CHILD AND ADOLESCENT DISORDERS (TD BENTON, SECTION EDITOR)

Refugee Children: Mental Health and Effective Interventions

Laura Pacione & Toby Measham & Cécile Rousseau

Published online: 10 January 2013# Springer Science+Business Media New York 2013

Abstract The mental health consequences of war andother forms of organized violence for children representa serious global public health issue. Much of the re-search on the mental health of war-affected civilianshas focused on refugees who have sought asylum inhigh-income countries and face the dual stress of atraumatic past and resettlement. This review will focuson the mental health of refugee children who have fledwar as well as interventions to both prevent and treatadverse mental health outcomes. While war can havedevastating mental health consequences, children raisedin the midst of armed conflict also display resilience.Effective interventions for refugee children will be dis-cussed both in terms of prevention and treatment ofpsychopathology, with a focus on recent developmentsin the field.

Keywords Refugee . Asylum-seeker . Child . Adolescent .

War . Displacement . Resettlement . Mental health .

Post-traumatic stress disorder . PTSD . Trauma .

Psychotherapy . Resilience . Prevention . Treatment .

Advocacy . Child and adolescent disorders . Psychiatry

Introduction

According to the United Nations High Commissioner forRefugees (UNHCR), an estimated 42.5 million personsworldwide were forcibly displaced by war or persecutionin 2011, of which 15.2 million were refugees and 26.4million were internally displaced persons [1]. Forty-six per-cent of refugees are children under the age of 18 [1]. Arefugee is defined by UNHCR as a person who flees acrossan international border because of a well-founded fear ofbeing persecuted for reasons of race, religion, nationality ormembership of a particular social group or political opinionand who is not able to seek or receive protection from theircountry of origin [2]. According to the Universal Declarationof Human Rights (1948), “Everyone has the right to seek andto enjoy in other countries asylum from persecution” [3].

Refugees are defined by specific legal criteria, whereasthe term “asylum seekers” refers to all people requestingrefuge outside their home country. In 2011, the top countriesof origin of refugees included Afghanistan, Iraq, Somalia,Sudan and the Democratic Republic of the Congo. The vastmajority of refugees settle in low- and middle-incomecountries with only a minority seeking asylum in high-income countries. In 2011, children made up 34 % of theworld’s asylum seekers, with South Africa, the USA,France, Germany and Italy receiving the highest numberof refugee applications [1, 4].

War is a human-created humanitarian emergency thatoften involves the direct targeting of civilians, resulting in

This article is part of the Topical Collection on Child and AdolescentDisorders

L. Pacione : T. MeashamÉquipe de recherche et d’intervention transculturelles, Divisions ofSocial and Transcultural Psychiatry and Child Psychiatry, McGillUniversity, Centre de recherche et de formation CSSS de laMontagne 7085 Hutchison, Local 204.11,Montréal, QC H3N 1Y9, Canada

L. Pacionee-mail: laura.pacione@mail.mcgill.ca

T. Meashame-mail: toby.measham@mcgill.ca

C. Rousseau (*)Équipe de recherche et d’intervention transculturelles, Divisions ofSocial and Transcultural Psychiatry and Child Psychiatry, McGillUniversity, Centre de recherche et de formation CSSS de laMontagne 7085 Hutchison, Local 204.2,Montréal, QC H3N 1Y9, Canadae-mail: cecile.rousseau@mcgill.ca

Curr Psychiatry Rep (2013) 15:341DOI 10.1007/s11920-012-0341-4

human rights atrocities [4]. The use of sexual violenceagainst civilians, including children, to disrupt family ties,instill terror and bring about compliance, is a factor in thedevelopment of war-associated psychopathology [5, 6]. Waroften intersects with a multitude of interacting factors,including underlying ethnic and political tensions, povertyand famine, to create complex humanitarian emergencies thatconfer an increased risk of adverse physical and mental healthoutcomes.

Effective prevention and treatment of psychopathology inchild refugees requires both evidence-based interventionsand public policy that upholds the rights of children toreceive care. An increasing securitization of immigrationpolicies, in particular since 9/11, has resulted in a deteriora-tion of the rights of foreigners in host countries [7]. Accessto economic and social rights, including health care, is notguaranteed. For example, a rapidly enacted Canadian policychange in June 2012 resulted in some asylum-seekers,including children, losing their health benefits [8].

Research Limitations

There are inherent difficulties in studying refugee mentalhealth, including logistical barriers to accessing subjects andthe challenges of conducting research in unsafe areas [9].Given the inequity of mental health research resources inlow- and middle-income countries, much of the research isfocused on refugees who have resettled in high-income hostcountries [10]. Additional research challenges include ethi-cal issues and a lack of appropriate cross-culturallyvalidated assessment tools [11, 12]. Owing to these and otherbarriers, there are a paucity of well-designed studies on effec-tive interventions for refugee children, with case reports andsmall cohort studies without control groups being the mostcommon research evidence available [13]. The literature alsotends to focus on posttraumatic stress disorder (PTSD) anddepression as the major sequelae of war to the exclusion ofother possible outcomes [14]. Some authors argue that aqualitative, participatory approach to research should be usedto achieve a more holistic understanding of refugee children[15]. Finally, recent intervention models that employ a step-wise approach of increasingly specialized interventions toaddress the overall needs of refugee families are bridging thegap between more holistic psychosocial models and morenarrow medical models of trauma [16].

The Child Refugee’s Experience

Children experience war differently than adults because oftheir dependent physical and social position [17]. Further-more, war has unique mental health consequences for

children that depend on their age and developmental stage[18, 19]. The refugee experience is typically broken downinto three distinct phases: pre-migration experiences of warin the country of origin, migration to a new host country andpost-migration experiences during resettlement.

