In order to best serve children who are refugees and who have experienced trauma, teachers must be trauma-informed and understand their role in classroom-based supports for these students.
Minnesota has a tradition of welcoming refugees. Approximately 3,000 refugees resettle here each year, with about 55% of these refugees being under the age of 18 (Minnesota Department of Health, 2016). As numbers of refugees increase worldwide, more and more refugees will continue to resettle in Minnesota (American Immigration Council, 2015). Therefore, as refugees continue to make their homes within our communities, it is more important than ever that teachers and other school staff members understand the implications of the term ‘refugee,’ and how to most effectively work with these students and families.
A refugee, according to the Immigration and Nationality Act of 1952 (2013) is “a person who is unable or unwilling to return to his or her home country because of a ‘well-founded fear of persecution’.” By definition, the term refugee implies having experienced fear-inducing circumstances or events, and in many circumstances, this danger has had the potential to be traumatic. Therefore, these individuals are at a high risk of experiencing posttraumatic stress disorder (PTSD), a mental health condition brought on by any traumatic event and characterized by intense flashbacks and anxiety. Refugee children are especially vulnerable to the effects of trauma, but unfortunately there is a relatively little research, as well as little awareness in schools, on how to provide care for children who are experiencing these challenges. To improve refugee children’s mental health in the most effective and accessible way, teachers and other school staff must support school-based methods to combat the unique trauma refugee children face. This article seeks to explain the trauma throughout all stages of refugees’ forced migration, discuss the current interventions used for refugee children, and offer specific ideas to teachers to support these students based on these accepted therapeutic practices.
Refugees and Experiences with Trauma
Refugees often experience trauma throughout their entire migration. In their countries of origin, they may experience loss, violence, and deprivation of basic needs (Hart, 2009; Isakson, Legerski, & Layne, 2015; Kia-Keating & Ellis, 2007). In refugee camps, although these are supposed to be safe places, oftentimes violence can break out among the inhabitants. Displacement and separation from family can also manifest itself in negative behaviors and emotions (Shannon, Wieling, McCleary, & Becher, 2015). Once refugees are able to leave the camp to migrate to their new home, they may face confusion, uncertainty, and a dangerous journey (Hart, 2009). Finally, once settled, they often experience poor living conditions and poverty, feel unsafe in a new country, must navigate unfamiliar expectations, and are separated from their families (Isakson et al., 2015; Shannon et al., 2015). Each of these traumas compound and collectively affect mental health (Betancourt, Newnham, Layne, Kim, Steinberg, Ellis, & Birman, 2012). Although refugee parents try to serve as a protective shield for their children, if they themselves are combating PTSD, they are less able to do so.
As a vulnerable population, children experience trauma especially acutely. There are several estimates of the percentage of refugee children who experience PTSD: from 19-54% for refugee youth to 50-90% for refugee elementary-age children (Isakson et al., 2015; Schottelkorb, Doumas & Garcia, 2012). Children who are refugees also experience other mental health issues: an estimated 3-30% of refugee children experience depression, while in a study of 60 war-affected refugee children ages 3-18 by Betancourt et al. (2012), 26.7% of the refugee children experienced anxiety (Isakson et al., 2015).
Effects of Trauma on Schooling
Stemming directly from these concerns are academic and behavioral issues. In the study above by Betancourt et al. (2012), 53.6% of the 60 children experienced academic problems and 44.6% exhibited behavioral difficulties in the classroom. As refugee children are constantly consumed by the fear of experiencing a flashback or the need to numb themselves against stressors, they are unable to regulate their behavior or process new information. If untreated, this can lead to maladaptive behaviors, including aggression and risky behavior (Kamaliddin, Hol, Leotaud, & McKinney, 2015).
