Considerations For Working With Children with Refugee Experience
- 1 Introduction
- 2 Experiences that Refugee Children May Face or Have Faced
- 2.1 Home Country Experiences (Pre-Migration)
- 2.2 Transit Experiences (Trans-Migration)
- 2.3 Post Migration Stressors (Host Country Experiences)
- 3 Trauma and the Child
- 3.1 Symptoms
- 3.2 Impact on Child Development
- 3.3 Associated Conditions
- 4 Principles of Working with Refugee Children who have been Traumatised
- 4.1 Family Systems Approach
- 4.2 Interdisciplinary Holistic Approach
- 4.2.1 Building Resilience
- 4.2.2 Create a Safe Space
- 4.2.3 Build Relationships and Supporting Attachment of the Child to their Parents/Caregivers
- 4.2.4 Help Children Understand and Manage Feelings and Emotions
- 4.2.5 Provide Opportunities for Mastery and Success
- 4.2.6 Developmental Approach
- 4.2.7 Working with Caregivers
- 4.2.8 Self- Care
- 5 Practical Considerations for Physiotherapists
- 6 Treatment Approaches
- 7 Resources
- 8 References
At least 79.5 million people around the world have been forced to flee their homes. Among them are nearly 26 million refugees, around half of whom are under 18 . In 2017, as many as 30 million children and youth under the age of 18 were forcibly displaced. Seventeen millions of these youth experienced violence or conflict in their home country, and approximately 13 million were eligible for refugee status. 
Children 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 cause delays in developmental. In addition to this, the challenge of life as a refugee may create further struggles in adjusting to their new environment, a new culture, a new school, a different educational system.
When working with children with refugee experience it is important to consider the interplay of these different factors and how they may impact the rehabilitation process.
Experiences that Refugee Children May Face or Have Faced
Home Country Experiences (Pre-Migration)
Pre-migration experiences include the challenges and threats children face that drive their families to seek refuge in 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, sexual violence (Link to article on Torture and its consequences) or Secondary Survivors of Torture, a term used for those whose loved ones have been tortured, causing the secondary survivor to now be vicariously affected by the trauma.
- Children may be fleeing war or violence in their home country where they have experienced bombings of their houses and/or towns, gunfire, 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.
- Many children will spend time in a refugee camp. 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 the general health of a child. Security in camps can be a great problem and even visiting the communal bathrooms can result in incidences of sexual violence.
- Children may experience arrest and torture during their translocation to the host country. 
- Children may be detained in prisons, military facilities, immigration detention centers, welfare centers, or educational facilities. While detained, migrant children are often deprived of a range of rights, such as the right to physical and mental health, privacy, education, and leisure. 
- Many unaccompanied children end up travelling with traffickers who may attempt to exploit them as workers, while refugee boys have been identified as the main victims of exploitation in the labor market; refugee girls aged between 13 and 18 have been the main targets of sexual exploitation.
Post Migration Stressors (Host Country Experiences)
This stage covers the challenges faced by refugees when attempting to integrate into the social, political, economic, and cultural framework of the host country society. The post-migration period involves adaptation to a new culture and re-defining one's identity and place in the new society. 
Children Often Lose their Role Models in a Refugee Situation
- Under normal circumstances, parents provide the primary role model for their children, contributing significantly to the development of their identities and to their acquisition of 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 refugee parents are present, their potential for continuing to provide role models for their children is likely to be hampered by the loss of their normal livelihood and pattern of living.
Children's Roles also Change in Refugee Situations
- If one parent is missing, a child may have to take on adult responsibilities. When a mother has to take over a missing father's productive tasks outside the home, for example, 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 lack of opportunities for play or to attend school and the older son may need to work to earn money and this potentially exposes him to exploitation in the labor 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 include their legal status as a refugee, the ability to seek employment, access to services such as health and education in the same way as citizens from the host country. (link to article 1, understanding the refugee experience)
Trauma and the Child
Millions of children are exposed to traumatic experience each year. A detailed breakdown on signs and symptoms according to age can be found here. Symptoms can include any of the following;
- 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 / 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
- Overly irritable and quick to anger
- Not wanting to go outside or play with others
- Aggressive Behavior
- Lack of Motivation
- Restlessness or Hyperactivity
- Acting younger than their age (regression)
- Acting older than their age (feeling they have to be the parent)
Impact on Child Development
The response to a given traumatic event may vary from one child to another; this depends on the nature and the duration of the traumatic stressors, the child’s characteristics (age, gender, history of stress exposure, and presence of supportive caregivers).
Attachment and RelationshipsTrouble with relationships, boundaries, empathy, and social isolation.
A child with a trauma history may have problems in developing healthy, supportive relationships with friends and significant others. This is important for the therapist to recognize that a rapport in working with them may take longer to develop
Physical HealthImpaired sensorimotor development, coordination problems, increased medical problems such as lowered immune system, and somatic symptoms, hyperarousal, food sensitivities, enuresis, encopresis.
