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Refugee children and adolescents exhibit resilience despite a history of trauma. However, trauma can affect a refugee child’s emotional and behavioral development. Mental health providers should consider how the refugee experience (e.g., exposure to hunger, thirst, and lack of shelter; injury and illness; being a witness, victim, or perpetrator of violence; fleeing your home and country; separating from family; living in a refugee camp; resettling in a new country; and navigating between the new culture and the culture of origin) may contribute to a child or adolescent’s emotional or behavioral presentation in a clinic, school, or community setting.

Mental Health Provider Considerations

When assessing trauma and mental health symptoms in refugee children:

  • Attending to engagement and cultural considerations are important first steps in mental health assessment with refugee children and families.
  • When assessing a child’s history, ask about the child’s background, past school experience, trauma history, and current stressors (including current trauma exposure such as community violence).
  • Ask about specific behaviors (e.g., isolating/not spending time with others, not enjoying or participating activities, frequent outbursts) that might be concerning for caregivers; this may be a culturally appropriate way to discuss mental health symptoms.
  • Ask about—and respect the caregiver or child’s interpretation of—the symptoms and concerns. You might ask, “Why do you think you are/your child is behaving this way?” or “You know your child best. Do you have any concerns?”
  • Try to assess if symptoms are culturally specific ways to express mental health distress. You might simply ask, “Do you know anyone else who has these same problems?”
  • Pay attention to the social and environmental stressors in the child’s life and how these may contribute to the symptoms described.
  • Children with school problems may have learning or cognitive differences/disabilities that are impeding his or her progress. While difficult to assess, due to differences in culture, language, and school exposure, these are important to identify.

When engaging refugee children and families in the treatment process:

  • Work to build trust with all family members, not only to increase the benefits of treatment, but also to ensure the family will accept your recommendations and referrals.
  • Listen to the family’s concerns, acknowledge the importance of their expressed primary problems, and address first the basic or most urgent needs.
  • Focus on aspects of the mental health services that relate to the family’s expressed values, such as supporting a child’s academic success.
  • When you are referring to other services, discuss what the resource can provide for the child or family and, if possible, facilitate the family’s contacting the referral.

Guidance for Primary Care Practitioners

Primary care visits may be a time that refugee families express concerns about their child’s functioning at home or school and/or providers may identify concerns about emotional or behavioral health. Most refugee children have experienced trauma which may affect their emotional, behavioral, and physical development. However, many refugee children are resilient and may not exhibit symptoms related to trauma.

When working with refugees in a medical setting:

  • Ask questions to learn about the child’s or family’s culture, language, and country of origin; don’t assume anything.
  • Provide culturally and linguistically sensitive services, when possible, by using cultural brokers or interpreters.
  • Identify and respect the roles of parents and other caregivers in a child’s life (e.g., even if children speak better English than a parent, do not use them as interpreters).
  • Keep in mind that trauma might present itself in various ways primary care settings, for example
    • Children may appear distressed or report stress-related symptoms.
    • Parents may report concern about a child’s behavior, attention, or lack of engagement in school.             
    • Parents may express concern about a child seeming sad, withdrawn, or irritable.
    • Parents may report developmental regression, sleep difficulties, and/or behavioral outbursts in younger children.
    • Parents or children may report somatic symptoms, such as body pain, headaches, and fatigue.

The interventions listed below have been used within the NCTSN to address trauma among refugee youth and families.

Trauma Systems Therapy for Refugees

Individual, Family, Systems

TST-R is a comprehensive method for treating traumatic stress in children and adolescents that adds to individually-based approaches by specifically addressing social environmental/system-of-care factors that are believed to be driving a child’s traumatic stress problems.