Considerations For Working With Displaced Children

Original Editor - Wala’a Awwad and Kamal Khalifa from The Center for Victims of Torture as part of the PREP Content Development Project

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

Introduction

At the end of 2021, at least 89.3 million people worldwide had been forced to flee their homes, including nearly 53.2 million internally displaced persons, 27.1 million refugees and 4.6 million asylum seekers. Children and young people between 0-17 years account for 41% of displaced persons. In 2021, as many as 30 million children and youth under the age of 18 were forcibly displaced. Of these children and young people, seventeen million experienced violence or conflict in their home country, and approximately 13 million were eligible for refugee status.

Children and young people 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 result in developmental delays. In addition to this, the challenge of life as a displaced person may create further struggles in adjusting to a new environment, a new culture, a new school, and a different educational system.

When working with children with experience of displacement, it is important to consider the interplay of these different factors and how they may impact the rehabilitation process.

Experiences that Displaced Children May Face

Home Country Experiences (Pre-Migration)

Pre-migration experiences include the challenges, and threats children face that drive their families to seek refuge in another part of their own or 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, or sexual violence; or Secondary Survivors of Torture, a term used for those whose loved ones have been tortured, thus causing the secondary survivor to be vicariously affected by the trauma.
• Children may be fleeing war or violence in their home country. They may have experienced bombings of their houses and/or towns, gunfire, or witnessed dead bodies of friends or family in the aftermath of an event.

 Transit Experiences (Trans-Migration) 

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

Camps for Displaced Persons

• Many children will spend time in a camp for displaced persons. 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 a child's general health. Security in camps can be a great problem; even visiting the communal bathrooms can result in sexual violence.

Arrest

• Children may experience arrest and torture during translocation to the host country.

Detention

• Children may be detained in prisons, military facilities, immigration detention centres, welfare centres, or educational facilities. While detained, migrant children are often deprived 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. Displaced boys have been identified as the main victims of exploitation in the labour market; displaced girls between 13 and 18 have been the main targets of sexual exploitation.

Post Migration Stressors (Host Country Experiences)

This stage covers the challenges displaced persons face when attempting to integrate into the host country's social, political, economic, and cultural framework. The post-migration period involves adaptation to a new culture and redefining one's identity and place in the new society.

Children Often Lose their Role Models

• Under normal circumstances, parents provide the primary role model for their children, contributing significantly to developing their identities and acquiring 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 parents are present, their potential for continuing to act as role models for their children is likely to be hampered by the loss of their normal livelihood and pattern of living.

Children's Roles Change

• A child may have to take on adult responsibilities if one parent is missing. When a mother has to take over a missing father's productive tasks outside the home, 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 a lack of opportunities for play or to attend school. Similarly, the older son may need to work to earn money, potentially exposing him to exploitation in the labour market.

Many Children Report Challenges Integrating into New Schools

• Bullying by fellow students and feelings of indifference from school teachers leave children feeling isolated and unsupported.

Other Challenges

• Other challenges include their legal status as a refugee, the ability to seek employment, and access to services such as health and education in the same way as citizens from the host country. 

Trauma and the Child

Symptoms

Millions of children are exposed to traumatic experiences each year. A detailed breakdown of signs and symptoms according to age can be found at the links below:

• 0 to 12 months
• 1 to 3 years
• 3 to 5 years
• 5 to 7 years
• 7 to 9 years
• 9 to 12 years
• 12 to 18 years

Overall signs and 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 and 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 behaviour
• 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 on Child Development

The response to a traumatic event may vary from child to child; this depends on the nature and duration of the traumatic stressors and the child’s characteristics, including 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 developing healthy, supportive relationships with friends and significant others.
• It is important for the therapist to recognise that it may take longer to develop a rapport with the child.

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 experience of displacement, their normal development is impacted due to growing under constant or extreme stress.
• Their brain, nervous system, immune system and their body’s stress response systems may not develop normally.
• Children adapt to frightening and overwhelming circumstances through the body’s survival response.
• When exposed to even ordinary stress levels, their systems may automatically respond as if under extreme stress. This may include rapid breathing and heart racing when they face a stressful situation. 

Emotional Regulation

Difficulty identifying or labelling feelings and communicating needs, an inability to relax, reduced capacity to manage emotions and/or self soothe:

•  Young children are less able to identify their emotions, verbalise their feelings, and manage their responses.
• Their emotional responses may be unpredictable or explosive.

