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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.

Cultural Considerations

Cultural considerations and mental health:

• Perception of the term “mental health” and explanations for mental health symptoms vary widely across cultures.
• Refugee and minority groups underutilize traditional mental health services in the US. Barriers to care can include language, stigma, limited cultural sensitivity of service providers, and access issues such as transportation.
• Be careful about using language such as “mental health” or “depression.” Naming specific behaviors or talking about concepts (“stress” or “adjustment”) may be more acceptable in some cultures.

Preparing to work with refugee children and families:

• Learn about the general culture of the family or community with whom you are working with, keeping in mind that there is variation within every cultural group and family (for more information on cultural resources click here).
• Identify how to access linguistic support and cultural resources (e.g., interpreters). Locate other service providers working with this community and consider meeting with them to discuss consultation or collaboration.
• Assess the barriers to care that apply to your agency, clinic, or practice. Work with local support services to address the obstacles you identify, such as location of services, transportation issues, or stigma associated with mental health services.

Child/Youth Considerations

• Consider a history of trauma for the child and/or family when refugee children are referred for behavioral, attention, or other general mental health concerns.
• Refugee children may present with a range of possible symptoms  associated with traumatic stress (for more description click here).
• Symptoms associated with traumatic stress may be expressed in different ways related to a child’s age or developmental level (for more information click here).
• Children may report physical symptoms such as body pain, headaches, or fatigue.
• Some refugee children may struggle to adjust to new cultural norms and expectations, new school environment (for more on schools click here), and a new language.

Preparing to work with refugee children and families:

• Refugee children and their parents may experience acculturation differently. As a result, acculturative stress may heighten family conflict, particularly during adolescence.
• A parent or caregiver may have a history of trauma or current experience of trauma that can affect his or her parenting behaviors.  
• During resettlement parents and children may experience shifts in their family and gender roles (e.g., a father who worked full time is now home with the children) which can affect family functioning.
• Parents may encounter new challenges in parenting related to their child’s exposure to a different culture and community structure. As a result, they may find that parenting strategies that worked in their own culture are less effective.
• Intergenerational trauma can also affect children and adolescents. Even when they have not directly experienced traumatic events, children can be effected by stories that parents and other family members recall and retell.
• Disciplinary strategies such as corporal punishment may be more common in some cultures. Refugee families are informed of US child welfare policies at the time of resettlement; however, parents may need help in learning alternative strategies for addressing behavioral concerns. 

Family Considerations

Welcoming refugee children and families into your practice:

• Provide culturally informed and linguistically sensitive services by using cultural brokers or interpreters when possible (for more on finding and using interpreters and cultural brokers link).
• Acknowledge the refugee experience, including both the difficulties that they may have been through and their resilience/strengths in facing/overcoming these obstacles. Ask families how they came to the US, where they were living before, and/or what is the family’s country of origin.
• Ask questions to familiarize yourself with the child’s culture and language; don’t make assumptions.
• Explain the process of your involvement and frame your role as a helper, as many families may not feel comfortable with or be familiar with mental health services. For example, describe to families how you might “help your child do well in school because it can be difficult adjusting to a new culture.”
• Respect existing roles within families (e.g., even if children speak better English than a parent, do not use them as interpreters).

Provider Considerations

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.

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.