My husband was a refugee and I knew from the start we would have problems. What I didn’t know is how little insidious things would creep into our marriage and affect everything. I don’t blame him for that but I do blame him for his actions against our children. He stole their lives and for that, sadly, I will never forgive him. I’m not happy that I have a failed marriage but I am happy to be out from his unhappiness… something I could not control nor would he acknowledge. I worry now, how my marriage and troubled past will affect my children. My goal is to normalize mental health in school systems and communities and for everyone to reap its benefits without having to make an appointment to seek help. That is wrong. It is our duty and responsibility to do what will help future generations heal from our past, and we all have past. Click here to learn more.
Red flags and clinical principles
Reprinted from “Trauma and Victimization” issue of Visions Journal, 2007, 3 (3), pp. 12-13
We know that the wounds from war are not confined to the battle field. Refugees from conflict zones often continue to experience trauma from persecution, imprisonment, torture and resettlement for a long time. Thus, it is important to understand the challenges of refugee families and communities.2 This piece identifies some red flags for post-traumatic stress disorder (PTSD) according to age, gender and culture, and provides some guiding principles for mental health workers in caring for refugees.*
Psychological distress from war is harmful to refugee children and adults regardless of racial or cultural background. Refugees may experience a sense of helplessness and despair. The most common mental health issue for refugees is post-traumatic stress disorder and related symptoms of depression, anxiety, inattention, sleeping difficulties, nightmares, and survival guilt.3-12
Trauma can look very different across the developmental stages. Here are some of what we know are danger signs:
- Birth to five years. Young children have difficulty explaining their trauma, but display their trauma by clinging to their mothers, trembling and uncalled for crying. They may also show their trauma through play and inappropriate behaviours for their age like thumb-sucking, nail-biting, bedwetting, frightened facial expressions, fear of darkness or sleeping alone, and little social interaction.13-14 According to the research, parents may not recognize possible trauma, because they mistakenly assume “the child wasn’t looking when it happened” or “was too little to know.”9
- Six to 11 years. Children at this age may become anxious, depressed, angry, unable to concentrate or socialize with peers, and may refuse to go to school. Others may experience sleeping difficulties, nightmares, fear of the dark, and physical ailments like vomiting, headaches or stomach aches. This age group is three times more likely to suffer from PTSD than adolescents, because they are at a younger stage of development.15-16
- Adolescents. Adolescents may be affected for a long time.13 They can feel as if they are frozen in the past, with no prospect of a future.17 Their trauma shows in school difficulties, eating disorders, alcohol abuse, teenage pregnancy, thoughts about suicide, or general ‘acting out.’ Most at risk are those who have lost family and community connections.18
- Adults. Traumatized adults tend to suffer from hypervigilance, emotional numbing and flashbacks or re-experiencing the trauma.1 They may startle easily, show the fight-or-flight response or a heightened sense of awareness, and suffer from nightmares, emotional detachment from oneself and others, and distorted emotions and perceptions.19-21 They may abuse drugs or alcohol, and become depressed, hostile and suicidal.
Girls tend to internalize the trauma and become anxious, withdrawn and depressed. Boys tend to externalize trauma and are more likely to and be inattentive, impulsive and hyperactive, or to engage in violent activities.19 However, findings are inconclusive regarding gender differences.
More important than gender, however, for youngsters is family separation, the murder of a parent (more likely to be the father, since more refugee men are murdered than women), parents’ emotional well-being, experience of torture by a family member, or the number and intensity of traumas.15-16,19,22
Findings point to commonalities in the human experience of emotional and physical pain and suffering across cultures.23-25 The expression of trauma may differ: e.g., Soviets tend toward alcohol abuse,26 while Ethiopians describe physical symptoms such as “burning all over, a tight feeling in the neck, and ‘insects crawling under the skin.’”27 Vietnamese have the think-too-much problem, and Latin Americans have “nervios” (nerves).26 However, we need to be careful about stereotyping. The suffering is universal.
Some Principles of Care**
Refugees may have faced many health challenges, physical injuries, hunger, diseases and emotional trauma. It is essential to provide medical and mental health care, as well as the housing, schooling, and employment needs essential to life in their new homeland.
