Investigate Populations that May Be at Increased Risk of Experiencing Trauma

Stressful Life Events and Associations With Child and Family Emotional and Behavioral Well-Being in Diverse Immigrant and

Refugee Populations

Jerica M. Berge, PhD, MPH, LMFT, Samaria Mountain, BS, Susan Telke, MS, Amanda Trofholz, MPH, RD, Katie Lingras, PhD, LP, Roli Dwivedi, MD,

and Lisa Zak-Hunter, PhD, LMFT University of Minnesota Medical School, Minneapolis, Minnesota

Objective: Although stressful life events (SLEs) have been suggested to be associated with child well-being, few studies have examined SLEs with child and family behavioral and emotional well-being, especially within diverse populations. The current study examined the associations between SLEs and child behavioral and emotional outcomes, in addition to family-level measures of well-being. Method: Children 5–7 years old and their families (n � 150) from 6 racial and ethnic groups (n � 25 each for African American, Hispanic, Hmong, Native American, Somali, White families) participated in this mixed-methods study. Participants were recruited through primary care clinics. Results: Results showed that all racially and ethnically diverse immigrant and refugee families were experiencing SLEs. The majority of diverse children were experiencing emotional and behavioral problems (i.e., hyperactivity, emotional) in the face of SLEs (i.e., combined SLE score, health-related events), with Somali children being at highest risk. Additionally, the majority of diverse families did not experience lower family functioning in response the SLEs, except regarding certain SLEs (i.e., health-related, legal). However, specific families (i.e., Somali) experienced lower family functioning in the face of multiple SLEs. Discussion: Health care practitioners should consider screening and providing extra resources for reducing stress in children, given all children in the study had some emotional and behavioral problems in the face of SLEs. Additionally, it would be important for practi- tioners to know which families are at greatest risk for experiencing SLEs (i.e., African American, Native American, Somali families) to ensure they are provided with the re- sources necessary to mitigate the impact of SLEs.

Public Significance Statement This study investigated Stressful Life Events (SLEs) in racially/ethnically diverse popula- tions. SLEs were prevalent and were associated with lower levels of emotional and behavioral well-being in some children. Many families experienced high levels of family functioning, despite having SLEs, which may provide potential intervention targets.

This article was published Online First August 27, 2020. X Jerica M. Berge, PhD, MPH, LMFT, Samaria Mountain,

BS, X Susan Telke, MS, and X Amanda Trofholz, MPH, RD, Department of Family Medicine and Community Health, Uni- versity of Minnesota Medical School, Minneapolis, Minnesota; Katie Lingras, PhD, LP, Department of Psychiatry, University of Minnesota Medical School, Minneapolis, Minnesota; Roli Dwivedi, MD and X Lisa Zak-Hunter, PhD, LMFT, Depart- ment of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, Minnesota.

Research is supported by National Heart, Lung, and Blood Institute Grant R01HL126171 (principal investiga-

tor: Jerica M. Berge, PhD, MPH, LMFT). The content is solely the responsibility of the authors and does not nec- essarily represent the official views of the National Heart, Lung and Blood Institute or the National Institutes of Health. Authors have no financial disclosures or conflicts of interest to report.

Correspondence concerning this article should be ad- dressed to Jerica M. Berge, PhD, MPH, LMFT, Depart- ment of Family Medicine and Community Health, Univer- sity of Minnesota Medical School, 717 Delaware Street Southeast, Room 425, Minneapolis, MN 55414. E-mail: [email protected]

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Families, Systems, & Health © 2020 American Psychological Association 2020, Vol. 38, No. 4, 380–395 ISSN: 1091-7527 http://dx.doi.org/10.1037/fsh0000524

380

Keywords: stressful life events, emotional well-being, behavioral problems, diverse families, immigrants/refugees

Stressful life events (SLEs) are discrete, acute stressors that disrupt an individual’s usual activities and typically result in substantial change and readjustment (Cronholm et al., 2015; Manyema, Norris, & Richter, 2018; Neece, Green, & Baker, 2012; Thoits, 2010). Some examples of SLEs include death, financial problems (e.g., job loss), interpersonal relation- ship problems (e.g., divorce, separation), health problems (e.g., diagnosis of a disease, exacer- bation of a disease, mental health condition), trauma (e.g., violence, sexual), and legal prob- lems (e.g., prison, jail time, problems with the police). SLEs and adverse childhood events (ACEs) are similar in that the event provoking the stress may be the same (e.g., divorce of a parent, sexual trauma); however, ACEs, by defi- nition, occur in childhood (�18 years), whereas SLEs may occur across the life span (Allen, Rapee, & Sandberg, 2008; Cronholm et al., 2015; Felitti, 1993; Felitti, 2019; Felitti et al., 2019; Ge, Natsuaki, & Conger, 2006; Manyema et al., 2018; Thoits, 2010).

