In the ongoing contentious debate surrounding immigration, the lives and experiences of resettled refugees are often an afterthought. War and armed conflict affect millions of people around the world each year, tens of thousands of whom flee their home countries for the U.S.
Resilience and Recovery after War: Refugee Children and Families in the United States, a recent task force report from the American Psychological Association:
reviews the research on the psychosocial effects of war,
identifies areas of needed culturally and developmentally appropriate research, and
provides recommendations for culturally and developmentally informed practice and programs.
The report is the product of the APA Task Force on the Psychosocial Effects of War on Children and Families Who are Refugees from Armed Conflict Residing in the United States. Images featured in this report are from the AjA Project, a nonprofit organization that utilizes photography-based educational programs to transform the lives of refugee and displaced youth by getting them to see themselves as agents of personal and social transformation.
Psychology is beginning to understand the full impact of armed conflict, displacement, and resettlement on children’s development and overall well-being. However, despite the mental health risks of the unimaginable hardship and trauma associated with war, there is evidence to suggest that war-affected children demonstrate tremendous resilience.
Psychologists and other mental health professionals can assist refugee children and their families with recovery by:
Recognizing and understanding the factors involved in psychosocial adjustment following war and violence
Providing comprehensive mental health services that are culturally and linguistically appropriate
Partnering with members of the refugee community in performing research, advocacy, and mental health care
Adhering to strong ethical standards in the research, practice, and advocacy to protect human rights of refugee communities
The treatment needs of refugee populations resettled in America are complex and diverse. Consequently, psychologists and other mental health providers must provide comprehensive services that are culturally competent and that integrate evidence-based practice with practice-based evidence. Sample vignettes in the report bring to life scenarios that war affected children and families face everyday. Each vignette is followed by a mental health care principle that takes theory and puts it into practice.
Researchers must utilize a wide range of methodologies to identify and understand cultural variations in well-being and distress and instill ethical considerations of the power disparities and vulnerabilities that exist for refugee populations in the conduct of their work. The report concludes with recommendations for advancing services and supports, the research and knowledge base, and education and training opportunities for refugee children and families.
Each year, tens of thousands of refugees flee their war-torn countries and communities and enter the United States. More than 40% are children. While the circumstances of their war experiences, their journeys to the United States, and the conditions in which they find themselves as new arrivals greatly vary, children displaced from war zones endure a tremendous amount of trauma, stress, and adversity that can impact their functioning and development (Birman et al., 2005; Lustig et al., 2004; Machel, 1996). These children and their families also demonstrate profound strength and resilience in their survival strategies, coping mechanisms, and abilities to adapt within what are often completely unfamiliar environments.
In this report, the American Psychological Association (APA) Task Force on the Psychosocial Effects of War on Children and Families Who Are Refugees From Armed Conflict Residing in the United States reviews the research on the psychosocial effects of war on children and families, identifies areas of needed culturally and developmentally appropriate research, and provides recommendations for culturally and developmentally informed practice and programs. Psychologists, in their roles within a variety of U.S. systems and institutions and in their work with other professionals, can be important resources in the lives of these war-affected children and their families and can work to enhance society’s understanding of their experiences and needs. This report takes a social and ecological transactional approach that emphasizes the role of culture and individual, family, and community factors in healing and resilience and underscores the multiple risk and protective factors that affect refugee children’s responses to their experiences as they develop and grow. A summary follows.
The field is only beginning to understand the full impact of armed conflict, displacement, and resettlement on children’s development and overall well-being. Despite the risk for mental health sequelae after exposure to the unimaginable hardship and trauma associated with war, the literature and clinical experience suggest that war-affected children demonstrate tremendous resilience (Garmezy, 1988; Klingman, 2002). Individual, family, school, and community influences provide sources of both risk and protective factors that influence the psychosocial adjustment of children affected by armed conflict (Betancourt & Kahn, 2008).
