Background
As of 2024, UNICEF estimates that nearly 49 million children worldwide have been forcibly displaced from their homes due to political conflict, violence, and climate change.1 Many of these children face multiple intersecting adversities, such as witnessing violent atrocities, family separation, financial difficulties, and the acculturation stress related to adjusting to resettlement communities. These adversities produce and exacerbate underlying mental health conditions for youth. One systematic review of 3003 children in 40 countries found that between 19%–54% of the study population had posttraumatic stress disorder and between 3%–30% had depression.2 Thus, forcibly displaced children represent a growing, vulnerable population in need of systematic intervention. In this article, we propose and review 3 main strategies for building the capacity of health care systems to address the needs of these children: 1) design trainings and improve collaboration between pediatricians and child psychiatrists; 2) implement standardized assessments for evaluating forcibly displaced youth; and 3) improve access to culturally competent care.
Training, Workshops, and Improved Collaboration Between Pediatricians and Child Psychiatrists
Pediatricians tend to be the primary health care source for forcibly displaced children. While important, the complex needs of forcibly displaced children may supersede the level of expertise and services that a pediatrician is able to provide.3 This gap is, in part, due to a lack of training of pediatricians and other health care professionals surrounding the needs of forcibly displaced children. Targeted education and training workshops designed by health care practitioners with extensive experience in refugee health have demonstrated promising results in building clinicians’ capacity.3 In one workshop, consisting of a series of lectures, clinical scenarios, and resources, participants reported increased comfort in asking refugee patients about their social and behavioral health as well as improved understanding of both the refugee experience and health screenings.
Workshops that leverage collaboration between child psychiatrists and pediatricians are another viable strategy to address the psychiatric needs of forcibly displaced children. Child psychiatrists experienced in working with forcibly displaced children can offer valuable insight into underlying psychiatric disturbances that are often overlooked in the primary care setting. An example of this is the somatization of distress among forcibly displaced individuals.4 Providing the tools and knowledge necessary for pediatricians to identify these psychological disturbances is crucial in the primary care setting to help address mental distress among forcibly displaced children as early as possible. Furthermore, collaboration between the 2 specialties could help address barriers to care at the local level. Pediatricians could connect with experienced child psychiatrists in their community who may serve as a resource for future referrals.
Creating a Standardized and Validated Mental Health Assessment Tool
Research has shown that forcibly displaced children are at an increased risk of mental health disorders. This is due to a myriad of risk factors pre- and postmigration, such as exposure to violence, discrimination, poverty, and having a parent with a mental health disorder. The effects of these variables are particularly evident in posttraumatic stress disorder, depression, and anxiety.2 While there are a variety of existing general standardized screening assessments, tools targeted for forcibly displaced children are underdeveloped, and there is a dearth of research on the validity and reliability of these tools.5 Thus, clinicians do not have a standardized protocol in place for mental health screening of forcibly displaced children. Standardized screening assessments would allow for early detection of mental health conditions, and/or risk assessment, and increase referrals to specialty care, which is crucial for improving future outcomes. Child psychiatrists can play a vital role in the process of developing a standardized methodology that can be used in the primary care setting when forcibly displaced children are first being evaluated.
Addressing the Gap in Access to Culturally Competent Health Care
The existing gaps in access to care widen even more when it comes to forcibly displaced children. Currently, programs such as the Pediatric Mental Health Care Access Program (PMHCA) from the Health Resources & Services Administration (HRSA) work to assist pediatricians and primary care providers with behavioral health assessments in children. Federal funding is awarded to programs across the nation, helping them build teams of professionals (ie, child and adolescent psychiatrists, care coordinators, behavioral professionals) who specifically address pediatric mental health concerns in their region. Awarded programs are listed on HRSA’s site, with teleconsultation phone lines available. However, federal programs like these are often underfunded and, as a result, unable to fully address accessibility issues. For example, HRSA-funded PMHCAs are currently unavailable in Oregon, Idaho, Arizona, Texas, and Pennsylvania.6 Consequently, PMHCA coverage in these regions (with the exception of Idaho) has been achieved through alternative funding, as detailed by NNCPAP (National Network of Child Psychiatry Access Programs).7 Thus, it remains crucial to advocate for continued funding and growth of PMHCAs nationwide.