Prior research has shown that SLEs are asso- ciated with negative health and well-being out- comes at the individual level, especially with children. For example, several cross-sectional studies have shown that SLEs (i.e., death, di- vorce, legal, health, financial) are associated with emotional and behavioral problems in chil- dren and adolescents including, depression, anxiety, disordered eating behaviors, child ad- justment problems, and reduced coping skills in response to stress (Allen et al., 2008; Berge, Loth, Hanson, Croll-Lampert, & Neumark- Sztainer, 2012; Ge et al., 2006; Harland, Reij- neveld, Brugman, Verloove-Vanhorick, & Ver- hulst, 2002; Loth, van den Berg, Eisenberg, & Neumark-Sztainer, 2008; Siegel et al., 1992). In addition, longitudinal studies have found that parental divorce was associated with more prob- lematic child behavior (e.g., conduct disorder) and lower emotional well-being (e.g., depres- sive symptoms, anxiety) into adolescence and adulthood (Conger et al., 2002; Ge et al., 2006; Thoits, 2010). Combined, these studies have suggested that SLEs can have immediate nega- tive influences on child health and wellness and

long-term impacts because they track into ado- lescence and adulthood. Researchers have also shown that SLEs (i.e., divorce, financial, legal) are associated with negative outcomes at the family level, such as lower family functioning, increased family conflict and interpersonal prob- lems, and reduced familial well-being (Allen et al., 2008; Conger et al., 2002; Kaczmarek & Trambacz-Oleszak, 2017; Manyema et al., 2018; Neece et al., 2012; Thoits, 2010). Whereas most of the prior research on SLEs has focused primar- ily on either the individual (e.g., child) or the family (e.g., family functioning) level, the current study investigated the influence of SLEs both at the individual child level and the family level.

In addition, few studies examining SLEs have been conducted with families across di- verse backgrounds (Cronholm et al., 2015). This may be particularly important because families from diverse backgrounds may be at higher risk of experiencing SLEs. For example, some studies have shown African American and Hispanic families report higher levels of ACEs, discrimination, and harassment, which have been shown to be associated with mental health problems (e.g., depression, disordered eating behaviors, low self-esteem, substance abuse; Ellis, MacDonald, Lincoln, & Cabral, 2008; Lee & Chang, 2012; Neumark-Sztainer et al., 2002; Ortega, Rosenheck, Alegría, & Desai, 2000; van den Berg, Mond, Eisenberg, Ackard, & Neumark-Sztainer, 2010) and chronic disease (e.g., diabetes, obesity, hypertension, cardiovas- cular disease; Arcan et al., 2014; Cooper et al., 2000; Krieger, Kosheleva, Waterman, Chen, & Koenen, 2011; Mensah, Mokdad, Ford, Green- lund, & Croft, 2005). In addition, immigration and citizenship have also been shown to be asso- ciated with health disparities (Escobar, Hoyos Nervi, & Gara, 2000; Gee, Ryan, Laflamme, & Holt, 2006; Grant et al., 2004). Furthermore, the sociopolitical climate in the United States has evolved from a climate of relative acceptance of racially and ethnically diverse immigrant and ref- ugee populations to one of nonacceptance (Abraído-Lanza, Armbrister, Flórez, & Aguirre, 2006; Guo, 2016; Siddiqui, 2016). These sociopo- litical shifts may also increase SLEs experiences

381STRESSFUL LIFE EVENTS IN DIVERSE FAMILIES

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by racially and ethnically diverse families (Hoyt, Zeiders, Chaku, Toomey & Nair, 2018; Williams & Medlock, 2017). Therefore, the current study investigated the prevalence of SLEs and their as- sociation with emotional and behavioral well- being outcomes in racially and ethnically diverse immigrant and refugee populations.

Family systems theory (FST; Whitchurch & Constantine, 1993; White, Klein, & Martin, 2015) supports the prior research findings de- scribed above showing that SLEs are influential at both the individual and family levels. Specif- ically, one tenet of FST is that events or behav- iors experienced in one family member influ- ence other family members, for worse or for better. For example, if a parent gets divorced and then experiences depression, it is highly likely that the child will be affected by the parent’s symptoms of depression either through less parental attention or care or by experienc- ing symptoms of depression themselves. In ad- dition, FST asserts that it is important to take into account cultural aspects of one’s family system when trying to understand how SLEs are experienced and ultimately impact individual well-being and family functioning. For exam- ple, if divorce or death occurs, some cultures may have traditions or rituals that help them adjust to such changes in ways that are healthy versus unhealthy, and these responses may be driven by cultural values or beliefs.

