed mothers received financial or
instrumental help from partners, relatives, or
friends in the years following an unwed birth.
For example, Teitler and colleagues report
that 96 percent of unwed mothers received
cash or in-kind support from private sources,
with 86 percent receiving help from the
children’s fathers and 64 percent from family
or friends (see table 2).̂ ‘̂ Employed mothers
were just as likely to receive help from private
sources as were unemployed mothers, and
most mothers in both groups received both
public and private support of some kind. For
all unwed mothers in fragile families, private
support was the most common form of
economic help received next to own eamings
and WIC food assistance, suggesting that
private safety nets are essential regardless of
employment status.

Although the vast majority of mothers in
fragile families receive private economic
support, the source and availability of support
vary by mothers’ relationship status. For
instance, data from the FFCWS suggest that
cohabiting mothers relied more often on their
partners for cash assistance, in-kind gifts, and
instrumental help with child care and trans-
portation than on other family members,
whereas single, or noncohabiting, mothers
relied more often on family and friends,
particularly when they had no relationship
with the father.̂ ^ Mothers’ fertility patterns
also affect the overall availability of private
support. Kristin Harknett found that unwed
mothers in the FFCWS with children by
more than one man reported significantly less

Although the vast majority
of mothers in fragile families
receive private economic
support, the source and
availability of support vary by
mothers’ relationship status.

available support than those with children by
one man.̂ ^ She concluded from these patterns
that smaller, denser kin networks offer
stronger private safety nets than broader,
weaker ties of the kind multipartnered
fertility might bring. Thus, assuming sources
of support are relatively interchangeable,
multipartnered fertility puts mothers in fragile
families at greater risk for low levels of private
support than does nonmarital childbirth itself.

Cash Assistance
Cash assistance from private networks is
a small but important part of many single
mothers’ economic support systems. Edin
and Lein found that among the 165 wage-
reliant mothers they interviewed, nearly half
received some cash from private networks
in a typical month, excluding nonresident
fathers, with an average of $140 from family
and friends and $226 from boyfriends among
those who received any help.^” More recently,
Melissa Radey and Yolanda Padilla estimated
that nearly 30 percent of unwed mothers
in the FFCWS received cash from family
or friends, excluding fathers, three years
after a nonmarital birth, with the average
being $1,172 a year or about $100 a month.””
Typically, this cash is used to make up the
difference in a given month between eamed
income, cash assistance, and the money

5 4 THE FUTURE OF OHiLDREN

Mothers’ Economie Conditions and Sotirees of Support in Fragile Families

needed to buy food, pay rent and utiUties, or
cover emergency expenses like car repairs.
Other studies suggest that although many
unwed mothers rely on cash assistance from
social networks periodically, the size of
private cash loans is typically small, account-
ing for no more than 5 percent of mothers’
income.”̂ In this way, cash assistance from
private sources may help mothers cope dur-
ing stressful times but does not fundamen-
tally change their economic circumstances.

In-Kind Assistance
A more common form of private support from
family and friends than cash loans is in-kind
assistance like presents for children and
household items. Mothers in Edin and Lein’s
study reported regularly receiving household
essentials like diapers and groceries as well as
coveted clothes and toys for children from
family members, boyfriends, and nonresident
fathers.̂ ^ Recently, in a qualitatiye study of
mothers participating in the New Hope
Project, a work support program for low-
income families in Milwaukee, Eboni Howard
found that material assistance was tlie most
preyalent—and perceiyed to be the most
helpful—type of informal support mothers
receiyed.^ In the FFCWS, most nonresident
fathers who were romantically involved with
the mother bought children clodies, toys,
medicine, or food at least sometimes, although
fathers’ in-kind assistance, like informal child
support, was much less frequent when parents
were not romantically involyed.^ In-ldnd
contributions not only fill in essential gaps in
the monthly budget, but also allow mothers to
proyide their children with nonessential items
that enhance their own and their children’s
subjectiye sense of well-being.

Instrumental Assistance
In addition to direct forms of private cash
and in-ldnd economic assistance, single

mothers often rely on their private networks
to provide instrumental assistance they might
not otherwise afford. Edin and Lein empha-
sized the importance of emergency and
regular child care that relatives provide. This
care was most often provided by children’s
maternal grandmothers and was both low-
cost and potentially preferable to the low-
quality center-based care available in poor
communities.*^^ The vast majority of unwed
mothers in the FFCWS—86 percent of
cohabiting mothers and 91 percent of single
mothers—reported someone in their social
network would provide child care in an
emergency, a necessity when regular child
care arrangements fall through. Family and
friends also provide mothers with transporta-
tion to and from work, which, for many
mothers, can mean the difference between
keeping and losing a job. Using data from the
FFCWS, research by Michelle Livermore
and Rebecca Powers”̂ and also by Melissa
Radey®** found that mothers who received
social support from family and friends to save
money were more likely to be employed than
mothers who receiyed no such support, eyen
when the mothers being compared had
similar employment records in the preyious
year. Kristin Harknett reached similar
conclusions examining employment patterns
in a sample of former welfare recipients.’̂ ”’
Oyerall, all of these forms of assistance—
cash, in-ldnd economic support, and instru-
mental assistance—may serye two important
economic purposes: to make ends meet and
to facilitate employment.

Instability of Private Support
Although most mothers in fragile families
receiye some kind of help from social net-
works at some point, priyate forms of support
differ from public benefits in that they are
often unpredictable and inconsistent. Using
both quantitatiye and qualitatiye data from

VOL. 20 / NO. 2 / FALL 2010 55

Ariel Kalil and Rebecca M. Ryan

the FFCWS (the latter drawn from a sub-
sample of the larger study), Sarah Meadows
documented the mismatch between unwed
mothers’ expectations of financial and instru-
mental support from family and friends and
their actual receipt of it.™ Approximately
one-third of unwed mothers expected their
social networks to provide financial and
instrumental assistance in an emergency but
did not receive help when they needed it, an
experience strongly linked with the emer-
gence of major depression five years after an
unwed birth. To the extent that poorer men-
tal health can undermine mothers’ employ-
abihty, the unpredictability and inconsistency
of private support networks can place moth-
ers in fragile families in double jeopardy.

Summary
Mothers in fragile families make ends meet by
relying on many different sources of income
and support. The vast majority are wage-
reliant, in Edin and Lein’s terms, meaning
that the largest share of their income comes
from own eamings. But because unwed moth-
ers’ incomes are low on average, most also
depend on eamings from cohabiting partners
and relatives. Mothers’ and others’ eamings,
combined, make up more than half of the
average household income in fragile families.
Such dependency on others’ eamings means
that mothers’ total incomes rise and fall with
the economy. For families without wealth or
assets to help weather unexpected adversity,
instability could precipitate income shocks
and financial crises with grave consequences
for mothers and children.

To mitigate these shocks, the vast majority of
mothers in fragile families rely on at least one
public benefit. Since welfare was reformed in
1996, cash assistance, such as TANF, has
become a less important source of income for
fragile families, while in-kind assistance, such

as food stamps, housing assistance, and
Medicaid, has become more important. Thus,
although roughly one-third of mothers in
fragile families received welfare in the year
after a nonmarital birth, cash assistance
accounted for little of their average income
package. By contrast, in-kind benefits
accounted for nearly a quarter. More than
cash programs, the invisible safety net of
in-kind benefits safeguards mothers and
children against the worst outcomes of life at
the economic margins.

To close the economic gaps left by earnings
and public support, mothers in fragile fami-
lies sometimes receive help from partners,
family, and friends. Periodic cash, in-kind,
and instrumental assistance from private
networks can prevent financial crises in times
of need, and stable forms of assistance, such
as child care, can promote job stability. In
these ways, private support is essential to
unwed mothers’ economic survival. However,
unlike public support, private safety nets are
not always consistent and dependable. Thus,
assistance from private sources may help
mothers cope during stressful times but may
not fundamentally improve their economic
circumstances unless it is offered consistently
and over long periods of time.

Conclusion
Mothers in fragile families experience higher
rates of poverty and material hardship than
their married counterparts. Although a large
share of these mothers cohabit with their
child’s father, and many more live with other
adults, unwed mothers have similar rates of
economic hardship across a variety of living
arrangements. Differences in economic
well-being are far larger between mothers in
fragile families and married mothers than
among unwed mothers in different living
arrangements, making clear that living

5 6 THE FUTURE OF CHILDREN

Mothers’ Economic Conditions and Sources of Support in Fragile Families

arrangements do not primarily drive eco-
nomic conditions in this population.

The primary cause of poverty and material
hardship, instead, appears to be unwed moth-
ers’ (and fathers’) low earnings. The limited
ability of mothers in fragile families to com-
mand high wages stems from low education
as well as physical, emotional, and mental
health problems. Indeed, very few unmar-
ried mothers in the FFCWS could support
themselves and their children at more than
twice the federal poverty level, given their
average eamings. Moreover, mothers with
low earnings are unlikely to be able to accu-
mulate assets or purchase a home, and a lack
of assets can exacerbate financial difficulties.

Civen these economic challenges, how do
mothers in fragile families make ends meet?
As we have shown, various public programs,
particularly those that provide in-kind assis-
tance, do successfully lessen economic hard-
ship in fragile families. However, many of the
most effective programs, such as the EITC,
hinge on mothers’ employment. As the
nation’s economy emerges painfully slowly
from recession, there is reason for concern
about the stability of the public safety net
for single mothers, particularly those with
little education and other barriers to employ-
ment. Henceforth, single mothers may turn
more often to private sources of support for

cash, in-kind, and instrumental assistance.
Although private safety nets are essential to
many mothers’ economic survival, they may
not facilitate long-term economic mobility.

Among promising policy prescriptions to
bolster fragile families’ economic supports,
perhaps the most important is to strengthen
the public safety net, particularly the “invis-
ible safety net” of in-kind benefits, to help
families cope in an unstable economy.
Moreover, as more single mothers enter the
labor market in today’s weak economy, it
may become increasingly important to have
a private safety net. A next step would thus
be to strengthen the availability and efficacy
of community-based programs that mimic
private financial or instrumental support
when mothers cannot receive it from their
networks. Examples include programs that
provide emergency cash assistance and food
aid directly as well as programs to foster and
perhaps formalize the provision of loans,
child care, and in-kind assistance among fam-
ilies. Overall, it is important for policy makers
to recognize that with rates of nonmarital
childbirth at their current level, and poten-
tially rising still, fragile families are likely
an enduring fixture among U.S. families. It
is thus essential to strengthen policies that
both support their economic self-sufficiency
and alleviate their hardship during inevitable
times of economic distress.

VOL. 20 / NO. 2 / FALL 2010 57

Ariel Kalil and Rebecca M. Ryan

Endnotes

1. Sara McLanahan, “Children in Fragile Families,” Working Paper 09-16-FF (Princeton: Center for

Research on

Child Wellbeing, 2009).

2. Susan E. Mayer and Christopher Jencks, “Poverty and the Distribution of Material Hardship,”/ouniaZ of

Human Resources 24, no. 1 (1989): 88-114.

3. Julien O. Teitler, Nancy E. Reichman, and Lenna Nepomnyaschy, “Sources of Support, Child Care, and

Hardship among Unwed Mothers, 1999-2001,” Social Service Review 78, no. 1 (2004): 125-48.

4. Melissa Radey, “The Influence of Social Supports on Employment for Hispanic, Black, and White

Unmarried Mothers,”/oMrnaZ of Family and Economic Issues 29 (2008): 445-60.

5. Carol Ann MacCregor, “Education Delayed: Family Structure and Postnatal Educational Attainment,”

Working Paper 09-07-FF (Princeton: Center For Research on Child Wellbeing, 2009).

6. Kristen Harknett and Jean Knab, “More Kin, Less Support: Multipartnered Fertihty and Perceived

Support among Mothers,”/oumaZ of Marriage and. Family 69 (2007): 237-53.

7. Michelle DeKlyen and others, “The Mental Health of Married, Cohabiting, and Non-Coresident Parents

with Infants,” American Joumal of Public Health 96, no. 10 (2006): 1836-41.

8. Aurora P. Jackson, Marta Tienda, and Chien-Chung Huang, “Capabilities and Employabihty of Unwed

Mothers,” Children and Youth Services Review 23, nos. 4-5 (2001): 327-51.

9. Wendy Sigle-Rushton and Sara McLanahan, “For Richer or Poorer? Marriage as an Anti-Poverty Strategy

in the United States,” Population 57, no. 3 (2002): 509-26.

10. Christine Perchesld, “Maternal Employment after a Birth: Examining Variations by Family Structure,”

Working Paper 08-18-FF (Princeton: Center for Research on Child Wellbeing, 2008).

11. Rebecca Blank and Michael Barr, Insufficient Funds: Savings, Assets, Credit, and Banking among Low-

Ineome Households (New York: Russell Sage Press, 2009).

12. Ibid.

13. Sigle-Rushton and McLanahan, “For Richer or Poorer?” (see note 9).

14. Wendy Sigle-Rushton and Sara McLanahan, “The Living Arrangements of New Unmarried Mothers,”

Demography 39, no. 3 (2002): 415-33.

15. Ibid.

16. Rebecca A. London, “The Interaction between Single Mothers’ Living Arrangements and Welfare

Participation,”/owmaZ of Policy Analysis and Management 19, no. 1 (2000): 93-117.

17. McLanahan, “Children in Fragile Families” (see note 1).

18. Cynthia Osborne and Sara S. McLanahan, “Partnership Instabihty and Child Wellbeing,”/owmfli of

Marriage and Family 69, no. 4 (2007): 1065-83.

19. Sarah Meadows, Sara McLanahan, and Jean Knab, “Economic Trajectories in Non-Traditional Families

with Children,” Working Paper 09-10-FF (Princeton: Center for Research on Child Wellbeing, 2009).

58 THE FUTURE OF CHILDREN

Mothers’ Economic Conditions and Sources of Support in Fragile Families

20. Kathryn Edin and Laura Lein, Making Ends Meet: How Single Mothers Survive Welfare and Low-Wage

Work (New York: Russell Sage Foundation, 1997).

2L Qin Gao and Irwin Garfinkel, “Income Packaging among Unwed Fragile Families: Variation across 20

Large U.S. Gities,” Working Paper (School of Social Work, Golumbia University, 2004).

22. Sigle-Rushton and McLanalian, “The Living Arrangements” (see note 14).

23. Gatherine Kenney, “Gohabiting Gouple, Filing Jointly? Resource Pooling and U.S. Poverty Policies,”

Family Relations 53, no. 2 (2004): 2 3 7 ^ 7 .

24. Jane Lawler Dye, “Participation of Mothers in Govemment Assistance Programs: 2004,” Gurrent

Population Reports May 2008, U.S. Bureau of tlie Gensus (www.census.gov/prod/2008pubs/p70-116

[accessed May 26, 2009]).

25. Julien O. Teitler, Nancy E. Reichman, and Lenna Nepomnyaschy, “Determinants of TANF Participation: A

Multilevel Analysis,” Social Service Review 81, no. 4 (2007): 633-56.

26. U.S. Department of Health and Human Services, “Public Assistance Use among Two-Parent Families: An

Analysis of TANF and Food Stamp Program Eligibility and Participation,” research brief (Office of the

Assistant Secretary for Planning and Evaluation, 2005).

27. Gao and Garfinkel, “Income Packaging” (see note 21).

28. Ibid.

29. Tax Policy Genter, “Earned Income Tax Gredit: Number of Recipients and Amount of Gredit, 1975-2007,”

Urban Institute and Brooldngs Institution (http://taxpolicycenter.org/taxfacts/displayafact.cfm?Docid=37

[accessed Sept. 22, 2009]).

30. Janet M. Gurrie, The Invisible Safety Net: Protecting the Nation’s Poor Children and Faniilies (Prtnceton

University Press,

2006).

31. Ibid.

32. Gao and Garfinkel, “Income Packaging” (see note 21).

33. Gurrie, The Invisible Safety Net (see note 30).

34. House Ways and Means Gommittee, Green Book 2004: Rackground Material and. Data on the Programs

within the Jurisdiction of the Committee on Ways and Means, 108th Gong., 2nd sess. (Washington:

Government Printing Office, 2004).

35. Teitler, Reichman, and Nepomnyaschy, “Sources of Support” (see note 3).

36. Gao and Garfinkel, “Income Packaging” (see note 21).

37. Daphne G. Hernandez and Kathleen M. Ziol-Guest, “Income Volatility and Family Structure Patterns:

Association with Stability and Ghange in Food Stamp Program Participation,”/owrnflZ and Family

Economic Issues 30 (2009): 357-71.

38. Douglas J. Besharov and Peter Germanis, “Welfare Reform—Four Years Later,” Public Interest 140 (2000):

17-35.

VOL. 20 / NO. 2 / FALL 2010 59

Ariel Kalil and Rebecca M. Ryan

39. Teitler, Reichman, and Nepomnyaschy, “Sources of Support” (see note 3).

40. Cao and Carfinkel, “Income Packaging” (see note 21).

41. Joanna Turner, Michel Boudreaux, and Victoria Lynch, “A Preliminary Evaluation of Health Insurance

Coverage in the 2008 American Community Survey,” Working Paper, health insurance (U.S. Bureau of the

Census, 2009).

42. Teitler, Reichman, and Nepomnyaschy, “Sources of Support” (see note 3).

43. Ibid.

44. Julia Overturf Johnson, “Who’s Minding the Kids? Child Care Arrangements: Winter 2002,” Current

Population Reports, October 2005, U.S. Bureau of the Census (www.census.gov/prod/2005pubs/p70-101

[accessed Sept. 22, 2009]).

45. Child Care Bureau, “Average Monthly Adjusted Number of Families and Children Served (FFY 2006),”

U.S. Department of Health and Human Services, Administration for Children and Families (www.acf hhs.

gov/programs/ccb/data/ccdf_data/06acf800/tablel.htm [accessed Sept. 22, 2009]).

46. Johnson, “Who’s Minding the Kids?” (see note 44).

47. Nicole D. Forry, “The Impact of Child Care Subsidies on Low-Income Single Parents: An Examination of

Child Care Expenditures and Family Finances,”/oumaZ of Family and Economic Issues 30, no. 1 (2009):

43-54.

48. Lisa A. Cennetian and others, “Can Child Care Assistance in Welfare and Employment Programs Support

the Employment of Low-Income Families?”/ouma? of Policy Analysis and Management 23, no. 4 (2004):

723-43.

49. David Blau and Erdal Teldn, “The Determinants and Consequences of Child Care Subsidies for Single

Mothers in the USA,” Joumal of Population Economics 20, no. 4 (2007): 719-41.

50. Cennetian and others, “Can Child Care Assistance in Welfare and Employment Programs” (see note 48).

51. Margaret L. Usdansky and Douglas A. Wolf, “When Child Care Breaks Down: Mothers’ Experiences with

Child Care Problems and Resulting Missed Work,” Joumal of Family Issues 29, no. 9 (2008): 1185-1210.

52. Nicole D. Forry and Sandra L. Hofferth, “Maintaining Work: The Influence of Child Care Subsidies on

Child Care-Related Work Disruptions,” Working Paper 09-09-FF (Princeton: Center for Research on

Child Wellbeing, 2009).

53. Karen Schulman and Helen Blank, “State Child Care Assistance Policies 2008: Too Little Progress for

Children and Families,” issue brief (National Women’s Law Center, 2008).