Survivors of torture have been shown to suffer intense and prolonged pain, and they have a greater risk of developing chronic pain and other health problems.28 Treatment of chronic pain from injuries that damaged nerves, muscles or bones may need more than one type of therapy, starting with medical care. Complementary therapies such as psychotherapy and body work appear to help the emotional and physical healing process.28-29
Since PTSD affects the whole family, it is important to learn its effects on all family members. Professionals who are family-centred are sensitive to the different ways families cope with loss and sorrow, and to their need to maintain their culture and language. These practitioners value cultural diversity and uniqueness across families and explore the need for community supports and reconnecting families with their cultural communities.1,28-31
Refugees face many challenges—a different language, culture and world view—but they also bring with them many strengths. As survivors of persecution and cultural and family losses, they are motivated to succeed and create a better life for themselves and their children. Amidst the pain and trauma, clinicians need to recognize their strengths.32
War trauma can affect future generations, as illustrated by the suffering of Indigenous and persecuted groups.33-34 There is a need for cultural competence based on respect, trust, empathy, care and understanding of the socio-political and historical forces that led refugees into exile.26,28-29,33 A culturally welcoming and safe environment is essential. Culture-sensitive care embraces cultural healing practices, including the role of spirituality and the mind–body–spirit connection.
* The essay is based on a review of international studies on PTSD in refugee children, complemented with interview data of service providers in Canada and the United States. The information gathered has been shared with respondents.
** The Vancouver Association of Survivors of Torture developed the VAST Therapeutic Principles of Care. See footnote reference 17.
About the author
Claudia is an Adjunct Associate Professor in the Pediatrics department at Oregon Health and Science University. Dr. Vargas has worked and done research on refugee services and disabilities in Canada and the United States.
- Herman, J. (1992). Trauma and recovery: The aftermath of violence—from domestic abuse to political terror. New York, NY: Basic Books.
- Martín-Baró, I. (1994). Writings for liberation psychology. Cambridge, MA: Harvard University Press.
- National Child Traumatic Stress Network, Refugee Trauma Task Force. (2005). Mental health interventions for refugee children in resettlement: White paper II. www.nctsnet.org/nctsn_assets/pdfs/promising_practices/MH_Interventions_for_Refugee_Children.pdf
- Yehuda, R. (Ed.). (2002). Treating trauma survivors with PTSD. Washington, DC: American Psychiatric Publishing.
- Pynoos, R.S., Kinzie, J.D. & Gordon, M. (2001). Children, adolescents, and families exposed to torture and related trauma. In E. Gerrity, T.M. Keane & F. Tuma (Eds.), The mental health consequences of torture (pp. 211-225). New York, NY: Kluwer Academic/Plenum Publishers.
- Baker, A. & Shalhoub-Kevorkian, N. (1999). Effects of political and military traumas on children: The Palestinian case. Clinical Psychology Review, 19(8), 935-950.
- Husain, S.A, Nair, J., Holcomb, W. et al. (1998). Stress reactions of children and adolescents in war and siege conditions. American Journal of Psychiatry, 155(12), 1718-1719.
- Montgomery, E. (1998). Refugee children from the Middle East. Scandinavian Journal of Social Medicine, 26(Suppl. 54): 1-152.
- Almqvist, K. & Brandell-Forsberg, M. (1997). Refugee children in Sweden: Post-traumatic stress disorder in Iranian preschool children exposed to organized violence. Child Abuse and Neglect, 21(4), 351-366.
- Goldstein, R.D., Wampler, N.S. & Wise, P.H. (1997). War experiences and distress symptoms of Bosnian children. Pediatrics, 100(5), 873-878.
- Hubbard, J., Realmuto, G.M., Northwood, A.K. et al. (1995). Comorbidity of psychiatric diagnoses with posttraumatic stress disorder in survivors of childhood trauma. Journal of the American Academy of Child and Adolescent Psychiatry, 34(9), 1167-1173.
- Leavitt, L.A. & Fox, N.A. (Eds.). (1993). The psychological effects of war and violence on children. Hillsdale, NJ: Lawrence Erlbaum Associates.
- National Institute of Mental Health. (2001). Helping children and adolescents cope with violence and disasters. Bethesda, MD: NIMH, National Institutes of Health, US Department of Health and Human Services. www.nimh.nih.gov/publicat/NIMHviolence.pdf
- Perry, B.D. & Azad, I. (1999). Post-traumatic stress disorders in children and adolescents. Houston, TX: Child Trauma Academy & Departments of Psychiatry, Pediatrics, Pharmacology and Neuroscience, Baylor College of Medicine. www.childtrauma.org/ctamaterials/PTSD_opin6.asp
- Garbarino, J. & Kostelny, K. (1996). The effects of political violence on Palestinian children’s behavior problems: A risk accumulation model. Child Development, 67(1): 33-45.
- Garbarino, J. & Kostelny, K. (1993). Children’s response to war: What do we know? In L.A. Leavitt & N.A. Fox (Eds.), The psychological effects of war and violence on children (pp. 23-39). Hillsdale, NJ: Lawrence Erlbaum Associates.
- Esfandiari, M. & MacQueen, F. (2000). The vitality of interconnectedness: VAST’s service delivery programme : First alone, then together. Refuge, 18(6), 50-55.
- Hodes, M. & Tolmac, J. (2005). Severely impaired young refugees. Clinical Child Psychology and Psychiatry, 10(2), 251-261.
- Perry, B.D. (1999). Effects of traumatic events on children. Interdisciplinary Education Series, 2(3), 1-22.
- Perry, B.D. (2000). Interdisciplinary Education Series: The vortex of violence: How children adapt and survive in a violent world. www.childtrauma.org/CTAMATERIALS/vortex_interd.asp. Adapted in part from Maltreated children: Experience, brain development and the next generation (W.W. Norton & Company, New York, in preparation
- Graessner, S., Gurris, N. & Pross, C. (Eds.). (2001). At the side of torture survivors: Treating a terrible assault on human dignity (J.M. Reimer, Trans.). Baltimore, MD: Johns Hopkins University Press.
- Papageorgiou, V., Frangou-Garunovic, A., Iordanidou, R. et al. (2000). War trauma and psychopathology in Bosnian refugee children. European Child and Adolescent Psychiatry, 9(2), 84-90.
- Anand, K.J. (1998). Clinical importance of pain and stress in preterm neonates. Biology of the Neonate, 71(1): 1-9.
- Cassidy, R.C. & Walco, G.A. (1996). Pediatric pain: Ethical issues and ethical management. Children’s Health Care, 25(4), 253-264.
- McGrath, P.J., Rosmus, C., Canfield, C. et al. (1998). Behaviours caregivers use to determine pain in non-verbal cognitively impaired individuals. Developmental Medicine and Child Neurology, 40: 340-343.
- Friedman, M. & Jaranson, J. (1994). The applicability of the posttraumatic stress disorder concept to refugees. In A.J. Marsella, T. Bornemann, S. Ekblad et al, (Eds.), Amidst peril and pain: The mental health and well-being of the world’s refugees (pp. 207-227). Washington, DC: American Psychological Association.
- Orley, J. (1994). Psychological disorders among refugees: Some clinical and epidemiological considerations. In A.J. Marsella, T. Bornemann, S. Ekblad et al (Eds.), Amidst peril and pain: The mental health and well-being of the world’s refugees (pp. 193-206). Washington, DC: American Psychological Association.
- Vargas, C.M., O’Rourke, D. & Esfandiari, M. (2004). Complementary therapies for treating survivors of torture. Refuge, 22(1), 129-137.
- Vargas, C.M., O’Rourke, D. & Esfandiari, M. (2004). A triangle of hope for survivors: Integrating psychotherapy and bodywork for chronic pain and cultural loss. Rehabilitation Review, 24(10), 18-21.
- Yoder, J. & Divenere, N. (2004). Family-centered care and the family’s perspective: Traumatic brain injury, cancer, and co-morbid learning challenges. In C.M. Vargas and P.A. Prelock, (Eds.), Caring for children with neurodevelopmental disabilities and their families: An innovative approach to interdisciplinary practice (pp. 35-68). Mahwah, NJ: Lawrence Erlbaum Associates.
- American Academy of Pediatrics. (2003). Family-centered care and the pediatrician’s role. Pediatrics, 112(3, Pt. 1): 691-696.
- Saleebey, D. (Ed.) (2002). The strengths perspective in social work practice (3rd ed.). New York, NY: Longman.
- Danieli, Y. (Ed.) (1998). International handbook of multigenerational legacies of trauma. New York: Plenum Press.
- Duran, E., Duran, B., Yellow Horse Brave Heart, M. et al. (1998). Healing the American Indian soul wounds. In Y. Danieli, (Ed.), International handbook of multigenerational legacies of trauma (pp. 341-354). New York, NY: Plenum Press.