Although there is a dearth of empirical studies documenting the effectiveness of available therapeutic interventions for waraffected children and families, the present literature indicates promising initiatives in individual treatment methods, family therapy, and group work in schools and other community settings. To address the diverse needs of this unique population, psychologists and other mental health providers must utilize various treatment models while upholding standards of care to the level of best practices. When working with refugee children and their families, the most effective practitioners provide comprehensive services, are culturally competent, and integrate evidence-based practice with practice-based evidence. Truly rich multicultural practice involves a process of community engagement that allows for dialogue, questioning, and adaptation of practice to fit a group’s beliefs and values while still providing culturally informed, effective care. Psychology must examine and recognize the efforts of providers in the field working with this population (Birman et al., 2005), allowing clinicians the flexibility to utilize evidence-based techniques and protocols when possible, while incorporating “practice-based evidence”—clinical interventions and existing practices reported to be successful with war-affected children (Birman et al., 2005).
Special Considerations in Treatment
Assumptions underlying clinical practice come from theory and treatment models developed in wealthy countries and Western culture; therefore, it is imperative they be critically examined in the care of culturally diverse refugee children and families. Psychologists must be aware of the often substantial power differential that exists in a relationship between refugee clients and professionals (Eth, 1992; Savin & Martinez, 2006) and maintain appropriate therapeutic boundaries. This is particularly important in cases involving human rights violations and other atrocities that may evoke strong transference reactions of dependency and gratitude in clients as well as powerful countertransference reactions in psychotherapists (Eth, 1992). When refugee community members are involved in outreach, interpreting, prevention, and mental health counseling, it is vital to ensure they uphold ethical practices, such as maintaining therapeutic boundaries and confidentiality in the context of a small or tight-knit refugee community. Informed consent may present particular challenges for refugee families, including cultural, educational, and linguistic differences between refugee clients and practitioners (Fisher, 2004; Vitiello, 2008) and the reluctance and/or fear of refugee families about signing legal forms and documents or not following the direction of an authority, such as the therapist or evaluator.
Service providers may find themselves challenged by the practices or beliefs of clients from different cultures that are in opposition to their own values. They are advised to seek supervision from within the field and from within the cultural community of their clients when faced with these tensions in order to determine how to proceed in an ethical manner that is respectful of cultural difference and consistent with the standards of practice of the field.
Given the constantly changing composition of refugee populations in the United States, providers’ flexibility is paramount. Inflexible psychological services that narrowly address the needs of specific cultural groups will ultimately be insufficient. True engagement takes place within a context of listening, eliciting, and collaborating and can mean the difference between providing appropriate care that is ultimately accepted by refugee clients and care that is, at best, potentially alienating and, at worst, detrimental. There is a need to train psychologists on the processes and vocabulary of cultural identity, going beyond the simple facts of individuals’ backgrounds and experiences.
Training for psychologists working with refugee populations should include nontraditional elements, such as interfacing and collaborating with other agencies, including cultural organizations not traditionally seen as “service providers” (such as community-based mutual assistance organizations) and working with language interpreters, cultural brokers, and
paraprofessionals. These resources can engage refugee families in treatment and connect them to the larger community. The field of psychology should also encourage and support the training of refugees as psychologists to promote research and practice appropriate to the needs of refugee children and families and increase the cultural competence of the field as a whole.
Providers who treat war-affected refugee children and their families are at risk of secondary or vicarious traumatization, an area often underemphasized in clinical training. Stories of human atrocities and violence, often a part of the experiences of waraffected refugees, can lead psychologists to feel angry, burned out, depressed, or, in some cases, detached from their work. Without proper supervision and processing around this specific issue—the emotional toll of hearing stories from war zones and attempting to address war’s human costs—psychologists are vulnerable to many overwhelming emotions and reactions. To minimize these difficulties, psychologists must learn self-care techniques during their training to work with war-affected children (Palm, Polusny, & Follette, 2004; Richardson, 2001; Trippany, Kress, & Wilcoxon, 2004).