54. Gina Adams, Kathleen Snyder, and Jodi R. Sandfort, “Getting and Retaining Child Care Assistance: How

Policy and Practice Influence Parents’ Experiences,” Occasional Paper 55, Assessing the New Federalism

(Urban Institute, 2002).

55. Elizabeth Rigby, Rebecca M. Ryan, and Jeanne Brooks-Gunn, “Child Care Quality in Different State Policy

Contexts,” Joumal of Policy Analysis and Management 26, no. 4 (2007): 887-908.

6 0 THE FUTURE OF CHILDREN

Mothers’ Economic Conditions and Sources of Support in Fragile Families

56. Edin and Lein, Making Ends Meet (see note 20).

57. Teitler, Reichman, and Nepomnyaschy, “Sources of Support” (see note 3).

58. Ibid.

59. Harknett and Knab, “More Kin, Less Support” (see note 6).

60. Edin and Lein, Making Ends Meet (see note 20).

61. Melissa Radey and Yolanda C. Padilla, “Kin Financial Support: Receipt and Provision among Unmarried

Mothers,”/oMmaZ of Social Service Research 35, no. 4 (2009): 336-51.

62. Julia R. Henly, Sandra K. Danziger, and Shira Offer, “The Contribution of Social Support to the Material

Well-Being of Low-Income Families,”/ouma/ of Marriage and Family 67, no. 1 (2005): 1 2 2 ^ 0 .

63. Edin and Lein, Making Ends Meet (see note 20).

64. Eboni C. Howard, “The Informal Social Support, Well-Being, and Employment Pathways of Low-Income

Mothers,” in Making It Work: Low-Wage Employinent, Family Life, and Child Development, edited by

Hirokazu Yosliikawa, Thomas S. Weisner, and Edward D. Lowe (New York: Russell Sage Foundation,

2006).

65. Rebecca M. Ryan, Ariel Kalil, and Kathleen M. Ziol-Guest, “Longitudinal Patterns of Nonresident Fathers’

Involvement: The Role of Resources and Relations,”/oumaZ of Marriage and Family 70, no. 4 (2008):

962-77.

66. Susanna Loeb and others, “Child Care in Poor Communities: Early Leaming Effects by Type, Quality, and

Stability,” Child Development 75, no. 1 (2004): 47-65.

67. Michelle M. Livermore and Rebecca S. Powers, “Employment of Unwed Mothers: The Role of

Govemment and Social Support,” yoMniöZ of Family and Economic Issues 27 (2006): 479-94.

68. Radey, “The Influence of Social Supports” (see note 4).

69. Kristen Harknett, “The Relationship between Private Safety Nets and Economic Outcomes among Single

Mothers,”/ourna/ of Marriage and. Family 68, no. 1 (2006): 172-91.

70. Sarali O. Meadows, “Is It There When You Need It? Mismatch in Perception of Future Availability and

Subsequent Receipt of Instrumental Social Support,”/oumaZ of Family Issues 30 (2009): 1070-97.

VOL. 20 / NO. 2 / FALL 2010 61

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The Unmet Need for Mental Health Services
Among Probationers’ Children

SUSAN D. PHILLIPS and RACHEL VENEMA
Jane Addams College of Social Work, University of Illinois at Chicago,

Chicago, Illinois, USA

LORENA ROQUE
Treatment Alternatives for Safe Communities, Chicago, Illinois, USA

This study explores the unmet need for mental health services
among children with parents on probation. A group of 77 proba-
tioners provided information on 170 children. Information about
children’s need for mental health services was based on the Child
Behavior Checklist and information about children’s receipt of
mental health services was based on the Child and Adolescent
Service Assessment. Approximately 1 in 4 participants had at least
one child with an indicated need for mental health services, but 9
out of 10 participants with children needing services had a child
who was not receiving services. This study suggests that probation
departments could play an important role in linking probationers’
children to mental health services.

KEYWORDS probation, parental incarceration, mental health,
children, services

A considerable amount has been written about children with parents in jails
and prisons in recent years, but little is known about probationers’ children.
The current study helps fill this gap in knowledge by exploring the preva-
lence of emotional and behavioral problems and the unmet need for mental
health services among a group of probationers’ children.

Children with parents in jails or prisons have taken the spotlight in
recent years due to the tremendous growth in correctional populations in

Address correspondence to Susan D. Phillips, PhD, Jane Addams College of Social Work,
University of Illinois at Chicago, 1040 W. Harrison St., MC 309, Chicago, IL 60607, USA. E-mail:
suephi@uic.edu

Journal of Offender Rehabilitation, 49:

110

–125, 2010
Copyright # Taylor & Francis Group, LLC
ISSN: 1050-9674 print=1540-8558 online
DOI: 10.1080/10509670903534845

110

the 1980s and 1990s (Blumstein & Beck, 1999). Probation populations also
grew dramatically during that same period. In the 1990s alone, the probation
population in the U.S. increased by more than a million people (Glaze &
Palla, 2004). Moreover, on any given day six times more people are on pro-
bation than in jails, and there are three times more people on probation than
in prison (Glaze & Palla, 2004).

Because data are not routinely collected on the number of probationers
who are parents, there is no definitive estimate of the number of children
whose parents are on probation. We know, however, that about 52% of
people in state prisons are parents and that they have an average of 2.2
children. If we assume that the same is roughly true of people on probation,
it would lead us to expect that there are about 2.2 million parents on
probation who are the parents of approximately 4.8 million children. This
compares to .8 million parents in prisons who have approximately 1.3 million
children (Glaze & Maruschak, 2008).

Nothing in this article should be construed as suggesting that the attention
children of incarcerated parents are receiving is unwarranted. Incarceration
can have consequences for children and families that are not inherent in
community-based criminal justice sanctions. For instance, approximately
48% of the parents in prison on any given day were living with their children
when they entered prison; 77% of imprisoned mothers and 26% of fathers
provided most of their children’s care; and 69% of these parents contributed
to their children’s financial support (Glaze & Maruschak, 2008). Incarcerating
parents, therefore, has potential emotional and economic consequences
for children that sentencing parents to probation or other community-based
punishments do not (Phillips, Erkanli, Keeler, Costello, & Angold, 2006).

Although parental incarceration can adversely affect children, both chil-
dren of incarcerated parents and children of probationers’ are at-risk popula-
tions. A number of problems occur at above average rates among people on
probation as well as people in jails and prisons that are well-established risk
factors for children developing serious problems. These include parental
substance abuse, mental health problems, histories of childhood abuse, inad-
equate education, and domestic violence (Adams, Olson, & Adkins, 2002;
Glaze & Bonczar, 2007; Glaze & Maruschak, 2008). Children whose parents
experience these problems have a greater than average risk of developing
emotional and behavioral problems, abusing drugs or alcohol, and becoming
involved in delinquency (Chatterji & Markowitz, 2001; Frick et al., 1992;
Johnson & Leff, 1999; Keller, Catalono, Haggerty, & Fleming, 2002). Accord-
ingly, a parent’s sentence to probation provides an important window of
opportunity to address problems they may have that might adversely affect
their children.

Ultimately, however, whether a specific child has a parent on probation
or in jail or prison may depend upon the point in time at which the child is
observed. About one in four parents in prison were on probation when they

Mental Health Services and Probationers’ Children 111

were sent to prison (Mumola, 2000). Based on this, a proportion of proba-
tioners’ children can be expected to eventually become part of the popu-
lation of children with incarcerated parents. Therefore, a parent’s sentence
to probation could also provide an important opportunity to prevent the par-
ent’s criminal recidivism and, in so doing, reduce the chances of his or her
children experiencing the adverse consequences associated with parental
imprisonment.

Information about children with incarcerated parents has been pub-
lished in many different fields in recent years, including psychology (e.g.,
Poehlmann, 2005), delinquency (e.g., Murray & Farrington, 2005), social
work (e.g., Abram & Linhorst, 2008), child welfare (e.g., Beckerman,
1994), and criminology (e.g., Phillips et al., 2006). A number of studies report
elevated rates of emotional and behavioral problems such as sadness, grief,
withdrawal, aggression, and delinquency (e.g., Fishman, 1990; Fritsch &
Burkhead, 1982; Hungerford, 1993; LaPointe, Picker, & Harris, 1985;
Lowenstein, 1986; Morris, 1965; Sack, 1977; Sack, Seidler, & Thomas,
1976); however, many of these are based on convenience samples and used
ad hoc measures of child problems. A few more recent studies have used
standardized measures (e.g., Child Behavior Checklist, Diagnostic Interview
Schedule for Youth) and more rigorous designs. These studies, however,
involved youth who may not be typical of the overall population of children
whose parents are involved in the criminal justice system (i.e., adolescents
receiving mental health services and children who were subjects of reports
of maltreatment). These studies found that children in these populations
whose parents had been involved with criminal authorities had higher rates
of emotional and behavioral problems than children in the general popu-
lation, but did not differ significantly from other children in the same settings.

Information specific to probationers’ children is even more limited. Per-
haps the best-known study of probationers’ children is a 25-year old study of
disruptions in children’s living arrangements, which compared 21 mothers
who were sentenced to probation to 54 mothers who were convicted of simi-
lar offenses, but sentenced to jail (Stanton, 1980). More recent (and relevant)
information comes from a nationally representative study of 5,501 children
who were subjects of reports of alleged maltreatment made to child protec-
tive services agencies. Population parameter estimates based on these data
indicate that at least 1 in 10 children who do not enter foster care live with
parents (typically mothers) who were on probation in the year prior to the
index allegation of maltreatment. Compared to their counterparts whose par-
ents had never been arrested, probationers’ children were more likely to
have primary caregivers who had substance abuse (45% of children of
probationers vs. 10% of children with never-arrested parents) or mental
health problems (30% vs. 24%), and who were current victims of domestic
violence (39% vs. 26%). They were also more likely to be living in extreme
poverty (36% vs. 24%) (Phillips & Dettlaff, 2009). Children’s exposure to

112 S. D. Phillips et al.

these risk factors decreased in the three years following the index report of
maltreatment at the same time that the proportion of children living with their
probationer-parents declined for reasons that could not be determined. Dur-
ing this period, however, the proportion of children with emotional and
behavioral problems increased (particularly among 6 to 10 year olds)
(Phillips, Leathers, & Erkanli, 2009).

THE CURRENT STUDY

The current study adds to the scant knowledge about probationers’ children
by exploring the prevalence of emotional and behavioral problems among a
group of children whose parents were sentenced to probation. In addition,
this study also examines the use of mental health services by children with
clinically significant problems. Data from several large-scale studies have
found that a substantial proportion of children who need mental health ser-
vices do not receive them (Costello & Janiszewski, 2007; Flisher et al., 1997;
Kataoka, Zhang, & Wells, 2002). Some of the factors associated with
children’s unmet need for services include poverty and parent psychopath-
ology and substance abuse—conditions that are found at above average
levels among probation populations.

METHODS

Participants

Participants in the current study were recruited through a not-for-profit
agency in a major urban area of a Midwestern state. Among other things,
the agency provides behavioral health recovery management services to
individuals with substance abuse and mental health disorders who are on
probation and court-ordered to services. This particular agency was chosen
as the setting for this exploratory study because of the organization’s history
of providing innovative intervention services to court-involved individuals
and the potential for the organization to use findings from this study to
develop programming.

Between May and August 2008, 77 participants were recruited from
among individuals whom judges consecutively ordered to the agency for
an assessment of their appropriateness for services. These individuals pro-
vided information on 170 children. Individuals were eligible to participate
in the study if they had children ages 1 to 18 and if they lived with those chil-
dren at least 50% of the time in the three months preceding the arrest leading
to their current court-ordered referral to the agency. Informed consent was
obtained from all participants. Each participant received $25 for taking part
in the study.

Mental Health Services and Probationers’ Children 113

Measures

CHILDREN’S CURRENT LIVING SITUATION

Study-specific questions were asked to determine children’s relationship to
the members of their current households, the extent to which children chan-
ged residences in the past year, and children’s current household incomes.

CHILDREN’S EMOTIONAL AND BEHAVIORAL PROBLEMS

Respondents completed age-specific versions of the Child Behavior Checklist
(CBCL) (Achenbach, 1991; Achenbach & Rescorla, 2000). One version is spe-
cific to children ages 1 through five and the other to children ages 6 to 18.
The version for children 1 to 5 contains 99 items and the version for 6 to
18 year olds contains 118. Items ask about children’s behaviors in the past
six months. Respondents rate items as not true, somewhat or sometimes true,
or very true=often true. Responses are then summed across sets of items in
such as way as to produce information about whether different types of syn-
dromes are present at a level one would expect to find among children in
clinical settings (i.e., a clinically significant score). Examples of syndromes
include anxious and depressed, withdrawn and depressed, attention pro-
blems, rule-breaking behavior, and so forth. Scores from the various syn-
drome scales can then be combined to categorize children as having
internalizing problems or externalizing problems (again, at a level one would
expect to find among children in clinical settings).

Several studies support the construct validity of the CBCL. Also, tests of
criterion-related validity using clinical status as the criterion (referred or
nonreferred) also support the validity of the instrument. Pearson’s r in studies
of the test-retest reliability of the CBCL range from 0.80 to 0.94 with an
average of 0.88 and Cronbach’s alpha in studies of the instrument’s internal
consistency range from 0.63 to 0.97 with an average of 0.88 (Achenbach &
Rescorla, 2000).

UNMET NEED FOR MENTAL HEALTH SERVICES

Children’s use of mental health services was assessed using the Child and
Adolescent Service Assessment (CASA, Ascher, Farmer, Burns, & Angold,
1996). The CASA is an interviewer-based instrument that asks about chil-
dren’s use of services for emotional, behavioral, attention, or substance abuse
problems in 31 settings. A study of the reliability of the CASA found that the
most intensive services (e.g., inpatient, out-of-home, juvenile justice) are
reported with very high reliability. Cohn’s Kappa ranges from .75 to 1.00. Ser-
vices with moderate intensity or intrusiveness (e.g., outpatient, crisis) are
reported with moderate reliability (parent K ¼ .81 to .47). Concurrent validity
of the CASA was assessed by comparing CASA data with data from a mental

114 S. D. Phillips et al.

health center’s management information system (MIS). As with the reliability,
concurrent validity improves as the intensity or intrusiveness of services
increases.

For purposes of this study, children were classified as having an unmet
need for mental health services if (a) their scores on the CBCL internalizing,
externalizing, or total problem scale fell in the clinical range (t-score � 64)
and (b) they had not received services from a specialty mental health
provider. These include services in the following settings: (a) psychiatric hos-
pital; (b) psychiatric unit in a general hospital; (c) drug or alcohol detoxifica-
tion unit; (d) residential treatment center; (e) partial hospitalization or day
program; (f) mental health center or clinic; (g) crisis center; (h) in-home
counseling or crises services; (i) services from a psychiatrist, psychologist,
social worker, or psychiatric nurse for emotional, behavioral, attention, or
substance abuse problems; or (j) case management or care coordination
for one of these problems.

Analyses

Three different units of analyses are used in this study. First, the study exam-
ines the proportion of parents (N ¼ 77) who identified at least one child with
an emotional or behavioral problem. Second, information is provided on the
proportion of children (N ¼ 170) experiencing various different behavioral
syndromes (e.g., internalizing, externalizing, emotional reactivity, and so
forth) and specific problems (i.e., item-level responses) most often occurring
at the highest level of severity. Third, the study identifies the proportion of
children with clinically significant emotional and behavioral problems
(n ¼ 43) who did and did not receive mental health services.

RESULTS

Respondents

A majority of participants in the current study were male (70%), Black (79%),
and older than 30 (78%). Based on information provided by participants, half
had been arrested more than 5 times and half had been to prison (Table 1).

Table 1 provides data on (a) the participants in the current study
(Column A), (b) all individuals who exited probation in 2001 in the county
in which the recruitment agency was located (including parents and nonpar-
ents) (Column B), and (c) all parents in the recruitment agency’s program
caseloads (includes both court-referred and nonreferred parents)
(Column C). Neither of these comparison groups are an exact match to the
population of interest (i.e., parents on probation who recently lived with
their children), nonetheless they are the best available points of reference
for placing the characteristics of study participants in context.

Mental Health Services and Probationers’ Children 115

Study participants differed from all adults exiting probation in the
county in which the study took place in several ways. More specifically:
(a) a greater proportion of participants were over age 30 (77% vs. 49%),
(b) Black (79% vs. 47%), (c) female (30% vs. 20%), and (d) had previously
been to prison (58% vs. 41%). These differences also existed in comparison
to all parents who received services from the recruitment agency, however,
the differences were generally less pronounced. The one exception was that
there was a more dramatic difference between study participants and parents
served by the agency in their histories of imprisonment (58% vs. 25%) than
there was between participants and people exiting probation in the index
county (58% vs. 41%).

Respondents’ Relationship to Children

Not all respondents who identified themselves as parenting minor children
prior to being arrested were children’s biological parents (Table 2). About
8% were children’s step- or adoptive fathers and about 12% were children’s
relatives (i.e., grandparents, aunts, and uncles).

The 77 respondents were parenting between one and eight children
(M ¼ 2.2) prior to their arrest (not shown). Collectively, they provided data
on 170 children ages 1 to 18.

TABLE 1 Comparison of Study Participants, All Adults Exiting Probation in County, and All
Parents in Recruitment Agency Caseloads

A B C

Participants
N ¼ 77

Adults exiting probation
in county

a
N ¼ 1,749

All parents in agency
caseloads

b
N ¼ 1,204

Participant demographic characteristics
Age (%)
18–20 0.0 19.7 5.6
21–30 Years Old 23.4 31.6 26.2
31–40 Years Old 28.6 25.6 39.1
Over 40 Years Old 48.1 23.1 29.0

Race (%)
Black 79.2 46.9 72.4
White 7.8 29.6 10.4
Hispanic 9.1 20.8 11.2
Other 3.9 2.6 6.0

Gender (%)
Male 70.1 80.0 75.9
Female 29.9 20.0 24.1

Criminal History (%)
Median no. prior arrests 5 NA 12
Prior prison sentence (%) 58.4 40.6 25.2

aBased on data from the 2000 Adult Probation Outcome Study (Adams et al., 2002).
b
Based on agency administrative records.

116 S. D. Phillips et al.

Child Characteristics and Current Living Arrangements

Table 3 provides data describing respondents’ children (N ¼ 170) and their liv-
ing arrangements at the time of the study. About one-quarter (24% or 48 out of
170 children) were pre-school age (<6). A majority (89% or 151 out of 170) were living with at least one parent (including step- or adoptive parents) and about 1 in 3 (37%, 67 of 170) were living with two parents. Relatives (e.g., grandparents, aunts, and uncles) were part of the households of 77 children (45%) and 4 chil- dren (2.4%) were in foster care. Approximately half (69 out of 170) of the chil- dren had changed residences at least once in the previous year with 1 in 4 (42 out of 170) experiencing multiple changes in residence. About 1 in 3 children (38%, 66 children) were living in households facing extreme economic hardship (annual household incomes below $10,000). The parents of about 1 in 5 chil- dren (33 children) did not know the total annual income of the households in which their children were currently living.

Emotional and Behavioral Problems

Based on their responses to the Child Behavior Checklist, 22 of the 77 partici-
pating probationers (29%) had one or more child with a clinically significant
emotional or behavioral problem (i.e., a score in the clinical range on the inter-
nalizing, externalizing, or total problem scale of the CBCL). This amounts to
approximately 25% or 43 of the 170 children about whom the respondents
provided data (Table 4). Emotional and behavioral problems were less preva-
lent among younger children (16.7%) than among 6 to 18 year olds (28.7%).