Another contributing factor to refugee children’s struggles is the need to adapt not only to a new culture, but to new roles within the family (Kia-Keating & Ellis, 2007). Oftentimes, children can adapt to the new country more quickly than their parents. Although parents attempt to shield their children from the dangers of their new home, they often are not able to fully understand this new place to the extent that their children do. This can cause anxiety for both parents and children because it is a redefinition of what the parental roles have been in the past, from a protector to someone who needs help (Hart, 2009). These new roles can evoke feelings of guilt for parents, as they feel as though they are not doing their job, and confusion for children, as they are thrown into an unexpected leadership role.
Barriers for Implementing Mental Health Interventions
It is important for teachers to understand that, although their students certainly require and deserve mental health services, many refugee children do not receive these mental health services due to several barriers (Price, Ellis, Escudero, Hoffman-Gottschling, Sander, & Birman, 2012). Structural barriers include a lack of mental health providers nearby, or a lack of insurance or money to pay for the services. Another barrier is struggling to meet basic needs of one’s family: if a parent must dedicate their time to finding employment, they will not have time to seek mental health interventions for their children (Shannon et al., 2015).
Perceptions can also serve as barriers. A parent may be unable or unwilling to identify a child’s mental health problem. They may be experiencing traumatic symptoms themselves, and so cannot identify their child’s maladaptive response, or they may blame themselves and do not want to admit that there is any issue. Furthermore, mental health awareness may not be an explicit part of their home culture, and so it may be harder to recognize. If they do recognize the problem, they may not want to ask for help from an unknown counseling center run by people who do not look like them and do not share their experiences. They especially do not want their child exposed to anything else that may be harmful. This stigma keeps families from taking advantage of services that may be available.
Why School-Based Interventions?
To overcome these barriers, one way to make mental health services more available to refugee children is to embed them within schools. School is one of the most influential social services families connect with when they move to the United States (Kia-Keating & Ellis, 2007). Because of this, schools are in the unique position to serve as the first point of contact between the family and community. By providing services in a setting to which families are already connected, it is more likely that the families will continue to take advantage of this service because they do not have to use outside time and resources to connect with another provider. Not only does the service become more accessible, but the stigma associated with receiving mental health support is also reduced (Kia-Keating & Ellis, 2007). All children must attend school, so receiving mental health support at school simply becomes another part of a child’s day, and not something that is viewed as strange.
Unfortunately, many schools lack the resources or the knowledge necessary to provide students with such services. As teachers, although we cannot always ensure that our schools provide these services, we can absolutely make sure that our own classrooms are trauma-informed. This support within the classroom helps refugee children feel as though they belong in their new community. In a study by Kia-Keating & Ellis (2007), it was found that, regardless of the level of trauma the students had experienced, an increased sense of school belonging led to a decrease in depression and social-emotional distress, and an increase in self-efficacy, motivation, and academic achievement. In providing this support to refugee children, the teacher sends a message that the children belong in the community and that the child is worth investing in. Therefore, it is important for teachers to be aware of current understandings of refugee children’s trauma and the interventions used to combat the effects of this trauma, so that teachers may use appropriate parts of these understandings in their own classroom settings.
KidNET: Narrative Exposure Theory
Currently there are a limited number of studies regarding how to best serve the vulnerable population of refugee children who desperately need mental health interventions. According to Schottelkorb et al. (2012), “there are no evidence-based treatments for traumatized refugee children at this time,” (p. 58) so instead, refugees are forced to settle for “evidence-informed” practice (Isakson et al., 2015). However, one widely accepted intervention for working with refugee children who have experienced trauma is narrative exposure therapy, or KidNET (Neuner, Catani, Ruf, Schauer, Schauer, & Elbert, 2008). In KidNET, children are asked to narrate the story of their lives, not just the trauma. They are asked to connect this narrative to certain items: rope, flowers, and rocks. The rope represents the timeline of a child’s life. As children work their way through their rope, they place flowers at happy parts in their lives and rocks at difficult parts.