Research: Gaps and Future Directions
To date, the primary focus of much of the research on refugee youth and other war-affected populations documents psychiatric symptomatology related to exposure to potentially traumatic war-related events. In particular, there is considerable interest in examining the dose–effect relationship between exposure to violence and levels of distress, most often in the form of PTS D (Barenbaum, Ruchkin, & Schwab-Stone, 2004; Stichick, 2001). However, there are other pressing and considerably more complex issues involved in the study and understanding of refugee populations.
In order to deepen an understanding of the long-term effects of war on children and develop an evidence base on interventions for war-affected children and families, a wide range of methodologies is needed to identify and understand cultural variations in well-being and distress (Betancourt & Williams, 2008), including qualitative methods (data in words), quantitative methods (data in numbers, often gained through survey research), and mixed methods (combining qualitative and quantitative methods in different sequences depending on the research questions at the heart of a study; Creswell, 2008). These three methods, plus community-based participatory methods and grounding assessments—an increasingly popular approach—provide unique approaches to understanding and working with these children and families. The same methodological challenges that pertain to identifying relevant mental health problems and syndromes apply to examining protective and promotive factors (e.g., social support, coping, and connectedness) within refugee groups, including recruitment and obtaining representative samples, the cultural validity of constructs, the cultural reliability and validity of instruments, solicitation methods and the use of multiple informants, accuracy of age information, and cultural variations in gender issues.
A Developmental and Longitudinal Perspective
The overwhelming majority of studies with war-affected and refugee children are cross-sectional, providing a one-time snapshot of the mental health and psychosocial well-being of study participants. One way to examine and understand the longitudinal and developmental trajectories of war-affected children is to consider the timing of research, incorporating a life-course perspective into protocols in order to examine long-term adjustment. A focus on cross-sectional symptom assessment also may be useful for understanding context during a certain instance of time, but it does not provide an opportunity to understand the impact of war and displacement on refugee children’s evolving developmental capacities. It is important to assess impaired or endangered development in addition to more commonly studied patterns of psychiatric symptomatology. Finally, it may be useful to examine the relationship of
symptomatology to development—that is, to what extent do symptoms of distress interact with and threaten children’s current and future developmental achievements? Although longitudinal research is complex and resource intensive, it is essential in order to document the trajectories of risk and resilience among refugee children and families as they resettle in the United States.
Intervention Research and the Translation of Research to Practice
Tension exists between the need to provide services to waraffected refugees and the need to conduct rigorous intervention research. A great deal of the mental health care delivered to refugees is not documented or studied in standardized ways and because of the lack of empirical data, treatments are often clinic-based and rely on the familiar strategies of psychotherapy and psychopharmacology, sometimes with accompanying case management services. In this way, mental health professionals may lose an opportunity to address the most commonly pressing psychosocial challenges for refugee families (Miller & Rasco, 2004). Clinic-based models of intervention are likely to be more effective in their impact on refugee children if complemented with various community-based services that link them and their families to key resources (Birman et al., 2008). Communitybased interventions that foster the creation of new social networks at all levels of the social ecology could benefit the entire family, reducing isolation and lack of social supports. Families may also benefit from interventions that target specific ongoing resettlement-based stressors, as well as other family stressors such as domestic violence.
The integration of local/refugee paraprofessionals into treatment and research teams or as providers of care may address the cultural and human resource gaps given the diversity of refugee populations in the United States and the limited number of mental health professionals familiar with these populations. The effectiveness of paraprofessionals relative to trained mental health professionals is well established in literature on nonrefugee populations (Hubble, Duncan, & Miller, 1999). Several studies also indicate that well-trained and supervised local paraprofessionals can effectively deliver care to war-affected children (Bolton et al., 2007; Hubbard & Pearson, 2004). A critical role for researchers and practitioners lies in documenting the conditions under which paraprofessionals are most effective. Issues that bear exploration include the type of supervision most helpful to a paraprofessional, the delineation of mental health and psychosocial problems best suited to services from paraprofessionals, the models of intervention most effective when enacted by paraprofessionals, and the ethical and practical considerations of training paraprofessionals from within refugee communities.
