Preventive Mental Health Interventions for Refugee Children and Adolescents in High-Income Settings

"Little attention has been given to the importance of family level processes (such as family relationships, communication, and resilience) in interventions for refugee children despite a body of literature indicating the importance of such dynamics in shaping healthy child adjustment."

This narrative review of preventive mental health interventions for refugee children arriving in high-income countries highlights the factors that inhibit the roll-out of informed interventions for this population: limited mental health research in children, high mobility of refugee populations, and complex cultural differences. The review examines a range of interventions delivered in high-income settings to individuals, through parenting and school programmes, and through broader socioeconomic interventions aimed at improving post-migration environment and at facilitating access to services. This summary highlights some of the communication elements of the review.

As the authors explain, many refugee children exhibit considerable resilience and strength in navigating changes and challenges; however, a proportion can develop major mental health difficulties with associated implications for academic and social functioning. For example, mental health problems might impede a refugee child's ability to adjust in the classroom and acquire a new language, with cascading consequences across several key facets of their resettlement such as establishing social support networks. Emerging evidence shows how previous exposure to potentially traumatic experiences interacts with the post-migration environment to either exacerbate or attenuate the risk of having post-traumatic stress disorder (PTSD).

Research on resilience cited here identifies eight protective factors to promote psychosocial well-being in adolescent refugees: finances to provide for necessities; host language proficiency; social support networks; engaged parenting; family cohesion; maintenance of cultural links; educational support; and faith or religious involvement. Potential targets identified for preventive work included: friends and peers; parents; extended family members; school staff; faith community networks; and resettlement agency case workers and health-care providers.

The review explores various types of mental health interventions. With regard to specific mental health interventions, the authors note, for example, that "[e]vidence thus far does not inform how to prevent PTSD in refugee children and only supports individual methods to treat PTSD, which for refugee children is beset with extraneous stressors such as poverty, transportation, linguistic challenges, and lack of parental support because of stigma or their own psychopathology, which might make it harder to identify and support difficulties in their children."

The section on parenting and family interventions considers, in turn research that has been conducted on: parenting style and parental mental health; family engagement with local culture and structures; and family-based mental health interventions. One insight shared here is that the "involvement of all family members is a powerful approach for family-based preventive mental health interventions. An adaptation of the family-based preventive and strengthening intervention used for families affected by HIV in Rwanda is showing promising acceptability for Bhutanese and Somali families in the USA [United States]....This intervention, led by refugees for refugees, includes ten modules delivered separately to caregivers and children, with a focus on building a united family narrative. This prevention initiative builds on the principle of task sharing, with its use of refugees to deliver the intervention, and thus provides a scalable model of an intervention, which could be integrated within a range of health and social care services."

In the area of school and peer interventions, the authors note that schools can, among other things, foster social–peer relationships and encourage a sense of belonging to the school community and the wider culture - all likely to play important roles in preventing mental illness. Language acquisition opportunities, institutional supports, instructional practices, and teacher–student engagement strategies are all encouraged. Students with better teacher–student relationships, teacher support, or a classroom disciplinary climate have been found to have a greater sense of belonging at school and had better attitudes toward school; these factors may support the mental health of newly arrived refugees in their schools.

The authors explain that the broader social context needs to be considered when determining how to prevent mental health problems in refugee children. For example, an Australian longitudinal study investigating 97 refugee adolescents showed how indicators of belonging - especially subjective social status in the broader community, and perceived discrimination and bullying - were key factors associated with well-being. Another issue is ensuring access to mental health services. One barrier mentioned is that many of the countries refugees come from have few mental health structures and have cultures where mental illness might be stigmatised, leading to distrust of the system. Greater emphasis is often placed by refugee communities on reaching for and receiving support from respective communities of faith. Studies have identified how young refugees, who often value self-reliance, are more likely to seek informal psychosocial support from friends in the first instance.

In conclusion, the authors suggest that "[w]hat is needed is a continuum of care and multi-level and cross-sectoral intervention models that can address the multitude of acculturative and resettlement stressors faced by resettled refugees." Among the questions they say warrant further attention is whether interventions directed at host populations can improve community engagement and broader social inclusivity for newly arriving refugee children and families. "There is now the possibility to conduct large-scale, courageous interventions, where public policy in refugee status determination and resettlement strategies can, if there is the political will, inform the evidence-base."