This month, BRYCS continues its focus on health and mental health in refugee children and their families (see last month’s Spotlight on holistic health) by highlighting the work of the National Child Traumatic Stress Network (NCTSN). [1]

The National Child Traumatic Stress Network

In 2001, in recognition of the impact of traumatic events on the nation’s children and youth, the U.S. Congress passed the Donald J. Cohen National Child Traumatic Stress Initiative establishing the National Child Traumatic Stress Network (NCTSN). Under the auspices of the U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration (SAMHSA), the NCTSN now encompasses 54 centers around the United States, coordinated by the National Center for Child Traumatic Stress (NCCTS) at UCLA and Duke University. The NCTSN mission is to raise the standard of care and improve access to services for traumatized children, their families, and communities throughout the United States. The NCTSN has organized several task forces staffed by member agencies that focus on special issues, such as child welfare, service integration, and refugees. This month’s Spotlight and Sidebar highlight the work of those NCTSN members serving refugee children and their families. [2]

The NCTSN’s Refugee Trauma Task Force’s Publications

In 2003, The Refugee Trauma Task Force published its Review of Child and Adolescent Refugee Mental Health ([White Paper I], Lustig, et al.) that provided an overview of the available literature. According to this literature, multiple traumas endured by refugee children included, “…direct exposure to war time violence, including combat experience, displacement and loss of home, malnutrition, separation from caregivers, detention and torture and a multitude of other traumatic circumstances affecting the children’s health, mental health, and general well-being,” and are linked to symptoms such as, “…anxiety, recurring nightmares, insomnia, secondary enuresis, introversion, anxiety and depressive symptoms, relationship problems, behavioral problems, academic difficulties, anorexia, and somatic (physical) problems.” [3]

This paper also noted a lack of access to mental health services for refugee children. Barriers are similar to those for all children, but are most likely compounded for refugees due to cultural and linguistic barriers. As noted in last month’s Spotlight, conceptions of health, illness, and healing may be quite different for refugees and have led to creative approaches to addressing mental health issues that may increase engagement and effectiveness for these populations.

Just this year, the National Child Traumatic Stress Network’s Refugee Trauma Task Force published Mental Health Interventions for Refugee Children in Resettlement: White Paper II (Birman, et al., 2005). This paper reviews a range of interventions described in the literature, and provides information regarding the documented effectiveness of these interventions. Although this field is just beginning to build a literature on “evidence-based practice” (interventions that have been demonstrated to be effective according to scientific principles), there is enough evidence to point practitioners in general directions.

This paper emphasizes the importance of comprehensive services that address children’s mental health within the context of their family, school, and community. These services range from prevention to programs that address mental health and trauma more directly. Approaches to mental health services reviewed in this paper include (1) trauma-informed treatments, such as school-based cognitive-behavioral therapy (see the Los Angeles Unified School District’s successful program for one example); parenting interventions for mothers; and art/expressive therapies; (2) strategies for increasing access and engagement in services, such as basing services in medical clinics or the schools; (3) increasing cultural competence through training mainstream service providers, using ethnically/linguistically matched professionals and paraprofessionals, and ethnic specific community-based health clinics (see last months Spotlight); and (4) integrating prevention services as part of or in addition to treatment through psychosocial approaches, including family-and-community-strengthening programs.

Another unique and useful product from the NCTSN’s Refugee Trauma Task Force is Children of War: A Video for Educators, which can be used to inform educators about the experiences of refugee children using a powerful medium: children telling their own stories. See the description below for more information, including how to order this video and the accompanying Resource Guide.

SUMMARY: Refugee-Related Resources from the NCTSN

For Practitioners and Program Managers
Lustig, et. al. (2003). Review of Child and Adolescent Refugee Mental Health: A White Paper from the National Child Traumatic Stress Network’s Refugee Trauma Task Force.
Analyzes recent empirical studies of mental health problems affecting refugees, with a focus on child and adolescent populations in the United States. Health care professionals seeking to provide treatment and support to these populations get information about: (1) the phases of the refugee experience, from preflight to resettlement; (2) stressors affecting refugee children, including preflight exposure to combat, separation from caregivers and traumas of life in refugee or detention camps, and the sense of loss associated with migration and stigma attached to their refugee status; (3) ways in which children attempt to cope with war and political violence and to protect themselves from the dangers and deprivations commonly experienced in refugee camps; (4) ways in which both acculturation and parental well-being can be protective factors against the stress of resettlement; (5) stress reactions and pathological outcomes, including post-traumatic stress disorder (PTSD) and depression; (6) physical health and its impact on stress and vice versa; and (7) interventions that focus on the individual or the family, are school-based, or focus on culturally relevant healing. Clinicians trained to treat traumatized refugee children must be sensitive to cultural variations in experiences of symptoms as well as culturally sanctioned approaches to treatment.