Pre-migration war experiences of children are highlyvariable and may include exposure to violence, separationfrom extended family and peer networks, and disruption ofschooling, with unaccompanied minors being particularly atrisk [20]. While some children are relatively sheltered fromtraumatic experiences, others experience multiple forms oftrauma, including witnessing war atrocities, being them-selves victims of torture or intimidation, separation fromfamily and deprivation of water and food [21]. Displace-ment from the home environment compounds traumaticexperiences by disrupting a person’s sense of attachmentto their home, familiarity with their surroundings and asense of self that develops from spending one’s life in aspecific place [22].

Migration experiences of children may also be traumaticand include separation from caregivers, exposure to violenceand harsh living conditions, poor nutrition and uncertaintyabout the future [23–25]. According to the UNHCR, in 2011there were 17,700 asylum applications from unaccompaniedchildren, mostly from Afghanistan and Somalia [1]. Thesechildren have generally been exposed to more traumaticevents and are at greater risk of psychopathology; however,they may also be seen as resourceful and capable [25–27].

Post-migration experiences for children include stress re-lated to their family’s adaptation; difficulties with education ina new language; acculturation, including shifts in ethnic andreligious identity; gender role conflicts; intergenerational con-flict within the family; and the experiences of discriminationand social exclusion [18, 28, 29]. Post-migration challengesfor refugee claimants seeking asylum may also includelengthy negotiations with the legal system to avoid rejectionof their claim and forced repatriation [30]. For the majority ofchild refugees who are unable to seek asylum in high-incomecountries, remaining in refugee camps can mean facing therisk of infectious disease, malnutrition, exposure to domesticviolence and sexual assault [31–34].

Mental Health Outcomes of War-Affected RefugeeChildren

Refugee children affected by war show a broad range ofmental health outcomes, and while the focus remains onpsychopathology, recent attention has been directed towardprotective factors [35, 36]. The association between warexperiences and the development of PTSD and depressionin refugee children is well established. A meta-analysis ofdata from 7,920 children affected by war found that 4.5 to

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89.3 % of children met criteria for PTSD with an overallpooled estimate of 47 %, 43 % met criteria for depression,and 27 % met criteria for a non-PTSD anxiety disorder [35].

Labeling those refugees who are suffering psychological-ly from trauma as mentally ill has been criticized by someauthors, who suggest that emotional suffering from severetrauma should be seen as a normal reaction to catastrophicsituations [37–39]. The medical model itself, which informsthe search for and labeling of pathology, may be ill suited todefine which reactions to catastrophic situations of trauma,loss and deprivation are expected versus pathological. In-deed, when studies determine rates of PTSD of up to 89 %among children affected by war, it raises the question ofwhether developing a disorder is an expected and possibly“normal” response to extreme situations invoking terror,horror and helplessness [35].

While many refugee children do not meet diagnostic crite-ria for PTSD, other internalizing or emotional problems havebeen reported, including adjustment disorders, sleep distur-bance, nightmares, grief reactions, inattention, social with-drawal and somatization [6, 40–42]. Adjustment disordercan present with a wide range of internalizing and externaliz-ing symptoms and often results from the acute and chronicstressors present during the whole migratory and resettlementprocess. Externalizing problems, including oppositional, ag-gressive, impulsive, hyperactive and antisocial behaviors, arereported in refugee children, more commonly in boys, and areassociated with witnessing violence [18, 26, 43]. In compar-ison, girls have been shown to be at greater risk for internal-izing problems, which are predicted by traumatic experiencesbefore and during migration and by stressful events post-migration [27, 42]. However, rates of PTSD have been shownto be approximately equal in boys and girls despite exposureto different types of trauma [6].

Prolonged grief is a disorder proposed for inclusion in theDiagnostic and Statistical Manual-V and the InternationalClassification of Disease-11 that involves yearning, avoid-ance of reminders, disbelief and feelings of emptiness [44,45]. Prolonged grief has been shown to be symptomaticallydistinct from depression and PTSD in bereaved children, butit has not yet been systematically studied in refugee children[46]. Given that prolonged grief is associated with signifi-cant impairment, and that specialized treatments may bebeneficial, this topic warrants further investigation in refugeeyouth [47, 48].

Refugees may also have cultural understandings of dis-tress that do not fit within prevailing diagnostic paradigms.In one study of ethnomedical syndromes among MayanGuatemalans living in UNHCR refugee camps in Mexico,48 % of children were considered to be suffering from susto,a fright condition thought to result from soul loss, charac-terized by symptoms consistent with PTSD, anxiety anddepression [49]. There are multiple “fright syndromes”

documented in different cultures that offer explanations forthe sequelae of traumatic events, and some, such as theculture-bound syndromes nervios and ataques de nervios,have been documented in children and adolescents [50–52].However, there is a paucity of research on cultural idioms ofdistress in refugee children.

Factors Affecting Mental Health Outcomes of RefugeeChildren

There are known risk and protective factors that influencethe mental health outcomes of war-affected children, andthis topic has recently been systematically reviewed [53••,54••]. For refugee children, exposure to pre-migration vio-lence is a well-established risk factor for psychopathology,and exposure to multiple traumatic events predicts worsemental health outcomes [53••, 54••, 55••, 56]. Furthermore,more severe forms of trauma are associated with higher risk.In one study of displaced children in Southern Darfur, beingabducted or raped, needing to hide to protect oneself, orbeing forced to hurt or kill family members were stronglypredictive of traumatic reactions, whereas being raped, see-ing others raped, the death of a parent and being forced tofight were the strongest predictors of depressive symptoms[6]. It is also important to view children’s experiences interms of their life histories because there is evidence thatcumulative traumatic experiences may be more salient tothe development of psychopathology than pre-migrationexperiences [57].