Thus, using FST as a framework, the main research questions addressed in the current study include (a) What is the prevalence of SLEs in White, African American, Latino, Na- tive American, Hmong, and Somali families? (b) What types of child emotional and behav- ioral problems and levels of family functioning are described in White, African American, La- tino, Native American, Hmong, and Somali families? (c) What is the association between SLEs and child emotional and behavioral well- being? and (d) What is the association between SLEs and family functioning? Results from this study will provide information about the influ- ence of SLEs at the individual and family lev- els, in addition to how SLEs are experienced across different racial and ethnic immigrant and refugee groups. Findings may be useful for practitioners who work with families (e.g., men- tal health workers, physicians) in addition to future intervention research.

Method

Data for the current study are from Phase 1 of Family Matters (Berge et al., 2017), a National Institutes of Health–funded observational study designed to identify novel risk and protective factors for childhood obesity in the home envi- ronments of racially and ethnically diverse and primarily low-income children (n � 150). Phase 1 of the Family Matters study included an in- depth observational study of diverse families using a variety of methods (in-home observa- tions, 24-hr dietary recalls, individual inter- views, surveys), with the goal of using these observations to inform the development of a culturally appropriate survey to be conducted within a larger sample of families (n � 1,200) during Phase 2, as well as subsequent interven- tions geared toward families of elementary school-age children. In-depth details about both study phases are published elsewhere (Berge et al., 2017). The University of Minnesota’s Insti- tutional Review Board Human Subjects Com- mittee approved all protocols used in the Family Matters study; all adult participants provided written informed consent and parental consent for their children, and all children assented to the study.

Participants

The study recruited children and their fami- lies attending family medicine clinics in the Minneapolis–Saint Paul, Minnesota, area be- tween 2015 and 2016 via a letter sent to them by their family physician. Children were eligible to participate in the study if they were between 5 and 7 years old, lived with their parent or pri- mary guardian more than 50% of the time, and were from one of six racial and ethnic groups (non-Hispanic White, non-Hispanic Black, La- tino, Native American, Hmong, or Somali). This highly diverse sample was intentionally recruited because children from racially and ethnically diverse households experience obe- sity and health disparities at a much higher rate than do their nondiverse counterparts, and it is important to identify modifiable factors to mit- igate obesity risk in childhood. The study im- plemented a stratified sampling strategy; within each of the six racial and ethnic groups (n � 25 families from each racial or ethnic group), half (n � 75) of the sample children recruited had a

382 BERGE ET AL.

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body mass index (BMI) �85 percentile, whereas the other half had a BMI between 5 percentile and 85 percentile. In-depth details regarding recruitment and study design are pub- lished elsewhere (Berge et al., 2017).

Parents and guardians were mostly mothers (91%) and were approximately 34.5 years old (SD � 7.1). Over half of the primary guardians (58%) were born in the United States. The educa- tional status was as follows: 40% of parents fin- ished high school or obtained a general equiva- lency diploma but had not attended college. About half (42%) of parents were working full time, and the majority (70%) of participants reported that their annual income was �$35,000. The majority of participants (66%) were receiving public assis- tance.

Procedures and Data Collection

Eligible families participated in two in-home visits that were 10 days apart. The current study uses data from the first home visit, which in- cluded a parent online survey. Researchers con- ducted in-home visits in the family’s preferred language (English, Somali, Spanish, or Hmong). Participants were paired with a re- search staff who was both bilingual and bicul- tural to ensure participant comfort as well as data collection accuracy.

Measures

Table 1 describes the measures used in the current study (e.g., parent report of SLEs, child emotional and behavioral problems, family functioning).

Statistical Analysis

Descriptive analyses were performed to char- acterize the sample of 149 families (one family was dropped from analyses because it did not complete the survey) with means and standard deviations across race for number of SLEs, child behaviors (Strengths and Difficulties Questionnaire subscales; Goodman, 2001), and family functioning and to evaluate modeling assumptions. Linear regression with Huber– White robust standard errors (to protect against possible misspecification of the error structure) were used to estimate means with 95% confi- dence intervals and p values. Adjusted models controlled for child gender, parent gender, edu-

cation, mental health (depression, anxiety), household income, number of children in the household, and time in the United States. Mod- els were fitted separately for each scale or sub- scale measure of child behavior, family func- tioning, and the occurrence of SLEs. All analyses were performed in Stata 15.1 SE (www.statacorp.com).

Results

Results of the current study are presented below by research question.

Research Question 1: What is the preva- lence of SLEs in White, African American, Latino, Native American, Hmong, and So- mali families?