No one specific problem or type of emotional or behavioral syndrome
was particularly prominent. About 20% of the 170 children (34 children)
were reportedly experiencing externalizing problems compared to 17% (29
children) with internalizing problems. Emotional reactivity was the most fre-
quently identified syndrome among young children, but was only present
among 4 children (8.3% of younger children) (Table 4). Rule-breaking was
the most commonly identified syndrome among older children, but was only
identified among 13 children (10.7% of children age 6 and up).

TABLE 2 Respondents’ Relationships to Children

1 thru 5
N ¼ 48
%(n)

6 to 18
N ¼ 122
%(n)

All children
N ¼ 170
%(n)

Relationship
Biological mother 16.7 (8) 25.2 (31) 22.8 (39)
Biological father 56.3 (27) 56.9 (70) 56.7 (97)
Stepfather 6.3 (3) 8.1 (10) 7.6 (13)
Adoptive father 0.0 (0) 0.8 (1) 0.6 (1)
Othera 20.8 (10) 8.1 (10) 11.8 (20)

aOther includes grandfathers (n¼9), grandmothers (n ¼ 6), aunts (n ¼ 3), and uncles (n ¼ 2).

Mental Health Services and Probationers’ Children 117

We also examined the prevalence of individual problems which res-
pondents reported to be ‘‘very true or often true’’ (not shown). The top five
problems most commonly reported at this level of severity for the 48 children
ages 1 through 5 were: (a) wanting and=or demanding attention (13 chil-
dren), (b) not wanting to sleep alone (12 children), (c) not being able to
wait (12 children), (d) not being able to sit still (11 children), and (e) being
upset by separation (11 children). Items endorsed at the highest level of
severity for the 122 children ages 6 through 18 were equally diverse. The
most frequently reported problems were: (a) wanting and=or demanding
attention (16 children), (b) being confused (16 children), (c) preferring

TABLE 3 Child Characteristics and Living Arrangements

1 thru 5
n ¼ 48
% (n)

6 to 18
n ¼ 122
% (n)

All children
N ¼ 170
% (n)

Child characteristics
Gender
Male 58.3 (28) 43.4 (53) 47.6 (81)
Female 41.7 (20) 56.6 (69) 52.4 (89)

Race
Black=African American 87.5 (42) 81.1 (99) 82.9 (141)
Hispanic 6.3 (3) 9.8 (12) 8.8 (15)
White 6.3 (3) 5.7 (7) 5.9 (10)
Other 0.0 (0) 3.3 (4) 2.4 (4)

Child living arrangements
Times child changed residence in the past year
None 50.0 (24) 63.1 (77) 59.4 (101)
1 time 12.5 (6) 17.2 (21) 15.9 (27)
2 times 22.9 (11) 8.2 (10) 12.5 (21)
3 times 8.3 (4) 8.2 (10) 8.2 (14)
4 or more times 6.3 (3) 3.2 (4) 4.1 (7)

Household composition
Any parenta 81.3 (39) 91.8 (112) 88.8 (151)
Mother 31.3 (15) 42.6 (52) 39.4 (67)
Father 16.7 (8) 11.5 (14) 12.9 (22)
Both 33.3 (16) 37.7 (46) 36.5 (62)

Any relative 43.8 (21) 45.9 (56) 45.3 (77)
Grandparent 33.3 (16) 32.8 (40) 32.9 (56)
Other Relativeb 20.8 (10) 26.2 (32) 24.7 (42)

Foster Parent 4.2 (2) 1.6 (2) 2.4 (4)
Annual household income
Less than 10,000 41.7 (20) 37.7 (46) 38.8 (66)
10,000–20,000 18.8 (9) 20.5 (25) 20.0 (34)
20,000–39,000 4.2 (2) 10.7 (13) 8.8 (15)
40,000–59,999 14.6 (7) 4.1 (5) 7.0 (12)
80,000 or more 2.1 (1) 2.5 (3) 2.4 (4)
Don’t know 14.6 (7) 21.3 (26) 19.4 (33)
Prefer not to answer 4.2 (2) 3.3 (4) 3.5 (6)

a
Includes biological, step, and adoptive parents.

bOther relatives include aunts and uncles.

118 S. D. Phillips et al.

older children (15 children), (d) dependency (14 children), (e) showing off
(13 children), and (f) being secretive (12 children).

Unmet Need for Services

Table 5 reports the use of mental health services by the 43 children with clini-
cally significant problems. Only 9 children were receiving any of the services

TABLE 4 Prevalence of Clinically Significant Emotional and Behavioral Problems

Ages 1 thru 5
(n ¼ 48)
% (n)

Ages 6 to 18
(n ¼ 122)
% (n)

All children
(N ¼ 170)
% (n)

Internalizing, externalizing, and total problem scales � 64
Any 16.7 (8) 28.7 (35) 25.4 (43)
Internalizing 10.4 (5) 19.0 (23) 16.5 (28)
Externalizing 14.6 (7) 22.1 (27) 20.0 (34)
Total 12.5 (6) 23.8 (29) 20.0 (34)

Syndrome scales � 64 Ages 1 thru 5 Syndrome scales � 64 Ages 6 to 18

Emotional reactivity 8.3 (4) Rule-breaking 10.7 (13)
Withdrawal 8.3 (4) Social problems 9.1 (11)
Sleep problems 6.3 (3) Somatic complaints 9.1 (11)
Somatic complaints 6.3 (3) Withdrawn=depressed 6.6 (8)
Aggressive behavior 6.3 (3) Anxious=depressed 5.8 (7)
Anxious=depressed 4.2 (2) Attention problems 5.0 (6)
Attention problems 0.0 (0) Aggressive behavior 4.2 (5)

Thought problems 4.1 (5)

TABLE 5 Services Received by Children with Clinically Significant Emotional or Behavioral
Problems

Service

Ages 1 thru 5
(n ¼ 8)
% (n)

Ages 6 to18
(n ¼ 35)
% (n)

All children
(n ¼ 43)
% (n)

Any service 12.5 (1) 22.3 (8) 20.9 (9)
Overnight=Inpatient
Residential treatment 2.9 (1) 2.3 (1)
Psychiatric=Drug treatment unit in hospital 2.9 (1) 2.3 (1)

Outpatient services
Day treatment=Therapeutic nursery 12.5 (1) 8.9 (3) 9.3 (4)
Services from psychiatrist, psychologist,
social worker, or psychiatric nurse

8.9 (3) 7.0 (3)

Case management or care coordination 8.9 (3) 7.0 (3)
Mental health center=Clinic 8.9 (3) 7.0 (3)
In-home counseling=Crisis services 12.5 (1) 5.7 (2) 7.0 (3)
Drug=Alcohol clinic 5.7 (2) 4.7 (2)
Social services or any other counseling
for behavioral, emotional, or attention
problems

14.3 (5) 11.6 (5)

Mental Health Services and Probationers’ Children 119

listed in the table. In other words, 4 out of 5 children (79%) who were ident-
ified by their parents as having an emotional or behavioral problem had an
unmet need for mental health services. The unmet need for services was sub-
stantial among both 1 to 5 year olds and 6 to 18 year olds. Only 1 of the 8
preschoolers (13%) who had clinically significant emotional and behavioral
problems and 8 of the 35 (22%) older children with problems were receiving
services. In terms of probationers, this equates to roughly 9 out of 10 (86.4%)
of the 22 parents with children who were experiencing problems who had a
child with an unmet need for services (not shown).

DISCUSSION

This exploratory study of emotional and behavioral problems among
probationers’ children and children’s unmet need for mental health services
found that the children of participating probationers had a greater than
average likelihood of experiencing problems and a lower than expected
likelihood of receiving services. Approximately 1 in 4 participants identified
a child with a clinically significant emotional or behavioral problem. This
equates to approximately 25% of the 170 children on whom data were
collected and contrasts with approximately 10% of children in the general
population who have similar problems (Achenbach, 1991). The finding
that emotional and behavioral problems were less prevalent among
younger children than among 6 to 18 year olds is consistent with research
showing a general increase in emotional and behavioral problems as
children age.

The unmet need for mental health services among participants’ children
was greater than expected. Data from the Methods for the Epidemiology of
Child and Adolescent Mental Disorders Study found that about 17% of
children with an indicated need for services had not received care (Flisher
et al., 2007). Similarly, a study of children with substance-abusing parents
conducted by the Center for Education and Drug Abuse Research found that
18% of children had an unmet need for services (Cornelius, Pringle, Jernigan,
Kirisci, & Clark, 2001). In the current study, more than three-fourths of
children experiencing problems had not received services.

There are two additional findings worth note. First, about half of the
respondents in the current study had served time in prison, thus affirming
that probationers’ children and children of incarcerated parents are
overlapping populations. Moreover, this study indicates that parents not only
‘‘graduate’’ from probation to prison, but also sometimes loop back through
the probation system. Second, 12% of respondents who were parenting chil-
dren were actually not the children’s parents, but their relatives. This suggests
that programs for children whose parents are involved in the criminal justice
system need to employ a broad definition of parent.

120 S. D. Phillips et al.

Implications

The generalizability of the current findings beyond the individuals who par-
ticipated in the study remains to be ascertained through more sophisticated
research. The individuals who took part in this study were court-ordered to a
treatment program and, therefore, may be more likely than probationers in
general to have mental health or substance abuse problems, factors which
are well-established correlates of child mental health problems. Accordingly,
the prevalence of emotional and behavior problems found among the
children in this study may not be typical of the broader population of proba-
tioners’ children. Second, the accuracy of parents’ reports of their children’s
current emotional and behavioral status and use of mental health services
warrants further exploration as parents had varying degrees of involvement
with their children prior to their most recent arrest. The fact that participating
parents did not know the current household incomes of approximately 20%
of their children gives us reason to wonder if they may also have been
equally unaware of their children’s emotional and behavioral problems or
use of services. Taking these limitations into consideration, this study pro-
vides sufficient evidence to believe that the emotional and behavioral
well-being of probationers’ children and factors which facilitate or hinder
their access to mental health services warrant further investigation.

A growing number of organizations are recognizing that children whose
parents are arrested and incarcerated are a vulnerable population and new
programs and policy reforms are being instituted to address the needs of this
population. In 2006, for example, the Open Society Institute of the Soros
Foundation funded a technical assistance project that resulted in the forma-
tion of partnerships between not-for-profit and governmental agencies in 14
states (Phillips, 2008). Similar groups exist in other states (e.g., California,
New York, and Arkansas). Given the proportion of probationers in the cur-
rent study who had been to prison as well as prior research showing that 1 in
4 parents in prison were on probation prior to entering prison, it may be
beneficial to include officials from adult probation in these efforts.

An increasing number of criminal justice programs address parenting
concerns of mothers and fathers who become involved with criminal
authorities. These include corrections-based parent education and visitation
programs as well as community-based substance abuse treatment programs
that allow mothers to continue parenting their children while receiving
treatment. The number of these programs has been increasing as criminal
justice entities have become more alert to the need for gender-sensitive pro-
gramming. One of the ‘‘selling points’’ of these programs is their purported
benefits to children. Evaluation of such programs, however, typically focuses
only on changes in parents’ behaviors (e.g., changes in knowledge of parent-
ing skills, substance use, and so forth) (Harm & Thompson, 1997; Palm, 2003;
Spring, 1998) and, in some cases, on improvements in family conditions (e.g.,

Mental Health Services and Probationers’ Children 121

reduced family conflict), some of which may have spill-over benefits for
children (Phillips, Gleeson, & Waites-Garret, 2009). Notably missing from
the evaluation of these programs are indicators of their effect on children’s
existing emotional and behavioral problems. For instance, studies of residen-
tial substance abuse treatment programs that allow women to remain with
their children while in treatment have examined the birth outcomes of chil-
dren born to mothers who are in treatment. Otherwise, very few studies have
examined the emotional and behavioral problems of children whose parents
enter treatment and even fewer have examined whether treating parents’
addictions leads to changes in problems children are already experiencing
(c.f., Catalano, 1999; Killeen & Brady, 2000; Metsch et al., 2001). The current
study suggests that it could be important for court-based treatment programs
to include a child component that involves screening for child mental health
problems and linkages to appropriate services.

Finally, a substantial proportion of the children in this study were living
in extreme poverty. In addition to poverty being correlated with involvement
in the criminal justice system, poverty—particularly chronic poverty—is also
associated with the risk for children developing emotional and behavioral
problems (McLeod & Shanahan, 1996) as well as with children’s need for
mental health services going unmet (Cornelius et al., 2001). No conclusions
can be drawn from the current study about the role parents’ current or past
involvement with the criminal justice system might have played in their chil-
dren’s current economic circumstances, the onset or course of their children’s
current emotional and behavioral problems, or their children’s unmet need
for services. However, a number of prior studies show that involvement with
criminal authorities has long-term negative consequences for individuals’
employability and earnings (Grogger, 1995; Needels, 1996; O’Brien, 2002).
Other studies show that parental incarceration predicts household economic
strain over and above the effect of parental substance abuse, parental mental
illness, and inadequate parent education (Phillips, Erkanli, Keeler, Costello,
& Angold, 2006). Accordingly, we would conclude by underscoring the point
made at the beginning of this article; namely, that a parent’s sentence to pro-
bation is an important opportunity to address problems that could result in
their eventual incarceration.

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The Impact of Health-Promoting
Behaviors on Low-Income Children’s Health:

A Risk and Resilience Perspective
Joan Yoo, Kristen S. Slack, and fane L. Holl

This study’s objective was to examine whether five child health-promoting behaviors by
caregivers would be associated with caregivers’ assessments of their children’s health as
“excellent,” controlling for an array of risk factors for adverse health outcomes.The study used
the third and fourth waves of the Illinois Families Study-Child Well-being Supplement—a
four-year panel study examining the impact of welfare reform on the well-being of the
youngest children of current and former welfare recipients. Logistic regression techniques
were used.The analytic results show that low-income children whose caregivers exercise child
health-promoting behaviors (for example, mealtime routines, dental hygiene practices, safety
practices), with the exception of having a regular bedtime, are more likely to be reported as
having excellent health than their low-income counterparts. Moreover, a statistically significant
cumulative effect above and beyond the individual effects of health-promoting behaviors was
found.The findings suggest that child health-promoting behaviors by caregivers can make a
difference in promoting better health for low-income children. Although large systemic changes
(for example, changes in health care policy) are needed to reduce overall health disparities
and to enhance health for all members of society, individual health-promoting behaviors may
lead to incremental improvements in low-income children’s health.

KEY W O R D S : caregivers; child health-promoting behaviors; low-income
children; physical health; risk and resilience framework

I
t has been well established that there are socio-
economic disparities in children’s physical health
outcomes (Case, Lubotsky, & Paxson, 2002;

Chen, Matthews, & Boyce, 2002). Children who live
below the federal poverty line have higher mortality
and morbidity rates than children in higher income
fan-lilies (Case et ah, 2002; Starfield, Robertson, &
Riley, 2002). However, less is known about within-
group variation in physical health outcomes among
low-income children. Using the risk and resilience
framework, the aim of this study was to examine
how, controlling for the presence of multiple risk
factors, child health-promoting behaviors initiated
by caregivers would explain within-group variation
in caregiver-reported health among children from
low-income families.

CONCEPTUAL FRAMEWORK: RISK AND
RESILIENCE MODEL
Although the medical model has been the pre-
dominant framework for examining determinants
of health, health researchers have emphasized the
need to apply alternative models, such as the risk and

resilience framework, that provide a more holistic
perspective on health with greater focuses on posi-
tive health and well-being (R. G. Evans & Stoddart,
1990;Vinson, 2002).

Resilience has generally been defmed by research-
ers in developmental psychopathology as a process
wherein a person exhibits better-than-expected
outcomes in the face of adversity (Garmezy, 1993;
Vinson, 2002). Three major components of this
framework—experience of adversity, adaptive out-
comes, and protective or promotive factors—are
discussed here.

First, for resilience to occur, there must be an
experience of adversity—that is, a single risk or mul-
tiple risks that may have significant negative effects
on an individual’s outcomes. Resilience researchers
have further emphasized the importance of under-
standing risk experiences at a more proximal than
distal level (Luthar, Cicchetti, & Becker, 2000; Mas-
ten, 2001; Rutter, 1990)—that is, risks that directly
affect children’s lives more imminently, as opposed to
distal risks (for example, low socioeconomic status)
that affect children through a chain of mediating

CCC Code: 0360-7283/10 $3.00 ©2010 National Association of Social Workers 133

A health-promoting behavior is considered

to be a promotive factor if it only has a

significant main effect on children’s health.

variables. For example, material hardships, which
reflect families’ living conditions and experiences
of meeting their basic physical needs (Ouellette,
Burstein, Long, & Beecroft, 2004), are considered
better approximations of the direct effects of low
income on children (Beverly, 2000). On the basis
of this rationale, we focused on three domains of
proximal risks—material hardship,caregivers health,
and children’s access to health care—found to be
associated with children’s physical health.

To date, most studies examining the impact of
material hardship on children’s physical health have
focused on the individual dimensions of hardship,
such as food hardship or housing conditions (for
example, Ashiabi & O’Neal,2007;Cook et al.,2006;
Kim, Sataley Curtis, & Buchanan, 2002; Weinreb,
Goldberg, Bassuk, & Perloff, 1998). These studies
have shown that children who experience food
hards hip, generally defined as unstable or insufficient
levels of food intake or insufficient variety of food
consumption due to financial constraints (Ashiabi
& O’Neal, 2007; Cook et al, 2006;Weinreb et. al.,
2002), and who experience housing insecurity and
poor-quality housing (Kim et al., 2002; Mueller &
Tighe, 2007; Weinreb et al., 1998) are more likely
to have health problems than children who do not
experience these hardships. In addition, there is
some evidence that cumulative experiences of ma-
terial hardship may also negatively affect children’s
health (Yoo, Slack, & Holl, 2009). Also, caregivers’
poor physical health and poor mental health have
been found to be negatively associated not only
with their children’s health, but also with their
preventive practices (Kahn, Zuckerman, Bauchner,
Homer, & Wise, 2002; McLennen & Kotelchuck,
2000; Minkovitz,0’Canipo, Chen, &Grason, 2002;
Scalzo, Williams, & Holmbeck, 2005). However,
other studies have cautioned that caregivers’physical
and mental health may also influence how caregivers
report their children’s health conditions (Waters et
al., 2000). Finally, previous research has shown that
children who do not have adequate access to health
care services are more hkely to have unmet health
care needs, which may have detrimental effects on

their health, than are children who do have such
access (Holl et al.,2000;Newacheck,Hughes,Hung,
Wong, &Stoddard, 2000).

When examining multiple risk factors, some re-
searchers use an additive model that tests the unique
relationships between individual risk variables and
outcomes (Ackerman, Izard, Schoff, Youngstroni, &
Kogos, 1999). Others use a cumulative approach, in
which risk experiences are summed into a single
score to account for the accumulation of co-
occurring risks (Appleyard, Egeland, van Dulmen,
& Sroufe, 2005). Acknowledging the strengths and
weaknesses of each approach, the present study
included three risk domains that capture the cumula-
tive effect of individual risks within each domain.

The second component of the risk and resilience
framework is the achievement of adaptive outcomes
despite adversities (Luthar et al.,2000;Rutter, 1990).
The emphasis is on the presence of positive outcomes
(for example, positive health and well-being) rather
than the mere absence of negative outcomes (for
example, illnesses and diseases [Masten, 2001; Ryff
& Singer, 1998]).This emphasis is one of the major
contributions offered by the risk and resilience
framework to health research.