Dissociation

Altered states of consciousness, amnesia, impaired memory:

• Dissociation is a defence mechanism children use to separate themselves from an overwhelming and terrifying experience.
• It can also occur later when the child faces stressful situations or has 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 if the experience is happening to someone else.
• Dissociation can affect a child’s ability to be fully present in daily life activities, classroom behaviour, and social interactions.
• It might appear 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 behaviour, aggression, disrupted sleep and eating patterns, trauma re-enactment, hypervigilance. 

Delays in Typical Developmental Milestones

Delays in 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

The effects of trauma exposure in children are complex and can predispose children to several associated disorders:   

• Post Traumatic Stress Disorder (PTSD)
• 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 Traumatised Displaced Children

Interventions for children with experience of displacement must include treatment for the child and some interventions for the caregivers. Therapeutic principles used with children include the following approaches:

• Family Systems Approach
• Interdisciplinary, Holistic Approach
• Developmental Approach

The sections below provide detailed descriptions of these approaches.

Family Systems Approach

Trauma affects the entire family. Working with the family maximises the therapeutic benefits for the child and the whole family. When the family functions 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 and 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

Trauma impacts the whole person, mind and body. Trauma healing requires attention to mind, body, spirit, and relationship. It is accomplished through an integrated interdisciplinary approach. The holistic viewpoint is that mental health is related to and interdependent on physical well-being and vice versa. Rehabilitation services should utilise a biopsychosocial approach that serves emotional healing and physical. Ensuring patients are referred to counselling and other social services as needed ensures multiple domains are addressed. Where possible, an interdisciplinary, holistic therapy team approach to rehabilitation should be embraced. This approach develops a greater understanding of an individual’s complex and wide-ranging issues following traumatic events. More importantly, the therapy results are greater than the sum of each discipline implemented individually.

Building Resilience

Resilience is the ability to respond to significant adversity, threat or loss in a way that allows a child and family to adapt and thrive. Rehabilitation professionals can use a strengths-based approach to help build resilience in children and families in several ways.

Create a Safe Space

Many children with experience of displacement have a lack of trust and a reduced sense of safety. Thus, the intervention can only be effective if the child and the therapist have a positive therapeutic relationship. The therapeutic relationship begins from the first meeting with the child and continues to build during the therapy sessions. The rehabilitation professional must learn skills to stay present and attentive in the face of distress and make an authentic connection with the child. Creating a welcoming and predictable environment where children and their families feel comfortable is an essential first step.

Build Relationships and Support the Attachment of the Child to their Parents/Caregivers

Help caregivers understand the signs and symptoms of trauma in their children and how it may impact behaviour. It is also important to help caregivers understand what they can do to help support their children. 

Help Children Understand and Manage Feelings and Emotions

Normalising children's signs, symptoms, and emotions is essential to help them understand and accept what they are experiencing and teach them simple ways to regulate their bodies at home and school.

Provide Opportunities for Mastery and Success

Through goal setting and engagement in games during therapy with and without caregivers present, children recognise and take pride in small achievements from week to week.

Developmental Approach 

Because trauma often disrupts development, it is important to tailor your therapy sessions and the exercise you provide to the child's developmental needs, not only the needs defined by age. 

• A thorough assessment is critical in being able to identify these needs.
• If using group work, consider grouping children according to needs instead of age.
• Use age-appropriate activities to aid engagement and understanding. For example, play-based assessment techniques and treatments with younger children using pictures instead of words.
• Use stories and metaphors to aid the explanation.

Working with Caregivers

Displacement trauma and related transitions are often very stressful for the child and the caregivers. Such stresses increase the demands on caregivers. However, this is a time when children often go through similar stresses and need more careful and sensitive guidance than ever.

Alongside the therapeutic sessions for children, it is important to engage caregivers so they can understand the effects of trauma on their children and the therapy process. This will help to reinforce learning from the rehabilitation sessions at home, which has the potential to improve the outcomes of therapy for the child significantly. It can also multiply the positive effects of treatment as others in the home (e.g. siblings) will also be impacted.

Self-Care

Working with children with experience of displacement can be emotionally difficult for a rehabilitation professional. Implementing personal self-care activities and using reflective skills to help increase self-awareness is essential to self-care. Read more on self-care for rehabilitation professionals here.

Practical Considerations for Rehabilitation Professionals

As with all trauma survivors, it’s important to use a trauma-informed care approach.

Assessment Tips

• Cultural Awareness: If the child is from a different cultural background, learn as much as possible about the child’s culture, and adapt your approach to addressing specific cultural, gender, and age considerations. For example, when providing metaphors or examples, ensure they are relevant and understood in the child’s culture. Being able to greet someone in their own language can help to break the ice.
• Explain the role of the rehabilitation professional in simple and clear ways. Depending on the country and access, some specific rehabilitation professions are not always well understood.  
• Language: use clear and simple language with the child, avoid complicated medical terms, and use an interpreter (if needed).
• Make sure to allocate enough time for the assessment. Children who have experienced trauma may find it difficult to focus and follow instructions. 
• Look for signs and symptoms of trauma and/or injury impacting developmental milestones in Physical, Cognitive/Behavioural, Psychological/Emotional/Social domains that interfere with function.
• Make time to meet the child and parent/caregiver separately and together to understand the key issues. Also, note any observations around the child/caregiver dynamic. If the attachment is an issue, consider allowing the parent/caregiver to be present throughout.
• Confidentiality: Explain that a confidentiality agreement can be negotiated. Hence, children have a safe space to share details privately while acknowledging that caregivers will be alerted if there are any threats to their safety. Consider the child’s body language to understand levels of comfort with a request and signs of dissociation, such as facial expressions, body posture and withdrawal motions, changes in muscular tension such as clenched fists, changes in breathing, vacant looks around the room, lack of responsiveness and slow movement.
• Complete the Objective Assessment for children under 16 in the presence of the caregiver. Children over 16 should be asked what they would prefer. The age at which you can treat a child without their parent/caregiver present will vary from country to country. Ensure you follow child protection policies specific to your country of practice or relevant organisation, keeping in mind the safety of both the child and the therapist. 
• Ensure children are empowered by seeking verbal consent for each activity and explaining what it entails.
• Set collaborative goals with the child and the caregivers. Recognising how trauma impacts a child and their living conditions as a refugee, be prepared to help provide pacing and guidance and scale back and make smaller goals where needed.
• Communicate what to monitor and modify during therapy sessions to other interdisciplinary team members where relevant to avoid potential re-traumatisation.

Treatment Approaches

Education about Trauma and its Symptoms: 

• For Children 
  • Engaging the children in a discussion about their symptoms using a body map where they can colour or add stickers to identify areas of sensations or pain or using role play and/or puppets can help explore and normalise symptoms for the children and address any fears they have.

• For Caregivers
  • Increase the caregiver’s awareness of the physical effects of trauma in children (as outlined above).
  • Explain that these are normal reactions, and children will experience at least some of them at some point after a traumatic situation. Emphasise that every child responds differently according to their age, gender, temperament and background.
  • Discuss whether the symptoms they see in their children are normal for their age (for example, bedwetting is normal for young children, but it is a cause of concern when there is a significant change (increase in frequency or severity).
  • Help the caregivers understand their role in creating a healing environment for their children and reinforce the learning of activities at home. The guidance that a physiotherapist may feel comfortable providing includes: creating a calm home environment; establishing routines; being emotionally and physically available to your child; looking after themselves with some self-care:  

Nervous System Regulation Techniques 

Many children who have had a traumatic experience perceive much of their external world as threatening, meaning their sympathetic nervous system remains overactive. Stimulating the Vagus nerve activates the Parasympathetic nervous system and helps the child to relax and calm down. Helpful techniques to achieve this include using controlled mindful breathing, mindfulness of movement and relaxation techniques. Contextualising these interventions for children is important to encourage compliance. Breathing exercises that may be useful are: ‘beanbag belly’, where a beanbag is put on the abdomen to aid diaphragmatic breathing in supine; ‘hard spaghetti/soft spaghetti’, where children learn principles of hold/relax as a physical relaxation technique. Mindful movements such as yoga-based practices encourage a mind-body connection where children learn to safely explore sensations associated with different movements. In some cases, children may avoid certain movements or activities because of the uncomfortable sensations that they create.

Pain Neuroscience Education (PNE)

Pain is one of the more common somatic symptoms seen in children. Using simple examples and metaphors, children learn that not all pain indicates damage and that feelings and thoughts can worsen and lessen their pain. The information and context in which children perceive their pain has been shown to modulate pain expectations and emotional response to pain. Even parental beliefs about the aetiology of the child's pain influence the child's pain outcomes. Therefore, parents should be involved during PNE.

Aerobic Exercise

Regular aerobic exercise has been shown to affect mental health, including improved concentration and self-esteem positively. It simultaneously can decrease symptoms of depression and anxiety. In promoting and practising different ways to exercise aerobically, children not only feel the immediate benefits of the exercise but also establish lifelong learning on how and why to maintain this practice. Games or activities which increase the joy of movement and encourage a fun experience are well received by children and often result in them teaching these activities to siblings and parents at home. Cone sprints, obstacle courses, aerobic dice, and timed circuit exercises are popular.

In addition to these benefits, aerobic exercise produces many of the same bodily sensations that often elicit anxiety reactions, such as increases in heart rate, respiration, and perspiration. Repeated exposure to anxiety-related interceptive stimuli through ‘safe’ aerobic exercise may therefore extinguish fear responses, accompanied by changes in how these stimuli are interpreted.

Posture and Emotion (The ‘Somatic Narrative’)

Posture is linked to emotion. Helping a child identify any changes in their posture when their emotions change enables them to recognise patterns of movement and posture. Examples include a slumped, rounded posture when sad and an open, expansive posture when happy or confident. Recognising these patterns and actively using this as a strategy can support positive emotions during the day. Acting these moods and movements out in role plays or group activities effectively communicates this learning.

Ergonomics and Preventative Advice

General education about ergonomic principles such as sitting, bending and lifting ensures healthy habits moving forward. It also acknowledges that trauma survivors already have a sensitised nervous system and are more likely to develop co-morbidities or conditions such as chronic pain later in life. Education covering prevention, ergonomics and how to manage acute injuries as they arise can help mitigate the descent into chronic pain states. 

Sleep Hygiene

Sleep is commonly affected following a traumatic experience. The consequences of poor sleep are wide-ranging. It affects physical health, recovery from sickness, the ability to manage pain, performance at school and the general ability to self-regulate behaviour during the day. Some helpful advice on sleep hygiene to children and caregivers will help them to structure their daily and bedtime routines to aid sleep. Using pictures or cards to help children identify helpful and unhelpful habits allows you to engage with them on this topic in an interactive way. 

In general, helpful advice is to:

• Create a Good Sleeping Environment.
  • Minimise disturbances such as noise and bright lights. Watching television or using phones before bed should be avoided. However, darkness may cause anxiety, so a dim night light can be helpful.
• Develop a Calm Bedtime Routine.
  • A consistent, relaxing routine before bed signals the brain that it is time to wind down, making it easier to fall asleep. This includes going to bed and getting up at the same time every day. Having an hour of quiet time. A bedtime story creates opportunities for bonding and attachment with caregivers. Stressful conversations between caregivers or children should be avoided.
• Avoid Caffeinated Products including Soda and Chocolate before Bedtime and limit drinking large quantities of fluids before bedtime.
• Practising Relaxation Techniques before Bed alone or with the caregiver is a great way to wind down, calm the mind, and prepare for sleep. Children should be encouraged to use some techniques taught during their treatment.
• Regular Exercise during the day helps provide natural tiredness in the body. Napping should be avoided (unless it is part of a small child's daily routine)
• Using the Bed for Other Activities should be avoided. However, depending on the child's living situation, this may be difficult. The idea is that the bed should be associated with sleep. When a child is awake during the night, they should be encouraged to get up, move around and do some relaxation or mindful exercises. This will help them to avoid getting into the habit of tossing and turning in bed at night.

Resources

Sleep Hygiene Resource

• CHOC Children's - Sleep Hygiene for Children
• Seattle Children's - Sleep Hygiene for Children                                                                      

Mindfulness Breathing and Yoga Poses and Progressive Muscle Relaxation

• Kid's Yoga Stories

Blogs

The Center for Victims of Torture provides insightful blogs, a great resource when considering effective and integrated care for children.

Finding the Most Effective Ways to Help Children Affected by War

• https://www.cvt.org/blog/healing-and-human-rights/finding-most-effective-ways-help-children-affected-war

Integrated Care for Children Brings Great Progress

• https://www.cvt.org/blog/healing-and-human-rights/integrated-care-children-brings-great-progress

Taking Extra Steps to Care for Survivors, Including Children

• https://www.cvt.org/blog/healing-and-human-rights/taking-extra-steps-care-survivors-including-children