Culturally informed ways to support mental health in refugee and asylum seeker children

Children of refugee and asylum seeker backgrounds are likely to have been exposed to significant adversity during crucial phases of their development. Experiences both pre- and post-migration can have significant effects on their mental health and wellbeing. These experiences can make children vulnerable to a range of mental health difficulties (Mares, 2016; Ziaian et al., 2013).

The research on the prevalence of mental health problems in refugee and asylum seeker children is inconclusive. Some findings suggest that mental health challenges are higher in refugee than non-refugee children (Henley & Robinson, 2011). For example, one study looked at 304 refugee and asylum seeker children aged 4–12 years living in South Australia (SA). It found that 4.9% of children had emotional and behavioural problems such as emotional symptoms, conduct problems, hyperactivity, peer problems and trouble with prosocial behaviour (Ziaian et al., 2013). Another study of 348 refugee children (n=180) and adolescents (n=168) aged 7–17 years living in SA indicated that 7.1% displayed symptoms consistent with depression (Ziaian et al., 2012).

However, findings from Building a New Life in Australia, a longitudinal study of resettled humanitarian migrants and their families in Australia, presented a mixed picture of children’s mental health. Some age groups had poorer outcomes on the Strengths and Difficulties Questionnaire (SDQ) total scores, but overall ratings were comparable to the mean scores of Australians of the same age (Winnie et al., 2018).

A range of cultural factors can influence an individual’s decision to seek treatment and their subsequent engagement in therapy. These include beliefs about the importance of family in healthcare, the cause of their difficulties, and stigma attached to mental illness and treatment (Porter & Haslam, 2005).

It is vital that practitioners working with refugees and asylum seekers are aware of their own cultural assumptions or biases, are culturally skilled and informed, and are open to different cultural perspectives on mental health problems. This includes awareness of differing values, avoidance of stereotyping, and the ability to understand and choose a treatment appropriate to the person’s cultural background (Porter & Haslam, 2005). Effective interventions utilise culturally appropriate ways of engaging with refugees. These interventions honour cultural systems and values, in a way that fosters recovery from mental illness (Due & Currie, 2021).

Due and Currie’s (2021) review of the research literature has identified six key competencies for practitioners working with refugee and asylum seeker children:

1. Knowledge of the complex needs of refugees
2. Use of holistic/strengths-based approaches
3. Ability for practitioners to work in coordination with others in the child’s network
4. Ability to build trust and therapeutic relationships
5. Seeking feedback from children and young people
6. Cultural competency² such that practitioners understand a child or young person’s cultural background and cultural differences.

Practicing cultural curiosity when engaging with children and families offers further considerations in adopting ‘culturally competent’ and ‘culturally curious³’ approaches to engaging with children and parents from refugee backgrounds.

The following sections outline some other culturally informed approaches that have been implemented in community and/or health care settings where mental health services are provided. The evidence for the effectiveness of such approaches is still emerging. Most have not yet been rigorously evaluated for use with refugee and asylum-seeker children and families, so please keep this in mind when considering adopting them in your own practice.

Recognising service barriers and facilitating access to services

Refugee and asylum seeker children may not have their mental health needs fully met because of differing cultural expectations and the unavailability of appropriate services. For example, refugee and asylum seeker children often only get referred to mental health services after displaying severely disruptive behaviour (Henley & Robinson, 2011). Further, refugee and asylum seeker children and families may be unaware of the range of mental health services available to them. Or they may disengage from services if they do not feel safe or confident that their needs will be met. It is therefore important for mental health practitioners to recognise that not all refugee and asylum seeker children and families are accessing appropriate services.

You can help refugee and asylum seeker children and families to access appropriate services by:

• working with case workers, interpreters or volunteers to ensure that children’s appointments do not conflict with different services (Henley & Robinson, 2011; Howard & Hodes, 2000)
• finding a suitable time for mental health interventions and ensuring they fit with other priorities. The initial re-settlement period can be overwhelming for families, and they may find it difficult to engage with mental health services when they are trying to become established in a new location. You may need to work with families to help them access services – for example by discussing public transport routes or facilitating access to childcare services for parents or children attending treatment
• finding bulk-billing treatment for mental health issues or other services that asylum seekers are eligible for
• working with the child’s network (Due & Currie, 2021). For example, attending a first appointment with the child and parents – bridging the gap of trust to services
• facilitating informed decision-making by taking time to explain all information and answering any questions in ways the child and family understand (Due & Currie, 2021)
• using strategies aimed at improving ‘cultural competency’ and ‘cultural curiosity’ to improve interactions and engagement between yourself and the family. This can make services more accessible and increase service use.

Building trust and rapport

Children and families from refugee and asylum seeker backgrounds may have pre- or post-arrival experiences that have led them to fear or mistrust authorities. A genuine interest in and respect for refugee and asylum seeker children and families are the most effective tools for building trust and rapport.