The last component of the risk and resilience
framework consists of individual, familial, and en-
vironmental factors that promote positive outcomes
and reduce negative outcomes in response to risks
and adversities (Masten & Garmezy, 1985). In the
present study, we focused on famiHal factors that are
characterized by child health-promoting behaviors
by caregivers of young children, including family
routines, dental hygiene practices, and home safety
practices.

To better understand the nature of the relation-
ship between child health-promoting behaviors
and children’s overall health as assessed by their
caregivers, we examined both the main and inter-
action effects of the health-promoting behaviors.
A health-promoting behavior is considered to be
a promotive factor if it only has a significant main
effect on children’s health (Sameroff, 2000). How-
ever, if there is a significant interaction effect, the
health behavior is considered be a protective factor
(Rutter, 1990).

Family routines are generally defined as patterned
interactions that are repeated on a regular basis over
time (Wolin & Bennett, 1984). Most studies that
have investigated the impact of family routines on
child outcomes examined its positive association

134 Health & SocialWork VOLUME 35, NUMBER Z MAY ZOIO

with psychological well-being (see Fiese et al, 2002,
for review). However, a few studies have shown that
regular family routines, such as regular mealtime and
bedtime routines, have positive effects on children’s
physical health (Boyce et al, 1977; Case & Paxson,
2002). Although few studies have examined the
link between dental hygiene practices and low-
income children’s physical health, regular dental
hygiene practices are directly related to children’s
oral health (Tiberia et al, 2007). Moreover, dental
hygiene practices in early childhood are found to
be predictive of oral health during adolescence
(Alm,Wendt, Koch, & Birkhed, 2008). In addition,
dental hygiene practices are commonly consid-
ered as indicators for health-promoting behaviors
(Lawton, Conner, oí McEachan, 2009). Most studies
that have examined the association between safety
precautions (for example, proper seat belt and car
seat use, childproofmg the home) and children’s
health focused on understanding the impact on
child injuries. Numerous studies have reported that
proper seat belt and car seat use is associated with
reductions in severe childhood injuries (see Howard,
2002, for review). However, the association between
childproofmg the home and childhood injuries is
less clear (S.A. Evans & Kohil, 1997; Jordan, Dug-
gan, & Hardy, 1993). Although understanding the
association between unintentional injuries and safety
precautions was beyond the scope of this study, home
childproofmg steps and seat belt and car seat use are
used as proxy measures for caregivers’ behavior as it
relates to children’s safety.

This study focused on explaining health variation
among low-income children, who are, as a group, at
greater risk for poor health than are higher income
children.Three research questions were examined:
(1) Do child health-promoting behaviors exercised
by caregivers have a promotive effect on low-income
children’s physical health, controlling for an array of
health risk factors? (2) Do child health-promoting
behaviors moderate associations between risk
factors and low-income caregivers’ assessments
of children’s physical health? (3) Do child health-
promoting behaviors have a cumulative effect on
low-income caregivers’ assessments of children’s
physical health?

METHOD

Study Design and Sample
The analyses reported in this article were conducted
using a subset of respondents from the Illinois Fami-

lies Study (IFS).The IFS was a five-year panel study
examining the well-being of welfare recipients and
their families during and following the implemen-
tation of Temporary Assistance to Needy Families
(TANF) in Illinois. A stratified sample of 1,899
families residing in Illinois and receiving welfare
cash benefits in September 1998 were randomly
selected from the 1998 TANF enrollment files of
nine counties in Illinois, which together represented
75 percent of the Illinois TANF caseload (Lewis et
al, 2000).

During the initial wave of the IFS, all respon-
dents who had at least one child under the age
of three (n = 582) were asked to participate in
a supplemental study called the Illinois Families
Study-Child WeU-being Supplement (IFS-CWB).
The IFS-CWB, a four-year panel study, was aimed
at understanding the links between welfare reform,
child maltreatment, and health and well-being of
the youngest child in the family. Annual surveys
were administered from 2001 to 2004 to collect
more in-depth information about focal children’s
health and well-being, access to health care services,
home environment conditions, and experiences
of economic hardship and respondents’ parenting
practices and health.

After an initial response rate of 72 percent (N =
1,363) for wave 1 of the IFS, the response rate for
the first wave of IFS-CWB (administered in 2001)
was 95 percent {N = 553).The retention rates for
the second, third, and fourth waves of IFS-CWB
were 88 percent (« = 484),92 percent (« = 445),and
91 percent [n = 405), respectively. Statistical weights
were applied to all analyses to adjust for the over-
representation of sample members from the smaller
counties and for nonresponse and attrition.

Although child health status measures and sev-
eral independent variables were measured in every
IFS-CWB survey wave, some of the variables on
health-promoting behaviors were measured only
during the third wave. In the interest of being con-
sistent lAiith timing of measurement, we obtained
the information for all key independent variables
from wave 3 IFS-CWB data rather than from earlier
waves. This reliance on the third IFS-CWB wave
for key independent variables also necessitated
the use of wave 4 IFS-CWB for information on
the dependent variable (that is, children’s posi-
tive health) to ensure the correct time order of
independent and dependent variables. As a result,
sample members who participated in both wave

Yoo, SLACK, AND H O L L / The Impact of Health-Promoting Behaviors on Low-Income Children’s Health 135

3 and wave 4 of IFS-CWB were included in this
study (« = 405)

Measures
Dependent Variable. Child health was assessed with
one of the most commonly used items in national
health surveys (for example, the National Health
Interview Survey). Respondents were asked to rate
the focal child’s general health status as “excellent,”
“very good,””good,””fair,” or”poor.”The validity
of this measure has been tested in other studies
and has been found to be associated with objec-
tive measures of child health, including childhood
mortality, morbidity, child functioning, and other
objective latent health measures (Case et al., 2002;
Slack et al., 2007). The objective of the study was
to examine factors that distinguish children who
were reported to be in excellent physical health
from those reported to be in less than excellent
health (that is, very good, good, fair, or poor health).
Children who were reported to be in “excellent”
health were coded 1 on this dichotomous outcome;
all others were coded 0.

Multiple Risks. Information for all independent
variables, including risk and health-promoting be-
havior variables, ŵ as obtained from IFS-CWB wave
3 data. Three domains of risk—material hardship,
caregivers physical and mental health, and child’s
access to health services—were included in the
analyses.

A cumulative material hardship index was created
using a commonly applied procedure (Appleyard et
al., 2005) in which each type of material hardship
is dichotomized so that 1 = high risk and 0 – low
risk. On the basis of recommendations from previous
studies (Danziger et al, 1999; Ouellette et al.,2004),
children were considered to be at high risk if each of
these six material hardship conditions were met: (1)
The caregiver answered “yes” to any of five housing
insecurity items, assessed as occurring within the past
year (for example, living in a car or other vehicle,
living in an abandoned building); (2) the caregiver
responded “yes” to two or more housing problems
items (for example, leaky roof, ceiling, or walls;
broken windows); (3) the caregiver reported that
the child was living in a crowded household (that is,
more than two people per bedroom); (4) the care-
giver answered “often” to any of four child-specific
food insecurity items derived from the USDA Core
Food Security Module (Price, Hamilton, & Cook,
1997); (5) the caregiver reported that any utilities

(for example, gas, electricity, oil, telephone) had
been turned off since the last interview due to lack
of payments; and (6) the caregiver reported that
he or she did not have a driver’s license or regular
access to a car and reported problematic public
transportation in the neighborhood. Then the six
dichotomized variables were summed to construct
a cumulative material hardship score. A cumulative
variable capturing caregiver’s poor physical and
mental health was also created for the analyses. First,
two dichotomous variables for caregiver’s physical
health and mental health were created to indicate
high risk. Caregivers were considered to be in poor
physical health if they answered “fair” or “poor” to
this question: “Overall would you say your health is
excellent, very good, good, fair, or poor?” Caregivers
were considered to be in poor mental health if their
scores were 16 or above on the 20-item Center for
Epidemiological Studies Depression Scale (Radloff,
1977). The summary score ofthese two variables
was used as an indicator for caregiver’s poor physical
and mental health.

Although the scales used to create the cumulative
variables were first dichotomized and then summed,
the statistical properties of the original scales (for
example, housing problems, food hardship, physical
functioning) were evaluated.With the exception of
the four-item housing instability scale, which yielded
an alpha of .69, the coefficient alphas for all other
scales ranged from .77 to .92.

Two measures were used to assess whether a child
had poor access to health care services. Due to low
variation in these measures, we created a dichoto-
mous variable, with 1 assigned to children whose
caregivers indicated that their child did not have a
usual place of care, that they used the emergency
room for regular medical care, or that their child had
not been able to receive necessary medical services
since the last interview because they were unable to
afford it and 0 assigned to children whose caregivers
indicated that their child had a usual place of care.

Child Health—Promoting Behaviors. Five care-
giver behaviors hypothesized to promote children’s
health were included in the analyses. Similar to
those for the risk variables, the scales in this analysis
were dichotomized. However, when the statistical
properties of the original scales for regular meal-
time and bedtime routines (four-item scale) and
childproofing the home were evaluated, each scale
yielded values of Cronbach’s alpha greater than .70.
Other health-promoting behaviors were derived

136 Health & Social Work VOLUME 35, NUMBER 2 MAY 2010

from single- or two-item measures that were not
part of a larger scale.

Regtilar routines: Children’s regular routines were
assessed using a six-item scale that asked how often
the family or the target child engaged in mealtime
and bedtime routines Qensen, James, Boyce, &
Hartnett, 1983). Responses ranged from “every
day” to “never.” Two dichotomous variables (regular
mealtime routine and regular bedtime routine) were
created, where 1 indicated that caregivers answered
“every day” to all of the related items and 0 was
assigned for all other responses.

Hygiene practices: Dental hygiene practices were
assessed by asking respondents whether the target
child brushed his or her teeth every day. A child was
considered to be engaging in regular dental hygiene
practices when he or she was reported to brush his
or her teeth every day. In previous analyses, we also
considered regular bathing as one of the indicators
for hygiene practices. However, the variable was
dropped due to lack of variability (approximately
75 percent of the respondents answered that their
focal child bathed once a day or more).

Safety practices: Two dichotomous variables (car
seat/seatbelt use and childproofmg the home) were
created to characterize caregivers’ behavior in rela-
tion to their children’s safety. A child was considered
to be using car seats regtilarly when she or he was
reported to be riding in a car at least once a month
and sitting in a car seat or wearing a seat belt “all or
most of the time.” A seven-item questionnaire that
asked whether respondents ever engaged in activities
to childproof their home (for example, put up gates
or barriers, installed locks or safety latches, kept syrup
of pecac) was used to assess whether respondents
childproofed their homes. A child was considered
to be living in a childproofed home if his or her
caregiver answered “yes” to six items or more.

Cumulative health-promoting behaviors: A cumula-
tive health-promoting behavior index was created
by summing up all five dichotomous health-pro-
moting behavior variables (range = 0 to 5). This
cumulative index was used to examine whether
child health-promoting behaviors by caregivers
yielded a cumulative effect above and beyond the
individual effects.

Finally, basic demographic variables—such as the
child’s age, gender, and race and ethnicity (non-
Hispanic white and other ethnicities, Hispanic, and
African American)—were included as controls, in
addition to caregiver’s age, marital status, cohabita-

tion with a significant other, and region of residence
(Cook County versus downstate Illinois) at the wave
] IFS interview.

Data Analysis
Logistic regression techniques were applied to ex-
amine the association between health-promoting
behaviors and children’s physical health, controlling
for basic demographic variables and risk factors.
Then, we examined the interaction effects of risk
factors and health-promoting behaviors by adding
the products of each risk and health-promoting
behavior variable. Also, the cumulative effect of the
health-promoting behaviors was examined,To test
the robustness of our findings, we conducted sen-
sitivity tests with a restricted sample that excluded
children with chronic conditions (for example,
developmental disabilities, physical illnesses) that
were expected to last 12 months or more.

Sample Characteristics
Descriptive statistics for key variables are presented
in Table 1. The descriptive statistics indicate that the
sample children experienced, on average, one type
of material hardship, and approximately 51 percent
of the children lived in households with at least one
type of material hardship. However, the mean of the
cumulative variable capturing caregiver’s poor health
was 0.32 {SD = 0.60),and approximately 25 percent
of the children lived with a caregiver who was re-
ported to be in poor physical or mental health.

RESULTS

Results from the logistic regression analyses are
presented in Table 2. The associations between
caregiver’s ratings of children’s health as excellent
and risk and demographic variables were examined
in model 1. Caregiver’s poor physical and mental
health was the only risk domain significantly asso-
ciated with ratings of children’s health as excellent
health (odds ratio [OR] = 0.542,p < .01 ).Children's age and being Hispanic, in comparison with being African American, were negatively associated with children's excellent health ratings.These results were consistent in subsequent models.

When health-promoting behaviors were included
in the analytic model, the variables, in general, had
a positive main effect (that is, promotive efFect) on
children’s health being rated excellent (see model
2). The odds of being in excellent health were ap-
proximately three times greater for children who had

Y o o , S L A C K , A N D H O L L / The Impact of Health-Promoting Behaviors on Low-Income Children’s Health 137

Table 1: Descriptive Characteristics of Illinois Families
Study-Child Well-being Supplement Wave 4 Children (n = 405)

Child
Gender (male)

Age (range = 1—7 years)

Race/ethnicity

African American (reference)

Hispanic

White and other ethnicities

Caregiver

Age of primary caregiver (range = 21-55 years)

Marital status

Currently married

Cohabiting with significant other

Not married and not cohabiting (reference)

Residing in Cook County (Chicago area)

Risk factors

Cumulative material hardships (range = 0-5)

Caregiver in poor mental or physical health (range = 0-2)

Poor access to health care services

Health-promoting behaviors

Family and child have regular mealtime every day

Child has regular bedtime and bedtime routines every day

Child brushes teeth every day

Car seat used all or most of time child rides in car

Home childproofed across six or more items

Dependent variable

Child in excellent health

56.90

80.88

8.47

10.65

12.11

12.08

75.74

91.29

3.80

32.19

43.77

89.59

76.02

31.97

47.29

3.91

31.33

0.73

0.32

1.40

6.58

0.87

0.60

regular mealtime routines or daily dental hygiene
practices than for those who did not regularly en-
gage in these behaviors. Children’s regular car seat
use increased their odds of heing in excellent health
by 80 percent, and living in a childproofed home
increased their odds of being in excellent health by
130 percent. However, an unexpected negative effect
was found for regular bedtime routines. Analytic
results indicate that children who had a regular
bedtime routine every day were less likely to be in
excellent health than were those who did not have
a regular routine.

A sensitivity test was used to examine whether
the effects of risk and promotive factors changed
for a subsample of children who did not have any
chronic conditions (n = 306).The results are pre-
sented in Table 3. Among the four variables that
had a positive effect on children’s health in model
2 (see Table 2), regular meals, brushing teeth every

day, and childproofmg the home maintained positive
effects. Regular car seat use, which had a significant
positive effect in the earlier model, was reduced
to marginal statistical significance in Table 3. The
negative effect of regular bedtime also maintained
its significance.

We examined the protective effects of caregiver’s
health-promoting behaviors by including interaction
terms for each risk factor and health-promoting
behavior individually and simultaneously in model
2. No statistically significant interaction effects
emerged.

Finally, ŵ e examined whether health-promoting
behaviors had a cumulative effect above and beyond
the individual effects. The results are presented in
Table 2 (model 3). Due to concerns of multicol-
linearity, dichotomous variables for regular meals
and regular bedtime were replaced with original
summary scores.The summary score for cunTulative

Health & Social Work VOLUME 35, NUMBER 2 MAY 2010138

Table 2: Logistic Regression Analyses for Children in Excellent Health (n = 405)

Child gender

I

Child age

African American (reference)

, Hispanic

White and other ethnicities

Caregiver’s age

I

Caregiver not married and not
cohabiting (reference)

,

Caregiver married

Caregiver cohabiting

Residing in Cook County

Cumulative material hardship

Caregiver’s poor health

Inadequate access to health care

Regular meals’

Regular bedtime’

Brushes teeth every day

Car seat use

Childproofed home

Cumulative health-promoting behaviors

Constant

0.355

0.166*

1.298**

0.324

0.010

0.223

0.081

0.406

0.407

0.017

1.426

0.847

0.273

0.723

1.010

0.631*

-0.202*

-1.626**

-0.789

0.017

0.248

0.089

0.440

0.443

0.018

1.879

0.817

0.197

0.454

1.017

0.444

-0.203*

-1.690**

-0.490

0.021

0.245

0.089

0.445

0.443

0.019

1.560

0.816

0.185

0.612

1.021

0.658 0.351

-0.556 0.370

0.559 0.399

0.034 0.136

-0.613** 0.206

-1.045 0.736

1.930

0.573

1.749

1.035

0.542

0.352

0.626

-0.590

0.632

0.131

-0.552*

-1.001

1.056**

-0.843**

1.024*

0.603*

0.852**

0.376

0.386

0.423

0.152

0.221

0.772

0.299

0.270

0.445

0.291

0.261

1.871

0.554

1.882

1.140

0.576

0.368

2.873

0.431

2.785

1.828

2.344

0.568

-0.538

0.597

0.019

-0.544*

-0.880

0.726*

-1.109**

0.555

0.137

0.300

0.498*

0.375

0.392

0.427

0.156

0.230

0.793

0.252

0.235

0.514

0.364

0.369

0.234

1.765

0.584

1.817

1.020

0.581

0.415

2.066

0.330

1.742

1.146

1.350

1.646

-0.169 0.666 0.844 -2.117** 0.868 0.120 -1.700 1.023 0.183
Notes: Model 1 shows associations between caregiver’s ratings of children’s health as excellent and risk and demographic variabies: in addition to those variables, model 2 shows
associations between caregiver’s ratings of children’s heaith as excellent and chiid health-promoting behaviors; buiiding on model 2, mode! 3 shows the association between
caregiver’s ratings of children’s health as excellent and cumulative health-promoting behaviors. Coeff. = coefficient; OR = odds ratio,
‘The dichotomous variable used in modeis 1 and 2 was replaced with the original summary score in model 3 due to issues of muiticoilinearity.
• p < .05. **p < .01.

health-promoting behavior had a mean of 3.48
and standard deviation of 1.26. The correlations
between cumulative health-promoting behaviors
and the dichotomized regular bedtime and meal
routine variables were greater than .60, whereas the
correlation between cumulative health-promoting
behaviors and the original summary score for the
two variables was around .50. The cumulative
health-promoting behavior variable was signifi-
cantly associated with children’s excellent health.
This fmding suggests that engaging in additional
health-promoting behavior increases the odds of
being reported by a caregiver as being in excellent
health (OR = 1.646,p < .05). Similar results (not shown) were found for the subsaniple of children without any chronic conditions.

DISCUSSION
Using a risk and resilience framework, we exam-
ined the association between several risk factors for
children’s adverse health outcomes, child health-

promoting behaviors exercised by caregivers, and
caregivers’ positive assessments of children’s health.
The results provide some evidence that health-
promoting behaviors have a positive association
with caregiver ratings of children’s physical health.
Specifically, children whose caregivers followed
regular family mealtime routines, engaged their
children in everyday dental hygiene practices, and
childproof their homes were more likely to be
assessed by their caregivers as being in excellent
health, regardless of the presence or absence of
chronic conditions, controlling for other health risk
factors.These fmdings support those from previous
studies examining the association between a single
type of health behavior and child outcomes (Case
& Paxson, 2002; Larson, Branscomb, & Wiley, 2006;
Peres et al., 2005).