For children with refugee experience their normal development is impacted as a result of growing under constant or extreme stress, the brain, the nervous system, the immune system and body’ stress response systems may not develop normally, children adapt to frightening and overwhelming circumstances by the body’s survival response, so if they are exposed to even ordinary levels of stress, their systems may automatically respond as if they are under extreme stress. This may include rapid breathing and heart racing when they face a stressful situation.
Difficulty identifying or labeling feelings and communicating needs, inability to relax, reduced capacity to manage emotions and/or self soothe. Young children are less able to identify their emotions, verbalize what they are feeling inside, and manage their responses. Their emotional responses may be unpredictable or explosive.
Altered states of consciousness, amnesia, impaired memory. Dissociation is a defense mechanism that children use to separate themselves from an overwhelming and terrifying experience and after when they face stressful situations or 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 as if the experience is happening to someone else.Dissociation can affect a child’s ability to be fully present in activities of daily life, classroom behavior, and their social interactions, it might appears as if the child is simply “spacing out,” daydreaming, or not paying attention
Problems with focus, learning, processing new information, language development, planning and orientation to time and space
Lack of consistent sense of self, body image issues, low self-esteem, shame and guilt.
Difficulty controlling impulses, oppositional behavior, aggression, disrupted sleep and eating patterns, trauma re-enactment, hypervigilance.
Delays in Normal Developmental Milestones
Across physical, emotional and behavioural domains
Regression in Recently Acquired Developmental Gains
Children may begin bedwetting again or regress in communication skills. 
The effects of trauma exposure in children are complex and can predispose children to a number of associated disorders;
- Post Traumatic Stress Disorder (PTSD)
- 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 Refugee Children who have been Traumatised
Intervention with children with refugee experience must include treatment for the child, and some interventions with the caregivers. Therapeutic principles used with children include:
Family Systems Approach
Trauma affects the entire family. Working with the family enables the therapeutic benefits to be maximized for the child and the whole family. When the family is functioning 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, 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, relationship and 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. Physiotherapy services should utilize a biopsychosocial approach that serves emotional healing as well as physical. Ensuring that patients are referred to counseling and other social services as appropriate ensures multiple domains are being 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, and more importantly, the therapy results are greater than the sum of each discipline implemented individually.
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. Physiotherapists can use a strengths based approach to help build resilience in children and families in a number of ways.
Create a Safe Space
As children with refugee experience often have lack of trust and sense of safety, the intervention can only be effective if there is a positive therapeutic relationship between the child and the therapist. The therapeutic relationship begins from the first meeting with the child, and continues to build during the therapy sessions. It’s important that the physiotherapist learns skills including the ability to stay present and attentive in the face of distress and to make authentic connection with the child. Creating a welcoming and predictable environment where children and their families can feel comfortable is an important first step.
Build Relationships and Supporting 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 behavior and what they can do to help support their children.
Help Children Understand and Manage Feelings and Emotions
Normalising the signs, symptoms and emotions children may be feeling is important to help them understand and accept what they are experiencing and teach them simple ways to regulate their bodies at home and in school.
Provide Opportunities for Mastery and Success
Through goal setting and engagement in games during therapy with and without caregivers present, children recognize and take pride in small achievements from week to week. 
Tailor your therapy sessions and the exercise you are providing to the child developmental needs, not only the ones that are defined by age, for trauma often disrupts development. A thorough assessment is critical in being able to identify these needs. If using group work, consider grouping children according to needs as opposed to just 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 explanation.
Working with Caregivers
Refugee trauma and the related transitions are often very stressful for the children and the caregivers, such stresses increase the demands on caregivers yet this is a time when children, who are often going through similar stresses, need careful and sensitive guidance more than ever.
Alongside the therapeutic sessions for children it is important to engage caregivers so as to enable them to understand the effects of trauma on their children and the process of therapy, to reinforce learning from the physiotherapy sessions at home, this has the potential to greatly improve the outcomes of therapy for the child, as well as multiply the positive effects of treatment as others in the home (e.g siblings) will also be impacted.
Working with children with refugee experience can be emotionally difficult for a Physiotherapist. Implementation of personal self-care activities, and using reflective skills to help increase self- awareness, are essential to self-care. (Link with the Self-care Article)
Practical Considerations for Physiotherapists
As with all trauma survivors, it’s important to use a trauma-informed care approach;
- Cultural Awareness: If the child is from a different cultural background, learn as much as you can about the child’s culture and adapt your approach to address specific cultural, gender, age considerations. For example, when providing metaphors or examples, make sure 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 that the role of a physiotherapist in simple and clear ways. Physiotherapy is not always well understood depending on the country and access.
- Language; use a 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/Developmental, Cognitive/Behavioral, Psychological/Emotional/Social domains and interfering with function.
- Make some time to meet both child and caregiver separately and together to understand the key issues and note any observations around child/caregiver dynamic. If attachment is an issue, consider allowing the parent/caregiver to be present throughout.