Post-migration factors in high-income countries, includingfamily cohesion, social support and positive school experien-ces, have been show to confer a protective effect, whereasperceived discrimination and exposure to violence conferredincreased risk [53••]. In a longitudinal study of young MiddleEastern refugees in Denmark, post-migration adaptation andstressors, including discrimination, were better predictors ofongoing psychological problems than traumatic experiencesbefore migration, highlighting the importance of the post-migration experience [18]. In a study of 267 children ofasylum seekers in Holland, social stressors, such as poormaternal mental health, small family size and having left aparent behind in the country of origin, were more significantstressors than aspects of the asylum seeking process, includinglegal status and length of stay in the host country [29]. Usingan ecological framework, children’s mental health outcomescan be viewed as dependent on the child’s family microsys-tem, including attachment relationships, social supportand good caregiver mental health; the larger communitymesosystem including supportive schools and day care;and the regional cultural, historical and political macrosystem[36, 54••].

The practice in many high-income countries of detainingrefugee claimants in settings that resemble prisons has led to

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research showing that detention is highly distressing forchildren and results in anxio-depressive symptoms and poorsocial adjustment [58]. Restrictive immigration practices areassociated with increased psychological distress, social iso-lation, poorer host-country language acquisition and greaterdifficulties with resettlement [30].

There is some evidence of intergenerational trauma trans-mission to children born to refugee parents that may affectmultiple generations [59]. A study that followed Vietnameserefugee families for 23 years after migration to Norway foundthat fathers’ PTSD on arrival predicted poorer mental health intheir offspring compared to their Vietnamese peers; however,as a group these Vietnamese children had fewer symptomsthan their Norwegian peers [60]. This suggests that despite thepresence of risk factors related to premigratory adversity,refugee children may sometimes have better mental healthoutcomes than host-country children. Indeed, there is someevidence that refugee families’ exposure to war-related traumamay play a protective role on the social and emotional func-tioning of adolescents who were born in the host country [61].This phenomenon may be related to overcompensation by thechildren of the survivors who are given the implicit duty tosucceed, given their parents’ struggles [61].

Resilience and Post-Traumatic Growth

While war can have devastating mental health consequences,children affected by war also display resilience, defined as theability to maintain stable, healthy psychological and physicalfunctioning despite being confronted with significant trauma[36, 62, 63]. Resilience is often used to describe people whodo not develop PTSD following exposure to trauma.

In contrast to resilience, post-traumatic growth describesa positive psychological change that goes beyond the abilityto resist being psychologically damaged by adversity [64].Post-traumatic growth is seen as the result of psychologicaladaptation following trauma, not the trauma itself. Positivechange is viewed as a process that acts in five domains: agreater appreciation for life, more meaningful interpersonalrelationships, recognition of personal strength, changed lifepriorities and spiritual/existential development [64]. Post-traumatic growth has been described in adult refugees andis associated with hope, religiosity, social support, higherquality of life and cognitive-emotional coping strategies,including positive refocusing, planning how to cope, puttinginto perspective and acknowledging the severity of traumaticexperiences [65–67]. Post-traumatic stress and post-traumaticgrowth have been found to co-exist, although less post-traumatic growth has been reported in more severely trauma-tized refugees [65, 66]. Some evidence exists in both adultsand children to show that resilient individuals who exhibitminimal post-traumatic stress have the lowest levels of post-

traumatic growth, lending support to the idea that positivechange arises from the process of adaptation to trauma [68].

Post-traumatic growth has primarily been studied inadults; however, measurement scales have now beendeveloped for children as young as 6 years old, and the subjecthas recently been systematically reviewed in children [69, 70].For children exposed to a variety of traumatic experiences,post-traumatic growth was associated with the presence ofsubjective psychological distress, social support/religiousinvolvement and cognitive-emotional coping strategies [70].

Effective Interventions for War-Affected RefugeeChildren

Interventions designed for refugee children should aim toprevent psychological distress and impairment and to pro-mote optimal emotional, social and cognitive development[71]. According to the Inter-Agency Standing Committee(IASC), emergency mental health and psychosocial supportfor refugee children should be implemented in a tieredmanner. Represented visually as a pyramid, the base isdedicated to universal provision of basic services to ensuresafety. The next layer of the pyramid involves strengtheningcommunity and family supports, followed by more focusednon-specialized support provided to a smaller number ofpeople. For individuals with the greatest need, specializedmental health services form the top of the pyramid. [72]. Allof these interventions are ideally implemented concurrentlyand with intersectorial collaboration. There is now researchevidence supporting the success of multilayered psychoso-cial intervention programs that address stress and adversityin areas of armed conflict [73].

Accessing Services

Children who have fled humanitarian emergencies and re-settled in countries of safety have multiple means of access-ing preventive and intervention services, which are usuallynot organized into a network. An advisory group called theAmerican Psychological Association Task Force on thePsychosocial Effects of War on Children and FamiliesWho Are Refugees From Armed Conflict Residing in theUnited States has recently reviewed mental health serviceprovision with practice points and recommendations for thispopulation [74]. Efforts to support school staff, primary careproviders and community workers are key because thesepersons may represent the first point of contact for refugeechildren and families in difficulty. Children and familieshave been offered both preventive and intervention help inschools in many host countries [75–77].

Recent Canadian guidelines address the approach tocommon health problems in immigrant and refugee youth

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presenting to primary care, including depression and PTSD[78]. Refugee children and families also present to specializedclinical services, which are not necessarily adapted to respondto their specific cultural, linguistic and psychosocial needs.Research in the UK has shown that refugee children are morefrequently referred by non-medical sources and that childrenwho receive services that are culturally and linguisticallyadapted are no more likely to drop out of treatment thanhost-country youth [79].

Tiered Prevention and Treatment Models

While the delivery of effective interventions for refugeeyouth is a field in evolution, clinical and research work withwar-affected and resettled refugees is beginning to point tothe need for multi-layered collaborative services that pro-vide culturally and linguistically adapted care, includingaccess to interpreters and culture brokers.