This practice is grounded in current understandings of episodic memory, or memories of specific events. These memories consist of declarative memories (the facts about the event) and nondeclarative representations (the emotional and sensory aspects one experienced during the event). Re-experiencing episodic memories can be problematic when one remembers the event so intensely that they are not just recalling the facts, but truly feeling the emotions and sensory experience (flashbacks). These flashbacks are incredibly overwhelming for anyone, especially a child, and typically results in avoidant behavior, or attempts to keep away from any thoughts, people, or places that may trigger these flashbacks (Neuner et al., 2008). It is important for teachers to understand that this “fight-or-flight” survival technique in refugee children is a predictable response. If a child is triggered and their response is to run out of the room or hide under a desk, for example, they are not trying to disrupt or distract the class, but are simply having an intense physiological trauma response.
Therefore, the goal of KidNET is to help children represent the traumatic event as a declarative memory, not a sensory-perceptual one (Neuner et al., 2008). By allowing children to tell their stories and connect these stories to tangible items, children can feel relief in making sense of their experiences, rather than being overwhelmed with re-experiencing the emotion and sensory components of the trauma. Teachers can support these students by first understanding how trauma and PTSD can affect learning, and then incorporating elements of these accepted practices into the educational setting.
Strategies for Processing Traumatic Events
It is important to note that teachers are unable to act as sole therapists to refugee students because teachers do not have the expertise to provide this care. However, all school staff (including teachers) can make sure the school environment is welcoming to refugee students, as well as incorporate principles of healing and current therapeutic practices that may be beneficial to these students in an educational setting.
Trauma-Informed Activities
First, teachers must be trauma-informed. In a study by Price et al. (2012), 90% of teachers reported that they had no training to support the emotional needs of their students, especially those of refugee children affected by trauma. All staff members must be educated about how trauma affects refugee children in and outside the classroom, and then use this knowledge to design trauma-informed activities.
One such activity can be taken directly from the principles of KidNET: creating a graphic “life map,” or a timeline of positive and negative events in students’ lives, perhaps even using the same symbols of rocks and flowers. This will not only help the students make sense of their experiences, but help teachers better understand their students as well. Students may use pictures and/or words on their life maps, depending on their ages and English abilities. Another graphic activity that can be helpful for refugee children who have experienced trauma is drawing their nightmares or flashbacks. In drawing these nightmares and explaining them to a teacher, students are given the opportunity to process their experiences and continue to transfer these sensory experiences into declarative ones (Kamaliddan et al., 2015). Research indicates that these sorts of opportunities for creativity in the classroom allow students to develop a personal account of their lives and experiences, as well as express their emotions to others, which in turn increases students’ self-esteem and problem-solving abilities (Tyrer & Fazel, 2014).
Facilitating a Sense of Safety and Control
Students who have PTSD also have a difficult time feeling safe and in control because they are fearful that they will re-experience the traumatic event. Teachers can help students combat this by practicing visualization techniques, such as imagining themselves in a safe place and starting to plan for their futures, because this helps them to believe that they will indeed have a future (Kamaliddan et al., 2015). Furthermore, because children with PTSD are in survival mode, they may have difficulties planning or setting goals for the future, so teachers may provide extra assistance and patience when supporting children in planning and reaching their goals.
School-Community Collaboration
It is important for teachers to not only utilize these current practices, but also to collaborate with the community to which the student belongs in order to recognize and utilize the resources the refugee child’s family already has. For example, a study by Betancourt et al. (2015) found that the most significant protective factors that combat the effects of trauma for Somali refugee families were faith, family communication, and community support. Clearly these are important values held in the Somali refugee community, and so should be at the forefront when designing interventions and developing relationships with that community. For example, teachers may encourage these students to talk about their own faith and how that makes them feel safe, or teachers may discuss decisions with the entire family, perhaps including extended family members. By adapting interventions to community norms and values, support will be more accessible to the students, and both students and families will have greater engagement (Price et al., 2012).
Conclusion
Although more research needs to be done regarding the specifics of the most effective mental health interventions for refugee children, it is clear that refugee children face unique and harmful trauma throughout their entire migration experience. However, it is important to remember that, although this article focused on refugee students, there are many English learners in our classrooms that have experienced similar traumatic events that are not necessarily characterized as refugees (including, but not limited to, undocumented students from Central and South America). These students require and deserve the supports and interventions outlined above to combat the effects of their traumas as well.