A major fmding of this study is that health-pro-
moting behaviors have a cumulative effect above and
beyond the individual effect of each health behavior.
This study suggests that there may be additional

Yoo, SLACK, AND HOLL / The Impact of Health-Promoting Behaviors on Low-Income Children’s Health 139

Table 3: Logistic Regression Analyses
for Children Without Any Chronic

Physical Conditions (n = 306)

Child gender
Child age
African American (reference)
Hispanic
White and other ethnicities
Caregiver’s age
Caregiver not married and not
cohabiting (reference)
Caregiver married
Caregiver cohabiting
Residing in Cook County
Cumulative material hardship

Caregivers poor health

Inadequate access to health care

Regular meals

Regular bedtime

Brushes teeth every day
Car seat use
Childproofed home

Constant
Note: OR = odds ratio.
*p < .10. *p < .05. **p < .01.

0.473

-0.250*

-1.709**

-0.115

-0.004

0.812′

0.066

0.978*

0.043

-0.439

-0.937

1.026**

-0.902**

1.607**

0.602′

0.829**

-2.782*

0.288

0.107

0.525

0.524

0.022

0.456

0.452

0.492

0.190

0.293

0.822

0.283

0.232

0.529

0.360

0.299

1.072

1.605

0.779

0.181

0.891

0.996

2.253

1.068

2.659

1.044

0.645

0.392

2.791

0.406

4.987

1.825

2.291

0.062

benefits to regularly engaging in multiple health-
promoting behaviors with low-income children.The
benefits may be derived from the actual cumulative
health effects of these behaviors or from the positive
effects of regularity and stability provided by these
behaviors in children’s daily lives. Although future
studies need to test these hypotheses, existing re-
search has demonstrated that regularity and stability
are critical for healthy child development, especially
for those children who are more hkely to live in
chaotic environments (Brody & Flor, 1997; G.W.
Evans, GonneUa, Marcynyszyn, Gentile, & Salpekar,
2005).Thus, this study supports the concept that a
more structured home environment with regular
routines may provide some incremental benefits for
physical health among children in poverty

No significant interaction effects between risk
variables and health-promoting behaviors were
found in the analyses.Therefore, results suggest that
the particular set of health behaviors examined have
promotive rather than protective effects on children’s
health. However, because the sample children were

mostly from low-income families with already
heightened levels of risk, variation in risk may
be liinited. Future studies are needed to examine
whether greater variation in risk exposure leads to
significant interaction effects in a more representative
sample of the general child population.

The negative association between regular bedtime
routines and children’s health was an unexpected
finding. This association persisted even when other
child and caregiver characteristics (for example,
children’s behavior problems, children’s health at
wave 3, parenting stress, caregiver’s self-efficacy)
were controlled for. We examined whether social
desirabihty bias may have influenced this finding
by analyzing the association between interviewer
assessments of respondents’ level of truthfulness in
answering survey questions at wave 1 IFS and the
key variables. (Interviewers were asked to rate a
respondent’s level of truthfulness during the wave
1 IFS survey interview Thus, this rating does not
directly reflect respondents’ level of truthfulness for
the survey waves used in this study. However, the
variable was deemed a reasonable proxy to examine
the possibility of social desirability bias.) We found
that respondents’ truthfulness was mildly associated
with regular bedtime routines and cumulative mate-
rial hardship (r= – . 1 1 , r = —.12, respectively; both
ps < .05) but not with other variables. It may be that respondents'biases in reporting regular bedtime routines influenced this association. However, fur- ther investigation using more objective measures is needed to determine whether social desirability bias has actually occurred in reporting regular bedtime routines. Moreover, future studies that examine a wider range of family routines and the mechanisms that may explain the associations with children's health outcomes are necessary to elucidate the implications of this unexpected finding.

Among the three risk domains, caregiver’s poor
health was the only one significantly associated
with children’s excellent health ratings. However,
this finding was not preserved when the sample was
restricted to children without chronic conditions,
suggesting that the negative association between
caregiver’s poor health and children’s excellent
health may be influenced by children’s chronic
conditions. However, the exact manner in which the
chronic conditions affect the association between
caregivers’ poor health and caregivers’ assessments
of children’s excellent health could not be discerned
in this study.

140 Health & Social Work VOLUME 35, NUMBER 2 MAY 2010

This study is among the first to examine the
effect of health-promoting behaviors on children’s
physical health using a risk and resilience framework.
Few studies have applied the risk and resilience
framework to children’s physical health (Gordon
Rouse, IngersoU, & Orr, 1998;Vinson, 2002), and
even fewer studies have tried to operationalize and
include positive physical health as the main outcome
of interest. The present study attempted to address
this gap in knowledge by using the risk and resil-
ience framework to understand children’s positive
physical health outcomes. An additional strength of
this study is its focus on understanding the within-
group variation in health among children -from
low-income families. Although numerous studies
have demonstrated socioeconomic disparities in
children’s physical health, few have shed light on
why variations in health exist among children of
similar socioeconomic status. This study suggests
that health-promoting behaviors can provide some
explanation for the within-group variation in low-
income children’s physical health.

Several limitations of the present study need to
be addressed. First, most of the information regard-
ing the key independent and dependent variables
was gathered from a single informant—the primary
caregiver. It is possible that the associations between
the independent and dependent variables were
overestimated due to this mode of data collection.
Second, we recognize that our measures of health-
promoting behaviors did not fuUy capture the behav-
iors’ multidimensional nature.This is attributable to
the relative paucity of validated measures currently
available to assess these behaviors (Committee on
Evaluation of Children’s Health, 2004), suggesting
that future work is needed to develop such multidi-
mensional measures.Third, the correlational design
of the present study is a limitation for understanding
the complex relationships among risk factors, health
behaviors, and children’s health. Although lagged
predictors were used to partially address this issue,
longitudinal studies that can test complex associa-
tions between key variables are needed.

IMPLICATIONS
The fmdings from this study support the growing
body of literature on the importance of regular
health-promoting behaviors (for example, regular
family meals, safety practices) of the family for
children’s health outcomes. Moreover, the significant
cumulative effect of health-promoting behaviors on

Although structural changes need to be
made to effectively reduce disparities

in child health, collaborative efforts in
promoting healthy behaviors may contribute

to a reduction in the damaging effects of
childhood poverty on health.

low-income children’s health suggests that there
may be additional benefits for caregivers and their
children in engaging in multiple types of health-
promoting behaviors. Although it cannot be deter-
mined from this study whether health intervention
and prevention programs that encourage families to
regularly engage in a wide array of health-promoting
behaviors can influence health disparities among
low-income children, the present findings suggests
that ongoing study to specifically address this ques-
tion is warranted.

Collaborative efforts between various agencies—
including health services, social services, educational,
and community-based agencies—to promote and
reinforce relevant health-promoting behaviors
at each developmental stage may contribute to a
cumulative effect of such behaviors on children’s
health. For example, anticipatory guidance and
health education programs in health care settings
can provide health information relevant to a child’s
health needs (for example, hygiene practices, safety
practices, healthy eating). Home-based services,
such as home visiting programs, can be effective in
increasing home safety and reducing child injury
(Sweet & Appelbauni, 2004). Moreover, effective
school-based or child care programs that involve
parents and communities may improve hygiene
practices, eating habits, and physical activities (Peters,
Kok, Ten Dam, Buijs, & Paulussen, 2009; Sandora
et al., 2005).

Low-income children are disproportionately at a
disadvantage for poor health outcomes during child-
hood as well as adulthood (Power & Kuh, 2006).
Although structural changes need to be made to
effectively reduce disparities in child health, collab-
orative efforts in promoting healthy behaviors may
contribute to a reduction in the damaging effects
of childhood poverty on health. liH’l’i

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Joan Yoo, PhD, MSSH^ is assistant professor. Department
of Social Welfare, College of Social Sciences, Seoul National

University, 599 Gwanak-ro, Gwanak-gu, Seoul, 151-746,

Korea; e-mail: yoo.joan@gmail.com. Kristen S. Slaek, PhD,

MSHÇis associate professor. School of SocialWork, University of

Wisconsin—Madison.Jane L. Holl, MD, MPH, is associate
professor. Department of Pediatrics and Institute for Healthcare

Studies, Feinberg School of Medicine, Northwestern Univer-

sity, Chicago. Tins research was supported by the John D. and

Catherine T. MacArthur Foundation, the Joyce Foundation, the

Woods Fund of Chicago, the National Institute of Child Health

and Human Development (Grants ROÍ HD39148 and K01

HD4Í703), the Administration for Children and Families

(Grant 90PA0005), and the Area Poverty Research Center of

the Institute for Research on Poverty, University of Wisconsin.

Survey data were collected by the Metro Chicago Information

Center.The authors thank Stephanie A. Robert,ArthurJ. Reyn-

olds, Dan Bolt, Mia Ihm, and the reviewers for their insightful

and helpful comments on the manuscript of this article.

Original manuscript received November 6, 2007
Final revision received November 6, 2009
Accepted December 7, 2009

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As this paper is being written – as at the time it will be
published and available to readers – wars and political violence
in many parts of the world continue to cause suffering,
destruction, and loss of life and leave their scars on those who
survive them. In one of her articles about children of wars,
Jagodić (2000), a Croatian psychologist, asked: “Is war a good
or a bad thing?” The answer is rather simple; yes it is bad,
indeed very bad for all. However, one major question arises,
especially in the context of intractable conflicts: Does one
necessarily become severely damaged when exposed to
intractable conflicts and violence? While historians study the
dynamics of wars past and political scientists their causes,
developmental psychologists can serve the cause of peace by
examining their effects on children and their families and by
analyzing conditions that lead to greater risk as opposed to
those that may protect children of violence adversity. We need
to understand at a deeper level the development and nature of
the state of mind and forms of behaviors of those children,
adolescents, and subsequently emerging adults, who are
victims of chronic exposure to political violence and unending
“social toxicity”. More appropriate approaches, policies, and
interventions can then be established that take into account the
mental scars that might be left with exposed children (Terr,
1992) as well as their resilience, adjustment, and coping skills.

Various related aspects of human development, the study of
trauma, and the potential effects of exposure to continued war
conditions on children and their families are presented here,
along with a number of questions and hypotheses that are
explored. The work consists of an extensive review, evaluation
and integration of existing published and unpublished sources.
Such a review may serve as a basis for drawing hypotheses and
tentative conclusions about future directions for research,
prevention, and intervention. This paper will accordingly draw
from the area of traumatic stress research with a special focus
on the meaning of living under war conditions (versus other
stress related conditions such as child maltreatment within the
family), particularly that which analyzes the quality of the

mental health infrastructures in both Israeli and Palestinian
societies. With this goal in mind we move now to a compre-
hensive review of studies examining traumatic stress in war
zones.

Traumatic stress in war zones

Overview

The following analysis consists of a comprehensive review and
integration of available published and (some) unpublished
studies on the effects of severe traumatic experiences on
children’s state of mind and functioning, especially in the
context of short and enduring exposure to harsh events and
adversities, as they relate to children who live in violent war
zones throughout the world as well as in Israel and the Pales-
tinian territories. The review focuses on the role of risk and
protective factors in determining the debilitating and
damaging effects as well as resiliencies of short term and
chronic catastrophic experiences on the future well being of
children and emerging adults.

We will explore the conditions that may leave profound trau-
matic and permanent “psychic scars” (Terr, 1992), as these
may attract children to violent groups as a mean for dealing
with disputes and conflict. Consequently, the children them-
selves may threat our society, in light of their likelihood to
exhibit heightened aggression, violence, and revenge seeking
(Garbarino & Kostelny, 1993a). We explore to what degree
growing under chronic danger, without adequate social
support systems, may be developmentally harmful to children
so that they are likely to perceive themselves as unworthy, the
adults around them as non-trustful, and the various social
institutions as threatening and unsafe (Garbarino & Kostelny,
1993a). The conditions under which children might become
outstandingly resilient in their capacity to tolerate even very
overwhelming adversities are examined as well.

International Journal of Behavioral Development
2008, 32 (4), 322–336

http://www.sagepublications.com

© 2008 The International Society for the
Study of Behavioural Development

DOI: 10.1177/0165025408090974

The well being of children living in chronic war zones:
The Palestinian–Israeli case

Abraham Sagi-Schwartz
University of Haifa, Israel

The paper presents a comprehensive review and integration of available studies on the effects of
severe traumatic experiences on children, especially in the context of short and enduring exposure
to harsh events and adversities, as they relate to children who live in violent war zones, in particular
in Israel and the Palestinian territories. The review focuses on the role of risk and protective factors
in determining the debilitating and damaging effects as well as resiliencies of short term and chronic
catastrophic experiences on the future well being of children and emerging adults.

Keywords: children; wars; Palestinian; Israeli; resiliency; vulnerability

This work is part of a larger project that was carried out during the
author’s residence as a Jennings Randolph Senior Fellow at the United
States Institute of Peace (USIP). The generous support of USIP is
deeply appreciated.

Correspondence should be sent to Abraham Sagi-Schwartz, Center
for the Study of Child Development, University of Haifa, 6035 Rabin
Building, Haifa 31905, Israel; e-mail: sagi@psy.haifa.ac.il

322-336 090974 Sagi-Schwartz (D) 19/6/08 16:05 Page 322

What is trauma?

Trauma is defined as a painful emotional experience, or shock,
often producing a lasting effect. There are various aspects of
trauma with a wide scope and many forms which result from
a broad range of occurrences including life-threatening situ-
ations stemming from natural or man-made disasters and
catastrophes; severe physical injury; torture; traumatic loss of
family members, friends and other significant attachment
figures; loss of one’s community or social environment;
physical/sexual abuse or assault; experiencing or witnessing
family or community violence; and exposure to war, terrorism,
kidnapping, violence, and political oppression. Children then
may become rather vulnerable, especially when they become
witnesses to violence (American Psychiatric Association,
1994).

Short term/acute versus long term/chronic exposure to
trauma

A distinction should be made between short-term versus long-
term effects. Some research suggests that negative effects in
children and youth exposed to political violence tend to decline
and disappear over time – even in war zones that induced
extremely high levels of violence and hostility, such as Bosnia,
Cambodia, and South Africa. Garbarino & Kostelny (1993a,
1993b) propose that non chronic short-term exposure to single
events may often result in natural adaptive reactions of fear and
anxiety. On the other hand, the long lasting status of chronic
exposure to trauma may involve PTSD symptoms, namely
severe psychological and psychiatric reactions. According to
conservation of resources theory (Hobfoll, 1989), a continued
stress sequelae may also result in resource loss and cascading
effects. Because there are no infinite quantities of positive
adaptational resources, a unique crystallization of personality
style may evolve when adaptive risk feelings are no longer
activated, accompanied instead by reckless, numbed, and
“pathologically brave” attitudes, even to the extent that some
children may become desensitized to danger (Garbarino &
Kostelny, 1993a, 1993b).

Response and coping are likely to depend on a variety of
factors, some of which age related. When trauma occurs
during infancy and toddlerhood, basic trust might be
hindered. Traumas associated with school-age children might
result in nightmares and sleep disturbances, regression and
clinginess to parents or caregivers, loss of concentration/
distractibility and learning difficulties, fearfulness and anxiety,
aggressive behaviors, and even increased propensity for
violence. Adolescents are likely to also display a wide spectrum
of symptoms and coping responses. At a less extreme degree
one can identify anxiety, problems at school and behavioral
problems. These problems, however, may evolve into more
extreme responses such as high levels of aggression and acting
out, numbness to feelings and pain and restricted emotional
development over time, loss of hope characterized by expec-
tation for short life, affiliation with violent groups, high-risk
taking and dangerous behaviors that may harm the
community, and even severe revenge seeking.

With findings coming primarily from institutional and foster
care studies (e.g. Nelson, Zeanah, & Fox, in press; Zeanah
et al., 2003), as well as from examinations of chronic child
maltreatment (e.g. Cicchetti & Valentino, 2006), research
increasingly suggests that trauma may also influence biological

regulatory processes. The child’s brain is structured and
neuronally organized by experience, and chronic and severe
stress may influence various systems such as the central
nervous and adrenal-cortical systems, with potential inter-
ference with the brain’s high levels of plasticity. Some even
suggest that this may result in pervasive, powerful, and
occasionally permanent effects, deficits and impairments at the
emotional, behavioral, cognitive, and social functioning levels
(e.g. see Couperus & Nelson, 2006; Curtis & Nelson, 2003;
Nelson, 2002; Romer & Walker, 2007; Shonkoff & Phillips,
2000). But what the biological effects of protracted political
violence might be still remains an open question.

In all, some of the responses to violence and trauma are
more self directed, which could be intervened with varied
degrees and likelihoods of effectiveness and success, whereas
other responses might be directed more toward others and the
society at large, in which case interventions are likely to
become more complex and perhaps even less effective. Along
this line, Garbarino & Kostelny (1993a, 1993b) conceptualize
two distinct types of dangers: acute versus chronic. Although
acute danger might be very damaging, we still might observe
responses that can be considered as situationally adaptive
because of their short lived duration. Chronic exposure to
danger, however, may have more far reaching and enduring
implications for developmental adjustment, with possible alter-
ations of personality, major changes in patterns of behavior or
articulation for making sense of ongoing danger – all of which
lead to negative conclusions about the worthiness of the self,
the reliability of adults and their institutions, and the most
appropriate approaches to adopt to the world (Garbarino &
Kostelny, 1993a, 1993b).

Some reactions to chronic danger, such as emotional with-
drawal, may appear adaptive in the short run but may become
a source of danger to the next generation. Garbarino, Dubrow,
Kostelny, & Pardo (1998) describe important findings about
children from Cambodia, Northern Ireland and the inner city
of Chicago with respect to moral development. They found that
children exposed to violence who have experienced chronic
trauma became fixated at what they referred to as the vendetta
stage of moral development. Such children do not know how to
reason or express their anger constructively but instead tend to
rely on escalating violence as a tool for survival. In this context
it is useful to refer to the ancient African proverb “It takes a
village to raise a child” that was borrowed by Hillary Clinton
(1996) to imply, justifiably, that a host of various community
based supportive systems are necessary to ensure, on top of the
obvious prerequisite contribution of the family, successful
raising of children and their productive integration into society:
“I chose that old African proverb to title my book because it
offers a timeless reminder that children will thrive only if their
families thrive and if the whole of society cares enough to
provide for them”, Clinton said (1996). So what happens when
the exact opposite takes place and political violence places the
entire community infra structure in jeopardy?

Borrowing some concepts from the fields of epidemiology
and immunology, Garbarino called such devastating
conditions (in particular in the context of chronic exposure to
war and danger) “social disaster” that includes the “toxic”
destruction of daily infrastructures that are so vital for gener-
ating positive moral interpretations. Ideas associated with
social toxicity therefore will be used throughout this paper to
assess the Israeli–Palestinian context.

