Strengthening Mental Health Support Services for Refugee Children Resettled in the U.S.

There are more than 11 million refugee children worldwide who have been forced to flee their homes due to persecution or a fear of persecution based on race, religion, nationality, or membership in a social or political group, often tied to experiences of war and armed conflict.¹ Increasing numbers of refugee children and youth are resettling in the U.S.^2,3 Refugee children experience elevated levels of depression, anxiety, posttraumatic stress disorder (PTSD), behavioral and social problems, social isolation, and family conflict compared to U.S. born children.⁴  These experiences can lead to mental health risks across the lifespan. While mental health services can reduce risks, they remain out of reach for many vulnerable children and youth nationwide, particularly refugee children and families. Though the quality of family, school, and community relationships shape the mental health of refugee children, few services are equipped to respond to children’s diverse needs in each of these contexts and there is little focus on prevention and the cultural diversity of resettling populations in the U.S.⁵ To improve mental health care for refugee children, key recommendations for federal and state policymakers include increasing investments in  a continuum of mental health services and in further developing effective family, school, and community- level prevention and treatment interventions. 

Refugee Children and Adolescents Face Various Traumas and Stressors Before, During, and After Migration 

In addition to exposure to trauma, experiences of war, persecution, displacement, and resettlement also disrupt sources of care and stability that are essential for supporting children’s healthy development and mental health.⁶ Disruptions can include separation from and death of parents and other family members, disrupted schooling, inadequate housing, and limited health care.⁴ Upon resettlement, refugee children and families experience additional post-migration stressors such as economic insecurity, xenophobia and discrimination, and the challenges of adjusting to life in a new culture and setting (e.g., loss of support networks, learning a new language).^7-9 

War, Forced Migration, and Resettlement Stressors Threaten the Mental Health and Well-being of Refugee Children and Families 

It is well documented that given exposure to trauma, loss, and life-disruption, refugee children and adolescents are at increased risk for depression, anxiety, PTSD, behavioral problems, and social difficulties compared to children born in the U.S.^10-13 Several experiences have been found to exacerbate these risks including pre-migration trauma events, separation from caregivers, displacement, and lack of post-migration social support.^4,14 Symptoms of distress vary by child age and require developmentally-tailored assessment and care.¹² 

War, forced migration, and resettlement stressors also influence parents and family relationships.¹⁵ Parents and caregivers often struggle with their own psychological difficulties resulting from trauma and chronic stress, which can compromise family relationships, parenting behaviors, and child well-being.^16-20 Forced migration and resettlement also rupture ties to networks of family, friends, and community leading to decreased social support and greater isolation and loneliness.^21,22 

Access to Mental Health Services in the U.S. is Limited for Refugee Children

Despite significant needs, access to mental health services for refugee children, youth, and families is limited in the U.S. Refugee children and families experience multiple barriers to accessing adequate mental health services, including limited availability of service providers, mental health stigma, cultural and language barriers, and mistrust of service systems.²³ In particular, utilization of evidence-based mental health services (i.e., interventions which have been tested and found effective) is very limited among refugee children, youth, and families.²⁴ Moreover, most mental health services are provided only when symptoms become severe, with few prevention-oriented interventions that focus on providing skills and supports to address trauma before more severe mental health disorders develop.^25,26 Though not specific to refugees, initial evidence suggests that interventions to promote mental health and prevent mental disorders are cost-effective.²⁷

Individual, Family, and Community-Based Prevention and Treatment Services Are Needed to Support the Mental Health of Refugee Children in the U.S.

A continuum of effective mental health services ranging from low intensity mental health supports within the community for all families to more intensive, trauma-specific supports for children already experiencing mental health disorders is needed to support the mental health of refugee children and adolescents.²⁸ 

• Schools and neighborhoods are important settings of development for refugee children and adolescents and as such, are promising venues for delivering prevention and intervention services.^29,30 Research suggests that school-based peer support, creative expression, psychoeducational programs, and group models developed and tested for refugee children and youth can help to reduce mental health problems, improve interpersonal functioning, and increase access to needed care.^31-34 For example, a school-based mental health program for Somali refugee youth in New England improved coping skills and reduced symptoms of PTSD using school-based groups and referrals to specialized services when indicated.³⁴
• Family-based mental health services can help prevent children’s mental health problems by improving parenting skills, parent-child relationships, and family functioning.^35-40 For example, a pilot study of a home visiting intervention for Somali Bantu and Bhutanese refugee families delivered by peers from the refugee community improved child mental health and behavioral problems and reduced family conflict.³⁵
• Individual therapies including cognitive behavioral therapies (CBT) and interpersonal therapy have produced consistent results in reducing symptoms of depression, anxiety, and PTSD for children affected by trauma including refugee children.^41-44

Mental Health Services for Refugee Children Need to Be Culturally Responsive and Trauma-Informed

Research highlights the importance of services being culturally responsive (i.e., integrating attention to language, cultural values, and cultural meaning)⁴⁵ and trauma-informed (i.e., grounded in an understanding of how trauma affects individuals and prioritizing safety, trusting relationships, and collaboration).⁴⁶ Culturally responsive and trauma-informed interventions improve engagement in services and are more acceptable and useful to culturally diverse refugee communities.^47,48 

How U.S. Policymakers Can Help Strengthen Refugee Children’s Mental Health and Well-being

Invest in Family, School and Community Mental Health Prevention Services. Replicate and expand promising interventions to increase the evidence base for prevention-oriented mental health services in schools, communities, and among families. This requires funding to evaluate interventions across settings and with diverse refugee populations and to expand implementation of effective prevention services. 

Provide Funding to Develop and Test New Mental Health Services Including Those for Early Childhood. There remain notable gaps in the availability of effective prevention and intervention services for refugee children and youth. These include services for young children (birth to eight years old) for whom promoting parent-child attachment, addressing caregiver depression, and facilitating cultural integration are important intervention targets.^21,49 Given refugee children’s experiences of discrimination and xenophobia, interventions are also needed to improve school and neighborhood climates to address bullying, educate students about different cultures and world events, and support new social connections and peer relationships for refugee children and adolescents.^50-51

Expand access to evidence-based mental health treatment for refugee children and families. For refugee children and adolescents with mental health disorders, effective individual mental health treatment should be made available. This requires ensuring refugees enroll in public insurance such as Medicaid and the Children’s Health Insurance Program (CHIP)⁵² and funding costs related to technical assistance and training of providers in evidence-based treatments to expand access to services. Funding is also needed to further examine the effectiveness of these individual therapies across diverse refugee communities.⁵³

Endnotes/References

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(2)  UNICEF (2021). Child displacement. UNICEF. https://data.unicef.org/topic/child-migration-and-displacement/displacement/

(3) Migration Policy Institute (2021). Afghan immigrants in the U.S. Migration Policy Institute. https://www.migrationpolicy.org/article/afghan-immigrants-united-states

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(6) Cummings, E. M., Merrilees, C. E., Taylor, L. K., & Mondi, C. F. (2017). Developmental and social–ecological perspectives on children, political violence, and armed conflict. Development and Psychopathology, 29(1), 1-10. https://doi.org/10.1017/S0954579416001061

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