In order to better support primary care and community-based professionals working in urban areas servicing multi-ethnic clientele, a community-based, tiered collaborative caremodel in Youth Mental Health has been implemented inMontreal, Canada, to support communities servicing multi-ethnic populations [80]. In this model, children and familiesare provided general psychosocial support by localcommunity-based health and social service clinics, in eitherthe clinics, their homes or schools. In addition, they are able toaccess primary medical care and youth mental health supportin the clinics. Child psychiatric consultants are linked with theyouth mental health teams and provide ongoing support andtraining to the community-based health, mental health andsocial service providers. Culturally adapted patient consulta-tions and case discussions are also provided so that childrenexperiencing significant mental health difficulties receive cul-turally adapted community clinic-based mental health inter-ventions, with referral to hospital-based psychiatric serviceswhen necessary. See Table 1 for key aspects of theassessment process of refugee children and families.

Another example of a multi-tiered prevention and interven-tion program was recently created for Somali youth resettledin New England in the US [81]. This pilot project, based onthe IASC intervention pyramid, provided multilayered com-munity, school and clinic-based programs depending on themental health and psychosocial needs of the participants. Thisstudy yielded promising results: there was a high level ofengagement, and students across all tiers of the programdemonstrated improvements in their mental health. Childrenneeding the highest level of care were treated with TraumaSystems Therapy, which addresses both trauma-associatedemotional dysregulation and social environmental stressors[82]. Students across all levels of the program showedimprovements in mental health and resources [81].

Specialized Mental Health Services

Unfortunately, data on effective psychotherapeutic interven-tions for refugees, and refugee youth in particular, are ex-tremely limited. In the adult literature, both Trauma-FocusedCognitive-Behavioral Therapy (TF-CBT) and Eye MovementDesensitization and Reprocessing (EMDR) are recommendedas first-line treatments for adults with PTSD, and thesetrauma-focused therapies have been shown to be superior tonon-trauma focused therapies [83, 84]. However, studies typ-ically focus on victims of single-incident traumas or childhoodabuse, and refugees may represent a unique population withdifferent needs. Furthermore, TF-CBT and EMDR have notbeen systematically evaluated in refugee populations,although a small pilot study using EMDR to treat adult refu-gees was recently published [85]. TF-CBT is also consideredfirst-line treatment for PTSD in children and adolescents, andamodified version has been developed for children exposed tomultiple complex traumas, although this therapy has not yetbeen evaluated in refugee youth [84, 86•]. Narrative ExposureTherapy (NET) has recently been used to treat refugee youthsuffering from symptoms of PTSD, and the evidence for NETin adult and child refugees was recently reviewed [87•].

NET was originally developed for multiply traumatizedvictims of organized violence in resource-poor settings, whereit can be delivered by trained non-professionals [88]. Thisshort-term manual-based therapy involves creation of a lifetime-line from birth to the present, which includes detailednarration of traumatic events leading to emotional habituation[89]. NET is thought to address impaired memory processingof traumatic events that results in a sense of constant threatbecause traumatic memories are easily activated and are notanchored contextually within a coherent narrative because oftrauma-associated hippocampal dysfunction [90]. The use ofnarrative may also help refugees heal from trauma by facili-tating a collective interpretation of their experiences, strength-ening cultural and historical identity, decreasing a sense ofpersonal responsibility and self-blame and developing afuture-oriented perspective [91].

NET has been adapted for children (KidNET) and can bedelivered by trained local counselors to children who remainin high-risk situations, such as those living in refugee campsor in war-affected neighboring countries [92]. The effective-ness of NET for refugee children resettled in high-incomecountries has also been demonstrated in a few small studies;however, larger well-designed trials are needed [93, 94].

Recent Canadian guidelines addressing the treatment ofPTSD rated the quality of the evidence base used to recom-mend EMDR, TF-CBT and NET for immigrant and refugeesas low or very low. They also noted the possibility of adverseevents with therapy such as traumatic re-experiencing andwithdrawal from active treatment [78]. Some authors havehypothesized that the timing and manner in which disclosure

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of war trauma occurs to children within a family may be moreimportant than the disclosure or nondisclosure of trauma inand of itself [95]. This may have clinical implications forassessment and treatment models, where clinical methods that“work around trauma” may be helpful. [95]. Furthermore,non-verbal therapies have been developed for torture survi-vors and their families, including group or family therapiesthat involve art, relaxation, movement, the dramatic or sym-bolic use of objects and the symbolic recreation of historicalreligious narratives [96].

Psychopharmacology

Pharmacologic treatment may be indicated for certain psy-chiatric disorders; however, the use of medication for mental

health problems in refugee children has not been evaluated.A recent review by The Cochrane Collaboration (2010)concluded that for both adults and children, there was insuf-ficient evidence to support or refute the use of combinedpsychotherapy and pharmacotherapy for PTSD compared toeither of these interventions alone [97]. Recent Canadianguidelines recommend against the use of psychotropic medi-cations for the first line treatment of PTSD in immigrant andrefugee children [78].

Advocacy

Families who are applying for refugee status in high-incomecountries often have needs in multiple spheres, includinglegal, occupational, educational, social and individual, and

Table 1 Key aspects of the tiered collaborative care model in the youth mental health assessment process for refugee children and theirfamilies [80, 95]

Provide a safe assessment space

- Respond to cultural, linguistic and psychosocial needs by providing access to professional interpreters and culture brokers, while recognizing thatsome families may be more comfortable without these services

- In addition to the patient and family, other family members or key people providing social support can be invited to the assessment

- A multi-disciplinary team representing multiple ethnocultural backgrounds will facilitate the assessment and emphasize the importance ofmultiple viewpoints. Social work, psychology, nursing, psychiatry and specialists in creative arts therapies and psychoeducation may beincluded, depending on the needs of the family

- Be cautious about encouraging disclosure of traumatic experiences. Consider discussing the meaning of trauma from an individual and familyperspective and explore the family’s beliefs about the value of disclosing trauma as a means of healing. Assessing parents and children/adolescents separately may help address the different and sometimes conflicting needs of family members to disclose their traumatic experiences

Attend to general safety and basic needs

- Determine the immediate basic needs of the family for shelter, food, clothing, etc.

