Mental Health Of Refugee Children
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Mental Health of Refugee Children

Mental health of refugee children is often affected by pre-migration as well as post-migration stressors.[1]:p.17 Compared to other immigrants, refugee children are more likely to have serious problems associated with malnutrition, disease, physical injuries, brain damage and sexual or physical abuse.[2]:p.5 These problems may affect the child's cognitive, social and emotional development, leading to serious mental deficiencies/illnesses including post-traumatic stress disorder (PTSD), anxiety and depression.[2]:p.5

Bantu refugee children from Somalia at a farewell party in Florida before being relocated to other places in the United States.

Nearly half of refugees are children, and almost one in three children living outside their country of birth is a refugee.[3] These numbers encompass individuals whose refugee status has been formally ascertained, as well as individuals in refugee-like situations with the similar protection concerns. Since 1980, 1.8 million refugees have been permitted to live in the United States, 40% of whom have been children. An estimated 95% of them resettle with their parents.[4] About 80% of the world's refugees are hosted by developing countries.[4] Presently, the countries from which most refugees originate include Afghanistan, Iraq, Somalia and Sudan.[4]

Key legal protections related to children, migration, and displacement

The Convention on the Rights of the Child, the most widely ratified human rights treaty in history, includes four articles that are particularly relevant to children involved in or affected by migration and displacement:[5]

  • the principle of non-discrimination (Article 2)
  • best interests of the child (Article 3)
  • right to life and survival and development (Article 6)
  • the right to child participation (Article 12)

States Parties to the Convention are obliged to uphold the above articles, regardless of a child's migration status.[5] As of November 2005, a total of 192 countries have become States Parties to the Convention.[6] Somalia and the United States are the only two countries that have not ratified the Convention.[6]

The United Nations 1951 Convention on the Status of Refugees provides a comprehensive legal code regarding the rights of refugees at the international level, defining what it means to be a refugee.[7] Providing protection to people who experience persecution and torture in their home countries, the Convention views refugees as people who are incapable of or reluctant to go back to their country of origin.[7]

The international definition of a refugee provided by the United Nations 1951 Convention is rigid and concerned more with violence and persecution.[8] For countries that have ratified it, the Convention serves as the primary basis for determining the status of a refugee. Although poor economic and environmental conditions are the forces driving the majority of people to seek refuge in other countries, the 1951 Convention on the Status of Refugees does not consider environmental and economic factors.[9] Different countries or continents may utilize a more context-specific definition. For instance, some countries have granted refugee status not based exclusively on persecution. For instance, the African Union specifically accommodates people affected by external aggression, occupation, foreign domination, and events seriously disturbing public order.[10] South Africa has also granted refugee status to Mozambicans and Zimbabweans following the collapse of their home countries' economy.[11]

Other international legal protection includes two of the Protocols supplementing the United Nations Convention against Transnational Organized Crime that reference child migration: (1) the Protocol to Prevent, Suppress, and Punish Trafficking in Persons, especially Women and Children;[12] and (2) the Protocol against the Smuggling of Migrants by Land, Sea, and Air.[13] Additionally the International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families covers the rights of the children of migrant workers in both regular and irregular situations during the entire migration process.

Distinction between asylum-seeking, immigrant, and refugee children

The involuntary nature of refugees' departure distinguishes them from migrant groups who have not undergone forced displacement.[14] Refugees are neither psychologically nor pragmatically prepared for the rapid movement and transition resulting from events outside their control.[14]

Asylum seekers differ from refugees in that asylum seekers are people, after having left their home country involuntarily, whose formal application for asylum in another country has an undetermined status.[15] These individuals require the international protection provided to refugees, but they are awaiting a decision regarding protection from the host country's government. Once they have received a positive response from the host government, they will legally be considered refugees. Refugees have the same rights to education, health, and social services as citizens of the host country, whereas asylum seekers do not.[16] For statistical purposes, the United Nations Children's Fund has included asylum seekers when calculating refugee totals since 2007.[3]

Children who are part of economic migrant families are different from both refugee and asylum-seeking children. According to the United Nations High Commissioner Fund, economic migrants are individuals who leave their home countries "for purely economic reasons."[10] Because they have the capability to decide what would be best for themselves and their families, economic migrants do not satisfy the Convention definition of a refugee.[10]

Unaccompanied children

Unaccompanied children are minors who are separated from their families once they reach the host country, or minors who decide to travel from their home countries to a foreign country without a parent or guardian.[8] Bhabha (2004) argues that it is more challenging for unaccompanied children than adults to gain asylum, as unaccompanied children are usually unable to find appropriate legal representation and stand up for themselves during the application process.[17] In Australia, for instance, unaccompanied children, who usually do not have any kind of legal assistance, must prove beyond any reasonable doubt that they are in need of the country's protection.[18] Many children do not have the necessary documents for legal entry into a host country, also often avoiding officials due to fear of being caught and deported to their home countries.[19]

Without documented status, unaccompanied children often face challenges in acquiring education and health care in many countries. These factors make them particularly vulnerable to hunger, homelessness, and sexual and labor exploitation.[20] Displaced youth, both male and female, are vulnerable to recruitment into armed groups.[21] Unaccompanied children may also resort to dangerous jobs to meet their own survival needs.[22] Some may also engage in criminal activity or drug and alcohol abuse.[23][24][25] Girls, to a larger extent than boys, are vulnerable to sexual exploitation and abuse, with far-reaching effects on their physical and mental health.[26]

Three stages of the refugee experience

Refugee experiences can be categorized into three stages of migration: home country experiences (pre-migration), transit experiences (transmigration), and host country experiences (post-migration).[8][27][28][29] The pre-migration stage refers to home country experiences leading up to and including the decision to move away. During the transmigration stage, refugees physically relocate to another country. The post-migration stage encompasses the refugee's integration into the social and cultural framework of the host country's society.[29] Both home country and transit experiences may cause significant stress for refugee children.[28] This stress can be exacerbated when the children arrive in the host country and are expected to adapt quickly to a new setting.[30]

Pre-migration factors

Pre-migration experiences include challenges and threats children face that drive them to seek refuge in another country.[31] Schininà, Sharma, Gorbacheva, and Mishra (2011) note that direct or witnessed experiences of violence and sexual abuse may characterize refugee children's pre-migration experiences.[32]

In 2014 the President of Honduras testified in front of the United States Congress that more than three-quarters of unaccompanied child migrants from Honduras came from the country's most violent cities.[33] In fact, 58 percent of 404 unaccompanied and separated children interviewed by the UNHCR about their journey to the United States indicated that they had been forcibly displaced from their homes because they had either been harmed or were under threat of harm.[34]

Protracted conflicts and long-standing political crises are responsible for Asia's largest refugee populations.[3] A 2016 report by the United Nations Children's Fund found that by the end of 2015, five years of open conflict in the Syrian Arab Republic had forced 4.9 million Syrians out of the country, half of which were children. The same report found that, by the end of 2015, more than ten years of armed conflict in Afghanistan had forced 2.7 million Afghans beyond the country's borders; half of the refugees from Afghanistan were children.[3]

Factors leading to mental health illnesses in refugee children are child labour (which includes recruitment as both soldiers and sex slaves), warfare and economic disparity.

  • Refugee children choose to leave their homeland due to poverty, political crisis, violent conditions, persecution, or a lack of protection due to human rights violations.[35]:p.9
  • While fleeing their country of origin, many unaccompanied children are forced to travel with human smugglers who may attempt to traffick them and to exploit these children as workers, such as child sex workers.[36] More children are traveling alone, with nearly 100,000 unaccompanied children in 2015 filing claims for asylum in 78 countries.[3] Children living in volatile economic conditions are particularly vulnerable to traffickers, and young girls are often the primary target of sexual exploitation.[35]:p.9 Many unaccompanied children fleeing from conflict zones in Moldova, Romania, Ukraine, Nigeria, Sierra Leone, China, Afghanistan or Sri Lanka are forced into sex trafficking.[37][35]:p.9 About 1.2 million children are trafficked for labour or sexual exploitation, representing about 50 percent of the 2.4 million people trafficked worldwide.[38]
Former child soldiers in the eastern Democratic Republic of the Congo.
  • During times of war, children can be recruited as child soldiers and placed on the battlefield. Many children are abducted and forced to become soldiers, whereas other children join voluntarily.[39]:p.1 Whether a child is abducted and forced into the army or joins voluntarily, war itself often becomes a part of the child's identity. This phenomenon - combined with the effects of conflict on the physical welfare and mental stability of the child - demonstrates how difficult reintegration may be when they are removed from the unstable environment.[39]:p.3 Former child soldiers are more likely to develop severe mental health problems including symptoms of PTSD, anxiety and depression.[40]
  • War can impair the mental faculties of children. Throughout the past century, the proportion of war victims who are civilians has increased from 5 per cent to over 90 per cent in certain conflict regions, and a majority of the affected civilians are children.[1]:p.9 Refugee children can suffer from physical trauma and mental trauma due to prolonged confrontation with violence.[41]:p.95 Children tend to feel the most helpless and vulnerable during times of conflict, and may experience feelings of shame and loss of self-confidence in their ability to control their own lives. Prolonged experiences with warfare also put children at risk of developing PTSD.[41]:p.95
  • Poverty affects both the physical and mental health of children.[42] Poverty is an important pre-migration factor to consider when characterizing mental illnesses in refugee children because it is intrinsically alienating and distressing. Poverty affects the development and maintenance of emotional, behavioral, and psychiatric problems.[42] Economic disparity can be a determinant and a consequence of poor mental health.[42]

Post-migration factors

Once a child is past the age of six months, their adaptation to their new surroundings is partially determined by the amount of trauma, stress, and violence the child has endured thus far in their lives.[43] Identification with an ethnic group is also important to a child's functioning.[43] Boys are more vulnerable than girls to poorly adapt to their new surroundings because they are less able to adequately articulate their problems. Children adapt easier in new countries when the size of their ethnic group is large, there is a degree of cultural continuity from the home country to the host country, and the ethnic group is maintained in the host country. The idea of a cultural melting pot is not conducive to a child's comfort in their new home, as maintaining cultural roots is more important in the early stages of resettlement. Families represent an important way to help refugee children adapt to their now home.[43]

Following a child's resettlement, the main issues are the adverse effects of a child's potential separation from family members and the stigma that accompanies a refugee during the process of resettlement.

Separation

Refugee children without caretakers have a greater risk of exhibiting psychiatric symptoms of mental illnesses following traumatic stress.[44]:p.9 Unaccompanied refugee children display more behavioral problems and emotional distress than refugee children with caretakers.[44]:p.9 Parental well-being plays a crucial role in enabling resettled refugees to transition into a new society. If a child is separated from his/her caretakers during the process of resettlement, the likelihood that he/she will develop a mental illness increases.[44]:p.17

Stigma

Refugees are at risk of stigmatization due to their race, ethnicity, and/or religion. Refugees can also be stigmatized if they encounter mental health deficiencies prior to and during their resettlement into a new society.[44]:p.14 Differences between parental and host country values can create a rift between the refugee child and his/her new society.[2]:p. 5 Less exposure to stigmatization lowers the risk of refugee children developing PTSD.[44]:p.14

Access to healthcare

Cognitive and structural barriers make it difficult to determine the medical service utilization rates and patterns of refugee children. A better understanding of these barriers will help improve mental health care access for refugee children and their families in North America.[45]

Cognitive and emotional barriers

Many refugees develop a mistrust of authority figures due to repressive governments in their country of origin. Fear of authority and a lack of awareness regarding mental health issues prevent refugee children and their families from seeking medical help.[46]:p.76 Certain cultures use informal support systems and self-care strategies to cope with their mental illnesses, rather than rely upon biomedicine.[47]:p.279 Language and cultural differences also complicate a refugee's understanding of mental illness and available health care.[47]:p.280

Other factors that delay refugees from seeking medical help are:[47]:p.284

  • Fear of discrimination and stigmatization
  • Denial of mental illness as defined in the Western context
  • Fear of the unknown consequences following diagnosis such as deportation, separation from family, and losing children
  • Mistrust of Western biomedicine

Structural barriers

Upon arrival to their host country, refugees encounter language barriers, a lack of culturally-competent care, cost complications, a lack of public awareness and access to information about available resources, and administrative deterrents for health care providers to take on refugee patients that prevent access to adequate mental health care services.

Language barriers

A broad spectrum of translation services are available to all refugees, but only a small number of those services are government-sponsored. Community health organizations provide a majority of translation services, but there are a shortage of funds and available programs.[48] Since children and adolescents have a greater capacity to adopt their host country's language and cultural practices, they are often used as linguistic intermediaries between service providers and their parents.[2] This may result in increased tension in family dynamics where culturally sensitive roles are reversed. Traditional family dynamics in refugee families disturbed by cultural adaptation tend to destabilize important cultural norms, which can create a rift between parent and child. These difficulties cause an increase of depression, anxiety and other mental health concerns in culturally-adapted adolescent refugees.[2]

Relying on other family members or community members has equally problematic results where relatives and community members unintentionally exclude or include details relevant to comprehensive care.[48] Health care practitioners are also hesitant to rely on members of the community because it is breaches confidentiality.[49]:p.174 A third party present also reduces the willingness of refugees to trust their health care practitioners and disclose information.[49] Patients may receive a different translator for each of their follow-up appointments with their mental health care providers, which means that refugees need to re-tell their story via multiple interpreters, further compromising confidentiality.[48]

Culturally competent care

Culturally competent care exists when health care providers have received specialized training that helps them to identify the actual and potential cultural factors informing their interactions with refugee patients.[48]:p.524 Culturally competent care tends to prioritize the social and cultural determinants contributing to health, but the traditional Western biomedical model of care often fails to acknowledge these determinants.[48]:p.527

To provide culturally competent care to refugees, mental health care providers should demonstrate some understanding of the patient's background, and a sensitive commitment to relevant cultural manners (for example: privacy, gender dynamics, religious customs, and lack of language skills).[48]:p.527 The willingness of refugees to access mental health care services rests on the degree of cultural sensitivity within the structure of their service provider.[48]:p.528

The protective influence exercised by adult refugees on their child and adolescent dependents makes it unlikely that young adult-accompanied refugees will access mental healthcare services. Only 10-30% of youth in the general population, with a need for mental healthcare services, are currently accessing care.[50]:p.342 Adolescent ethnic minorities are less likely to access mental healthcare services than youth in the dominant cultural group.

Parents, caretakers and teachers are more likely to report an adolescent's need for help, and seek help resources, than the adolescent.[50]:p.348 Unaccompanied refugee minors are less likely to access mental health care services than their accompanied counterparts. Internalizing complaints (such as depression and anxiety) are prevalent forms of psychological distress among refugee children and adolescents.[50]:p.347

Other obstacles

Additional structural deterrents for refugees:

  • Complicated insurance policies based on refugee status (e.g. Government Assistant Refugees vs. Non-), resulting in hidden costs for refugee patients[51]:p.47 According to the United States Office of Refugee Resettlement, an insurance called refugee Medical Assistance is available in the short term (up to 8 months), while other such as Medicaid and CHIP are available for several years.[52]
  • Lack of transportation[53]:p.600
  • A lack of public awareness and access to information about available resources[54]:p.77
  • An unfamiliarity with the host country's healthcare system, amplified by a shortage of government or community intervention in settlement services[55]:p.600

