Considerations For Working With Displaced Children

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Original Editor - Wala’a Awwad and Kamal Khalifa

Top Contributors - Naomi O'Reilly, Jess Bell, Tony Lowe, Kim Jackson, Ewa Jaraczewska, Rucha Gadgil and Kirenga Bamurange Liliane  

Introduction

At least 79.5 million people around the world have been forced to flee their homes. Among them are nearly 26 million refugees, around half of whom are under 18 . In 2017, as many as 30 million children and youth under the age of 18 were forcibly displaced. Seventeen millions of these youth experienced violence or conflict in their home country, and approximately 13 million were eligible for refugee status.

 Children who have experienced trauma or extreme stress may develop complex mental and physical health needs. This can include post-traumatic stress disorder, depression and anxiety disorders. The impact of a traumatic experience and the accompanying psychological morbidities can cause delays in developmental. In addition to this, the challenge of life as a refugee may create further struggles in adjusting to their new environment, a new culture, a new school, a different educational system.  

When working with children with refugee experience. It’s important to consider the interplay of these different factors and how they may impact the rehabilitation process.

What are the Experiences that Refugee Children May Face or Have Faced?

Home Country Experiences (Pre-Migration)

Pre-migration experiences include the challenges and threats children face that drive their families to seek refuge in another country.   

• Children can be Primary survivors of torture and may have experienced any number of horrors such as being kidnapped, beaten, isolated, deprived of food and water, threatened, sexual violence (Link to article on Torture and its consequences) or Secondary survivors of torture, a term used for those whose loved ones have been tortured, causing the secondary survivor to now be vicariously affected by the trauma.
• Children may be fleeing war or violence in their home country where they have experienced bombings of their houses and/or towns, gunfire, witnessed dead bodies of friends of family in the aftermath of an event. 

 Transit Experiences (Trans-Migration) 

This process includes the often perilous journey between home countries and host countries.

• Refugee Camps: Many children will spend time in a refugee camp. Some camps operate at levels below acceptable standards of environmental health; overcrowding and a lack of wastewater networks and sanitation systems are common. Access to food and medication can be limited often impacting the general health of a child. Security in camps can be a great problem and even visiting the communal bathrooms can result in incidences of sexual violence.
• Arrest: Children may experience arrest and torture during their translocation to the host country.
• Detention: They may be detained in prisons, military facilities, immigration detention centers, welfare centers, or educational facilities. While detained, migrant children are often deprived of a range of rights, such as the right to physical and mental health, privacy, education, and leisure.
• Trafficking: many unaccompanied children end up travelling with traffickers who may attempt to exploit them as workers, while refugee boys have been identified as the main victims of exploitation in the labor market; refugee girls aged between 13 and 18 have been the main targets of sexual exploitation.

Post Migration Stressors (Host Country Experiences)

This stage covers the challenges faced by refugees when attempting to integrate into the social, political, economic, and cultural framework of the host country society.  The post-migration period involves adaptation to a new culture and re-defining one's identity and place in the new society. 

• Children often lose their role models in a refugee situation. Under normal circumstances, parents provide the primary role model for their children, contributing significantly to the development of their identities and to their acquisition of skills and values. Separation from one or other parent, very often the father in circumstances of flight, can deprive children of an important role model. Even when both refugee parents are present, their potential for continuing to provide role models for their children is likely to be hampered by the loss of their normal livelihood and pattern of living.
• Children's roles also change in refugee situations. If one parent is missing, a child may have to take on adult responsibilities. When a mother has to take over a missing father's productive tasks outside the home, for example, an older daughter may have to substitute for the mother in caring for younger children. As a result, the daughter's developmental needs might be neglected because of overwork or lack of opportunities for play or to attend school and the older son may need to work to earn money and this potentially exposes him to exploitation in the labor market. 
• Many children report challenges in integrating in to new schools. Bullying by fellow students and feelings of indifference from school teachers leave children feeling isolated and unsupported. 
• Other challenges include the legal status as a refugee and the ability to seek employment and access services such as health and education in the same way as citizens from the host country.  (link to article 1, understanding the refugee experience)

Symptoms of Trauma in a Child

Millions of children are exposed to traumatic experience each year. A detailed breakdown on signs and symptoms according to age can be found here. Symptoms can include any of the following;