- Assess the physical and mental health needs of the entire family and their ability to access care; liaise with primary care providers and communityworkers as needed

- Inquire about post-migration stressors including family conflict, discrimination, violence and intimidation

- Discuss basic resettlement issues, such as the need for employment and language instruction; provide referral to community resources

Assess family and community supports

- Explore areas of strength and resilience, including individual, family, social and cultural factors.

- Assess social resources, including members of a child and family’s extended support network, community supports and other involvedprofessionals

- Determine social, occupational, educational, linguistic and legal needs of the family members and liaise with social and health agencies, specificcommunity resources for refugees, schools, immigration and legal services, and/or housing authorities as needed

Specialized evaluation

- Elicit a multiplicity of viewpoints, for example, individual, collective, traditional and spiritual, to understand how the presenting mental healthproblem is perceived and understood by the patient and family.

- Demonstrate openness and respect for different viewpoints; be aware of cultural biases and the impact of unequal power relationships in theclinical assessment.

- Empower the family by providing appropriate psychoeducation and normalization.

- Explore other models of care being practiced by the family, such as traditional or religious care.

- Elicit the patient’s and family’s treatment goals and preferred treatment strategies to facilitate the co-creation of a treatment plan.

- If appropriate to the family’s treatment goals, with their permission, consider involving a religious leader, traditional healer or other authority inthe development of a holistic plan of care.

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can benefit from integrated assistance in multiple domains[13]. Refugee children often have concerns about the presentrather than the past, and identifying their needs and priorities isimportant to the provision of appropriate care [98]. Health careworkers may need to assume non-traditional roles in order tosupport and empower refugee families through tasks such asliaison with social agencies, communication with schools,immigration or housing authorities, or testifying in court[99]. Political advocacy can be used to influence migratorypolicies or increase access to health care services for asylumseekers. In Canada, the Canadian Medical Association, alongwith seven other national organizations, recently spoke outagainst government cuts to refugee health care [100].

Conclusion

Child refugees are at risk for a variety of mental healthproblems related to their experiences of organized violencein their home countries, as well as the displacement andresettlement processes. Refugee children display resilienceas well as psychopathology, and recent research has delineatedrisk and protective factors that influence mental health out-comes. There is a paucity of research on effective treatmentinterventions for refugee children. A multi-tiered approach tointervention is recommended with preventative psychosocialinterventions offered more broadly and specialized servicesoffered to smaller numbers of refugee children with the great-est need. Further studies on effective interventions are a pre-requisite for promoting mental health and treating thepsychological sequelae of war, displacement and resettlementfor refugee children.

Disclosure No potential conflicts of interest relevant to this articlewere reported.

References

Papers of particular interest, published recently, have beenhighlighted as:• Of importance•• Of major importance

1. United Nations High Commissioner for Refugees: Global Trends2011. Available at http://www.unhcr.org/4fd6f87f9.html.Accessed September 2012.

2. United Nations High Commission on Refugees: Convention relat-ing to the Status of Refugees Available at http://www2.ohchr.org/english/law/refugees.htm. Accessed September 2012.

3. United Nations General Assembly: Universal Declaration of Hu-man Rights. Available at http://www.unhcr.org/refworld/docid/3ae6b3712c.html Accessed September 2012.

4. Raleigh C: Armed Conflict Location and Event Dataset. Availableat http://www.acleddata.com/. Accessed September 2012.

5. Marsh M, Purdin S, Navani S. Addressing sexual violence inhumanitarian emergencies. Glob Public Health. 2006;1:133–46.

6. Morgos D, Worden JW, Gupta L. Psychosocial effects of warexperiences among displaced children in southern Darfur. Omega.2007;56:229–53.

7. Crepeau F, Jimenez E. Foreigners and the right to justice in theaftermath of 9/11. Int J Law Psychiatry. 2004;27:609–26.

8. Caulford P, D’Andrade J. Health care for Canada’s medicallyuninsured immigrants and refugees: whose problem is it? CanFam Physician. 2012;58:725–7.

9. de Jong JP, Scholte WF, Koeter MW, Hart AA. The prevalence ofmental health problems in Rwandan and Burundese refugeecamps. Acta Psychiatr Scand. 2000;102:171–7.

10. Razzouk D, Sharan P, Gallo C, et al. Scarcity and inequity ofmental health research resources in low-and-middle incomecountries: a global survey. Health Policy. 2010;94:211–20.

11. Allden K, Jones L, Weissbecker I, et al. Mental health and psycho-social support in crisis and conflict: report of the Mental HealthWorking Group. Prehosp Disaster Med. 2009;24 Suppl 2:s217–27.

12. Hollifield M, Warner TD, Lian N, et al. Measuring trauma andhealth status in refugees: a critical review. Jama. 2002;288:611–21.

13. Murray LK, Cohen JA, Ellis BH, Mannarino A. Cognitive be-havioral therapy for symptoms of trauma and traumatic grief inrefugee youth. Child Adolesc Psychiatr Clin N Am.2008;17:585–604. ix.

14. Montgomery E, Foldspang A. Validity of PTSD in a sample ofrefugee children: can a separate diagnostic entity be justified? IntJ Methods Psychiatr Res. 2006;15:64–74.

15. Chatty D, Crivello G, Hundt GL. Theoretical and MethodologicalChallenges of Studying Refugee Children in the Middle East andNorth Africa: young Palestinian, Afghan and Sahrawi Refugees. JRefug Stud. 2005;18:387–409.

16. Miller KE, Rasmussen A. War exposure, daily stressors, andmental health in conflict and post-conflict settings: bridging thedivide between trauma-focused and psychosocial frameworks.Soc Sci Med. 2010;70:7–16.

17. Boyden J, De Berry J. Children and youth on the front line:ethnography, armed conflict and displacement. UK: BerghahnBooks; 2004.

18. Montgomery E. Long-term effects of organized violence onyoung Middle Eastern refugees’ mental health. Soc Sci Med.2008;67:1596–603.