Accessibility aside, experts working within PMHCAs are not necessarily trained in working with forcibly displaced children and their families, and they may not have sufficient knowledge of diverse cultures/backgrounds. When it comes to seeking mental health counseling, it has been shown that interpreters alleviate hesitancy among patients.8 Treatment regimens that center on patient-specific cultural frameworks, and move away from solely applying a “Western” approach to psychiatric care, have also seen better engagement and improvement in the mental well-being of patients and their families.9 Expanding programs such as PMHCAs to include interpretation services, cultural competency training, and advocating for greater funding are vital to increasing accessibility and providing culturally sensitive and trauma-informed mental health care in this patient population.
In addition to expanding existing programs, it is important to look at successful community-based models for guidance. For example, Project SHIFA (Supporting the Health of Immigrant Families and Adolescents), a multitier intervention for the Somali refugee community in New England, provides prevention services, school-based programs, and trauma therapy, with longitudinal tracking showing improvements in mental health outcomes, particularly when resource hardships are considered.10 Emphasizing a holistic approach across school, home, and clinic settings, Project SHIFA highlights the critical role psychiatrists can play by collaborating with educators, caseworkers, and other stakeholders to address the social determinants of health. Such programs allow psychiatrists to actively participate in the resettlement process and deliver more culturally sensitive, effective psychiatric care for pediatric asylee populations.
Conclusion
Adverse childhood experiences are markedly significant in forcibly displaced children, who continue to be a growing population. Without access to proper support, these experiences can affect their social and cognitive development and emotional well-being. Addressing these concerns through workshops and education, establishing a standardized screening method, improving accessibility through federally funded programs, and providing culturally competent care is crucial (Tables 1 and 2).11 While forcibly displaced children face a significant number of obstacles, they also possess great strength and resilience. Emphasis on the solutions proposed herein can help these children flourish despite the adversities they have encountered.
Plain Language Summary
Forcibly displaced children, comprised of children around the world affected by violence, political conflict, and climate change, are a growing, at-risk population. The most recent estimates, by UNICEF in 2024, suggest 49 million children have been affected. This article explores mental health among forcibly displaced children, issues they may face, and gaps in the current health care system—hoping to draw attention to an important, timely topic. Finally, we propose solutions to alleviate these issues, along with resources and additional educational materials for interested readers.
About the Authors
Xiao Kuang, BS, Georgetown University School of Medicine, Washington, D.C., USA.
Tayyiaba Farooq, BS, MS, Rowan-Virtua School of Osteopathic Medicine, Stratford, New Jersey, USA.
J. Corey Williams, MD, Georgetown University School of Medicine, Washington, D.C., USA.
Nima Sheth, MD, Georgetown University School of Medicine, Washington, D.C., USA.
Correspondence to:
Xiao Kuang, BS; email: Xlk2@georgetown.edu
Funding
The authors have reported no funding for this work.
Disclosure
The authors declare that there are no conflicts of interest regarding the publication of this article.
Acknowledgments
This article is part of a special Clinical Perspectives series that will shed new and focused light on clinically important topics within child and adolescent psychiatry. The series discusses the care of children and adolescents with psychiatric disorders from a new vantage point, including populations, practices, and clinical topics that may be otherwise overlooked. The series was edited by JAACAP Deputy Editor Lisa R. Fortuna, MD, MPH, MDiv; JAACAP Connect Editor David C. Saunders, MD, PhD; and JAACAP Editor-in-Chief Douglas K. Novins, MD.
Author contributions
Writing – original draft: Xiao Kuang (Lead), Tayyiaba Farooq (Lead). Writing – review & editing: J. Corey Williams (Supporting). Conceptualization: Nima Sheth (Supporting).