INTERNATIONAL JOURNAL OF BEHAVIORAL DEVELOPMENT, 2008, 32 (4), 322–336 323

322-336 090974 Sagi-Schwartz (D) 19/6/08 16:05 Page 323

Effects of wars worldwide

In general, data worldwide show at times of crises consistent
elevated levels of posttraumatic stress symptoms (PTSD),
albeit with varying degrees of depth and rate, as well as
additional mental health problems and psychological reactions
in a wide spectrum of domains and in many war zones. The
list of studies is (unfortunately) rather extensive and addresses
the impact of political violence on: Bosnian-Herzegovian
children (Goldstein et al., 1997; Smith et al., 2002), Cambo-
dian children (Dickason, Him, & Sack, 1999; Kinzie et al.,
1986; Sack et al., 1995), Chinese children and youth (Chan,
1985; Raddock, 1977), displaced children in Croatia (Zivcic,
1993), Iraqi children and youth (Abdel-Khalek, 1997), Kosovo
children and parents in Sweden (Almqvist, & Broberg, 2003),
Kurdish-Iraqi children (Ahmad, 1992; Ahmad et al., 2000;
Punamäki, Muhammed, & Abdulrahman, 2004), Kuwaiti
children during the Iraqi invasion in 1990 (e.g., Macksoud,
Dyregrov, & Raundalen, 1993; Nader and Fairbanks, 1994;
Nader, Pynoos, Fairbanks, Al-Ajeel, & Al-Asfour, 1993),
displaced Iranian children (Kalantari, Yule, & Gardner, 1990),
Lebanese children during the civil war in Lebanon (Macksoud,
1992; Macksoud and Aber, 1996; Saigh, 1989, 1991), children
and youth experiencing the war Northern Ireland (Blease,
1983; Ferguson & Cairns, 1996; Lyons, 1974; Muldoon, &
Trew, 2000), South African youth (Dawes, Tredoux, &
Feinstein, 1989; Fassaert, 1992; Straker, 1992), and South
American children (Cervantes et al., 1989). It should be noted
that although the list of studies reporting negative effects is
indeed long, still some recent reviews have suggested that not
always can we find negative associations between exposure to
political violence and various functioning outcomes (e.g.,
Cairns, 1996; Cairns & Dawes, 1996; Jones, 2004; Muldoon
& Trew, 2000; Shaw, 2003).

The aforementioned review of the nature, scope and level of
trauma suggests that various outcomes may be discerned
depending on the definition used for traumatic effects (e.g.,
PTSD or some types of psychopathology, distress reactions,
anxiety and the like) and the context of its evaluation.
Moreover, studies vary in their methodology; very often relying
on self-reports and telephone surveys and sometime even on
the basis retrospective appraisal; sometime on the basis of
convenience and clinical samples, and often with objective
difficulties to include appropriate comparisons or reported
norms with which to compare areas, hence resulting in merely
within-group designs without a reference point to compare the
findings either with non-exposed groups or with existing
normative data – but at least some of these studies help us shed
light on the role of individual differences.

Also many of the studies take a one-dimensional rather than
a multi-dimensional approach (e.g. focusing on self reported
psychological assessment with no further external information
about the participants’ functioning and other important
indices such as day to day routine engagements like work and
community activities), and often generating questions that are
bound to yield negative outcomes, most of which without
longitudinal data.

At the same time one should not over criticize the state of
the art because war studies are difficult to carry out and
sometime even inappropriate for research within certain time
contexts and circumstances. And yet, we must look carefully
at inconsistencies given the different regions, nature of
conflict, conceptualizations, different methodologies,
measures, etc. Because some inconsistency may appear in the
data, appraisal of each finding or series of findings needs to be
done with care and within the appropriate context, before we
can draw more firm conclusions about the effects of exposure
to war traumas.

Finally, as discussed before, a distinction must be made
between short-term versus long-term effects. Some work that
has looked at enduring effects of exposure to political violence
suggests that negative effects tend to decline and disappear
even in war zones that induced extremely high level of violence
and hostility, including for example Bosnian adolescents
(Becker, McGlashan, Vojvoda, & Weine, 1999), Cambodian
adolescents who left to Canada (Rousseau, Drapeau, &
Rahimi, 2003) and South African children (Braungart &
Braungart, 1995; Setiloane, 1991). Such a differentiation is
essential, especially when one is interested in underpinning the
effects of exposure to chronic-intractable conflicts, and there-
fore it will become an integral part of our evaluation of the
work done in Israel and the Palestinian territories. It should be
noted that the two sides name the Arab–Israeli wars differently
(for a review of the conflict see Morris, 2001) and, therefore,
when the wars are reviewed in an Israeli or Palestinian
contexts, the Israeli and Arab terminologies are employed
respectively. To illustrate the different meaning the two sides
attribute to the wars, Table 1 depicts both the Arab and Israeli
titles of the various wars.

The Israeli case

Israel has been part of an intractable conflict for six decades,
since its foundation in 1948. Despite the conflict’s longevity
and potential psychological implications, the scope of research
on the psychological impact of the conflict is sparse with the
possible exception of the more extensive research around the
Gulf War. This should not be surprising because during Israel’s

324 SAGI-SCHWARTZ / THE PALESTINIAN–ISRAELI CASE

Table 1
Major wars in the Arab–Israeli conflict 1948–2006

Year Name of war (by Israelis) Name of war (by Arabs)

1948 War of Interdependence Al Nakba (catastrophe)
1956 Suetz War/Operation Kadesh Sinai War/the tripartite aggression
1967 Six Day War 1967 War/June War/Al Naksa (the setback)
1973 Yom Kippur War Ramadan War or October War
1982 Operation Peace for the Galilee (First Lebanon War) The Invasion
1987–1993 Intifada Intifada (uprising)
2000–2005 Al Aqsa Intifada Al Aqsa Intifada
2006 Second Lebanon War The Lebanon Invasion

322-336 090974 Sagi-Schwartz (D) 19/6/08 16:05 Page 324

first several wars (in particular, the Independence War, 1948;
Operation Kadesh, 1956; Six-Day War, 1967), the country was
still not sufficiently aware of the emerging need to assess the
conflict’s psychological effects, nor did it have sufficient
resources and established academic infrastructures for
conducting such research.

The Six-Day War in particular created strong feelings of
euphoria among Israelis that certainly distracted interest from
studying the effects of the war on its children. Also, the limited
number of studies might reflect an ethical understanding that
during war time it is inappropriate to carry out such research
with children, especially when the country is preoccupied with
issues of survival and self-defense. The Yom Kippur War and
its negative effects on the mood of the nation opened up the
field, but still to a limited extent.

With this in mind, the current review is based upon data
derived from war-related studies over all Arab-Israeli wars.
Specifically, I rely upon work associated with the Six Day War
(1967), Yom Kippur War (1973), Operation Peace for the
Galilee (1982–1985), non specific artillery shelling between
wars, the Gulf War (1991), as well as the two Intifadas
(1987–1993, 2000–20051 respectively). At present no data are
available for the second War in Lebanon (summer 2006). For
the convenience of the reader a summary of each of the studies
reviewed below is presented in Table 2.

Meijer (1985) reports data about children who were born
and examined in1967 and who were reexamined at the end of
the first grade of elementary school. It was reported that “war
children” as compared with those born after the war had
significantly more developmental delays and regressive, non-
affiliative and dissocial behavior. The author consequently
concluded that a disturbed mother–child relationship existed
in the war group. However, when the sample, design and
statistical analyses, as well as various other non significant vari-
ables, are examined, it could be the case that the (few) signifi-
cant findings reported merely capitalized on chance. Although
the 6 years post war data seem to suggest impressive longitu-
dinal negative effects, the various limitations of the study
suggest that we should be cautious about the study’s far
reaching conclusions.

Ziv, Kruglanski, & Shulman (1974) examined the psycho-
logical reactions of Israeli children living in border settlements
that were under frequent artillery shelling following 1967. The
main findings showed that shelled children expressed more
patriotism and signs of courage than did non-shelled children.
Interpretation of these data, in time perspective, may suggest
that children who had to take cover in shelters used more patri-
otism and expression of courage as a coping mechanism –
which was rather typical and acceptable in a society that
developed social norms that strongly justified the Six-Day War
and which was rather proud about the victory. Also comparing
shelled versus non-shelled Israeli children, Ziv and Israeli
(1973) found in both groups low level of anxiety. It appears
that studies of Israeli children exposed to artillery shelling have
discovered only limited signs of anxiety or other psychological
malfunctioning – at worst with only transient rise in distress.

As for the Yom Kippur War (1973), Milgram and Milgram
(1976) compared data collected on 5th and 6th graders before
the war’s eruption and about two months thereafter. The
general anxiety of the children nearly doubled from time of pre
war to time of war. It should be noted that the study is
restricted in scope because all children were recruited from
only two schools in Tel Aviv and its generalizabililty is there-
fore limited. One should also remember that the Yom Kippur
War was perceived, during many of its initial phases, as poten-
tially leading to a forthcoming catastrophe for Israel, hence
resulting in a national mood of declining confidence and
security, which may in part explain the powerful increase in
level of anxiety. The authors suggest therefore that the rise in
anxiety during the Yom Kippur War is normative, but they also
suggest that it was associated with only transient effects,
especially given other data showing that, despite the preceding
the Six-Day War and the War of Attrition (1968–1970), Israeli
children at time of relative calm are as low in anxiety as
American counterparts. Milgram and Milgram’s (1976) report
is consistent with Kaffman’s work (1977) on kibbutz children
under war stress, suggesting that during the Yom Kippur War,
the kibbutz network was able to develop and rely upon organ-
ized group cohesiveness as measures that facilitated reduction
in the severity of reactions to stress and psychiatric symptoma-
tology among children and adult members of the kibbutzim.

Information about the War in Lebanon (1982–1985) and its
effects on children is also limited. Existing research is found
with adult populations along two lines. The first primarily
focuses on the long term combat effects on soldiers, with data
examining various aspects, including individual differences
such as coping, locus of control and social support as they
relate to combat-related posttraumatic stress disorder
(Solomon, Mikulincer, & Avitzur, 1988) as well as the
enduring effects 20 years post war, especially in combat stress
reaction casualties (Solomon & Mikulincer, 2006). It should
be noted though that the majority of the comparison veterans
who participated in this study did not exhibit PTSD, suggest-
ing that soldiers directly engaging in combat activities may
have sufficient resilience to cope with such traumatic experi-
ences. It is important to note that the Israeli military is
comprised of soldiers who fulfill their mandatory service
(18–21 years of age) as well as those who are on their reserve
duty (approximately 21–50 years of age). Therefore, these
findings and conclusions represent the entire military popu-
lation that participated in the first War in Lebanon.

The second line of research during the war in Lebanon is an
evaluation of what was referred to as “Pulse of a nation:
Depressive mood reactions of Israelis to the Israel-Lebanon
War” (Hobfoll, Lomranz, Eyal, Bridges, & Tzemach, 1989).
This work is based on eleven national Israeli samples concern-
ing the mood in Israel over 11 occasions between 1979 and
1984, and it consisted of interviews prior to, during, and
following the 1982 War in Lebanon. The research group also
evaluated major newspaper headlines that appeared concur-
rent to each national sampling, so that the relationship between
major national events and depressive mood could be explored.
The results appeared to fluctuate, with an increase in depress-
ive mood during the war’s outbreak followed by a decline in
depressive mood subsequent to the most intensive period of
the war, which, the authors suggested, is indicative for adap-
tation that may take place in reaction to continued stressful
circumstances. The authors also reported a peak in depressive
mood when the massacre of Palestinians at the Sabra and

INTERNATIONAL JOURNAL OF BEHAVIORAL DEVELOPMENT, 2008, 32 (4), 322–336 325

1 The Al-Aqsa Intifada never officially ended. February 2005 is used by some
as a turning point when Mahmoud Abbas was elected President of the Palestin-
ian National Authority and met with Israel Prime Minister, Ariel Sharon, at
Sharm-el-Sheikh where both sides announced an end to the violence. It is still
debatable whether the events after February 2005 should be considered part of
the Intifada or as independent events (www.GlobalSecurity.org).

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326 SAGI-SCHWARTZ / THE PALESTINIAN–ISRAELI CASE

Table 2
Summary background of studies in Israel

Author War Age Design Measures

Meijer (1985) Six-Day War Infants (Time 1) Quasi-experimental – Various aspects of early
7-year (Time 2) longitudinal (war children development, social and asocial

vs. non-war children) behavior

Ziv, Kruglanski, & Shulman Shelling between 4th, 5th, 6th, 7th, and 8th Quasi-experimental Local patriotism, covert
(1974) wars graders (shelled vs. non-shelled) aggression, appreciation of

courage

Ziv & Israeli (1973) Shelling between 10-year-olds Quasi-experimental Anxiety
wars (shelled vs. non-shelled)

Milgram & Milgram (1976) Yom Kippur War 5th and 6th graders Pre- and post war Anxiety

Kaffman (1977) Yom Kippur War Age not specified Clinical report Clinical report about reactions
to stress and psychiatric
symptomatology

Solomon, Mikulincer, & Peace for the Young adults Individual differences Coping, locus of control and
Avitzur (1988) Galilee (1982 (correlational) social support explaining

war in Lebanon) combat-related posttraumatic
stress disorder

Solomon & Mikulincer Peace for the Young adults Longitudinal – 20 years Combat stress reaction and
(2006) Galilee follow up PTSD

Hobfoll, Lomranz, Eyal, Peace for the Young adults Cross-sectional (before, Depressive mood
Bridges, & Tzemach (1989) Galilee 11 national samples during, after the war)

Hoffman & Bizman (1996) First Intifada 4th and 9th graders Cross-sectional Pessimism–optimism

Solomon (1995) Gulf War Different sampling and Review of all studies Different procedures and
recruitment procedures different research designs measures (interviews, self

(with and without control, report, telephone surveys,
cross sectional, retrospective data collection)
mini-longitudinal)

Laor et al. (1996) Gulf War Preschoolers Individual differences Association between family
(correlational) cohesion and symptomatic

reaction

Laor & Wolmer (2000) Gulf War 8–10 years old Individual differences Capacity for image control as a
(correlational) protective factor against long

term effects of trauma

Schwarzwald et al. (1997) Gulf War 5th, 7th, and 10th graders Individual differences Association between
(correlational) posttraumatic symptoms and a

sense of future orientation

Slone, Adiri, & Arian (1998) First Intifada
(post Gulf War) 6th and 7th graders Comparing Israelis vs. Exposure to political stressors

Palestinians

Slone (2008); Slone, Lobel, First Intifada
& Gilat (1999) (post Gulf War) 6th and 7th graders Individual differences Association between exposure to

(correlational) political stressors and reported
distress

Shalev et al. (2002) Al-Aqsa Intifada Adults Select, non-representative Self report PTSD

symptoms

survey

Yagur, Greenspoon, & Al-Aqsa Intifada Adults Select, non-representative Self report PTSD symptoms
Ponizovsky (2002) survey

Somer, Ruvio, Soref, & Sever Al-Aqsa Intifada Adults Comparison (more and Telephone survey (mood,
(2005) less affected areas) posttraumatic symptoms, and

coping strategies)

Bleich, Gelkopf, & Solomon Al-Aqsa Intifada Young adults Representative strata Telephone survey (traumatic
(2003) sampling stress-related and PTSD

symptoms, sense of safety)

Demb (2006) Al-Aqsa Intifada Adolescents Exploratory Coping and resilience

322-336 090974 Sagi-Schwartz (D) 19/6/08 16:05 Page 326

Shatilla refugee camps took place, which seems to be rather
normative response under such circumstances. In all, these ups
and downs seem to be rather appropriate and normative as far
as anticipated increase and decrease in the level of depressive
mood along the various events that took place.

Chronologically, the next major war related experience of
Israelis is the first Intifada (1987–1993). Not much research is
associated with this Intifada, excluding the period of the Gulf
War that coincided with the timing of the Intifada (see below).
It should also be noted that, for the most part, the Intifada’s
immediate consequences for Israeli children are rather remote,
because it consisted primarily of a direct confrontations
between Palestinians and the Israeli military in the occupied
territories.

One study addressed the attitudes toward war and peace of
4th and 9th graders during 1989 Intifada (Hoffman, & Bizman,
1996). In a nutshell, the data portray a complex duality:
pessimism regarding the likelihood of reducing hostility on the
one hand, and a great deal of optimism regarding the prospects
of peace on the other hand; in the mind of these children we
therefore observe a mixture of anger mingled with hope. It
should be noted that these are group data about how Israeli
children and adolescents attribute explanations and causes to
the conflict and its prospect. Such supposedly conflicting data
may be seen as reflecting the complexity of the ecology and
perhaps these “conflicting” findings may be accounted for also
by existing individual differences that were not explored in this
study. Perhaps some children and youth may be more at the
positive side and it is these participants who might have
contributed to the appearance of the hope dimension, whereas
some may be positioned more on the negative side and thereby
affecting the pessimistic dimension.

The Gulf War and the Scud attacks on Israel during the
winter of 1991 were extraordinary and frightening for most
Israelis. In fact, this was a war between the United States and
Iraq and the Israeli population found itself immersed in that
war indirectly and passively. Israel was requested (or forced)
by the US to sit aside passively despite Iraqi Scud missiles
hitting Israeli civilian population centers. Because of the threat
of unconventional weapons, Israelis had to seal their homes
and wear gas masks when the attacks took place. It is not
surprising, therefore, that this war attracted a number of
mental health researchers who assessed the influence of the

attacks on all segments of the population: children and their
parents, adults and elderly. Indeed, this Gulf War’s uniqueness
resulted in the production of many publications, more than
have been generated in any of the other wars or Intifadas.

It is not surprising that initial psychosocial reactions were
observed as natural short term responses, but were they only
transient and eventually adaptive in the most part? And how
about enduring effects and more long lasting traces of this
traumatic experience? Solomon (1995) has provided a
comprehensive and excellent account of the scientific work
conducted around the effects of the Gulf War, and subse-
quently there is no need to detail here various aspects of the
available studies. My own appraisal of the existing research
converges fully with Solomon’s account. Therefore, I will refer
only to the main directions and will also reiterate at least one
specific dimension that seems to be critical to my global review
and analysis in this paper, namely the place of individual differ-
ences in the Gulf War body of research and in studies of the
effects of wars in general.

Taken together and with only few exceptions (e.g., Rosen-
thal and Levi-Shiff, 1993 with infants/toddlers and their
mothers), as Solomon’s concludes, the Gulf War did not have
any profound effect on the Israeli population at large, certainly
not in terms of enduring negative outcomes. It should be noted
that that different studies employed different sampling and
recruitment procedures (i.e. representative, clinical,
convenience), different research approaches (quantitative
versus qualitative), different procedures and measures (e.g.,
interviews, self report, telephone surveys, retrospective data
collection, just to name a few) and different research designs
(i.e. with and without control, cross sectional, mini-longitudi-
nal). Keeping in mind the aforementioned diverse methodo-
logical approaches, the picture nevertheless seems to be rather
clear and uniform, pointing to the fact that the Israeli society
coped rather adaptively without showing substantial signs of
psychopathology and unusual malfunctioning. Most studies
showed some degrees of distress, which is rather expected in
such an uncertain situation, especially with the threat of
biological and chemical attack. But both adults and children
maintained adaptive control and those initially observed tran-
sient stressful reactions evaporated rather rapidly, and various
community services, including the school system, were quickly
reopened and returned to normative operation.

