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date: 19 December 2018

Mental Health of Migrant Children

Summary and Keywords

The psychosocial well-being of migrant children has become an urgent issue facing many Western countries as the number of migrant children in the population increases rapidly and health-care systems struggle to support them. Often, these children arrive with extensive exposure to trauma and loss before facing additional stressors in the host country. Yet, these children do not access mental health support even when available due to multiple barriers. These barriers include cultural and linguistic barriers, the primacy of resettlement needs, and the stigma attached to mental health illness. In order to improve mental health services for migrant children, there is a need to move away from focusing on trauma and mental health symptoms and to look instead at migrant children’s well-being across multiple domains, including activities that can promote or diminish psychological well-being. Trauma Systems Therapy for Refugees (TST-R) is an example of an approach that has succeeded in overcoming these barriers by adopting a culturally relevant and comprehensive approach to mental health care.

Keywords: migrant, refugees, cultural brokering, mental health, trauma, Trauma Systems Therapy for Refugees

The Western world is facing a historical number of migrants arriving at their borders. Migrants can include both those who leave their country of birth seeking better opportunities, as well as those displaced by war and other conflicts (e.g., Bhugra, 2004; Rogler, 1994). In this article, the term “migrant” is used to describe all those who leave their country of origin and arrive in another country. Special attention is paid to refugees, who are a unique group among migrants. It is important to note that often terms such as “refugee,” “asylum seeker,” and “migrant” can be very political. They can be used to grant or deny services and legal status to remain in the host country.

Worldwide the number of displaced people has reached unprecedented heights with over 65.6 million people displaced from their places of habitual residence (UNHCR, 2017). Over 40% of those of displaced persons around the world are children (UNHCR, 2017). Within the number of displaced people are refugees who represent a unique population. The refugee status is codified in Article 1 of the United Nations Convention on the status of refugees. To gain this status a person must be outside of their country of habitual residence and must be unable to return due to fear of persecution based on group membership (UN General Assembly, 1951). As of 2017, there are close to 23 million refugees around the world and over 50% of refugees are children under the age of 18 (UNHCR, 2017). In countries where conflict uproots populations, children are often severely impacted due to their greater vulnerability, according to the United Nations High Commissioner for Refugees (UNCHR, 2017).

While much of the burden of refugees and other migrants falls on neighboring countries with Turkey, Jordan, and Lebanon hosting the majority of Syrian refugees, many refugees dream of reaching the West where they believe they are more likely to build a better future for themselves or their children (UNHCR, 2017). This has led to thousands of refugees taking dangerous journeys to reach Europe. While many have died trying to find a safe haven, large numbers have succeeded in reaching European shores (Taylor, 2017). Since 1990, millions of migrants from the south have arrived on the shores of the European Union/Europe. Countries such as Germany, Britain, and France are now faced with the task of supporting these large numbers of refugees so that they can successfully integrate. Canada has generously opened its doors to Syrian refugees, resettling more than 50,000 since 2015. While policy changes by the new administration have slowed the flow of refugees into the United States, the United States still hosts a large number of refugees because of the historic numbers allowed in prior to and during the Obama administration.

In addition, the United States has its own migration crisis and hosts populations who, while not having the refugee status, have similar experiences of trauma and loss. The terms that are used to define different groups of migrants can often seem confusing and arbitrary. While who is a refugee is often clear if we go back the UN-granted status, there are children who meet that definition and are not granted the status due to politics (Belhadj Kouider, Koglin, & Petermann, 2014). For example, many of the youth from the Northern Triangle (Guatemala, Honduras, and El Salvador) face violence and loss similar to that faced by children from war-torn countries, and yet those children do not receive the refugee designation nor get the same protections as children from Syria (Berthold & Libal, 2016).

Regardless of the status granted, in many Western countries, the percentages of children who are first- or second-generation immigrants are fast growing as a result of this increase in displacement and migration worldwide. As a result, we are seeing an increase in the percentage of children who are migrants in our communities, hospitals, and schools (Belhadj Kouider et al., 2014). In the United States, for example, migrant children already represent a quarter of all children; and in some European countries, the numbers are even higher with 39% of children in Switzerland and 26% of children in Germany being first- or second-generation migrant children (Belhadj Kouider et al., 2014).

Many migrant children and families arrive with extensive histories of trauma and loss and face additional stressors in resettlement (Fazel et al., 2014; Stermac, Elgie, Clarke, & Dunlap, 2012). In most instances, these migrants arrive without warning and overwhelm the systems of care of the host country. Reception services are often focused on meeting the basic needs of these refugees such as food and shelter. Mental health needs are not addressed when migrant children arrive unless the person is in such acute distress that they cannot function without receiving care (Bronstein & Montgomery, 2011). This oversight is problematic because the migration experience makes mental health one of the key issues that must be addressed to support the successful integration of migrant children into the host communities. This is especially true of refugee children who have a higher prevalence of both exposures to traumatic events and higher levels of mental health symptoms such as posttraumatic stress disorder (PTSD) and depression compared to the general population (Betancourt, Frounfelker, Mishra, Hussein, & Falzarano, 2015a; Fazel, Wheeler, & Danesh, 2005; Oort et al., 2007).

This article will discuss the experiences of refugee and other migrant children and families during pre-flight, flight, and resettlement. It will then look at the gaps in the current approach to supporting these vulnerable children. It will then present a model program that seeks to address these gaps and has been successful in engaging this population in mental health services. Finally, it will use a case vignette to illustrate how providers can engage refugee and other migrant youth by reframing care in two key ways. First, by moving from a Western framing focused on individual symptoms toward a family/community-oriented holistic approach and, second, from a deficit-based medical model toward a resilience and strength-based model that builds on strength and resources that already exist in the community.