19. Punamäki R-L. The uninvited guest of War enters childhood:developmental and personality aspects of war and militaryviolence. Traumatology. 2002;8:181–204.

20. Bean T, Derluyn I, Eurelings-Bontekoe E, et al. Comparingpsychological distress, traumatic stress reactions, and experiencesof unaccompanied refugee minors with experiences of adolescentsaccompanied by parents. J Nerv Ment Dis. 2007;195:288–97.

21. Macksoud MS, Aber JL. The war experiences and psychosocialdevelopment of children in Lebanon. Child Dev. 1996;67:70–88.

22. FulliloveMT. Psychiatric implications of displacement: contributionsfrom the psychology of place. Am J Psychiatry. 1996;153:1516–23.

23. Centres for Disease Control and Prevention (CDC). Malnutritionand micronutrient deficiencies among Bhutanese refugee children −Nepal, 2007. MMWR Morb Mortal Wkly Rep. 2008;57:370–3.

24. Basak P. The impact of occupation on child health in a Palestinianrefugee camp. J Trop Pediatr. 2012;58:423–8.

25. Denov M, Bryan C. Tactical maneuvering and calculated risks:independent child migrants and the complex terrain of flight.New Dir Child Adolesc Dev. 2012;136:13–27.

Curr Psychiatry Rep (2013) 15:341 Page 7 of 9, 341

26. Derluyn I, Mels C, Broekaert E. Mental health problems inseparated refugee adolescents. J Adolesc Health. 2009;44:291–7.

27. Hodes M, Jagdev D, Chandra N, Cunniff A. Risk and resiliencefor psychological distress amongst unaccompanied asylum seek-ing adolescents. J Child Psychol Psychiatry. 2008;49:723–32.

28. Ellis BH, MacDonald HZ, Klunk-Gillis J, et al. Discrimination andmental health among Somali refugee adolescents: the role of accul-turation and gender. Am J Orthopsychiatry. 2010;80:564–75.

29. Wiegersma PA, Stellinga-Boelen AA, Reijneveld SA. Psychoso-cial problems in asylum seekers’ children: the parent, child, andteacher perspective using the Strength and Difficulties Question-naire. J Nerv Ment Dis. 2011;199:85–90.

30. Steel Z, Momartin S, Silove D, et al. Two year psychosocial andmental health outcomes for refugees subjected to restrictive orsupportive immigration policies. Soc Sci Med. 2011;72:1149–56.

31. Feseha G, G/mariam A, Gerbaba M. Intimate partner physicalviolence among women in Shimelba refugee camp, northernEthiopia. BMC Publ Health. 2012;12:125.

32. Hynes M, Barbara LC. Observations from the CDC: sexualviolence against refugee women. J Women’s Health Gend BasedMed. 2000;9:819–23.

33. Mahamud AS, Ahmed JA, Nyoka R, et al. Epidemic cholera inKakuma Refugee Camp, Kenya, 2009: the importance of sanita-tion and soap. J Infect Dev Ctries. 2012;6:234–41.

34. Tappis H, Doocy S, Haskew C, et al. United Nations HighCommissioner for Refugees feeding program performance inKenya and Tanzania: a retrospective analysis of routine HealthInformation System data. Food Nutr Bull. 2012;33:150–60.

35. Attanayake V, McKay R, Joffres M, et al. Prevalence of mentaldisorders among children exposed to war: a systematic review of7,920 children. Med Confl Surviv. 2009;25:4–19.

36. Betancourt TS, Khan KT. The mental health of children affectedby armed conflict: protective processes and pathways to resil-ience. Int Rev Psychiatry. 2008;20:317–28.

37. Joseph S, Williams R. Understanding posttraumatic stress: theory,reflections, context and future. Behav Cogn Psychother.2005;33:423–41.

38. Mollica RF, Wyshak G, Lavelle J. The psychosocial impact ofwar trauma and torture on Southeast Asian refugees. Am J Psy-chiatry. 1987;144:1567–72.

39. WaEA O’D. The current status of post traumatic stress syndromeas a diagnostic category: problems and proposals. J TraumaStress. 1992;5:421–39.

40. Geltman PL, Grant-Knight W, Ellis H, Landgraf JM. The “lostboys” of Sudan: use of health services and functional healthoutcomes of unaccompanied refugee minors resettled in the US.J Immigr Minor Health. 2008;10:389–96.

41. Lee YM, Shin OJ, Lim MH. The psychological problems of northkorean adolescent refugees living in South Korea. PsychiatryInvestig. 2012;9:217–22.

42. Montgomery E. Trauma, exile and mental health in young refu-gees. Acta Psychiatr Scand Suppl. 2011;440:1–46.

43. Mels C, Derluyn I, Broekaert E, Rosseel Y. The psychologicalimpact of forced displacement and related risk factors on EasternCongolese adolescents affected by war. J Child Psychol Psychi-atry. 2010;51:1096–104.

44. Morina N, von Lersner U, Prigerson HG. War and bereavement:consequences for mental and physical distress. PLoS One. 2011;6:12.

45. Wakefield JC. Should prolonged grief be reclassified as a mentaldisorder in DSM-5?: reconsidering the empirical and conceptualarguments for complicated grief disorder. J Nerv Ment Dis.2012;200:499–511.

46. Spuij M, Reitz E, Prinzie P, et al. Distinctiveness of symptoms ofprolonged grief, depression, and post-traumatic stress in bereavedchildren and adolescents. Eur Child Adolesc Psychiatry.2012;21:673–9.

47. Shear K, Frank E, Houck PR, Reynolds 3rd CF. treatment of com-plicated grief: a randomized controlled trial. Jama. 2005;293:2601–8.

48. Stroebe M, Schut H, Stroebe W. Health outcomes of bereave-ment. Lancet. 2007;370:1960–73.

49. Smith BD, Sabin M, Berlin EA, Nackerud L. Ethnomedicalsyndromes and treatment-seeking behavior among Mayan refu-gees in Chiapas, Mexico. Cult Med Psychiatry. 2009;33:366–81.