Overall, families reported experiencing be- tween one and two SLEs in the prior 6 months. In addition, there were significant differences in the prevalence of SLEs by race or ethnicity (see Table 2; p � .007). African American and Na- tive American families reported the highest prevalence of SLEs overall. When examined across the four specific categories of SLEs (i.e., health-related, financial, interpersonal, and le- gal), Native American and African American families reported the most health-related SLEs, African American families reported the most interpersonal SLEs, and Hmong families re- ported the most financial and legal SLEs.

Research Question 2: What types of child emotional and behavioral problems and levels of family functioning are described in White, African American, Latino, Na- tive American, Hmong, and Somali families?

Across races, there were significant differ- ences in average child emotional and behavioral problems as measured by the Strengths and Difficulties Questionnaire subscales, including emotional problems (p � .01) and peer prob- lems (see Table 2; p � .001). Specifically, White families reported the lowest scores and Native Americans reported the highest scores for both emotional problems and peer problems. There were also significant differences in aver- age prosocial (e.g., helping others) scores across race and ethnicity (p � .004), with higher prosocial scores for White and lower scores for

383STRESSFUL LIFE EVENTS IN DIVERSE FAMILIES

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384 BERGE ET AL.

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el l-

be ha

ve d,

us ua

lly do

es w

ha t

ad ul

ts re

qu es

t” “[

C hi

ld ’s

na m

e] ca

n be

sp ite

fu l

to ot

he rs

A ve

ra ge

sc or

e w

ith re

ve rs

e co

di ng

fo r

[c hi

ld ’s

na m

e] is

ge ne

ra lly

w el

l- be

ha ve

d, us

ua lly

do es

w ha

t ad

ul ts

re qu

es t”

H ig

he r

sc or

es in

di ca

te hi

gh er

co nd

uc t

pr ob

le m

s. (t

ab le

co nt

in ue

s)

385STRESSFUL LIFE EVENTS IN DIVERSE FAMILIES

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an Ps

yc ho

lo gi

ca l

A ss

oc ia

tio n

or on

e of

its al

lie d

pu bl

is he

rs .

T hi

s ar

tic le

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

T ab

le 1

(c on

ti nu

ed )

C on

st ru

ct Q

ue st

io n

R es

po ns

e op

tio ns

O pe

ra tio

na liz

ed va

ri ab

le

E m

ot io

na l

Pr ob

le m

s “[

C hi

ld ’s

na m

e] of

te n

co m

pl ai

ns of

he ad

ac he

s, st

om ac

h- ac

he s,

or si

ck ne

ss ”

“[ C

hi ld

’s na

m e]

ha s

m an

y w

or ri

es or

of te

n se

em s

w or

ri ed

” “[

C hi

ld ’s

na m

e] is

of te

n un

ha pp

y, de

pr es

se d,

or te

ar fu

l” “[

C hi

ld ’s

na m

e] is

ne rv

ou s

or cl

in gy

in ne

w si

tu at

io ns

, ea

si ly

lo se

s co

nfi de

nc e”

“[ C

hi ld

’s na

m e]

ha s

m an

y fe

ar s,

ea si

ly sc

ar ed

”

A ve

ra ge

sc or

e. H

ig he

r sc

or es

in di

ca te

hi gh

er em

ot io

na l

pr ob

le m

s.

H yp

er ac

tiv ity

“[ C

hi ld

’s na

m e]

is re

st le

ss ,

ov er

ac tiv

e, ca

nn ot

st ay

st ill

fo r

lo ng

” “[

C hi

ld ’s

na m

e] is

co ns

ta nt

ly fid

ge tin

g or

sq ui

rm in

g” “[

C hi

ld ’s

na m

e] is

ea si

ly di

st ra

ct ed

, co

nc en

tr at

io n

w an

de rs

” “[

C hi

ld ’s

na m

e] ca

n st

op an

d th

in k

th in

gs ou

t be

fo re

ac tin

g” “[

C hi

ld ’s

na m

e] ha

s a

go od

at te

nt io

n sp

an ,

se es

w or

k th

ro ug

h to

th e

en d”

A ve

ra ge

sc or

e w

ith re

ve rs

e co

di ng

fo r

• “[

C hi

ld ’s

na m

e] ca

n st

op an

d th

in k

th in

gs ou

t be

fo re

ac tin

g” •

“[ C

hi ld

’s na

m e]

ha s

a go

od at

te nt

io n

sp an

, se

es w

or k

th ro

ug h

to th

e en

d” H

ig he

r sc

or es

in di

ca te

hi gh

er hy

pe ra

ct iv

ity .