- Confidentiality: Explain that a confidentiality agreement can be negotiated so 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 dissociations like 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 13 in the presence of the caregiver. Children over 13 should be asked what they would prefer. Consider child protection policies of your country or relevant organization.
- Make sure children are empowered by seeking verbal consent for each activity and explaining what it entails.
- Set collaborative goals with the child and the caregivers. In recognizing how trauma impacts a child and their living conditions as a refugee, be prepared to help provide pacing and guidance and to scale back and make smaller goals where needed.
- Communicate what to monitor and what to modify during therapy sessions to other members of the interdisciplinary team where relevant to avoid potential re-traumatization.
Education about Trauma and its Symptoms:
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 plays and/or puppets helps explore and normalise symptoms for the children and address any fears they have.
Important areas to address as a Physiotherapist’s with caregivers are the following areas;
- 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 as some point after a traumatic situation. Emphasize that every child responds differently according to their age, gender, temperament and background.
- Discuss whether the symptoms they are seeing in their children are normal for their age (for example bedwetting, is normal for young children, 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 at home for their children, and reinforce the learning of activities at home. Guidance that a physiotherapist may feel comfortable to provide includes creating a calm home environmental; 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 that 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. Contextualizing these interventions for children is important to encourage compliance. Breathing exercises like ‘beanbag belly’ where a beanbag is put on the abdomen to aid diaphragmatic breathing in supine or ‘hard spaghetti/soft spaghetti’, where children learn principles of hold/relax as a physical relaxation technique. Mindful movements such as yoga based practices for children encourages a mind-body connection where children learn to safely explore sensations associated with different movements. In some cases, children may be avoiding 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. By using simple examples and metaphors, children lean that not all pain indicates damage and that feelings and thoughts can both 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 etiology of the child's pain influences the child's pain outcomes, therefore, parents should be involved during PNE. (Link to pain article)
Regular aerobic exercise has been shown to have positive effects on mental health such as improved concentration and self-esteem and simultaneously decrease symptoms of depression and anxiety. In promoting and practicing different ways to aerobically exercise, the children not only feel the immediate benefits of the exercise, they are also establishing lifelong learning on how and why to maintain such 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, timed circuit exercises are popular exercises.
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 the changes in their posture when their emotions change such as a slumped, rounded posture when sad and an open expansive posture when happy or confident enables them to recognize patterns of movement and posture and actively use this as a strategy to support positive emotions during their day. Acting these moods and movements out in role plays or group activities is an effective way to communicate this learning.
Ergonomics and Preventative Advice
General education about ergonomic principles such as sitting, bending and lifting ensures healthy habits moving forward, but also acknowledges that trauma survivors already have a sensitized nervous system with higher co-morbidities or conditions such as chronic pain developing later in life. Preventative advice and education ergonomically and in understanding how to manage acute injuries as they arise can help mitigate the decent in to chronic pain states.
Sleep is commonly affected following a traumatic experience and the consequences of poor sleep are wide ranging affecting physical health recovery from sickness, ability to manage pain, performance at school and general ability to self-regulate behavior during the day. Some helpful advice to children and caregivers together will help them structure their daily and bedtime routine to aid sleep. Using pictures or cards to help children identify what are helpful and unhelpful habits, allow you to engage with them on this topic in an interactive way.
In general, helpful advice is to;
- Create a Good Sleeping Environment. Minimize disturbances such as noise and bright lights. Watching television or using phones before bed should be avoided. However, darkness may cause anxiety and so a dim night light can be helpful.
- Develop a Calm Bedtime Routine. A consistent, relaxing routine before bed sends a signal to 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 bed time story creates opportunities for bonding and attachment with caregivers. Stressful conversations between caregivers or with children should be avoided.
- Avoid Caffeinated Products including Soda and Chocolate before Bedtime and limit drinking large quantities of fluids in the hours leading up to bedtime.
- Practicing Relaxation Techniques before Bed alone or together with the caregiver is a great way to wind down, calm the mind, and prepare for sleep. Children should be encouraged to use some of the techniques taught to them during their treatment.
- Regular Exercise during the day helps provide a natural tiredness in the body. Napping should be avoided (unless it is part of smalls children’s daily routine)
- Using the Bed for Other Activities should be avoided. This however may be difficult to do depending upon the living situation of the child. The idea being that the bed should be associated with sleep. Where a child is awake during the night, where possible, the child should be encouraged to get up and move around doing some of their relaxation or mindful exercises to avoid them getting in to habits of tossing and turning in bed at night.
Sleep Hygiene Resource
Mindfulness Breathing and Yoga Poses and Progressive Muscle Relaxation
The Centre for Victims of Torture provide really insightful blogs, which provide a great resource when considering effective and integrated care for children.
Finding the Most Effective Ways to Help Children Affected by War
Integrated Care for Children Brings Great Progress
Taking Extra Steps to Care for Survivors, Including Children
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