50. Livanis A, Tryon GS. The development of the Adolescent Nerv-ios Scale: preliminary findings. Cult Divers Ethnic Minor Psy-chol. 2010;16:9–15.

51. Lopez I, Rivera F, Ramirez R, et al. Ataques de Nervios and theirpsychiatric correlates in Puerto Rican children from two differentcontexts. J Nerv Ment Dis. 2009;197:923–9.

52. Simons RaH, CC (Eds) The Culture-Bound Syndromes: FolkIllnesses of Psychiatric and Anthropological Interest. USA: Rei-del Publishing; 1985.

53. •• Fazel M, Reed RV, Panter-Brick C, Stein A. Mental health ofdisplaced and refugee children resettled in high-income countries:risk and protective factors. Lancet. 2012;379:266–82. This com-prehensive systematic review examines the evidence base forindividual, family, community, and societal risk and protectivefactors for the mental health outcomes of child and adolescentrefugees who resettle in high-income countries. The implicationsof the data with respect to design of interventions, policy andfuture research are also discussed. See also Reed et al. (2012).

54. •• Reed RV, Fazel M, Jones L, et al. Mental health of displacedand refugee children resettled in low-income and middle-incomecountries: risk and protective factors. Lancet. 2012;379:250–65.This comprehensive systematic review examines the evidence basefor individual, family, community, and societal risk and protectivefactors for the mental health outcomes of children and adolescentrefugees displaced to low- and middle-income countries. Researchand policy recommendations to guide the development and assess-ment of effective interventions are also discussed.

55. •• Ellis BH, MacDonald HZ, Lincoln AK, Cabral HJ. Mental healthof Somali adolescent refugees: the role of trauma, stress, and per-ceived discrimination. J Consult Clin Psychol. 2008;76:184–93.This study examines the effect of a multi-tiered programfor Somali refugee youth that includes prevention and com-munity resilience building, school-based early interventiongroups for at-risk students and direct intervention for stu-dents with significant psychological distress due to trauma.This novel model of treatment resulted in improvement inmental health and resources for all participants.

56. Thabet AA, Ibraheem AN, Shivram R, et al. Parenting supportand PTSD in children of a war zone. Int J Soc Psychiatry.2009;55:226–37.

57. Berthold SM. The effects of exposure to community violence onKhmer refugee adolescents. J Trauma Stress. 1999;12:455–71.

58. Kronick R, Cleveland J, Rousseau C. Mandatory detention ofrefugee children: a public health issue? Paediatr Child Health.2011;16:65–7.

59. Karenian H, Livaditis M, Karenian S, et al. Collective traumatransmission and traumatic reactions among descendants ofArmenian refugees. Int J Soc Psychiatry. 2011;57:327–37.

60. Vaage AB, Thomsen PH, Rousseau C, et al. Paternal predictors ofthe mental health of children of Vietnamese refugees. ChildAdolesc Psychiatry Ment Health. 2011;5:2.

61. Rousseau C, Drapeau A, Rahimi S. The complexity of traumaresponse: a 4-year follow-up of adolescent Cambodian refugees.Child Abuse Negl. 2003;27:1277–90.

62. Bonanno GA. Loss, trauma, and human resilience: have weunderestimated the human capacity to thrive after extremelyaversive events? Am Psychol. 2004;59:20–8.

63. Bonanno GA, Brewin CR, Kaniasty K, Greca AML. Weighingthe costs of disaster. Psychol Sci Public Interest. 2010;11:1–49.

341, Page 8 of 9 Curr Psychiatry Rep (2013) 15:341

64. Tedeschi R, Calhoun L. Posttraumatic growth: conceptual foun-dations and empirical evidence. Psychol Inq. 2004;15:1–8.

65. Hussain D, Bhushan B. Posttraumatic stress and growth amongTibetan refugees: the mediating role of cognitive-emotional reg-ulation strategies. J Clin Psychol. 2011;67:720–35.

66. Kroo A, Nagy H. Posttraumatic growth among traumatized So-mali refugees in Hungary. J Loss Trauma. 2011;16:440–58.

67. Teodorescu DS, Siqveland J, Heir T, et al. Posttraumatic growth,depressive symptoms, posttraumatic stress symptoms, post-migration stressors and quality of life in multi-traumatized psy-chiatric outpatients with a refugee background in Norway. HealthQual Life Outcomes. 2012;10:84.

68. Levine SZ, Laufer A, Stein E, et al. Examining the relationshipbetween resilience and posttraumatic growth. J Trauma Stress.2009;22:282–6.

69. Clay R, Knibbs J, Joseph S. Measurement of posttraumaticgrowth in young people: a review. Clin Child Psychol Psychiatry.2009;14:411–22.

70. Meyerson DA, Grant KE, Carter JS, Kilmer RP. Posttraumaticgrowth among children and adolescents: a systematic review.Clin Psychol Rev. 2011;31:949–64.

71. Peltonen K, Punamaki RL. Preventive interventions among chil-dren exposed to trauma of armed conflict: a literature review.Aggress Behav. 2010;36:95–116.

72. Inter-Agency Standing Committee (IASC): IASC Guidelines onMental Health and Psychosocial Support in Emergency Settings.2007: Available at http://www.humanitarianinfo.org/iasc/.Accessed September 2012.

73. Jordans MJ, Komproe IH, Tol WA, et al. Practice-driven evaluationof a multi-layered psychosocial care package for children in areas ofarmed conflict. Community Ment Health J. 2011;47:267–77.

74. American Psychological Association (APA): Resilience and recov-ery after war: Refugee children and families in the United States.2010: Available at http://www.apa.org/pi/families/refugees.aspx.Accessed September 2012.