Pe er

Pr ob

le m

s “[

C hi

ld ’s

na m

e] ha

s at

le as

t on

e go

od fr

ie nd

” “[

C hi

ld ’s

na m

e] is

ge ne

ra lly

lik ed

by ot

he r

ch ild

re n”

“[ C

hi ld

’s na

m e]

is pi

ck ed

on or

bu lli

ed by

ot he

r ch

ild re

n” “[

C hi

ld ’s

na m

e] ge

ts al

on g

be tte

r w

ith ad

ul ts

th an

w ith

ot he

r ch

ild re

n”

A ve

ra ge

sc or

e w

ith re

ve rs

e co

di ng

fo r

• “[

C hi

ld ’s

na m

e] ha

s at

le as

t on

e go

od fr

ie nd

” •

“[ C

hi ld

’s na

m e]

is ge

ne ra

lly lik

ed by

ot he

r ch

ild re

n” H

ig he

r sc

or es

in di

ca te

hi gh

er pe

er pr

ob le

m s.

Pr os

oc ia

l “[

C hi

ld ’s

na m

e] is

co ns

id er

at e

of ot

he r

pe op

le ’s

fe el

in gs

” “[

C hi

ld ’s

na m

e] sh

ar es

re ad

ily w

ith ot

he r

ch ild

re n,

fo r

ex am

pl e

to ys

, tr

ea ts

, pe

nc ils

” “[

C hi

ld ’s

na m

e] is

he lp

fu l

if so

m eo

ne is

hu rt

, up

se t

or fe

el in

g ill

” “[

C hi

ld ’s

na m

e] is

ki nd

to yo

un ge

r ch

ild re

n” “[

C hi

ld ’s

na m

e] of

te n

of fe

rs to

he lp

ot he

rs (p

ar en

ts ,

te ac

he rs

, ot

he r

ch ild

re n)

”

A ve

ra ge

sc or

e. H

ig he

r sc

or es

in di

ca te

hi gh

er pr

os oc

ia l

be ha

vi or

.

386 BERGE ET AL.

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an Ps

yc ho

lo gi

ca l

A ss

oc ia

tio n

or on

e of

its al

lie d

pu bl

is he

rs .

T hi

s ar

tic le

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

T ab

le 1

(c on

ti nu

ed )

C on

st ru

ct Q

ue st

io n

R es

po ns

e op

tio ns

O pe

ra tio

na liz

ed va

ri ab

le

C on

tr ol

va ri

ab le

s Pa

re nt

ed uc

at io

n “W

ha t

is th

e hi

gh es

t gr

ad e

or ye

ar of

sc ho

ol th

at Y

O U

ha ve

co m

pl et

ed ?”

1. M

id dl

e sc

ho ol

or ju

ni or

hi gh

2. So

m e

hi gh

sc ho

ol 3.

H ig

h sc

ho ol

or G

E D

4. V

oc at

io na

l, te

ch ni

ca l,

tr ad

e or

ot he

r ce

rt ifi

ca ti

on pr

og ra

m 5.

A ss

oc ia

te de

gr ee

6. B

ac he

lo r

de gr

ee 7.

G ra

du at

e or

pr of

es si

on al

de gr

ee (M

S, M

B A

, M

D ,

P hD

, et

c. )

8. O

th er

Fa ct

or sc

or e

H ou

se ho

ld in

co m

e “W

ha t

is yo

ur ye

ar ly

T O

T A

L H

O U

SE H

O L

D in

co m

e? (i

.e .,

in co

m e

fr om

A L

L fa

m ily

m em

be rs

w ho

se jo

b he

lp s

su pp

or t

th e

fa m

ily )”

“T hi

s in

cl ud

es w

ag es

, ca

sh as

si st

an ce

, So

ci al

Se cu

ri ty

, ch

ild su

pp or

t, et

c. ”

1. L

es s

th an

$2 0,

00 0

2. $2

0, 00

0– $3

4, 99

9 3.

$3 5,

00 0–

$4 9,

99 9

4. $5

0, 00

0– $7

4, 99

9 5.

$7 5,

00 0–

$9 9,

99 9

6. $1

00 ,0

00 or

m or

e

Fa ct

or sc

or e

H ou

se ho

ld ra

ce “W

hi ch

ra ci

al /e

th ni

c gr

ou p

be st

de sc

ri be

s yo

ur fa

m ily

?” W

hi te

A fr

ic an

A m

er ic

an H

m on

g So

m al

i N

at iv

e A

m er

ic an

L at

in o

Pa rt

ic ip

an ts

se lf

-i de

nt ifi

ed w

hi ch

ra ci

al /e

th ni

c gr

ou p

be st

de sc

ri be

d th

ei r

ho us

eh ol

d.

N o.

of ch

ild re

n in

th e

ho us

eh ol

d “H

ow m

an y

ch ild

re n

(y ou

ng er

th an

18 ye

ar s

ol d)

ar e

liv in

g in

th e

ho m

e? ”

1, 2,

3, 4,

5, 6,

7, 8,

9, 10

� 1,

2, 3,

4�

T im

e in

th e

U ni

te d

St at

es “H

ow m

an y

ye ar

s ha

ve yo

u liv

ed in

th e

U ni

te d

St at

es ?”