Psychological Impact of Migration on Children

There is strong evidence that the migration experience can negatively impact the psychological well-being of migrant children (Bhugra, 2004; DuPlessis & Cora-Bramble, 2005; Fichter et al., 1988; Stevens, Vollebergh, Pels, & Crijnen, 2007; Stevens & Vollebergh, 2008). The migration experience is often said to involve three distinct stages: pre-migration, during migration, and post-migration. Migrant children often face multiple stressors in each of these stages, and their mental health status is impacted by levels of stress experienced during these different stages of migration (Kirmayer et al., 2011). In their country of birth, children might see family members killed or attacked. They are forced to leave all they know behind and undertake dangerous and uncertain journeys. For example, children from Latin America who migrate to the United States might face physical violence, separation from family members, and forced displacement (Chavez & Menjívar, 2010; Locke, Southwick, McCloskey, & Fernández-Esquer, 1996). During flight, children and their caregivers often face hunger and threats to their lives, such as from human smugglers or coyotes who are hired to bring children from Latin America to the United States (Berthold & Libal, 2016) or from dangerous and often deadly transoceanic journeys in the case of migrants from the Middle East and Africa. In this stage, these children and their families face hunger, homelessness, and constant fear of being harmed.

Once they arrive in the country of asylum, migrant children often face new stressors, including community violence and xenophobia, the stress of adapting to a new culture and language, inappropriate placement in school, and the stress of uncertain status and potential deportation (Betancourt et al., 2015b; Berthold & Libal, 2016). The stress related to legal status is especially cruel, as it means that the sense of accomplishment for arriving in the desired destination is replaced by the fear the family might now face a long road to achieving permanent legal status. As countries of asylum are overwhelmed by the number of arrivals and enact more stringent immigration policies to try and stem the flow, the safety of these places is no longer guaranteed; the threat of being rejected and removed creates additional traumas and worse outcomes for migrant children.

In addition to the fear of being deported, migrant children face other traumas in resettlement as their families are often resettled in high-crime areas where they are exposed to community violence and where they often face discrimination and harassment (Berthold, 2000; Pumariega, Rothe, & Pumariega, 2005). Thus, migrant children and their families come to host countries with a history of trauma exposure and loss, which is often exacerbated by stressors faced in the country of settlement. These experiences could lead to youth experiencing higher levels of mental health distress. Research has shown that refugee and migrant children, especially those from conflict zones, experience higher levels of trauma than native-born children (Merikangas et al., 2010; Betancourt et al., 2015a). There is also evidence that some migrant children experience more mental health issues compared to children born in the resettlement country. For example, due to the experience of violence in the countries of birth and during migration, refugee children often report higher trauma exposure than native-born children (Hadfield, Ostrowski, & Ungar, 2017; Hjern, Angel, & Jeppson, 1998; Montgomery, 2008; Tousignant et al., 1999). Furthermore, migrant children are at risk for a higher prevalence of mental health disorders such as PTSD (e.g., Munroe-Blum, Boyle, Offord, & Kates, 1989). Research by Kia-Keating & Ellis (2007) shows that young refugees have experienced, on average, 7.7 traumatic events with a range of 0 to 22. This same research showed that one in three refugee youth sampled met the full criteria for PTSD. It is not only refugee children who arrive in host countries with trauma and its impacts. Other migrant children also bring with them experiences of trauma similar to those experienced by refugees, despite not having the official refugee designation in host countries (Berthold & Libal, 2016).

Barriers to Access to Care and Gaps in Mental Health Services for Migrant Children

Despite the higher trauma exposure and the presence of mental health needs, immigrant and refugee children are less likely to access mental health services and to face greater barriers to care than native-born children (Ellis et al., 2011; Nadeau & Measham, 2006). Why are these children not accessing these services despite the obvious need? In some instances, mental health services are not available or are not accessible due to factors that are beyond the caregiver’s control, but migrant children often do not access mental health services even when they are available. Multiple barriers to mental health care have been identified, including stigma attached to mental illness, lack of culturally and linguistically appropriate services, as well as the primacy of basic needs such as housing and employment that families struggle to secure in their new home (Ellis, Miller, Baldwin, & Abdi, 2011; Lustig et al., 2004.). The lack of culturally and linguistically accessible services has been cited as one of the primary barriers to care for refugees (e.g., Cheng, Drillich, & Schattner, 2015). Often, due to culturally different beliefs and understandings around psychological stress, migrant families may have a different explanation for a child’s symptoms and may not trust the help offered by providers (Rousseau et al., 2007). Furthermore, providers often lack the cultural and linguistic resources to explain diagnoses and treatment in a culturally relevant way. Additionally, parents might not wish to have the stigma of mental illness associated with their children whose safety and survival was the motivating force for their undertaking a dangerous journey (Baily, 2017). Moreover, migrant families might prioritize everyday needs over mental health needs as they strive to build a new life in a new country. This primacy of concrete needs has been identified as one of the key barriers that could prevent refugees and other migrants from seeking help for mental health symptoms that may not be seen as a priority compared to the urgency of meeting basic needs. This continues to be the case even when mental health symptoms may be interfering with achieving resettlement goals. Finally, families might not be able to identify the mental health needs as easily as they are able to identify the challenges of resettlement. Thus an approach that integrates both psychological and resettlement needs may be more acceptable than one that is solely focused on mental health symptoms (Betancourt et al., 2015a).