Physical

• Fatigue 
• Bodily aches and pains such as stomach pain or headaches
• Increased muscle tension
• Changes in posture 
• Decreased balance and coordination
• Decreased flow and vitality to movement

Psychological/ Emotional:

• Excessive fear (people, places, noises, etc).
• Separation anxiety
• Crying easily
• Expresses feelings of sadness or worry
• Expressing feelings of hopelessness
• Lack of concentration (at home, at school)
• Sleep problems including nightmares

Behavioural

• Overly irritable and quick to anger
• Not wanting to go outside or play with others
• Aggressive behavior
• Lack of motivation
• Restlessness or hyperactivity
• Acting younger than their age (regression)
• Bedwetting
• Acting older than their age (feeling they have to be the parent)

Impact of Trauma on a Child’s Development

The response to a given traumatic event may vary from one child to another; this depends on the nature and the duration of the traumatic stressors, the child’s characteristics (age, gender, history of stress exposure, and presence of supportive caregivers).

Attachment and Relationships

Trouble with relationships, boundaries, empathy, and social isolation.

A child with a trauma history may have problems in developing healthy, supportive relationships with friends and significant others. This is important for the therapist to recognize that a rapport in working with them may take longer to develop

Physical Health

Impaired sensorimotor development, coordination problems, increased medical problems such as lowered immune system, and somatic symptoms, hyperarousal, food sensitivities, enuresis, encopresis. 

For children with refugee experience their normal development is impacted as a result of growing under constant or extreme stress, the brain, the nervous system, the immune system and body’ stress response systems may not develop normally, children adapt to frightening and overwhelming circumstances by the body’s survival response, so if they are exposed to even ordinary levels of stress, their systems may automatically respond as if they are under extreme stress. This may include rapid breathing and heart racing when they face a stressful situation. 

Emotional Regulation

Difficulty identifying or labeling feelings and communicating needs, inability to relax, reduced capacity to manage emotions and/or self soothe. Young children are less able to identify their emotions, verbalize what they are feeling inside, and manage their responses. Their emotional responses may be unpredictable or explosive.

Dissociation

Altered states of consciousness, amnesia, impaired memory. Dissociation is a defense mechanism that children use to separate themselves from an overwhelming and terrifying experience and after when they face stressful situations or any trauma reminders. Children may perceive themselves as detached from their bodies, or somewhere else in the room watching what is happening to their bodies. They may feel as if they are in a dream or some altered state that is not quite real or as if the experience is happening to someone else.Dissociation can affect a child’s ability to be fully present in activities of daily life, classroom behavior, and their social interactions, it might appears as if the child is simply “spacing out,” daydreaming, or not paying attention

Cognitive Ability

Problems with focus, learning, processing new information, language development, planning and orientation to time and space

Self-Concept

Lack of consistent sense of self, body image issues, low self-esteem, shame and guilt.

Behavioural Control

Difficulty controlling impulses, oppositional behavior, aggression, disrupted sleep and eating patterns, trauma re-enactment, hypervigilance. 

Delays in Normal Developmental Milestones

Across physical, emotional and behavioural domains

Regression in Recently Acquired Developmental Gains

Children may begin bedwetting again or regress in communication skills.

Associated Conditions Arising as a Result of Trauma

The effects of trauma exposure in children are complex and can predispose children to a number of associated disorders;   

• PTSD (link to PREP article)
• Depression.
• Attention-Deficit / Hyperactivity Disorder (ADHD)
• Oppositional Defiant Disorder (ODD)
• Conduct Disorder
• Anxiety Disorders
• Eating Disorders
• Sleep Disorders
• Communication Disorders
• Separation Anxiety Disorder
• Reactive Attachment Disorder

Principles of Working with Refugee Children who have been TraumatiseIntervention with children with refugee experience must include treatment for the child, and some interventions with the caregivers. Therapeutic principles used with children include: 

Family Systems Approach:  Trauma affects the entire family. Working with the family enables the therapeutic benefits to be maximized for the child and the whole family. When the family is functioning well, it provides a better healing environment at home for children to recover from their trauma and promotes their well-being.

Empowering the caregiver is a key priority. Providing educational sessions to the caregivers in physiotherapy sessions can reinforce effective parenting strategies, healthy coping methods, and provide opportunities to increase attachment with their children. This also has a healing effect on the caregiver as they feel more effective. 

Interdisciplinary/Holistic Approach

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