School-based interventions that actively utilize resources refugee families inherently possess are the most accessible, effective, and inclusive method to support these students and their families. By caring for refugee children in this way, we are best able to make sure that students are happy, healthy, and successful.
References
American Immigration Council (2015). An overview of U.S. refugee law and policy. Immigration Policy Center. Retrieved from http://www.immigrationpolicy.org/just‐facts/refugees‐fact-sheet
Betancourt, T. S., Newnham, E. A., Layne, C. M., Kim, S., Steinberg, A. M., Ellis, H., & Birman, D. (2012). Trauma history and psychopathology in war-affected refugee children referred for trauma-related mental health services in the United States. Journal of Traumatic Stress, 25, 682-690. doi: 10.1002/jts.21749
Betancourt, T. S., Abdi, S., Ito, B., Lilienthal, G. M., Agalab, N., & Ellis, H. (2015). We left one war and came to another: Resource loss, acculturative stress, and caregiver-child relationships in Somali refugee families. Cultural Diversity and Ethnic Minority Psychology, 21, 114-125. doi: 10.1037/a0037538
Hart, R. (2009). Child refugees, trauma and education: Interactionist considerations on social and emotional needs and development. Education Psychology in Practice, 25, 351-368. doi: 10.1080/02667360903315172
Immigration and Nationality Act of 1952, 8 U. S. C. § 1101 (2013).
Isakson, B. L., Legerski, J., & Layne, C. M. (2015). Adapting and implementing evidence-based interventions for trauma-exposed refugee youth and families. Journal of Contemporary Psychotherapy, 45, 245-253. doi: 10.1007/s10879-015-9304-5
Kamaliddin, H., Hol, D., Leotaud, V. R., & McKinney, D. (2015, October 15). Treating the trauma of young Syrian refugees. The New York Times. Retrieved from http://www.nytimes.com/2015/10/13/health/treating-the-trauma-of-young-syrian-refugees.html?_r=0
Kia-Keating, M. & Ellis, B. H. (2007). Belonging and connection to school in resettlement: Young refugees, school belonging, and psychosocial adjustment. Clinical Child Psychology and Psychiatry, 12, 29-43. doi: 10.1177/1359104507071052
Minnesota Department of Health. Refugee health statistics. Minnesota.gov. Retrieved from http://www.health.state.mn.us/refugee/stats/
Neuner, F., Catani, C., Ruf, M., Schauer, E., Schauer, M., & Elbert, T. (2008). Narrative exposure therapy for the treatment of traumatized children and adolescents (KidNET): From neurocognitive theory to field intervention. Child and Adolescent Psychiatric Clinics of North America, 17, 641-664. doi: 10.1016/j.chc.2008.03.001
Price, O. A., Ellis, B. H., Escudero, P. V., Hoffman-Gottschling, K., Sander, M. A., & Birman, D. (2012). Implementing trauma interventions in schools: Addressing the immigrant and refugee experience. Advances in Education in Diverse Communities: Research, Policy, and Praxis, 9, 95-119. doi: 10.1108/S1479-358X
Schottelkorb, A. A., Doumas, D. M., & Garcia, R. (2012). Treatment for childhood refugee trauma: A randomized, controlled trial. International Journal of Play Therapy, 21, 57-73. doi: 10.1037/a0027430
Shannon, P. J., Wieling, E., McCleary, J. S., & Becher, E. (2015). Exploring the mental health effects of political trauma with newly arrived refugees. Qualitative Health Research, 25, 443-457. doi: 10.1177/1049732314549475
Tyrer, R. A. & Fazel, M. (2014). School and community-based interventions for refugee and asylum seeking children: A systematic review. PLOS ONE, 9, 1-12.
Additional Resources
For more information, visit the National Child Traumatic Stress Network at http://nctsn.org/trauma-types/refugee-trauma/guidance-teachers.