Housing and employment are seen as crucial to successful resettlement, and both the refugees and those tasked with helping them are focused on securing those key resources. However, in the United States, the refugee resettlement program does not require refugee resettlement agencies to ensure that refugees are connected to mental health services. Even when a refugee is exhibiting mental health symptoms such as depression or PTSD, he or she often refuses to slow down for mental health counseling or to seek help for these symptoms. Often when a refugee is referred to a mental health provider and is offered counseling to help with symptoms, the response might be “my symptoms will get better once I secure (put here any concrete need such as housing/good job/good school/family reunification)” (Rousseau, Measham, & Nadeau, 2013). Clinicians are often told, “Talking will not help me but if you help me with those things, I will feel better.” The migrant is thus focused on obtaining basic material necessities and reestablishing normal life as soon as possible; they do not wish to talk about “problems” she or he perceives as unhelpful rumination on bad things that happened in the past and cannot be changed. The presenting symptoms are often perceived as transitory and attributed to current stressors rather than a history of trauma and loss. Of course, both are often contributing factors. The current stressors exasperate the symptoms that may be due to past traumas and tasks that are key to success in the host country may be impeded by past traumatic experiences increasing stress and symptoms. Nevertheless, it is hard to engage migrants in mental health services without addressing their concrete needs (Rousseau, Measham, & Nadeau, 2013).

Additionally, even when services are available, the way we structure service provision might itself represent a barrier. The Western medical model is usually focused on working with the individual child rather than addressing the social ecology in which the child lives (Miller & Jordans, 2016). Services are framed as addressing a “deficit” that must be “cured” for the child, and the cure that is being offered is something that is not known to the family and its culture. This is problematic and disempowering because at a point when migrant families feel that they have an achieved a long-sought dream, they are told that the horrific experiences they overcame are going to have long-lasting negative effects on their children. This snatches a victory from their hands by telling them their child will not achieve the goals that they fought so hard to give him or her, such as academic and professional success. Even worse, families are asked to depend on an alien system of care and models of healing for their child’s recovery, leaving them helplessly dependent on Western “experts” for solutions. This deficit-based approach has been argued to potentially “diminish the capacity of human beings to deal with anxiety and suffering, deny their resilience, render them incapacitated by their trauma and indefinitely dependent on external actors for their psychosocial survival” (Gozdziak, 2004, p. 206).

To improve mental health outcomes for migrant children there is a need for programs that address the identified barriers and engage families in a more holistic and meaningful way. This can be done by realizing that these barriers are interconnected. Stigma cannot be reduced and trust cannot be built without overcoming the linguistic and cultural barrier; the primacy of concrete needs has to be addressed in order to both engage migrant families but also to reduce new stressors that can exacerbate the mental health symptoms. There is a need to move away from Western conceptualization of mental health and take a more holistic approach that integrates values, experiences, and worldviews of the population being served. This includes shifting from deficiency-based approaches to a resilience- and strength-based one, paying attention to the urgent concrete needs of families and forming collaborative alliance with communities. Ultimately, the goal is that mental health services will not be seen as something outside of the daily lives and cultural frames of the community served but rather as an integrated part of their daily lives that enhance what is already working. This also means prioritizing the relief of current stressors, including discrimination and xenophobia, which exacerbate psychological symptoms and reduce the sense of safety and belonging that can promote healing.

Promising Approaches: A Social-Ecological and Culturally Relevant Mental Health

Given the diverse experience of migrant children and the failure of existing models to meet their needs, there is a need to develop an innovative approach that overcomes the identified barriers and engages children and their families in services. The knowledge to do this is already there. Experts in refugee and migrant mental health have identified key characteristics that a successful mental health intervention for this population must contain. The American Psychological Association recommends that services for refugee youth should be comprehensive, culturally relevant, and community based as well as use practice-based evidence with evidence-based practices (APA, 2010). The Interagency Standing Committee (IASC) of United Nations and other humanitarian organizations endorse a stepwise pyramid approach that focuses on helping families and children secure basic necessity and then working toward higher-level mental health support services. This represents an ideal model for working with refugees and others displaced by conflict or violence (Measham et al., 2014). Many subject area experts agree that in order to be effective, mental health interventions must pay attention to the linguistic and cultural needs of the community served; they must also be holistic, address needs beyond what is traditionally considered mental health, and be in partnership with the community being served. These recommendations have been adopted by providers and have shown promise in engaging and enhancing mental health services for refugees and other migrants (Ellis et al., 2011; Murray, Davidson, & Schweitzer, 2010).

An example of a successful intervention with a specific group of migrant children that uses this pyramid approach is Trauma Systems Therapy for Refugees (TST-R). Trauma Systems for Refugees is an adaptation of Trauma Systems Therapy (Saxe, Ellis, & Kaplow, 2006), an evidence-based intervention that is premised on the belief that a trauma system is composed of a child who is unable to self-regulate and a social environment that is unable to provide the support necessary to help the child self-regulate. TST-R layers TST with attention to cultural and linguistic needs of refugees and a commitment to address social environmental stressors that uniquely impact migrant children’s psychological well-being. It employs a cultural broker in order to enhance both community and family engagement and provider cultural knowledge when serving migrant communities. A cultural broker is a professional who combines cultural and clinical expertise and who acts as a bridge between the clinical team and the community. Cultural brokering is “the act of bridging, linking, or mediating between groups or persons of differing cultural backgrounds” (Goode, Sockalingam, & Snyder, 2004; Jezewski, 1990). In TST-R, cultural-brokering maintains key components of cultural competency such as enhancing the cross-cultural knowledge and skills of service providers (Kohn-Wood & Hooper, 2014), but combines it with aspects of cultural humility such as the importance of self-awareness and self-evaluation and the need for providers to recognize their own biases (Tervalon & Murray-Garcia, 1998). Practices combining cultural competence and cultural humility can promote provider cultural knowledge while at the same time ensuring that providers and their institutions are listening to the communities they serve.