75. Fazel M, Doll H, Stein A. A school-based mental health inter-vention for refugee children: an exploratory study. Clin ChildPsychol Psychiatry. 2009;14:297–309.

76. Rousseau C, Benoit M, Lacroix L, Gauthier MF. Evaluation of asandplay program for preschoolers in a multiethnic neighbor-hood. J Child Psychol Psychiatry. 2009;50:743–50.

77. RousseauC,Guzder J. School-based prevention programs for refugeechildren. Child Adolesc Psychiatr Clin N Am. 2008;17:533–49. viii.

78. Rousseau C, Pottie K, Thombs BD, et al. Canadian collaboration forimmigrant and refugee health guidelines for immigrant health,Appendix 11: post traumatic stress disorder, evidence review fornewly arriving immigrants and refugees. CMAJ. 2012: Available athttp://www.cmaj.ca/content/suppl/2010/06/07/cmaj.090313.DC1/imm-ptsd-11-at.pdf. Accessed November 2012.

79. Howard M, Hodes M. Psychopathology, adversity, and serviceutilization of young refugees. J AmAcad Child Adolesc Psychiatry.2000;39:368–77.

80. Rousseau C, Measham T, Nadeau L. Addressing trauma in collabo-rative mental health care for refugee children. Clin Child PsycholPsychiatry, 2012. Available at http://ccp.sagepub.com/content/early/2012/05/22/1359104512444117.abstract. AccessedNovember 2012.

81. Ellis BH,Miller AB, Abdi S, et al. Multi-tier mental health programfor refugee youth. J Consult Clin Psychol. 2012. Available at http://psycnet.apa.org/psycinfo/2012-23383-001/. Accessed November2012.

82. Saxe GNE, Heidi B, Kaplow, Julie B. Collaborative treatment oftraumatized children and teens: The trauma systems therapyapproach. New York: Guilford Press; US; 2007.

83. Ehlers A, Bisson J, Clark DM, et al. Do all psychological treat-ments really work the same in posttraumatic stress disorder? ClinPsychol Rev. 2010;30:269–76.

84. National Institute for Health and Clinical Excellence: Post-traumatic stress disorder (PTSD): The management of PTSD inadults and children in primary and secondary care 2005: Avail-able at http://http://publications.nice.org.uk/post-traumatic-stress-disorder-ptsd-cg26. Accessed September 2012.

85. Ter Heide FJ, Mooren TM, Kleijn W, et al. EMDR versus stabi-lisation in traumatised asylum seekers and refugees: results of apilot study. Eur J Psychotraumatol. 2011;2:16.

86. • Cohen JA, Mannarino AP, Kliethermes M, Murray LA. Trauma-focused CBT for youth with complex trauma. Child Abuse Negl.2012;36:528–41. This article describes a method by which TF-CBT can be adapted for youth with complex trauma. Using astep-by-step approach, practical modifications to the treatmentphases of TF-CBT are proposed and illustrated with case exam-ples. This treatment method has only been validated in non-refugee populations thus far, but shows promise and may helptherapists adapt TF-CBT for youth with multiple traumas.

87. • Robjant K, Fazel M. The emerging evidence for NarrativeExposure Therapy: a review. Clin Psychol Rev. 2010;30:1030–9. This publication reviews the evidence for the use of NarrativeExposure Therapy (NET) for adults, and an adapted version forchildren (KidNET), to treat PTSD as the result of trauma andorganized violence. Evidence for the efficacy of NET and KidNETis presented for both resettled refugees and those who remain involatile and insecure settings.

88. Neuner F, Schauer M, Klaschik C, et al. A comparison of narra-tive exposure therapy, supportive counseling, and psychoeduca-tion for treating posttraumatic stress disorder in an african refugeesettlement. J Consult Clin Psychol. 2004;72:579–87.

89. Schauer M, Neuner F, Elbert T. Narrative exposure therapy − ashort term intervention for traumatic stress disorders after war,terror or torture. Seattle: Hogrefe; 2005.

90. Neuner F, Catani C, Ruf M, et al. Narrative exposure therapy forthe treatment of traumatized children and adolescents (KidNET):from neurocognitive theory to field intervention. Child AdolescPsychiatr Clin N Am. 2008;17:641–64.

91. Gemignani M. The past if past: the use of memories and self-healing narratives in refugees from the former yugoslavia. JRefug Stud. 2011;24:132–56.

92. Catani C, Kohiladevy M, Ruf M, et al. Treating children trauma-tized by war and Tsunami: a comparison between exposure ther-apy and meditation-relaxation in North-East Sri Lanka. BMCPsychiatry. 2009;9:22.

93. Ruf M, Schauer M, Neuner F, et al. Narrative exposure therapyfor 7- to 16-year-olds: a randomized controlled trial with trauma-tized refugee children. J Trauma Stress. 2010;23:437–45.

94. Schaal S, Elbert T, Neuner F. Narrative exposure therapy versusinterpersonal psychotherapy. A pilot randomized controlled trialwith Rwandan genocide orphans. Psychother Psychosom.2009;78:298–306.

95. Measham T, Rousseau C. Family disclosure of war trauma tochildren. Traumatology. 2010;16:85–96.

96. Hardi L, Kroo A. Psychotherapy and psychosocial care of torturesurvivor refugees in Hungary: “a never-ending journey”. Torture.2011;21:84–97.

97. Hetrick SE, Purcell R, Garner B, Parslow R. Combined pharma-cotherapy and psychological therapies for post traumatic stressdisorder (PTSD). Cochrane Database Syst Rev. 2010;7.

98. Jones L. Responding to the needs of children in crisis. Int RevPsychiatry. 2008;20:291–303.

99. Rothe EM. A psychotherapy model for treating refugee childrencaught in the midst of catastrophic situations. J AmAcad PsychoanalDyn Psychiatry. 2008;36:625–42.

100. Canadian Medical Association. Continue coverage for refugees:CMA. Canadian Medical Association Bulletin. Can Med Assoc J.2012;184:1212.

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