Ethical considerations are critical in the context of refugee research because of the inordinate power disparities and vulnerabilities that exist for refugee populations. Given their past experiences of war atrocities and political violence, it is particularly important to address issues of trust, disclosure, and the question of ownership of the narrative. Additional ethical considerations for researchers include balancing their rights with those of the participants; understanding the social, historical, and cultural context of their research in the presentation and use of research findings; and identifying their own underlying political viewpoints (APA, 2002a; Estroff, 1995; Gomez et al., 2001; Morrow & Smith, 2000).
Implementing ethical requirements may call for increased creativity and flexibility on the part of the researcher and ultimately may create opportunities for improved research (Allden et al., 2009). When existing ethical guidelines are not sufficient or seen as less “ethical” in certain cultural groups, researchers must promote ethical research by developing appropriate and/or additional ethical approaches (Leaning, 2001). It is critical that individual participants feel free to participate or to not participate in research and that institutional review boards carefully examine the ethical dimensions of conducting research with traumatized, vulnerable populations. Addressing both individual and community consent in a refugee population may uphold ethical standards and create a more effective study (Ellis, Kia-Keating, Yusuf, Lincoln, & Nur, 2007).
War and armed conflict affect millions of people around the world each year, sending thousands into flight from their homes and their countries in the hope of escaping chaos and violence (UNHCR, 2007). In the midst of these refugees—some formally recognized by governments and welcomed into other countries and some fleeing without status and recognition—are thousands of children who have experienced and survived devastating and profoundly stressful events. Some witness the destruction of their homes and communities and experience threats and persecution, attacks, and killings. Their journeys from their home countries are often rife with violence and instability and characterized by long periods without the most basic childhood needs, such as proper nutrition, housing, and education. Some of these children travel alone and some with parents, caregivers, and other family members.
The APA Task Force on the Psychosocial Effects of War on Children and Families Who Are Refugees From Armed Conflict Residing in the United States created this report with the objective of assisting the field of psychology in addressing the needs of war-affected children and families who came to the United States. Psychologists—in their roles as clinicians, researchers, educators, and advocates—have tremendous potential to assist the many children who arrive in the United States seeking safety after the violence and disruption of war.
Ensuring positive outcomes for refugee children and families requires stakeholders within the clinical practice, research, education, and public policy sectors to be culturally competent and cognizant of the various interacting factors that influence refugees’ mental health and adjustment upon resettlement, including:
effects of migration and armed conflict
risk and resilience
cultural and religious beliefs and background
characteristics of the family and host community
Stakeholders within each of these sectors must collaborate with each other, family members, and community members in order to improve the ethics, feasibility, and effectiveness of mental health care for refugee children and families.
The following recommendations focus broadly on ways that the field of psychology can address the needs of this population across practice, research, education, and policy domains. These recommendations require further communication and collaboration within the field of psychology and in interdisciplinary collaboration with other fields that are involved in the care and adaptation of refugee children.
Services and Supports
War-affected children may need supportive services to promote health and well-being after resettlement in the United States. Such services may address a range of needs, including basic daily living, education, and physical and mental health, across the numerous contexts in which these children function. Such services must be accessible and affordable, as well as culturally and linguistically appropriate.
To promote this standard of care, the task force recommends that APA:
Support opportunities for sharing of practice methods and theories within the field of psychology that are developed to address the special needs of refugee children and families, recognizing that there may be methods of treatment that incorporate culturally syntonic techniques into practice.
Advocate for the implementation of school-based mental health programs and interventions that demonstrate clinical effectiveness with refugee children and adolescents.