TST-R was specifically created to address the multiple barriers faced by migrant children in need of mental health interventions. It addresses the cultural and linguistic barriers, the stigma attached to mental health, and the primacy of concrete needs. Part of the TST-R team approach is to provide advocacy to support everyday hassles so that a family’s daily stressors are reduced and the potential for worsening of psychological symptoms is averted. The team uses a social-ecological model (Bronfenbrenner, 1979) based assessment to evaluate the child and family’s needs in multiple domains, which are identified as refugee core stressors.

Mental Health of Migrant ChildrenClick to view larger

Figure 1. Refugee children and youth core stressors.

Reprinted from Refugee Trauma and Resilience Center, 2018. Reprinted with permission.

Mental Health of Migrant ChildrenClick to view larger

Figure 2. Trauma Systems Therapy for Refugees (TST-R) Multi-Tiered Prevention and Intervention Model.

Reprinted from Mental Health in Refugee and Post-Conflict Populations by M. A. Benson, S. M. Abdi, A. B. Miller, and B. H. Ellis (in Press). Reprinted with permission.

TST-R thus is not only an intervention that addresses mental health symptoms but also issues such as housing, school placement, and acculturation to ease resettlement stressors and promote family and child functioning.

The TST-R clinical team includes a clinician and a cultural broker. The team expands to include other service providers as needed. For example, a family struggling with legal issues may be referred to a lawyer who works closely with the team. In addition, the clinical team partners with ethnic-based community agencies to provide services that are tailored to the specific needs of migrant families and to extend the clinical team’s capacity to address concrete support. TST-R teams usually focus on specific cultural communities to try and tailor the intervention to their needs. In places where there are not enough numbers to warrant that kind of focus and resources, they might bring together a group of migrant populations that share similar experiences and engage diverse cultural experts to provide cultural knowledge and support.

TST-R is tiered intervention with cultural brokering and support integrated into each tier.

The first tier focuses on laying the foundation for a collaborative relationship with the community and building trust by forming partnerships and providing psycho-education around mental health needs for the whole community. The second tier focuses on providing social support to refugee and migrant children through social-skills building in school-based groups. These groups allow us to support children without the stigma attached to mental health diagnoses while also connecting migrant youth to services, thus allowing for the identification of youth who need a higher level of care. Finally, those youth identified as needing individual therapy or an even more intense family-focused intervention can be engaged into services in tiers 3 and 4. Often the first two tiers laid the foundation for access to higher-level services for children needing more individualized clinical care. Through the building of partnerships in the first two tiers, families form a trusting relationship with providers and community psycho-education, and the partnership with cultural brokers reduces stigma and provides linguistic and cultural support.

Through the cultural brokers who act as patient navigators/case managers, families are supported to access other needed resources as part of clinical services. Sometimes the greatest need a migrant family has is reading the mail, if they cannot read the language of the host country. This may be causing much psychological distress given the importance of some of the papers they are waiting for, such as a notification about their immigration status. Thus having someone who speaks their language and who they can go to for support around resettlement stressors creates a place of safety and support. These concrete services may reduce daily stressors. Cultural brokers also act as gateway providers to more mental health services. They build a relationship of trust with the client. The cultural brokers can use this trust to connect them to other providers.

TST-R is school-based service that addresses a child’s individual symptoms and family stressors, as well as supports positive parental adjustment and school belongingness, all of which are crucial to a child’s psychological well-being. The intervention is school based because school is one of the first places that migrant youth connect within the host community. It is also one of the few places that parents can seek help for a child who is struggling with mental health issues and the stigma attached to them (Ellis et al., 2011). A school is also a place of hope and recovery for children and families, as educational success is important to refugee families. By using a holistic lens to assess and address mental health needs in a safe comfortable environment, the TST-R team is able to engage families in partnership around their sources of pain, such as assisting a family with obtaining permanent housing, applying for permanent immigration status, or working with a child’s school to provide appropriate school placement. The focus is placed on what the family identifies as important rather than what the clinical team might consider to be a priority, such as the child’s symptoms. Aligning with the family around priorities is part of an engagement strategy that seeks to both reduce current stressors in the child’s social environment and build trust with the family. The ultimate objective is to create a situation where the family is engaged in services, the child receives mental health support, and trust and alliances are built. In addition, current stressors that could be contributing to the child’s symptoms or those of the child’s caregivers (or other family members) are reduced. TST-R has been previously piloted with refugees and has been shown to be successful in engaging refugee families (Ellis et al., 2011).

Case Study

Asha was a 39-year-old woman from East Africa. She arrived in the United States as a refugee and lives with her three children. Her husband was killed during the war in Somalia. Asha’s teenage daughter, Sahra, was having trouble in school. She had many unexplained absences and seemed to be depressed when in school, often crying and refusing to participate in learning. Asha had gone through horrific experiences in Africa. Her village was attacked by militia. Her husband was killed, and the women, including Asha, were raped. Sahra was about four years old when these events took place. She spent most of her early childhood in refugee camps, and the family migrated when she was about 12 years old. Asha never sought help for her trauma even though she was having nightmares and constantly feared that she would be attacked again. She never considered that her children were affected by these horrific events as she believed they were too young to understand what had happened.