Birman, (2005). Mental Health Interventions for Refugee Children in Resettlement: White Paper II. National Child Traumatic Stress Network’s Refugee Trauma Task Force.
Argues for the necessity, and outlines the characteristics, of a comprehensive mental health services model for making mental health interventions with refugee children. Providers of mental health services to traumatized refugee children get information about: (1) mental health issues for refugee children in resettlement, including previous exposure to trauma, stresses of resettlement, and barriers to receiving services; (2) the importance of culturally competent and comprehensive mental health and social services; (3) research and analysis to date concerning the effectiveness of comprehensive services for children, including strategies involving trauma-informed treatments for children, psycho-educational and parenting interventions for mothers, and art and expressive therapy; (4) strategies to improve access to care and engagement in services; (5) approaches to cultural competence, including enhancing cultural awareness and sensitivity of mainstream providers, using ethnically matched professionals and paraprofessionals, and offering services in culture-specific clinics or centers; and (6) interventions designed to address the stresses of resettlement, including case management and preventive interventions. A focus on studying existing practices with refugee children can serve the long-term goal of developing evidence-based interventions for traumatized refugees.

For Schools
Children of War: A Video for Educators

A number of NCTSN member organizations address Refugee Trauma. A collaborative work group composed of representatives of more than 10 organizations serving refugee/immigrant children developed CHILDREN OF WAR: A VIDEO FOR EDUCATORS. The video is a moving, 30-minute program depicting the experiences of refugee children in America. It opens with highlights from the play Children of War, in which a group of refugee youth from around the world present their stories in their own words. The program goes on to document the consequences of refugee trauma and focuses on ways that these traumatic experiences affect children in American schools. This information is also relevant to mental health providers and emergency management planners.

This video was created to inform school personnel about the often unrecognized lives of many youth in their schools. The purpose of the video is to define the importance of exposure to war and displacement and to describe the effects of this trauma exposure on school behavior, academic performance, and school violence. CHILDREN OF WAR: A VIDEO FOR EDUCATORS also may be educational for those who set up emergency management systems in states and local communities as well as those who provide mental health services in a variety of settings.

An accompanying Resource Guide contains discussion questions, suggests ways that teachers and administrators can help refugee/immigrant children in their schools, and provides avenues to additional resource materials. The practical suggestions listed in the Resource Guide will also be useful to those responsible for planning community responses to disasters.

Contact Judy Holland, National Center for Child Traumatic Stress, to obtain a copy of the video. The CHILDREN OF WAR resource guide may be downloaded online.

Resources available through the BRYCS Clearinghouse:

For Practitioners

Cultural Competence:

  • EthnoMed: Ethnic Medicine Information from Harborview Medical Center (Web site) This Web site contains information about the cultural beliefs of, and pertinent medical issues surrounding, recent immigrants and refugees in the United States. Based at the University of Washington’s Harborview Medical Center in Seattle. Also housed on this site are patient education materials in languages including English, Amharic, Cambodian, Khmer, Oromo, Somali, Spanish, Vietnamese, Chinese, Russian, Tagalog, Korean, and Tigrinya.
  • CulturedMed (Web site) This Web site contains information on diverse health beliefs of different cultures, well as cross cultural interactions between providers and patients in an effort to promote cultural competence.
  • Non-Western Concepts of Mental Health. “This discussion guide examines non-western concepts of mental health specifically from Mozambique and Angola. It looks at the ways in which mental health and illness can be understood outside the framework of western biomedical paradigms.” – Publishers Description

Mental Health:

For Program Managers

For Educators and Schools

  • Tips for Teachers During Times of Trauma. This guide for teachers in times of trauma was updated after the events of September 11, 2001–the terrorist attacks on the World Trade Center and the Pentagon. These traumatic events could cause refugees to experience trauma or become re-traumatized. For many refugees, their English-as-a-Second-Language (ESL) programs are the places where they will find their primary, in-depth contact with Americans with whom they can feel safe and where they can ask questions.
  • Mental Health of Refugee Children: A Guide for the ESL Teacher. Provides guidance to English as a Second Language (ESL) teachers about the challenges facing newly resettled refugee children in the United States.
  • Mental Health and the ESL Classroom: A Guide for Teachers Working with Refugees. This manual guides English-as-a-Second-Language (ESL) teachers by outlining the complex burdens that refugee students carry and setting out concrete steps that ESL teachers can take in order to turn their classrooms into effective and welcoming teaching and learning environments. (ERIC No. ED467256)
  • The Handbook of Frequently Asked Questions Following Traumatic Events: Violence, Disasters, or Terrorism. Provides guidance to parents, teachers, clinicians, and other caregivers in talking to children who have been exposed to traumatic events. In times of crisis, children require special attention so that they can develop the skills needed to become resilient enough to deal with and overcome traumatic experiences.
1 Much of the information and text for this Spotlight is drawn from a recent article in Dialogue 3-17-05, an NCTSN publication, reprinted here with permission of the primary author, Judy Holland, of the National Center for Child Traumatic Stress. This article is now available on the SAMHSA DTAC Web site:
2 See the list of NCTSN centers serving refugee children and their families.
3 Birman, (2005). Mental Health Interventions for Refugee Children in Resettlement: White Paper II. National Child Traumatic Stress Network’s Refugee Trauma Task Force.