INTERNATIONAL JOURNAL OF BEHAVIORAL DEVELOPMENT, 2008, 32 (4), 322–336 327

Table 2
Continued

Author War Age Design Measures

Solomon & Lavi (2005) Al-Aqsa Intifada 12–15 years old – Comparison (more and – Self report posttraumatic
less proximate symptoms, future orientation
neighborhoods to toward peace
Palestinian zones) – Association between exposure

– Individual differences to political violence and
(correlational) attitude toward peace

Shamai & Kimhi (2006) Al-Aqsa Intifada Adolescents Individual differences Association between exposure to
(correlational) political violence and attitude

toward compromise

Bleich et al. (2003) Al-Aqsa Intifada Adults Telephone survey Traumatic related symptoms,
sense of safety with respect to
self and significant others, future
orientation

322-336 090974 Sagi-Schwartz (D) 19/6/08 16:05 Page 327

Although there were several casualties as well as destruction
of some private housing and public facilities, children and
adults did hardly experience witnessing direct losses, injuries
or physical damage. There was no shortage of food or any other
necessities, the families remained intact during the Scud
attacks themselves, and the media played a very positive role –
all of which ensured a rapid and smooth return to normal and
normative routines that eventually helped maintain rational
decisions and prevent disorganization.

A number of studies also looked at the differential effects of
the Gulf War on basic individual differences in parental capa-
bilities as well as in children characteristics. For example, Laor
et al. (1996), in their examination of the differential effects of
traumatic displacement following a Scud missile attack, found
inadequate family cohesion to predict symptomatic reaction in
preschoolers. Laor & Wolmer (2000) also found that a higher
capacity for image control by children displaced due to the
destruction of their homes after the missile attack on Tel-Aviv
served as protective factor against the long-term effect of
trauma, hence pointing to individual difference in the plastic-
ity among children. For a somewhat different outcome,
Schwarzwald et al. (1997) found with 5th, 7th, and 10th graders
that future perception was basically positive, but, once again,
with individual variability showing an association between
posttraumatic symptoms and a sense of future orientation.

The couple of years following the Gulf War there remained
the challenge of coping with the first Intifada in Israeli society,
and again relatively little research of psychological domains
related to the Intifada can be found, especially as it pertains to
the well being of children. One study comparing Israeli
children and Palestinian children in Gaza (Slone, Adiri, &
Arian, 1998) shows that Palestinian children reported signifi-
cantly greater exposure to political stressors. Most of the Israeli
children (74%) reported low to moderate exposure to political
life events and only 3% reported very high exposure. In
contrast most Palestinian children reported high to very high
levels of exposure (72%). Also for the Israelis, a linear relation
was found between increased severity of political life events
exposure and level of reported distress (Slone, 2006; Slone,
Lobel, & Gilat, 1999), which points again to the role of indi-
vidual differences and variability; not all children are similarly
affected by the events. Some children perceive the events as
stressful, but, at same time, other children do not appraise the
events as stressful and therefore report low level of distress.

A growing body of research can be seen with regard to the
Al-Aqsa Intifada, again with a mix of more carefully versus less
carefully designed studies, which, of course, influences the
nature, quality and validity of the findings. Shalev et al. (2002)
describe a select, non-representative survey with adults that
took place between October 2000 and July 2001(immediately
after the eruption of the Al Aqsa Intifada) in a settlement near
Jerusalem, showing PTSD symptoms when there is a continu-
ous exposure to stress. They suggest that the fears may be
focused and real thereby protecting the individual and prevent-
ing exposure to danger, but, by and large, without necessarily
affecting functioning. A similar trend has been reported by
Yagur, Greenspoon, & Ponizovsky (2002) on the basis self
reports made by a select sample in a primary care physician
clinic in Gilo, a Jerusalem neighborhood that had been under
frequent, sometimes intense gunfire emanating from the neigh-
boring Palestinian Authority areas.

In another telephone survey with a sample of adults (60%
response rate), purposely over-representing more damaged

areas, the researchers assessed level of exposure to terrorism
for individuals residing in more and less affected areas, along
with their psychological responses and coping strategies during
the peak of the violence. Extreme reactions were reported
(Somer et al., 2005), especially with adults residing in the most
frequently targeted zones, but the authors say that “the effects
of major national trauma were not limited to those directly
exposed to it”. Indeed some mood measures, what they refer
to as the national mood in Israel, appeared to be unrelated to
the level of exposure to terrorism, namely those who had been
traumatized directly were no more likely to develop a negative
mood than other citizens. The authors conclude that the terror
campaign against Israel touched the lives of many Israelis and
negatively affected the general mood of many, regardless of
place of residence. At the same time this is a mood assessment
and, naturally, mood can and should be affected by the
conflict, but when it comes to stronger psychological response,
adults residing in the most severely hit neighborhoods were
also those who suffered most from posttraumatic symptoms.

In an attempt to determine the magnitude of exposure to
terrorist attacks and the prevalence of traumatic stress-related
and PTSD symptoms, and sense of safety after 19 months of
terrorism in Israel (since the eruption of the Al Aqsa Intifada),
as well as to also identify correlates of the psychological
sequelae and the modes of coping with the terrorism – one
more telephone survey was conducted in April–May 2002,
employing a strata sampling method with a representative
sample of Israeli residents older than 18 years (57% response
rate), and provided further information about rates of distress
and PTSD (Bleich et al., 2003). It should be noted that the
survey participants indeed showed distress and lowered sense
of safety with regard to themselves and their relatives, but at
the same time very few reported a need for professional help
with a majority of respondents expressing optimism about
their personal future, the future of Israel, and about their self-
efficacy with regard to their ability to function after a terrorist
attack. The authors suggest that given the nature and duration
of the Israeli traumatic experience, the psychological impact
may indeed be considered as somewhat moderate, with no
apparent high levels of psychiatric distress, all of which imply
adaptive coping processes.

Thus far, data has been reported about adults in the context
of the Al Aqsa Intifada. Demb (2006) examined the relation-
ship between multiple protective factors at the individual,
social, and familial levels, and the resilience displayed in a large
sample of Israeli adolescents. The prevalence of resilient indi-
viduals found in her study (76%) is consistent with other data
reported thus far about adults’ capacity to cope rather adap-
tively, even under continued stressful events and the devastat-
ing experiences of the Intifada.

In the summer of 2001, a most pertinent study with
adolescents from Jerusalem, Gilo, and the Jewish settlements
in the occupied territories examined the relationship between
exposure to political violence and posttraumatic symptoms,
future orientation, and attitudes toward peace (Solomon &
Lavi, 2005). A higher percentage of youths in the settlements,
as compared with Jerusalem or Gilo, reported moderate to very
severe levels of posttraumatic symptoms. At the same time,
adolescents’ future orientation responses were moderately
optimistic. Moreover, exposure to political violence was found
to be related to both PTSD symptoms and to attitudes toward
peace, but not to future orientation. In fact, the association
discerned between level of exposure and attitudes toward

328 SAGI-SCHWARTZ / THE PALESTINIAN–ISRAELI CASE

322-336 090974 Sagi-Schwartz (D) 19/6/08 16:05 Page 328

peace talks suggests that youths are likely to become more open
to peace negotiations once a decline in violence is more
evident. Thus as the authors propose, these findings seem to
reflect a complex interrelationship of political violence, post-
traumatic stress symptoms, and attitudes toward peace, ulti-
mately raising the quest for combining mental health
considerations with peace related issues – which are exactly in
the core of the present paper.

Importantly, Solomon and Lavi (2005) go on to propose
that one must appraise the heterogeneity in youth attitudes
toward peace talks. From a traditional human development
point of view, we can clearly witness here individual variabil-
ity rather than a uniform homogeneous group that rejects
peace. Such expected developmental variability is well reflected
in Shamai and Kimhi’s findings (2006) showing that the lower
the level of exposure to political violence the greater the
support for political compromise, as well as in Solomon and
Lavi’s (2005) findings which also show that negative attitudes
toward the peace talks were associated with increased levels of
exposure.

The Al Aqsa Intifada is perhaps one of the most horrible
experiences with which Israelis have had to cope since the
founding of Israel. The Intifada has drastically changed life in
Israel, and when an actual suicide bombing happens, the
damaged scene looks unimaginable and inhuman, so hard to
describe, share and absorb. Bleich et al. (2003) have shown
that as a result of this Intifada, Israelis experience a lowered
sense of safety with respect to themselves and their significant
others. Yet despite all these adversities, as outlined by Bleich
et al. (2003), we still observe an overall consistent line of
optimism, and individual as well as communal resilience. The
strongest factor to account for these phenomenal capacities
appears to be a very solid family and community infrastruc-
ture. Thus the data suggest an impressive capacity of many
Israelis to cope and maintain life’s routines intact.

In fact, already during the mid 80s, before the eruption of
the Intifadas, Milgram (1982, 1986) attributed the relatively
low stress responses of Israeli children to the social norms,
social cohesiveness, and support that developed in the differ-
ent communities. The present review of war-related research
on Israeli children and adults over the past five decades
suggests that even when the intractable conflict with the Pales-
tinians continues and the threat of suicide bombings is ongoing
– some members of the population react in times of crises with
varying degrees of normative distress, for the most part with
little severe PTSD symptoms or psychological or behavioral
problems, which most often might be transient and disappear
over time. From a developmental and adaptational point of
view, future research should focus more directly on those
children who remain resilient after experiencing war-related
atrocities.

Wiener (2004) observes that when a terrorist attack
happens, the immediate response is one of anger, anxiety, and
depression. This is to be expected as part of the human
development repertoire. Relatively soon thereafter all these
natural reactions seem to weaken and even disappear, at least
for the majority of the population that has not been directly
affected or harmed by the event (those directly affected are
usually a small minority). To a large extent, as Wiener
proposes, such resilience is apparently associated with well
formed individual and societal infrastructures such as a func-
tioning labor market, schools, health systems, active shopping
malls, various community services including synagogues,

youth movements, and extra curricular activities for children –
in all, infrastructures that create a more or less continuous
sense of “business as usual”.

So the availability and sustainability of solid infrastructures
at all societal levels, and a desire and capability of most people
to rely upon these layers of infrastructures, may have created
a well adapted synergy, apparently transformed into flexible
and resilient mental health infrastructures. And above all,
research has shown a wide spectrum of individual differences
in adaptation capacities, making it possible that at least some
people may be more resilient in their coping even under the
most disastrous of circumstances.

The Palestinian case

Most of the data evaluated in this section has been produced
by a group of researchers and professionals at the Gaza
Community Mental Health Program (GCMHP), often in
cooperation with the Finish psychologist Punamäki (see this
volume). The GCMHP group should be commended for
conducting important work during times of great adversity,
providing the international community with critical infor-
mation about vulnerability and resilience of individuals living
under extremely hazardous life conditions. A large portion of
the findings reported here is based on waves of data collected
during and following the first and second Intifadas (for more
information, see Qouta, Punamäki, & El Sarraj in this volume).
Of course, the work of other researchers will also be examined
(see Table 3 for a summary of all reviewed studies).

An additional important point to make at this time is about
the nature of measurements employed to assess the well being
of children and families. Naturally, from a mental health
perspective, one is interested in looking at measures such as
PTSD, depression, anxiety, and other related symptom
measures. But equally important is also the need to explore
resiliency factors that can help children cope under extreme
conditions, sometimes even catastrophic circumstances of
foreign occupation. Thus other measures become pertinent,
including parental role and functioning, social networks,
community services, political engagement and activity, and a
host of other day-to-day variables that do not necessarily fall
within the realm of traditional psychological symptomatology.
The research in the Palestinian territories has adapted to this
broad spectrum of variables.

To the best of my knowledge, the first internationally
published study about the psychological well being of Pales-
tinian children appeared in the late 1980s (Punamäki, 1988).
The timing of this study is important for our purposes. In
general, her study shows that children are not necessarily
helpless and that oppression might lead to activism even
among children 8–14 years old, with older kids showing more
activism. At the same time she found some differences associ-
ated with the time context. Palestinian children (N = 42)
observed in the West Bank in 1985, which is after the invasion
of Israel to Lebanon, were found to show more signs of
perceived helplessness as compared with a group (N = 66)
assessed in 1982 (before the war in Lebanon). Thus, in time
perspective, the invasion to Lebanon by Israeli military troops,
although not taking place at Palestinian territories but at neigh-
boring Arab territories, had negative effects upon Palestinian
children. Recall that we talk here about the pre-Intifadas era,
so that timing becomes an important player developmentally,
and the eruption of the first Intifada can be seen as a case in

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330 SAGI-SCHWARTZ / THE PALESTINIAN–ISRAELI CASE

Table 3
Summary background of studies in the Palestinian territories

Author War Age Design Measures

Punamäki (1988) Before and after 8–14 years old Cross-sectional (before Coping modes
the 1982 Invasion and after the war)
to Lebanon

Baker (1990) First Intifada 6–15 years old Descriptive, individual Locus of control, self-esteem,
differences (correlational) psychological symptomatology

Baker, & Kanan (2003) First Intifada 6–15 years old Descriptive, comparison PTSD symptoms, depression,
under various proximity self-esteem
distances to military fire
zones

Barber (2008a, 2008b) First Intifada 20–27 years old Descriptive Political activism,
felt-victimization, perceived
meaning of experiences, various
psychological indicators,
personal growth

Haj-Yahia (2008) First Intifada 14–20 years old Descriptive survey, Internalizing and externalizing
comparison under various symptoms

levels of exposure to
military attacks

Khamis (2005) (Post) First 12–16 years old Descriptive, individual PTSD symptoms, family
Intifada differences (correlational) ambiance and parental discipline

Qouta, Punamäki, & El Sarraj First Intifada Parents and their Comparison under various Anxiety scale, MMPI,
(1998) 7–11-year-olds traumatic experiences children’s psychological

symptoms

Punamäki, Qouta, & El Sarraj First Intifada 11–12 years old Individual differences Perceived parenting styles,
(1997a, 1997b) (correlational) children’s resources, political

activity, psychological
adjustment

Qouta & El Sarraj (1994); First Intifada 8–14 years old Descriptive under curfew Externalizing and internalizing
El Sarraj & Qouta (2005) experiences symptoms

Qouta, Punamäki, & El Sarraj First Intifada 11–12 years old (Time 1) Individual differences Political activity, psychological
(1995) 12–13 years old (Time 2) (correlational) and resources and wellbeing

longitudinal (one year) –
pre- and post Oslo Treaty

Qouta, Punamäki, & El Sarraj First Intifada 10–12 years old (Time 1) Individual differences Political activity, mental flexibly,
(2001); 13–15 years old (Time 2) (correlational) and psychological adjustment, PTSD
Qouta, Punamäki, & El Sarraj longitudinal (three years) symptoms, emotional disorders
(2001) – pre- and post Oslo Treaty

Abdeen, Qasrawi, Shibli, Al-Aqsa Intifada 14–17 years old Descriptive survey, PTSD symptoms, somatic
& Shaheen (2008) comparison under various complaints

levels of exposure to
military attacks

El Sarraj & Qouta (2005) Al-Aqsa Intifada 12–14 years old Descriptive Identifying with “Martyrdom”

Lavi & Solomon (2005) Al-Aqsa Intifada 12–14 years old Comparison of Anxiety, depression, anger,
Palestinians living in Israel PTSD symptoms, future
and in the occupied orientation
territories

Qouta, Punamäki, & El Sarraj Al-Aqsa Intifada Mothers and their Descriptive and individual PTSD symptoms and mental
(2003, 2005) 6–16-year-olds differences (correlational) health indicators

Qouta & Odeh (2005) Al-Aqsa Intifada School age (age not Descriptive PTSD symptoms and various
specified) symptomatology indicators

Qouta (2004) Al-Aqsa Intifada 10–19 years old Descriptive survey PTSD symptoms

Qouta & El Sarraj (1994) Al-Aqsa Intifada 10–19 years old Descriptive survey PTSD symptoms

Shalhoub-Kevorkian (2006) Al-Aqsa Intifada 14–19 years old Qualitative Feelings of anger and resistance,
sense of potency and control

Thabet, Abed, & Vostanis Al-Aqsa Intifada 9–18 years old Quasi-experimental PTSD symptoms, anxiety
(2002)

Thabet, Abed, & Vostanis Al-Aqsa Intifada 9–15 years old Descriptive and individual Exposure to traumatic events
(2004) differences (correlational) and PTSD symptoms

Thabet, Karim, & Vostanis Al-Aqsa Intifada 3–6 years old Comparison under various PTSD symptoms and various
(2006) traumatic experiences symptomatology indicators

322-336 090974 Sagi-Schwartz (D) 19/6/08 16:05 Page 330

point to illustrate that reactions might change from more help-
lessness, as was the case after the war in Lebanon, to more
activism – as is the case with the eruption of the first Intifada.
This issue will be discussed in the following sections.

When we shift to studies that address the effects of living
under prolonged occupation as well as that of the Intifadas, it
generally should not be surprising that we find high prevalence
of psychological symptoms and reactions in the Palestinian
territories, a zone which is continuously exposed to severe
adversities. In this regard, Qouta, Punamäki, & El Sarraj
(2005) assessed the prevalence and determinants of PTSD
among 121 Palestinian mothers and their young children, all
living in areas of bombardment, none of whom had previous
mental health problems. The results showed high rates of
PTSD signs with various degrees of severity (e.g., 54% severe,
34% moderate and 11% mild or questionable). There was also
a significant link between the mental health of mothers and
that of their children, namely, when mothers’ psychological
problems increased, children’s problems also did.

In a different study of 547 school-age children exposed to
traumatic events, 63% were reported as having full posttrau-
matic stress symptomatology (Qouta & Odeh, 2005). In
addition, the prevalence of attention problems, lack of concen-
tration and hyperactivity, sleep and speech problems as well
as aggressive behavior rose during the Al-Aqsa Intifada to
approximately 13%–14%. In a recent GCMHP study, Qouta,
Punamäki, & El Sarraj (2003) reports that only 2% of
Palestinian children showed no symptoms of PTSD whereas
9% displayed light symptoms, 34% developed medium level
symptoms and 55% suffered from PTSD. Although it is not
clear from the report whether comprehensive psychiatric
assessments were conducted, such findings are indeed
worrying even if the potential bias of self-reported assessments
is taken into consideration. In another recent research project
(Qouta & Odeh, 2005) on 944 children in Gaza (mean age =
15.1), results revealed a high level of PTSD: about third of the
children suffered from severe level of PTSD symptoms.

At the same time Qouta (2004) states that in their observa-
tions they were able to discern signs of coping. For instance,
he proposes that many children’s drawings, showing how
children raising the Palestinian flag in front of Israeli tanks, can
be seen as an indication that they can cope with the trauma by
maintaining a sense of identity and pride, despite fear and
anxiety. Along similar lines, Baker (1990) in his study of 5–16
year-old Palestinians experiencing the first Intifada in refugee
camps, villages and towns in both the West Bank and the Gaza
Strip suggests that active participation in the conflict may
enhance self-esteem and protect children from the develop-
ment of negative psychological symptomatology. Qouta further
points out that as professionals they realize how difficult it is
to be a parent in the Palestinian environment, especially when
parenting means providing a secure base and a haven of safety
to ensure normal growth. He nonetheless reports that in all
GCMHP research projects, Palestinian parents are found to do
their utmost to produce a secure environment for their
children.

Most of the research with Palestinian samples focused on
school children and adolescents, with little reported research
into the effect of war on the well-being of pre-school children.
In one of these studies, Thabet, Karim, & Vostanis (2006)
investigated in 3–6 years old children the relationship between
exposure to traumatic events and emotional problems. They
found that exposure to traumatic events, such as raids and

shelling of the children’s houses, was associated with various
behavioral and emotional problems, and as such, the findings
are consistent with those of previous studies in this age-group
areas of war with Lebanese pre-school children (e.g. Zahr,
1996) and with displaced Israeli pre-school children after Iraqi
Scud missile attacks (Laor et al., 1996).