� 1

ye ar

1– 5

ye ar

s 5–

10 ye

ar s

10 –2

0 ye

ar s

20 –3

0 ye

ar s

30 �

ye ar

s

Fa ct

or sc

or e

Pa re

nt an

xi et

y an

d pa

re nt

de pr

es si

on “O

ve r

th e

pa st

2 w

ee ks

, ho

w of

te n

ha ve

yo u

be en

bo th

er ed

by th

e fo

llo w

in g

pr ob

le m

s? ”

“N ot

be in

g ab

le to

st op

or co

nt ro

l w

or ry

in g”

1. N

ot at

al l

2. Se

ve ra

l da

ys 3.

M or

e da

ys th

an no

t 4.

N ea

rl y

ev er

y da

y

Fa ct

or sc

or e

“F ee

lin g

do w

n, de

pr es

se d,

or ho

pe le

ss ”

Fa ct

or sc

or e

387STRESSFUL LIFE EVENTS IN DIVERSE FAMILIES

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an Ps

yc ho

lo gi

ca l

A ss

oc ia

tio n

or on

e of

its al

lie d

pu bl

is he

rs .

T hi

s ar

tic le

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

Latino families. In addition, across racial and ethnic groups, there were significant differences in overall family functioning, with White fam- ilies reporting higher overall (i.e., 40.36 partic- ipants [pts]) family functioning and Latino fam- ilies reporting lower family functioning (i.e., 35.28 pts; see Table 2; p � .001).

Research Question 3: What is the associ- ation between SLEs and child emotional and behavioral problems in White, African American, Latino, Native American, Hmong, and Somali families?

There were many significant results in the full sample (i.e., all races combined) when examin- ing the associations between SLEs and child emotional and behavioral problems (see Table 3). For example, there was an average increase of 0.14 (95% confidence interval [CI: 0.00, 0.27]; effect size � 0.34) in emotional problems when considering the occurrence of any SLE. For health-related SLEs, there was an average increase of 0.15 ([0.02, 0.29]; effect size � 0.36) in conduct problems. The occurrence of a legal-related SLE resulted in an average in- crease of 0.24 ([0.04, 0.44]; effect size � 0.57) in conduct problems and of 0.14 ([0.01, 0.26]; effect size � 0.41) in peer problems.

Overall, Somali children had higher levels of emotional and behavioral problems scores for health-related, financial, interpersonal, and legal SLEs compared to all other races and ethnici- ties. Specifically, SLEs were positively associ- ated with conduct problems, emotional prob- lems, hyperactivity, and peer problems and negatively associated with prosocial behaviors for Somali children.

Research Question 4: What is the associ- ation between SLEs and family function- ing in White, African American, Latino, Native American, Hmong, and Somali families?

Overall, family functioning change scores were significantly different across racial and ethnic groups regarding the occurrence of any SLE (p � .05). For example, Somali families experiencing any SLE had an average decrease of 5.18 (95% CI [�8.76, �1.60]; effect size � �1.00) in family functioning. Regarding spe- cific SLEs, a health-related SLE resulted in an average decrease of 4.80 ([�8.40, �1.20]; ef-T

ab le

2 U

na dj

us te

d M

ea n

Sc or

es an

d St

an da

rd D

ev ia

ti on

s of

St re

ss fu

l L

if e

E ve

nt s,

C hi

ld B

eh av

io rs

, an

d F

am il

y F

un ct

io ni

ng A

cr os

s R

ac e/

E th

ni ci

ty

Pr ev

al en

ce s

of SL

E s,

em ot

io na

l an

d be

ha vi

or al

pr ob

le m

s, an

d fa

m ily

fu nc

tio ni

ng

H ou

se ho

ld ra

ce

pa A

fr ic

an A

m er

ic an

W hi

te H

m on

g L

at in

o N

at iv

e A

m er

ic an

So m

al i

St re

ss fu

l lif

e ev

en ts

A ny

(r an

ge �

0– 12

) 2.

33 (1

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(r an

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on du

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s 0.

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ve ra

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an ge

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a Fo

r bi

va ri

at e

te st

ac ro

ss di

ff er

en ce

s am

on g

ra ce

s fo

r sc

or es

.

388 BERGE ET AL.

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

A m

er ic

an Ps

yc ho

lo gi

ca l

A ss

oc ia

tio n

or on

e of

its al

lie d

pu bl

is he

rs .

T hi

s ar

tic le

is in

te nd

ed so

le ly

fo r

th e

pe rs

on al

us e

of th

e in

di vi

du al

us er

an d

is no

t to

be di

ss em

in at

ed br

oa dl

y.