Support and advocate for federal policy initiatives that assist in the adjustment and self-sufficiency of refugee and war-affected children and families.
Provide coverage for case-management services for war-affected refugee children and families that address basic needs and access to essential resources (e.g., medical, mental health, job placement, housing).
Support the development of a range of services for unaccompanied refugee minors, such as mental health and medical services, adequate housing and provision of daily needs, school placement and support.
Develop and disseminate culturally and linguistically appropriate evidence-based and evidence-informed practices for prevention, intervention, and treatment of mental and behavioral health problems among refugee children and families in both traditional and nontraditional settings (e.g., home-based, community-based, school-based, detention centers).
To advance the knowledge base regarding the mental and behavioral health of war-affected children and families, the task force recommends that APA advocate for support of research that:
Examines the broad range of war, displacement, and resettlement stressors that can affect the mental and behavioral health of refugee children and families and identifies culturally specific definitions of well-being, distress, and healing, as well as coping strategies that refugee children and families use.
Examines the feasibility, adaptation, and efficacy of evidence-based interventions, including clinic-based, community-based, or school-based interventions, and evaluates practice-based evidence using rigorous scientific designs for use with refugee children and families. Research should include the role of factors that enhance treatment access, engagement, and retention for war-affected children and families.
Uses qualitative, quantitative, and mixed methods in a complementary fashion to improve validity and cultural significance.
Uses both longitudinal and cross-sectional design to identify trajectories of risk and resilience in war-affected children and families.
Examines adaptational issues in refugee children such as language acquisition, identity development, acculturation, peer relationships, and mental health in relation to school and educational factors.
Education and Training
To improve and enhance training opportunities in refugee studies for graduate students and encourage training for and retention of professionals who work with refugee children and families, the task force recommends that APA:
Continue to promote graduate training in multicultural practice and research.
Advocate for federal policy initiatives for training in psychology such as:
- Graduate Psychology Education Program: Supports the interdisciplinary training of psychology graduate students while the students provide supervised mental and behavioral health services to underserved populations (e.g., children and victims of abuse and trauma).
- Minority Fellowship Program: Trains minority mental health professionals to provide culturally and linguistically competent and accessible mental health and substance abuse services for diverse populations.
Encourage training programs to include self-care and boundary management in order to prevent secondary traumatization in caregivers working with war-affected children and families.
Encourage continuing education programs for practicing psychologists and mental health professionals to include instruction on multicultural practice and the importance of effective collaboration between psychologists and interdisciplinary resource agencies, community leaders, paraprofessionals, and cultural brokers to address the reallife needs of war-affected children and families.
To improve collaboration/interface between and among individuals, organizations, and systems that provide care to waraffected refugee children, the task force recommends that APA:
Support opportunities for dialogue and formal collaboration between researchers and practitioners who work with refugee children in order to enhance the evidence base on effective treatment with this population and strengthen the effectiveness of clinical services being offered.
Advocate for systematic collaboration and communication between the interdisciplinary systems (i.e., health care, education, legal/immigration, resettlement, social services) that provide services to refugee children and families in order to enhance service effectiveness, reduce redundancy of care, and create strong networks of support for this vulnerable population.
Provide opportunities for collaboration and bidirectional training between psychologists and community leaders/paraprofessionals/cultural brokers.
Engage in advocacy activities that are consistent with APA policy supporting the ratification of the UN Convention on the Rights of the Child by the U.S. Congress, which recognizes the rights of every child, including refugee children, to human dignity and the potential to realize their full capacities.
Stakeholders within each of these sectors must collaborate with each other, family members, and community members in order to improve the ethics, feasibility, and effectiveness of mental health care for refugee children and families.
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Task Force Members
Katherine Porterfield, PhD, Chair
Adeyinka Akinsulure-Smith, PhD
Molly A. Benson, PhD
theresa Betancourt, scD
B. Heidi Ellis, PhD
Maryam Kia-Keating, PhD
Kenneth Miller, PhD