Structural deterrents for healthcare professionals:

  • Heightened instances of mental health complications in refugee populations[56]:p.47
  • A lack of documented medical history, which makes comprehensive care difficult[56]:p.49
  • Time constraints: medical appointments are restricted to a small window of opportunity, making it difficult to connect and provide mental health care for refugees[57]:p.93
  • Complicated insurance plans, resulting in a delay in compensation for the healthcare provider[58]:p.174

Access to education

Adapting to a new school environment is one of the major tasks facing refugee children when they arrive in a new country or refugee camp.[59] Although education is crucial in the psychosocial adjustment and cognitive growth of refugee children,[60] a maximum of 50% of refugee children at the primary education level are enrolled in school.[61] Due to these circumstances, it is important for educators consider the needs, obstacles, and successful educational pathways for children refugees.[4]

Issues faced

Structure of the education system

Schools in North America lack the necessary resources for supporting refugee children, particularly in negotiating their academic experience and in addressing the diverse learning needs of refugee children.[62] Complex schooling policies that vary by classroom, building and district, and procedures that require written communication or parent involvement intimidate the parents of refugee children.[62] Educators in North America typically guess the grade in which refugee children should be placed because there is not a standard test or formal interview process required of refugee children.[63]:p.189

Sahrawi refugee children learning Arabic and Spanish, math, reading and writing, and science subjects.

The ability to enroll in school and continue one's studies in developing countries is limited and uneven across regions and settings of displacement, particularly for young girls and at the secondary levels.[64] The availability of sufficient classrooms and teachers is low and many discriminatory policies and practices prohibit refugee children from attending school.[64] Educational policies promoting age-caps can also be harmful to refugee children.[63]:p.176

Residence

Refugee children who live in large urban centers in North America have a higher rate of success at school, particularly because their families have greater access to additional social services that can help address their specific needs.[63]:p.190 Families who are unable to move to urban centers are at a disadvantage.

Language barriers and ethnicity

Acculturation stress occurs in North America when families expect refugee youth to remain loyal to ethnic values while mastering the host culture in school and social activities. In response to this demand, children may over-identify with their host culture, their culture of origin, or become marginalized from both.[65] Insufficient communication due to language and cultural barriers may evoke a sense of alienation or "being the other" in a new society. The clash between cultural values of the family and popular culture in mainstream Western society leads to the alienation of refugee children from their home culture.[62]

Many Western schools do not address diversity among ethnic groups from the same nation or provide resources for specific needs of different cultures (such as including halal food in the school menu). Without successfully negotiating cultural differences in the classroom, refugee children experience social exclusion in their new host culture.[62] The presence of racial and ethnic discrimination can have an adverse effect on the well-being of certain groups of children and lead to a reduction in their overall school performance.[63]:p.189

Other obstacles

Although high-quality education helps refugee children feel safe in the present and enable them to be productive in the future, some do not find success in school.[66]:p.67 Other obstacles may include:[46]

  • Disrupted schooling - refugee children may experience disruptive schooling in their country of origin, or they may receive no form of education at all. It is extremely difficult for a student with no previous education to enter a school full of educated children.[66]:p.71
  • Trauma - can impede the ability to learn and cause fear of people in positions of authority (such as teachers and principals)[46]:p.340
  • School drop outs - due to self-perceptions of academic ability, antisocial behaviour, rejection from peers and/or a lack of educational preparation prior to entering the host-country school. School drop outs may also be caused by unsafe school conditions, poverty, etc.[46]:p.341
  • Parents - when parental involvement and support are lacking, a child's academic success decreases substantially. Refugee parents are often unable to help their children with homework due to language barriers. Parents often do not understand the concept of parent-teacher meetings and/or never expect to be a part of their child's education due to pre-existing cultural beliefs.
  • Assimilation - a refugee child's attempt to quickly assimilate into the culture of their school can cause alienation from their parents and country of origin and create barriers and tension between the parent and child.[46]:p.340-344
  • Social and individual rejection - hostile discrimination can cause additional trauma when refugee children and treated cruelly by their peers[46]:p.350
  • Identity confusion[46]:p.352
  • Behavioral issues - caused by the adjustment issues and survival behaviours learned in refugee camps[46]:p.355

Developments

Role of teachers

North American schools are agents of acculturation, helping refugee children integrate into Western society.[60]:p.291 Successful educators help children process trauma they may have experienced in their country of origin while supporting their academic adjustment.[67] Refugee children benefit from established and encouraged communication between student and teacher, and also between different students in the classroom.[67] Familiarity with sign language and basic ESL strategies improves communication between teachers and refugee children.[59] Also, non-refugee peers need access to literature that helps educate them on their refugee classmates experiences.[67] Course materials should be appropriate for the specific learning needs of refugee children and provide for a wide range of skills in order to give refugee children strong academic support.[59]

Classroom environment

Refugee children thrive in classroom environments where all students are valued. A sense of belonging, as well as ability to flourish and become part of the new host society, are factors predicting the well-being of refugee children in academics.[65] Increased school involvement and social interaction with other students help refugee children combat depression and/or other underlying mental health concerns that emerge during the post-migration period.[68]

Parent - teacher relationship

Educators should spend time with refugee families discussing previous experiences of the child in order to place the refugee child in the correct grade level and to provide any necessary accommodations[63]:p.189 School policies, expectations, and parent's rights should be translated into the parent's native language since many parents do not speak English proficiently. Educators need to understand the multiple demands placed on parents (such as work and family care) and be prepared to offer flexibility in meeting times with these families.[59][62]

Supporting the academic adjustment of refugee children

Syrian refugee children attend a lesson in a UNICEF temporary classroom in northern Lebanon, July 2014

Teachers can make the transition to a new school easier for refugee children by providing interpreters.[67] Schools meet the psychosocial needs of children affected by war or displacement through programs that provide children with avenues for emotional expression, personal support, and opportunities to enhance their understanding of their past experience.[69]:p.536 Refugee children benefit from a case-by-case approach to learning, because every child has had a different experience during their resettlement. Communities where the refugee populations are bigger should work with the schools to initiate after school, summer school, or weekend clubs that give the children more opportunities to adjust to their new educational setting.[67]

Bicultural integration is the most effective mode of acculturation for refugee adolescents in North America. The staff of the school must understand students in a community context and respect cultural differences.[46]:p.331 Parental support, refugee peer support, and welcoming refugee youth centers are successful in keeping refugee children in school for longer periods of time.[46]:p.334 Education about the refugee experience in North America also helps teachers relate better with refugee children and understand the traumas and issues a refugee child may have experienced.[46]:p.333

Case study

Vietnamese refugees

Vietnamese refugee mother and children at a kindergarten in upper Afula, 1979.

Most of these refugees have minimal formal education and little English proficiency. Upon arrival in the US, Vietnamese households are usually large including minor children, married children, grandchildren, other relatives and non-relatives.[70]:p.5

Vietnamese children face many problems within their schools and are affected by the backgrounds of schoolmates alongside their own backgrounds. These differentiations in backgrounds and cultures place them at a higher risk of pursuing disruptive behaviour.[70]:p.7 Contemporary Vietnamese American adolescents are prone to greater uncertainties, self-doubts and emotional difficulties than other American adolescents. Vietnamese children are less likely to say they have much to be proud of, that they like themselves as they are, that they have many good qualities, and that they feel socially accepted.[70]:p.11

Despite these issues and the fact that Vietnamese children attend urban public schools that many middle-class families have abandoned, they are making significant progress in education. Vietnamese adolescents are less likely than their American peers to drop out of high school, and Vietnamese young adults were more likely than their American peers to attend college.[70]:p.10

See also

References

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