In order to establish trust, the first appointment often needs to be longer, and/or several appointments may be needed for a comprehensive assessment (Henley & Robinson, 2011). A positive therapeutic relationship and conditions of trust and safety are essential to help refugee and asylum seeker children recover from mental health challenges (Hosking, 1990). For service providers, understanding the effects of migration and settlement is fundamental to successful engagement with refugee and asylum seeker children and families.

Trauma-informed approach

Health care centres and primary care providers play a crucial role in promoting resilience and reducing the negative outcomes of trauma. Trauma-informed care (TIC) has been identified as best practice for refugee and asylum seeker children, youth and their families (Miller et al., 2019). In the practice and research literature, there are different descriptions of the elements/ principles of TIC but broadly they all share the same characteristics: that services are trauma aware, safe, strengths-based and integrated. TIC aims to avoid further harm that can arise from re-traumatising children and families (Griffin et al., 2022).

Emerging Minds’ resource on supporting recovery from trauma provides further information useful for professionals working with refugee and asylum seeker children who have experienced trauma.

Use of interpreters

Interpreters are often involved when practitioners work with refugee and asylum seeker children and families from non-English speaking backgrounds. Appropriate preparation, debriefing, training and supervision may help reduce any issues that arise when working with interpreters.

As reported by D’ardenne et al., (2017) there are several other considerations for practitioners when working with interpreters. It is important to:

• find out if your clients know the interpreter. Ensuring interpreters are not known to clients will protect the confidentiality of children and families
• establish clear roles and responsibilities for yourself and the interpreters. Ensure that interpreters understand the basic principles of the interventions that they are translating to children and families
• be aware of the potential negative emotional impact on interpreters when refugee and asylum seeker children and families recount their experiences; and
• consider the possibility that the interpreter may have had similar experiences to the children and families they are helping.

Organisational supports

Organisational processes, structures and leadership are important supports for practitioners working with refugee and asylum seeker families. They provide the context for safe and effective services. Organisational supports that can enable work with refugee and asylum seeker families include:

• leadership and support for reflective practice and supportive peer-to-peer conversations
• formal training and supervision in culturally competent practice and a culturally curious approach
• recognising and rewarding professional development in cultural competence
• enabling adequate access to interpreters; and
• actively working to build a culturally diverse workforce (Dolman, Ngcanga & Anderson, 2020; Henley & Robinson, 2011).

There is currently limited research evidence for the effectiveness of specific interventions that address the mental health of refugee children. However, the following are two types of mental health interventions that have been used with refugee and asylum seeker children and families.

Interventions enriching family relationships

Practitioners working with refugee and asylum seeker families sometimes use an inclusive framework or interventions that enhance family relationships to help parents understand the purpose of the practitioner-child relationship. One example of an intervention designed to enhance family relationships is multiple-family support and education groups.

Multiple-family group draws on mental health services theory. It is underpinned by the principle that family has a powerful influence on help-seeking behaviours and pathways to care for persons experiencing mental health problems (Henley & Robinson, 2011; Weine et al., 2008). There is emerging evidence to suggest that families who were engaged in these groups demonstrated increased social support, family hardiness, problem-solving communication and family communication around mental health issues, which led to increased access to mental health services.

Intervention for mental health difficulties

Cognitive–behavioural therapy (CBT) is one of the more evidence-based treatment interventions for refugee and asylum seeker children and families. It has been shown to help with a range of mental and emotional health issues, including post-traumatic stress disorder (PTSD), anxiety and depression (Lawton & Spencer, 2021).

In CBT, the therapist and client work collaboratively in changing the client’s maladaptive thinking and behavioural patterns, releasing them from cycles of negativity, and learning practical skills to move forward. Trauma-focused CBT is a subset that is specifically adapted for PTSD symptoms (Lawton & Spencer, 2021). Therapists can be counsellors, psychologists or mental health social workers who undertake specialist training to provide CBT.

A systematic review assessing the effects of CBT on PTSD, anxiety and depression in refugee and asylum seeker children showed CBT had a positive impact on symptoms (Lawton & Spencer, 2021). CBT can also be provided by trained professionals within school settings to fit into the school timetable and thus potentially increase service use. Furthermore, culturally-adapted CBT may be effective for children and refugee children with trauma-related disorders (Nickerson et al., 2011).

Children from refugee and asylum seeker backgrounds can experience a range of mental health conditions that can have significant impacts on their and their family’s wellbeing. While there is limited research evidence, practitioners can use tailored trauma-informed approaches to support children and families from refugee and asylum seeker backgrounds to address and prevent potential mental health challenges.

Overall, addressing the prevention and treatment needs of refugee and asylum seeker children and families involves a multifaceted approach which may require more time and resources. However, effective treatment and support can greatly improve the mental health of these children and families, making it easier for them to resettle and begin their new lives.

The authors would like to acknowledge and thank the practitioners, researchers and key experts that were consulted with in the development of this resource. Special thanks to Dr Joanna Schwarzman (Australian Institute of Family Studies) and Nadine Hantke for assistance in reviewing this resource and providing invaluable input.

Disclaimer: Views expressed in this publication are those of the individual authors and may not reflect those of the Australian Institute of Family Studies or the Australian Government.

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