Asha herself was having problems with Sahra at home. Sahra often refused to help with chores, and she was violent toward her other siblings and even to her mother. Sahra also refused to speak the family’s native language and only spoke English. Since Asha did not speak much English, she and Sahra did not communicate much.

The school called Asha multiple times requesting that she come for a meeting to discuss her daughter’s school issues. The school counselor explained to Asha that they felt that her daughter needed to see a therapist, and they asked her to sign consent for a referral. Asha refused to sign the papers. She told the counselor that her daughter was not “crazy” so she did not want her to go to a therapist. Finally, the school became aware of the availability of a TST-R team in the school and referred Sahra to the team.

The first thing the TST-R team did was have a cultural broker go to the home and talk to the mother. The cultural broker was from a similar culture and understood the importance of using non-stigmatizing language to frame services. She used strength-based language focusing on the parent’s goals for the child.

I know you want your daughter to succeed. Education is very important for a child's success, but youth who are sad, angry, or stressed because of things that have happened to them in the past can have difficulties focusing on lessons, listening, and getting along with others. This can interfere with their learning and impact their future. I want to work with your child so that I can help her learn how to manage these feelings/memories/difficulties. I know how important your daughter's future is to you. I know you crossed borders and walked miles, you sacrificed much to bring her to safety. I am committed to helping Sahra so that she can achieve the hopes and dreams you had for her.

What the cultural broker is doing is aligning with the parent’s priorities, thus developing a common goal/vision for the child so that the parent feels that the provider is helping them achieve what is important to them. Often refugee parents feel that outside experts come to them and act like they know the children better than the parents do. For parents struggling to maintain their parental authority in the face of an alien and often challenging environment, it is important for them to feel that what we are doing with their children is driven by their goals and dreams for them.

The mother told the cultural broker that the family was overwhelmed by multiple resettlement stressors such as lack of adequate housing, unemployment, and fear of losing benefits. She also was afraid she was losing her children, who were no longer acting the way children acted in her native culture. Sahra was already refusing to speak her native language. The family was currently homeless, and Sahra had to change schools four times in the previous year due to the family moving from shelter to shelter. Asha also explained that she felt overwhelmed and had not been sleeping or eating well. She expected life would be easy once she arrived in the United States, but it seemed as though things were getting even worse. She was still reexperiencing some of the previous trauma as well as struggling with new stressors. She asked for help with getting better housing, which she felt would help Sahra who now has to share a room with two younger siblings and had no privacy.

The cultural broker also met with Sahra who told her that she was being harassed at school by other kids who made fun of the way she dresses and tried to pull off her hijab. She said she hated school and did not want to come to class anymore. She also said that she was feeling sad because her mother is always crying and yelling. Sahra told the clinical team that she wished that she had died in the attack on her village because she hated her life.

The TST-R team assessed Sahra in the four refugee core stressors (see Figure 1) and found that she was facing difficulties in all four. She was facing discrimination and alienation at school; she was struggling with acculturative issues; Sahra had a history of trauma and had not been assessed for PTSD or other mental health symptoms, and she and her family faced resettlement hassles due to unstable housing and limited financial resources to pay rent.

The cultural broker invited Sahra to a group attended by many refugee and immigrant youth. She explained to the mother that these groups would help her daughter adjust to school and provide support for her. It was also important that the groups were led by a co-ethnic who would be able to help the mother communicate with the school if there were other issues. These non-clinical groups were focused on supporting migrant youth like Sahra in learning social skills such as communications and conflict resolutions. The groups provided support for those youth and also taught young people how to identify and manage emotion. Through group participation, Sahra was able to connect with her peers, share her feelings, and learn that others have gone through similar experiences. She was able to do this in a safe and supportive space. The groups were also in place for youth to identify issues such as being harassed by other students and to ensure that the school attended to these issues.

In TST-R, the home-based clinical team works with the whole family by providing family therapy and also by connecting the family to resources and support services. This home-based team was able to address resettlement issues such as helping the family secure permanent housing. They also provided therapy around acculturative stressors within the family, focusing on identifying triggers and developing better child-parent communication skills. The presence of the home-based team also reduced the family’s isolation and addressed the discrimination faced by Sahra at school. Finally, through psychoeducation and individual and family therapy, the clinical team was able to address the trauma and its impact on both family and individuals in the family. Because the team was focusing holistically on multiple stressors, including acute housing and educational needs, the family was welcoming of the therapy as part of a comprehensive care that addressed priority issues for the family. They saw the psychological therapy as supporting all their problems rather than something alien that was being brought to them by outsiders. Stigma was no longer an issue since the family saw the team as a support system to advance success rather than address a deficit. The cultural broker who continued to be a key part of the home-based team acted as a bridge to other services and helped maintain this holistic and culturally relevant aspect of the intervention. Sahra responded well to the treatment. She started attending school regularly and she reported better relationships with her mother and siblings. The mother’s symptoms also diminished, and she was able to access additional support through an ethnic-based agency where staff spoke her native language. Services were terminated after six months although the family stayed connected to the program. Sahra became a mentor for other youth who were going through similar experiences in her school.