T ab

le 3

A dj

us te

d P

re di

ct ed

M ea

n Sc

or e

C ha

ng e

an d

95 %

C Is

fo r

F am

il y

F un

ct io

ni ng

an d

C hi

ld B

eh av

io rs

by SL

E O

cc ur

re nc

e A

cr os

s an

d W

it hi

n R

ac e

SL E

an d

SD Q

su bs

ca le

a

H ou

se ho

ld ra

ce

pb A

ll ra

ce s

co m

bi ne

d A

fr ic

an A

m er

ic an

W hi

te H

m on

g L

at in

o N

at iv

e A

m er

ic an

So m

al i

A ny

SL E

C hi

ld be

ha vi

or C

on du

ct pr

ob le

m s

0. 14

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390 BERGE ET AL.

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fect size � �1.48) and legal SLEs resulted in an average decrease of 7.61 ([�10.39, �4.83]; effect size � �0.93) in family functioning score for Somali families.

Discussion

Results of the current study support and ex- tend prior research by being one of the first studies to examine SLEs in diverse immigrant and refugee families and to examine the asso- ciation between SLEs at the individual child and family levels (Thoits, 2010).

Descriptive results showed that the preva- lence of SLEs was between one and two in White, Hmong, Somali, African American, La- tino, and Native American families, with Afri- can American and Native American families experiencing the highest prevalence of SLEs (i.e., two or more). Although one or two SLEs may seem like a low number, prior research on ACEs has shown that even one or two ACEs increased one’s risk of numerous health, behav- ioral, and social problems throughout the life span (Felitti, 1993, 2019; Felitti et al., 2019). Additionally, ACEs and SLEs tend to be cumu- lative, and the accumulation of ACEs or SLEs has a strong graded relationship with health risk (cardiovascular, mental health, weight-related) and mortality (Felitti, 1993, 2019; Felitti et al., 2019). Taken together, these findings suggest that White and non-White groups experience SLEs and may need resources to reduce their potential impact, but especially African Amer- ican, Native American, and Somali groups may need them.

In addition, descriptive results showed that child emotional and behavioral problems were experienced at low to moderate levels, with the highest occurrence of problems being hyperac- tivity, conduct disorder, behavioral problems, and emotional problems occurring among non- White children. Also, children from non-White backgrounds experienced higher prevalence of emotional and behavioral problems; thus, fam- ilies may also benefit from resources to help reduce the potential negative impact of these child emotional and behavioral problems. Fur- thermore, descriptive results showed that most families reported relatively high family func- tioning. Ultimately, this strength may be helpful for mitigating the potential negative impact of SLEs. For example, health care providers who

work with families or interventionists who carry out family-based interventions could leverage family support as a potential protective factor when SLEs occur. FST supports these findings, in that strong family relationships are expected to be protective during challenging times, ac- cording to FST.

Results also indicated significant associations between SLEs and child emotional and behav- ioral well-being and family functioning overall, as well as differences by race and ethnicity. Regarding child emotional and behavioral prob- lems, the occurrence of any SLE was associated with higher levels of emotional problems in all children. This finding supports prior studies showing SLEs have immediate and long-term influences on child emotional and behavioral well-being (Allen et al., 2008; Ge et al., 2006; Harland et al., 2002; Siegel et al., 1992). In addition, this result supports prior work related to ACEs and cumulative risk, in that the more SLEs a person and/or family experiences, the higher likelihood they have of experiencing negative health and well-being outcomes (Fe- litti, 1993, 2019; Felitti et al., 2019).

Additionally, results showed that health- related SLEs were associated with higher levels of emotional and behavioral problems in all children. Thus, it may be the case that certain SLEs can have a stronger influence on chil- dren’s emotional and behavioral well-being than other SLEs. Furthermore, when examined by race and ethnicity, Somali children had the highest levels of all behavioral and emotional problems across all SLEs. Overall, these results suggest that children are experiencing higher levels of emotional and behavioral problems in the face of SLEs and that Somali children may be at highest risk. It is important for future research to both further examine this relation- ship to identify potential protective factors for prevention as well as to identify resources to help with treatment for children. Regarding So- mali children, it may be important for qualita- tive research to be conducted to better under- stand how Somali families experience SLEs and how they perceive their family functioning, in addition to their child’s emotional and behav- ioral well-being, in the face of SLEs.

Regarding family functioning, there was no significant association between total SLEs and overall family functioning; however, when cer- tain SLEs occurred (e.g., health-related, legal),

391STRESSFUL LIFE EVENTS IN DIVERSE FAMILIES

T hi

s do

cu m

en t

is co

py ri

gh te

d by

th e

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er ic

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lo gi

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they were associated with lower family func- tioning within racially/ethnically diverse sub- populations. This supports prior studies show- ing SLEs are associated with lower family functioning and extends prior research by show- ing there may be differences by race or ethnicity (Thoits, 2010). Thus, it may be the case that specific SLEs are harder to cope with than oth- ers for particular populations. For example, So- mali families reported lower family functioning in the face of health-related and legal SLEs. There may also be differential implications for certain types of SLEs for different racial or ethnic groups (e.g., legal issues may have dif- ferent implications or be of a different type on average for Latino families vs. Somali fami- lies).

Overall, findings from the current study un- derscore the importance of applying critical race theory to the understanding of physical, emo- tional, and behavioral health concerns in chil- dren and families and for discussing race and immigrant and refugee status in the context of assessing SLEs (Cunningham, 2014; Cunning- ham & Scarlato, 2018). Many important factors, such as discrimination or harassment, structural racism, citizenship experience, reason or story for leaving country of origin, and trauma or torture, may influence study findings. It is im- portant for future research, especially qualita- tive, to further investigate these findings to in- form interventions and implications for practitioners.

Strengths and Limitations

This study had both strengths and weak- nesses. A marked strength of the study is the diversity of the sample population, which in- cluded racially and ethnically diverse, immi- grant and refugee, and low-income families. Examining both individual child-level emo- tional and behavioral well-being and familial well-being was another strength of the study. In addition, the ability to control for multiple po- tential confounders (i.e., parent gender, weight, education, income, mental health (depression, anxiety), number of children in the household, and time in the United States) is a further strength. One limitation of this study is that other confounding variables related to child and family functioning that can vary between groups by citizenship experience or immigra-

tion status, such as voluntarily leaving one’s country of origin versus fleeing for safety and access to community services or resources, were not assessed and may change the findings in this study; these variables should be studied in future research. Another limitation of the study is the overall small sample size (n � 150) and even smaller sample size when examining associations by each racial and ethnic group (n � 25 per group). However, given SLEs and mental health outcomes have not been studied in such diverse populations before, including immigrant and refugee households, this study provides an initial important examination of these factors that future larger studies can use as a starting point to verify results and expand findings. In addition, the cross-sectional nature of the study limited our ability to understand temporality of the associations. Furthermore, this study relied on parent report of SLEs and child emotional and behavioral problems, which may have introduced some social desirability bias. The measure of SLEs was also limited to the prior 6 months, and it may be important to assess a longer time period of exposure to SLEs, such as 12 months. The SLE measure, Strengths and Difficulties Questionnaire, and family func- tioning measure are also limited by being vali- dated on only some of the populations we stud- ied. It may also be possible that families who are immigrants or refugees have difficulty understanding the way survey questions are asked or there may not be words for survey items that are easily translatable into their language; however, all survey materials were translated into Spanish, Hmong, and Somali by individuals from their own local commu- nities. Additionally, immigrant or refugee families come from a variety of contexts, and it may be the case that families from war-torn countries may report and/or experience SLEs differently from families from other countries and backgrounds.

Conclusion

Results of the current study showed that all families in this racially and ethnically diverse and immigrant and refugee sample were expe- riencing SLEs. In addition, the majority of di- verse children were experiencing emotional and behavioral problems (i.e., hyperactivity, emo- tional problems) in the face of SLEs (i.e., com-

392 BERGE ET AL.

T hi

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bined SLE score, health-related events), with Somali children being at highest risk. Addition- ally, the majority of diverse families did not experience lower family functioning in re- sponse the SLEs, except regarding certain SLEs (i.e., health-related, legal). However, specific families (i.e., Somali) experienced lower family functioning in the face of the majority of SLEs. These results suggest implications for practitio- ners (mental health and health care providers) working with diverse families regarding SLEs. For example, it would be important for practi- tioners to know that the majority of families experience one or two SLEs and that given the cumulative nature of SLEs it would be impor- tant to provide families with resources to min- imize the stress produced by these events. In addition, practitioners should potentially con- sider screening for SLEs and providing extra resources for children, given all children in the study had some emotional and behavioral prob- lems in the face of SLEs and the impact of cumulative risk with SLEs (Felitti, 1993, 2019; Felitti et al., 2019). Additionally, it would be important for practitioners to know which fam- ilies are at greatest risk for experiencing SLEs (i.e., African American, Native American, So- mali families) to ensure they are provided with the resources necessary to mitigate the impact of SLEs. Practitioners may also want to utilize family-level resources, given results of this study showed most diverse families had high family functioning in the face of SLEs. Further- more, practitioners working with Somali fami- lies may want to provide resources for both family functioning and child emotional and be- havioral problems when SLEs are experienced.

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Received January 16, 2020 Revision received April 28, 2020

Accepted July 5, 2020 �

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