Thus far we have observed that within normative samples
children living in a war zone like the Gaza strip are at high risk
of displaying signs of PTSD and depressive symptoms. The
GCMPH group has also reported data about some effects of
more specific types of adversities. One study about the effects
of house demolitions (Qouta et al., 1998) examined the effects
of losing one’s home, as well as witnessing the demolition of
others’ houses, on the mental health of Palestinian adults and
children.

The main findings showed that adults exposed to a house
demolition exhibited a higher level of anxiety, depression, and
paranoiac symptoms, when compared with witnesses and
controls. Similar to adults, children in the loss group also
showed a higher level of psychological symptoms when
compared to witnessing children and controls. The authors
note, however, that the study is limited due to its reliance on
self-report measures and lack of psychiatric interviews or
family measures.

Similar findings with 9–18 year-old children and adolescents
are reported for those exposed to home bombardment and
demolition during the Al Aqsa Intifada compared with controls
(Thabet, Abed, & Vostanis, 2002). In this regard, proximity to
areas of military attacks was found to be associated with
increased rate of depression (Baker & Kanan, 2003) and place
of residence, mainly refugee camps, was associated with higher
rates of PTSD symptoms during the first Intifada (Khamis,
2005). Also, in two large survey samples, one assessing 1185
14–20-year-old adolescents in the West bank following the first
Intifada (Haj-Yahia, 2008) and the other assessing 2100 14–17
year-old youth in the West Bank and Gaza during the Al Aqsa
Intifada (Abdeen, Qasrawi, Shibli, & Shaheen, 2008), more
extensive and severe exposure to Israeli military operations,
was positively associated with more internalizing and external-
izing indicators in the first study, as well as with more post-
traumatic distress and somatic complaints in the second study.

One more specific adversity studied by the GCHMP group
is curfews and their effects on children (El Sarraj & Qouta,
2005; Qouta & El Sarraj, 1994). The group reports that
experiencing curfews was associated with various negative
psychological outcomes: e.g. 66% of the children began to
fight each other, 54% were afraid of new things, 38% started
to develop aggressive behavior, 19% started to suffer from
bed-wetting and 2% showed speech difficulties. In all, the
authors propose that the conflict’s longevity and the fact that
it is chronic rather than acute may explain the increased rates
of PTSD.

An Israeli research group from Tel Aviv (Lavi & Solomon,
2005) has also examined recently the effects of chronic
exposure to trauma on Palestinian children, showing that
participants who live in the Palestinian territories reported
that they experienced significantly more traumatic events
than did Palestinians who live in Israel. Those living in the
Palestinian Authority also reported higher levels of post-
traumatic symptoms as well as more pessimistic future orien-
tation accompanied by less favorable attitudes towards peace
prospects. Clearly, Lavi and Solomon (2005) add several
important dimensions by assessing not only Palestinians in the

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322-336 090974 Sagi-Schwartz (D) 19/6/08 16:05 Page 331

occupied territories but also by comparing them to those Pales-
tinians who live in Israel under much better life conditions.
Moreover, they looked not only at mental health parameters
but also at indices of future orientation, an important obser-
vation when one wishes to draw conclusions about the poten-
tial link between traumatic experiences and prospects for
peace.

Some of Shalhoub-Kevorkian (2005, 2006) recent quali-
tative findings with regard to Palestinian children facing the
“security fence” or the “separation wall” (in the Israeli and the
Palestinian terminologies respectively) point to children’s
narratives that emphasize, to a large extent, their struggle
between stressful daily experiences and resilience and coping
strategies. The author suggests that the construction of the wall
added diverse meanings to the way children perceive the world
around them. The data suggest that the wall triggers a great
deal of anger and resistance. Palestinian children describe the
new challenge of how to deal with the wall, by crossing it
despite the physical barriers and by denying its existence with
an attempt to maintain a sense of potency and control rather
than helplessness.

Thus far the review has focused primarily on prevalence and
rates of PTSD and other psychological reactions. Earlier
studies have noted that the consequences of war can be moder-
ated by levels of social support and family dynamics and func-
tioning (Cohen & Dotan, 1976; Laor et al., 1996; Zahr, 1996).
Moreover, maternal capacity to cope with stress was also found
to be an important protective factor (Laor et al., 1997). Along
these lines Punamäki et al. (1997a, 1997b) have carried out,
in real war time conditions, a study that examined various
aspects of individual differences as they interact with effects of
war conditions. Despite the small sample size and primarily use
of self report measures, the study sheds important light on the
role of individual differences in children living under
conditions of violent conflict. In this study too, the results
showed that exposure to traumatic events increased psycho-
logical adjustment problems. It should be noted that the higher
the number of traumatic events children experienced, the more
negatively they perceived the functioning capacity of their
parents. Moreover, the poorer they perceived parenting, the
more neuroticism and low self-esteem were reported.

Similarly, in a post first-Intifada study with 12–16 year old
children, Khamis (2005) has found that children who were
reported to have more PTSD symptoms endured more stress-
ful family conditions. Moreover, in a recent research project
(Thabet et al., 2004) with 9–15 year-olds living in four refugee
camps in the Gaza strip during the Al Aqsa Intifada the authors
report a wide list of PTSD symptoms as being differentiated
and predicted by the level of exposure to traumatic events.
Taken together, the major implication is that not all children
react in the same level of severity despite exposure to profound
adversity.

Equally important is the discussion of the interplay between
traumatic events and political activism: The more traumatic
events children reported, the more they were engaged in politi-
cal activity, and the more politically active they were, the
stronger was their reporting of psychological adjustment
problems (Punamäki et al., 1997a, 1997b). Finally, when
children’s perceptions of their parents were positive, they also
reported better psychological adjustment, hence suggesting
that good parents were perceived as protecting their children.
The researchers suggest that at times of exposure to external
trauma, children and their parents function as a collaborative

unit, the quality of which is predictive of psychological adjust-
ment (Punamäki et al., 1997a, 1997b). On balance, the data
highlights the role of risk as well as protective factors and
suggest that there are no black or white answers even under
conditions of severe war adversity.

Barber’s (2008a, 2008b) extensive series of studies of
adolescents in the Palestinian territories also confirms the
more complex picture portrayed by the Gaza-Finnish team. He
reports data suggesting that youth who have been exposed to
chronic violence as well as engaged actively in political conflict
do not necessarily show an increase in psychological problems,
violence, and aggression. He contends that when studying the
effects of political violence on children and adolescents, we
must appraise the meaning that they attach to the conflict they
experience. Barber suggests that once such perceived meaning is
given more consideration, it might account for those findings
that fail to show dysfunction in children and youth who have
been chronically exposed to political violence. He provides
data suggesting that youth’s political activism, even when
accompanied by violence, has important implications for
positive identity and personal growth.

In a critically important attempt to look longitudinally at the
differential effects during times of heightened political violence
versus times of more peaceful expectations, Qouta, Punamäki,
& El Sarraj (2001) and Qouta et al. (2001) examined the
effects of cognitive capacity, perceived parenting, traumatic
events, and activity, which were first measured in the midst of
the political violence of the Intifada in 1993 and then a year
later and three years later when the Oslo accord was in motion.
PTSD, emotional problems and school performance were
assessed in Palestinian children, 13–15 years of age at time of
follow up. The results show a complex pattern of interaction
between individual differences and various child characteristics
at a time of a high level of political violence and afterwards
when the Intifada ended.

In the midst of the Intifada, politically active children were
reported to show the highest levels of psychological symptoms,
whereas a year and three years later children who were more
active during the Intifada suffered less from various emotional
problems, as reported by their mothers, than passive children.
Also, political activity was found to be a resiliency factor, in
particular when children felt loved and cared for at home.
Moreover the researchers (Qouta et al., 1995) found that
acceptance of the Oslo Accords and a subsequent participation
in the resulting festivities served as a buffer against the negative
impact of the traumatic experiences. The more active the
children were during the Intifada, the more their self-esteem
increased because of the Oslo Accords. In contrast, increased
neuroticism and decreased self-esteem were found only among
those children who did not accept the peace treaty and who
did not participate in the festivities. Finally, results from the
same sample also revealed (Qouta et al., 2001) that, in the
midst of violence, the mental flexibility of children was not
associated with good psychological adjustment; it was found to
moderate long-term negative consequences of traumatic
events and to enhance well being three years later, when the
political events became more peaceful. The fact that Intifada-
related traumas did not increase children’s emotional disorders
three years later, if their perception was characterized by high
flexibility and low rigidity, is indeed a promising finding.

In all, according to the reports of Barber (in 2008a, 2008b)
and the GCMHP group children’s political activity may play
differential mental health roles at times of acute crisis or under

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322-336 090974 Sagi-Schwartz (D) 19/6/08 16:05 Page 332

more favorable conditions. The most promising outcome
reported is that severe psychological symptoms may dissipate
with the decline in acute political violence and danger. These
findings go hand in hand with the stress-evaporation model
(Solomon, 1993; Solomon & Kleinhauz, 1996). Indeed, the
initial Oslo Accords signed between Israel and the PLO posi-
tively influenced Palestinian children’s well-being. This was a
positive turning point which concluded the era of the first
Intifada.

One cannot overlook however the large amount of toxicity
among Palestinians in the sense of Garbarino’s (1995) descrip-
tions, especially given the lack of sufficient infrastructures in
the Palestinian territories in all areas of life, along with the
feelings associated with the eruption of the Al Aqsa Intifada.
Contrasted with the first Intifada, described by Carmi Gilon,
a former Israeli chief of Shin Bet (General Security Service),
as an Intifada of hope, the Al Aqsa Intifada was described as
an Intifada of despair.2 The main question of course is whether
daily conditions in the Palestinian territories have cultivated
the ground for what Garbarino refers to as truncated moral
development in which a vendetta mentality begins to predom-
inate, giving rise to the atrocious suicide bombings committed
by some Palestinian youngsters who explode themselves in
buses, restaurants, and other public areas. This topic of suicide
bombers is complex and beyond the scope of this paper. At the
same time it deserves some attention, especially when we
evaluate the mental health infrastructure of Palestinian society.

In his “Staircase to Terrorism: A Psychological Explo-
ration”, Moghaddam (2005a) presents a staircase metaphor
that relies on findings that may promote a better scientific
understanding of terrorism. For the purpose of his discussion,
terrorism is defined as “politically motivated violence, perpe-
trated by individuals, groups, or state-sponsored agents,
intended to instill feelings of terror and helplessness in a popu-
lation in order to influence decision making and to change
behavior” (Moghaddam, 2005a, p. 161). Moghaddam evalu-
ates research on terrorism in Islamic societies and Northern
Ireland, among other regions, and concludes that if we really
want to develop effective anti-terrorism strategies we must look
at causes rather than symptoms of terrorism. In this regard,
Moghaddam proposes that “under certain conditions on the
ground floor, where the vast majority of people remain, some
dissatisfied individuals will search on higher floors for solutions
to perceived injustices. If solutions are not found, they are
more likely to climb to the top of the staircase and commit
terrorist acts” (Moghaddam, 2005b, p. 1040). In fact, this is a
five-level staircase that is narrowing from the ground level to
the top level, where the upper level represents the entry into
terrorist life and actions. Accordingly, and this is a rather
critical point, most people will remain on the ground level
despite extensive exposure to adversity and toxicity. Those who
reach the top floor – the level of severe violence and terrorism
– are the minority, and they reach the top most likely because
of despair.

Conceptually this model deals with perceived options, which
for the minority of people are seen as the last resort. If people
feel deprived, humiliated, desperate, and unable to effectively
change their destiny via acceptable measures (i.e. negotiations,
legal protests, and the like), some may begin perceiving

extremely violent acts as the only option left. Thus the only way
to minimize the likelihood of such extreme violence is by
providing concrete means that will form alternate perceptions
that are more positive. As Moghaddam concludes (2005b,
p.1040): “the staircase leads to higher and higher floors, and
whether someone remains on a particular floor depends on the
doors and spaces that person imagines to be open to her or
him on that floor.”

In this regard, El Sarraj and Qouta (2005), prominent Pales-
tinian mental health leaders in Gaza, contend that suicide
among young Arabs is extremely rare and even shameful,
because in contrast with what is commonly believed suicide is
perceived as an act that goes against God. Moreover, they
assert that the road to suicide killing is long. However, El Sarraj
and Qouta propose that in the case of Palestinians who never
possessed a state army for their defense, and who have been so
humiliated and desperate, one should not be surprised with the
outcomes. Shalhoub-Kevorkian (2005, 2006) in her descrip-
tion about Palestinian children having to cope with the new
security fence/separation wall brings narratives where children
also explained that their family’s daily survival became more
restricted with the wall. They revealed the way economic,
social, and political hardships further reduced their daily
options for survival, thus raising their levels of anger and frus-
tration, and fueling desires for revenge.

One of the worrisome observations made by El Sarraj and
Qouta (2005) is that an increasing number of Palestinian
children are identifying with “Martyrdom” as a plausible
option. Although the explanations for why and how the
phenomenon of “Martyrdom” evolves are multifaceted, one
plausible reason is an unusually deep emotional expression of
a desire for revenge. Along this line, in a recent GCMHP
research project, 34% of boys from 12–14 years of age said
they considered that the best thing to do in life is to die as a
martyr. El Sarraj and Qouta further maintain that the history
of Palestinians is composed of a series of disasters which took
place in different periods of time, with a serious impact on the
Palestinian psychological state of mind, and they conclude that
“the mood of Palestinian people is still fluctuating between
hope and despair”.

From a human development perspective, it is not surprising
that such profound toxicity might nurture what I refer to as
“seeds of hate”. From a developmental and phenomenologi-
cal stand point, it makes complete sense to expect it, when a
society endures day-to-day life under such devastating
conditions. In this regard, Shikaki (2006) has proposed in his
Palestinian public opinion research that termination of nego-
tiations when violence erupts leaves the public dependent on
violence as the only means to address grievances and deliver
gains, a process that is fully consistent with Moghaddam’s
analysis of the staircase to terrorism.

To illustrate that such a process is not necessarily Palestin-
ian-specific and that it can take place elsewhere, let us place
the analysis also in an Israeli perspective. One of the declara-
tions made by Ehud Barak, former Prime Minister of Israel
and former Chief of Staff of the Israeli Defense Forces, is
rather powerful. While campaigning for the position of Prime
Minister, in 1998, he said: “If I was a young Palestinian I might
have also joined a terrorist organization . . .” (Verter, 1998).
Moghaddam (2005b) said further that “terrorists are made,
not born. . . . Under certain conditions psychologically normal
adults (italics, A.S-S) can inflict serious and even lethal harm
on others.” Barak, as a leader of a sovereign country, with an

INTERNATIONAL JOURNAL OF BEHAVIORAL DEVELOPMENT, 2008, 32 (4), 322–336 333

2 “Peace as a security option”, lecture delivered at the Israel Institute of
Technology (Technion), Haifa, Israel, May 23, 2001.

322-336 090974 Sagi-Schwartz (D) 19/6/08 16:05 Page 333

apparently “good enough” childhood background in a secure
environment in an Israeli kibbutz, allowed himself to say it
loud and clear, from a standpoint of strength. So such
destructive thoughts are apparently a normative part of the
human development repertoire, all the more so when the
reality of others, like that of the Palestinians, is so poisoned
and toxic.

Both Israeli and Palestinian societies have their share in
creating toxic environments as well as being affected by their
respective toxic environments. At the same time it is clear that
improved infrastructures facilitate the delivery of basic human
needs to the broad population the and as such help reduce
toxicity. Israel as a developed country has a much stronger
infrastructure than that of the Palestinian Authority, hence is
less likely to need in reality the “narrowing staircase to terror-
ism”, although such a perceived option was also in the mind of
one of its peace oriented leaders.

To summarize, Qouta (2004) notes that trauma acquires
special characteristics in the Palestinian context. Despite
reports of various symptoms of PTSD and other behavioral-
psychological problems, Palestinian children evince impressive
stamina and strength, and as Qouta and Odeh (2005) note in
a way that “science cannot explain”. Qouta concludes that
their research findings refute the claim that Palestinian parents
push their children to war. Instead, the findings show that
feelings of expressed love and support are core emotions in
most Palestinian parents, apparently serving as important
protective factors. Qouta further asserts that the trauma and
violence have become a challenge for Palestinian children in
Gaza that may not necessarily or always result in negative
outcomes but instead may result in adaptive coping skills.

Conclusions

We have reviewed published as well as unpublished material,
and some of the reported findings are exploratory and there-
fore should be viewed tentatively with only speculative
conclusions. With such qualifications, it should be noted that
despite the debilitating effects of exposure to chronic political
violence and traumas, various protective factors have been
described. Some children and youth seem to be resilient even
when exposed to adversities, and it is proposed that the
majority is able to cope effectively with the after effects of their
trauma exposure, especially when supported by the family and
by other facilitative factors in the community. Children in war
zones who are competently cared for by their own parents or
familiar adults were reported to suffer far fewer negative effects
than those without such support. Moreover, the community
(e.g. schools, community centers, various religious activities)
can be conceived as a safe haven, especially when there are
opportunities for interaction with people and environments
that are positive for development (Garbarino & Kostelny,
1993a, 1993b).

But there are also limits to the effectiveness of the various
protective factors. Although good parenting can moderate the
negative impact of traumatic experiences, the impact of
violence on parents may create a vicious circle in that their own
capacity to parent might be compromised to some degree.
When parents lose resources, they themselves might become
helpless and ineffective.

On balance, the data from the Israeli and Palestinian cases
seem to be consistent with our findings with Holocaust

survivors and their offspring across three generations (Sagi-
Schwartz et al., 2003) suggesting an outstanding coping and
human endurance. It once again may refute traditional psycho-
logical thinking about direct transmission of trauma and its
negative effects, especially when one makes a clear distinction
between trauma that is inflicted from within the family, as is the
case with domestic violence, versus trauma induced by politi-
cal violence, the source of which comes from outside the family
(Sagi-Schwartz et al., 2003; van IJzendoorn, Bakermans-
Kranenburg, & Sagi-Schwartz, 2003). It apparently becomes
more feasible to work through traumas associated with external
sources, or at least to be able to cope adaptively even when the
particular trauma cannot be completely resolved (as is the case
with many Holocaust survivors).

In all, the adverse effects of political violence in war zones
are evident but their extent, depth, and duration vary consid-
erably, depending on the nature of the traumatic events (acute
or chronic, direct or indirect exposure, severity), outcomes
measurement (e.g. PTSD, psychological distress, etc.), and the
presence of protective factors – such as family cohesion, avail-
ability of supportive community and social networks and func-
tioning parents – are likely to alleviate negative effects. Risk
factors such as family chaos and malfunctioning parents,
diminished social networks, and destroyed communities and
infrastructures, loss of housing, and uprooting are likely to
have the opposite effect.

Finally, there is a great deal of individual variability in the
capacity of children and adolescents to adapt despite adverse
experiences with political violence. Therefore one may
conclude that despite experiencing an intractable political
conflict, both Palestinian and Israeli children and youth might
have been able to maintain an adequate mental health infra-
structure, based on underestimated strength and coping
capacities. Perhaps this is not surprising given recent work in
developmental sciences (Masten, 2001) concluding that
adaptive functioning is normative and not necessarily the
exception to the rule – even under very adverse life circum-
stances. But further research is certainly begged for in order to
further substantiate this assertion.

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