Conclusion

Refugee and other migrant children often come to host countries with histories of multiple traumatic experiences. These children and their families struggle with multiple stressors that may inflict additional traumas and exacerbate mental health symptoms in resettlement. Despite demonstrated mental health need and risk for additional exposure to risk factors, these youth often do not seek help due to multiple barriers. Given the increasing number of migrant children in our communities there is an urgent need to develop approaches that can engage these children and their families in mental health care.

Culturally relevant programs that are comprehensive and address multiple stressors faced by these children and their families represent the best practice to increase access and improve mental health outcomes. These programs must target multiple domains in the social ecology since the migration experience can impact not just the child’s psychological well-being but also family functioning and social support. Furthermore, the host community’s capacity to integrate and support migrant children and families can be protective even in the face of previous trauma experiences.

Trauma Systems Therapy for Refugees (TST-R) is a school-based program that was developed to meet the unique needs of refugee and other migrant children. TST-R goes beyond mental health symptoms and assesses migrant children on multiple domains that are crucial to psychological well-being including acculturative, resettlement, and isolation stressors.

Often, these children are the only ones in their families that are connected to service systems because they have to attend school where teachers and counselors may notice that these children are struggling. Thus school-based interventions are an effective way to introduce them to these services. TST-R harnesses this access to migrant children and their families by providing services in school and at home. Approaches such as TST-R move away from what is wrong with a child to what can we do in the child’s social ecology to reduce stressors and promote positive outcomes; this refocuses our efforts from deficit-based pathology to strength-based resilience. It leads us away from questions such as “why won’t they accept mental health services?” to “how do we build services that provide migrant children and their families with the means to overcome past trauma and prevent future traumas?”

References

American Psychological Association. (2010). Resilience and recovery after war: Refugee children and families in the United States. Washington, DC: Author.Find this resource:

Baily, C. D. (2017). Investigating the mental health needs of unaccompanied immigrant children in removal proceedings: A mixed methods study (Doctoral dissertation, Columbia University).Find this resource:

Belhadj Kouider, E., Koglin, U., & Petermann, F. (2014). Emotional and behavioral problems in migrant children and adolescents in Europe: A systematic review. European Child & Adolescent Psychiatry, 23(6), 373.Find this resource:

Berthold, S. M. (2000). War traumas and community violence: Psychological, behavioral, and academic outcomes among Khmer refugee adolescents. Journal of Multicultural Social Work, 8(1–2), 15–46.Find this resource:

Berthold, S. M., & Libal, K. (2016). Migrant children’s rights to health and rehabilitation: A primer for US social workers. Journal of Human Rights and Social Work, 1, 85–95.Find this resource:

Betancourt, T. S., Frounfelker, R., Mishra, T., Hussein, A., & Falzarano, R. (2015a). Addressing health disparities in the mental health of refugee children and adolescents through community-based participatory research: A study in 2 communities. American Journal of Public Health, 105(3), 475–482.Find this resource:

Betancourt, T. S., Abdi, S., Ito, B. S., Lilienthal, G. M., Agalab, N., & Ellis, H. (2015b). We left one war and came to another: Resource loss, acculturative stress, and Caregiver-Child relationships in Somali refugee families. Cultural Diversity and Ethnic Minority Psychology, 21(1), 114–125.Find this resource:

Bhugra, D. (2004). Migration and mental health. Acta Psychiatrica Scandinavica, 109(4), 243–258.Find this resource:

Breslau, J. (2011). Review of the book Migration and mental health, by Bhugra, D. & Gupta, S. Psychological Medicine, 41(10), 2233–2234.Find this resource:

Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Cambridge, MA: Harvard University Press.Find this resource:

Bronstein, I., & Montgomery P. (2011). Psychological distress in refugee children: A systematic review. Clinical Child Family Psychology Review, 14(l), 44–56.Find this resource:

Chau, K., Baumann, M., Bernard, K., & Nearkasen, C. (2012). School difficulties in immigrant adolescent students and roles of socioeconomic factors, unhealthy behaviours, and physical and mental health. BMC Public Health, 12(1), 453.Find this resource:

Chavez, L., & Menjívar, C. (2010). Children without borders: A mapping of the literature on unaccompanied migrant children to the United States. Migraciones internacionales, 5(3), 71–111.Find this resource:

Chen, A. W., & Kazanjian, A. (2005). Rate of mental health service utilization by Chinese immigrants in British Columbia. Canadian Journal of Public Health/Revue Canadienne de Sante Publique, 96(1), 49–51.Find this resource:

Cheng, I., Drillick, A., & Schattner, P. (2015). Refugee experiences of general practice in countries of resettlement: A literature review British Journal of General Practice, 65(632), 171–176.Find this resource:

Clifford, B. S. (2014). Academic publishing, part III: How to write a research paper (so that it will be accepted) in a high-quality journal. Annals of Neurology, 77(1), 8–12.Find this resource:

Correa-Velez, I., Gifford, S., & Barnett, A. (2010). Longing to belong: Social inclusion and wellbeing among youth with refugee backgrounds in the first three years in Melbourne, Australia. Social Science & Medicine, 71(8), 1399.Find this resource:

DuPlessis, H. M., & Cora-Bramble, D. (2005). Providing care for immigrant, homeless, and migrant children. Pediatrics, 115(4), 1095–1100.Find this resource:

Ellis, B. H., Lincoln, A. K., Charney, M. E., Ford-Paz, R., Benson, M., & Strunin, L. (2010). Mental health service utilization of Somali adolescents: Religion, community, and school as gateways to healing. Transcultural Psychiatry, 47(5), 789–811.Find this resource:

Ellis, B., Miller, A., Baldwin, H., & Abdi, S. (2011). New directions in refugee youth mental health services: Overcoming barriers to engagement. Journal of Child & Adolescent Trauma, 4, 69–85.Find this resource:

Fazel, M., Karunakara, U., & Newnham, E. A. (2014). Detention, denial, and death: Migration hazards for refugee children. The Lancet Global Health, 2(6), e314.Find this resource:

Fazel, M., Wheeler, J., & Danesh, J. (2005). Prevalence of serious mental disorder in 7000 refugees resettled in western countries: A systematic review. The Lancet, 365(9467), 1309–1314.Find this resource:

Fichter, M. M., Elton, M., Diallina, M., Koptagel-Ilal, G., Fthenakis, W. E., & Weyerer, S. (1988). Mental illness in Greek and Turkish adolescents. European Archives of Psychiatry and Clinical Neuroscience, 237(3), 125–134.Find this resource:

Gao, Q., Li, H., Zou, H., Cross, W., Bian, R., & Liu, Y. (2015). The mental health of children of migrant workers in Beijing: The protective role of public school attendance. Scandinavian Journal of Psychology, 56(4), 384–390.Find this resource:

Goode, T. D., Sockalingam, S., & Snyder, L. L. (2004). Bridging the cultural divide in health care settings: the essential role of cultural broker programs. Washington, DC: National Center for Cultural Competence.Find this resource:

Gozdziak, E. M. (2004). Training refugee mental health providers: Ethnography as a bride to multicultural practice. Human Organization, 63, 203–210.Find this resource:

Hadfield, K., Ostrowski, A., & Ungar, M. (2017). What can we expect of the mental health and well-being of Syrian refugee children and adolescents in Canada? Canadian Psychology, 58(2), 194.Find this resource:

Henley, J., & Robinson, J. (2011). Mental health issues among refugee children and adolescents. Clinical Psychologist, 15, 51–62.Find this resource:

Hjern, A., Angel, B., & Jeppson, O. (1998). Political violence, family stress and mental health of refugee children in exile. Scandinavian Journal of Public Health, 26, 18–25.Find this resource:

Hollifield, M., Warner, T. D., Lian, N., Krakow, B., Jenkins, J. H., Kesler, J., . . . Westermeyer, J. (2002). Measuring trauma and health status in refugees: A critical review. Journal of the American Medical Association, 288, 611–621.Find this resource:

Igareda, N. (2017). Forced marriage in Europe: From a migration problem in a global world to the old phenomenon of gender violence/les mariages forces en europe: D’un probleme li la migration dans un monde globalise l’anciene phenomene de la violence de genre. Rivista Di Criminologia, 2, 4–12.Find this resource:

Isakson, B. L., Legerski, J. P., & Layne, C. M. (2015). Adapting and implementing evidence-based interventions for trauma-exposed refugee youth and families. Journal of Contemporary Psychotherapy, 45, 245–253.Find this resource:

Jezewski, M. A. (1990). Culture brokering in migrant farmworker health care. Western Journal of Nursing Research, 12(4), 497–513.Find this resource:

Kia-Keating, M., & Ellis, B. H. (2007). Belonging and connection to school in resettlement: Young refugees, school belonging, and psychosocial adjustment. Clinical Child Psychology and Psychiatry, 12(1), 29–43.Find this resource:

Kirmayer, L. J., Narasiah, L., Munoz, M., Rashid, M., Ryder, A. G., Guzder, J., . . . Pottie, K. (2011). Common mental health problems in immigrants and refugees: General approach in primary care. Canadian Medical Association Journal, 183(12), 959–967.Find this resource:

Kohn-Wood, L., & Hooper, L. (2014). Cultural competency, culturally tailored care, and the primary care setting: Possible solutions to reduce racial/ethnic disparities in mental health care. Journal of Mental Health Counseling, 36(2), 173–188.Find this resource:

Lai, D. W. L., & Surood, S. (2010). Types and factor structure of barriers to utilization of health services among aging South Asians in Calgary, Canada. Canadian Journal on Aging/La Revue Canadienne Du Vieillissement, 29(2), 249–258.Find this resource:

Locke, C., Southwick, K., Mccloskey, L., & Fernández-Esquer, M. (1996). The psychological and medical sequelae of war in Central American refugee mothers and children. Archives of Pediatrics & Adolescent Medicine, 150(8), 822–828.Find this resource:

Lustig, S. L., Kia-Keating, M., Knight, W. G., Geltman, P., Ellis, H., Kinzie, J. D., . . . Saxe, G. N. (2004). Review of child and adolescent refugee mental health. Journal of the American Academy of Child & Adolescent Psychiatry, 43(1), 24–36.Find this resource:

Measham, T., Guzder, J., Rousseau, C., Pacione, L., Blais-McPherson, M., & Nadeau, L. (2014). Refugee children and their families: Supporting psychological well-being and positive adaptation following migration. Current Problems in Pediatric and Adolescent Health Care, 44(7), 208–215.Find this resource:

Merikangas, K. R., He, J. P., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., . . . Swendsen, J. (2010). Lifetime prevalence of mental disorders in US adolescents: Results from the National Comorbidity Survey Replication–Adolescent Supplement (NCS-A). Journal of the American Academy of Child & Adolescent Psychiatry, 49(10), 980–989.Find this resource:

Miller, K. E., & Jordans, M. J. (2016). Determinants of children’s mental health in war-torn settings: Translating research into action. Current Psychiatry Reports, 18(6), 58.Find this resource:

Montgomery, E. (2008). Long-term effects of organized violence on young Middle Eastern refugees’ mental health. Social Science & Medicine, 67, 1596–1603.Find this resource:

Montgomery, E., & Foldspang, A. (2005). Seeking asylum in Denmark: Refugee children’s mental health and exposure to violence. European Journal of Public Health, 15, 233–237.Find this resource:

Montgomery, E., & Foldspang, A. (2008). Discrimination, mental problems and social adaptation in young refugees. European Journal of Public Health, 18, 156–161.Find this resource:

Mulvaney-Day, N., Alegria, M., & Sribney, W. (2007). Social cohesion, social support, and health among Latinos in the United States. Social Science & Medicine, 64(2), 477.Find this resource:

Munroe-Blum, H., Boyle, M. H., Offord, D. R., & Kates, N. (1989). Immigrant children: Psychiatric disorder, school performance, and service utilization. American Journal of Orthopsychiatry, 59(4), 510.Find this resource:

Murray, K. E., Davidson, G. R., & Schweitzer, R. D. (2010). Review of refugee mental health interventions following resettlement: Best practices and recommendations. American Journal of Orthopsychiatry, 80(4), 576–585.Find this resource:

Nadeau, L., & Measham, T. (2005). Immigrants and mental health services: Increasing collaboration with other service providers. The Canadian Child and Adolescent Psychiatry Review, 14(3), 73.Find this resource:

Nadeau, L., & Measham, T. (2006). Caring for migrant and refugee children: Challenges associated with mental health care in pediatrics. Journal of Developmental & Behavioral Pediatrics, 27(2), 145–154.Find this resource:

Pumariega, A. J., Rothe, E., & Pumariega, J. B. (2005). Mental health of immigrants and refugees. Community Mental Health Journal, 41, 581–597.Find this resource:

Rousseau, C., Measham, T., & Nadeau, L. (2013). Addressing trauma in collaborative mental health care for refugee children. Clinical Child Psychology and Psychiatry, 18(1), 121–136.Find this resource:

Rogler, L. H. (1994). International migrations: A framework for directing research. American Psychologist, 49, 701–708.Find this resource:

Rousseau, C., Benoit, M., Gauthier, M. F., Lacroix, L., Alain, N., Viger Rojas, M., . . . Bourassa, D. (2007). Classroom drama therapy program for immigrant and refugee adolescents: A pilot study. Clinical Child Psychology and Psychiatry, 12(3), 451–465.Find this resource:

Saxe, G. N., Ellis, H. B., & Kaplow, J. B. (2006). Collaborative treatment of traumatized children and teens: The trauma systems therapy approach. New York: Guilford.Find this resource:

Slobodin, O., & de Jong, J. T. V. M. (2015). Mental health interventions for traumatized asylum seekers and refugees: What do we know about their efficacy?. International Journal of Social Psychiatry, 61(1), 17–26.Find this resource:

Stevens, G. W., & Vollebergh, W. A. (2008). Mental health in migrant children. Journal of Child Psychology and Psychiatry, 49(3), 276–294.Find this resource:

Stevens, G. W., Vollebergh, W. A., Pels, T. V., & Crijnen, A. A. (2007). Problem behavior and acculturation in Moroccan immigrant adolescents in the Netherlands: Effects of gender and parent-child conflict. Journal of Cross-Cultural Psychology, 38(3), 310–317.Find this resource:

Stermac, L., Elgie, S., Clarke, A., & Dunlap, H. (2012). Academic experiences of war-zone students in Canada. Journal of Youth Studies, 15(3), 311–328.Find this resource:

Taylor, A. (2017, April 25). Over 1,000 migrants and refugees have died crossing the Mediterranean so far this year. Washington Post.Find this resource:

Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117–125.Find this resource:

Tousignant, M., Habimana, E., Biron, C., Malo, C., Sidoli-LeBianc, E., & Bendris, N. (1999). The Quebec Adolescent Refugee Project: Psychopathology and family variables in a sample from 35 nations. Journal of the American Academy of Child & Adolescent Psychiatry, 38(11), 1426–1432.Find this resource:

Turabian, K. L. (2013). A manual for writers of research papers, theses, and dissertations (8th ed.). Chicago: University of Chicago Press.Find this resource:

Tyrer, R. A., & Fazel, M. (2014). School and community-based interventions for refugee and asylum seeking children: A systematic review. PLoS One, 9(2), e89359. ProQuest.Find this resource:

Ungar, M. (2013). Resilience, trauma, context, and culture. Trauma, Violence, & Abuse, 14, 255–266.Find this resource:

UNHCR. (2009). Global trends: refugees, asylum seekers, returnees, internally displaced and stateless persons. Geneva, Switzerland: UN High Commissioner for Refugees.Find this resource:

UNHCR. (2017). Global Trends: Forced Displacement in 2016. Geneva: UN High Commissioner for Refugees.

UN General Assembly. (1951). Convention relating to the status of refugees. UN General Assembly, 189, 137.Find this resource:

Oort, F. V. A. van, Ende, J. van der, Crijnen, A. A. M., Verhulst, F. C., Mackenbach, J. P., & Joung, I. M. A. (2007). Ethnic disparities in mental health and educational attainment: Comparing migrant and native children. International Journal of Social Psychiatry, 53(6), 514–525.Find this resource:

William, L. S. (2016). The Mediterranean challenge within a world of humanitarian crises. Forced Migration Review, 51, 14–16.Find this resource: