- Refugee children are at high risk for C-PTSD.
- Early intervention can have lifelong benefits.
- Care should be culturally and linguistically appropriate.
Kristina—the refugee experience of one child from Kharkiv
The outbreak of war in Ukraine led 12-year-old Kristina and her mother to flee the country in order to find safety and refuge in Poland. Her father enlisted in the Ukrainian military and has been declared missing in action. While attempting to get through the evacuation corridor, their refugee convoy was shot at and one of the buses in the convoy was hit by a shell.
In the ensuing chaos, Kristina was briefly separated from her mother.
Once in Poland, Kristina and her mother were housed in a dormitory-style transit camp where Kristina was assaulted. While they have now found a longer-term housing solution. Kristina’s mother initially experienced severe emotional difficulties and Kristina assumed the burden of cooking, shopping, cleaning, and comforting her mother. A psychologist at Kristna’s new school in Poland diagnosed her with complex post-traumatic stress disorder (C-PTSD).
Risk factors for C-PTSD and PTSD
Post-Traumatic Stress Disorder (PTSD) is often the result of a one-time traumatic event or a time-limited traumatic event. The traumatic event is typically impersonal. A car accident or a natural disaster can be very traumatic, but they will not make me feel personally targeted.
Complex PTSD (C-PTSD) results from continued and repeated exposure to the trauma (Karatzias et al., 2017). The traumatic experiences are often relational (such as an assault by a trusted relative or neighbor) and especially personal (such as targeting by ethnic group). The risk of C-PTSD compared to PTSD increases with greater exposure to traumatic events in a “dose-response” (Hyland et al., 2017).
A lack of agency, where the child feels that they are powerless to escape from or overwhelm their attackers, can make the development of C-PTSD more likely.
Distinguishing between C-PTSD and PTSD
C-PTSD is characterized by disturbances in self-organization (DSO) and clinicians should be alert to symptoms related to affective regulation, self-concept, and interpersonal relations (Cloitre, Garvert, Brewin, Bryant, & Maercker, 2013; Maercker et al., 2013a, 2013b).
Proposed changes to the diagnostic category of “disorders associated with stress” in the 11th revision of the International Classification of Diseases and Related Health Problems (ICD-11) are meant to facilitate distinguishing between C-PTSD and PTSD.
Linguistic and cultural challenges in treating C-PTSD in children
The linguistic and cultural challenges that Kristina’s therapist will face are significant. The American Psychological Association guidelines call for linguistically and culturally appropriate care for migrant children and adolescents. In the case of Kristina, whose first language is Russian, the therapist should be fluent in Russian and familiar with the culture of the region in Eastern Ukraine where Kristina lived (Ellis et al., 2011; Murray, Davidson, & Schweitzer, 2010).
Early intervention and effective care for refugee children
Addressing the mental health impacts of multiple adverse childhood experiences (ACEs) can help limit the effects of these experiences on the well-being of the child later in life.
Adults who experienced multiple adverse events in childhood tend to experience more physical and emotional health challenges, including a higher prevalence of chronic physical diseases, problems in psychological development, and diminished interpersonal skills. While not all refugee children are affected the same way, the number and intensity of ACEs experienced have been shown to predict both PTSD and C-PTSD.
Early and effective intervention can provide short-term relief and improve long-term outcomes.
Therapy can support rehabilitation and recovery
Having a close relationship where the trauma survivor shares their traumatic experiences and feels supported and heard can support greater psychological wellbeing.
Trauma Systems Therapy for Refugees (TST-R) can be a gateway approach for building a relationship between therapists and refugee children.
Trauma Systems Therapy for Refugees (TST-R)
TST-R was adapted from Trauma System Therapy (TST) in order to address the unique experiences of refugee children and adolescents. TST’s approach acknowledges the psychological needs of children within the context of family and community in order to improve their mental health. TST-R emphasizes the interplay of parents, caregivers, and the community (Ellis et al., 2011).
TST-R presents a four-tier approach for treating trauma in refugee children and adolescents.
- Parental and Community Engagement. Building trust between communities and clinicians. Delivering culturally appropriate mental health education. Identifying community needs. De-stigmatizing mental health services.
- Skill-based prevention groups. Improve self-control, reduce stress brought on by the experience of culture shock, and increase social support. Reduce the stigma associated with mental health services. Identify children who may require a higher degree of mental health intervention.
- Individual therapy. A focus on children and adolescents who have exhibited significant mental health struggles.
C-PTSD is unique in its combination of symptoms, making it complex to diagnose. The duration, number, and intensity of traumatic experiences that refugee children may have experienced put them at high risk for C-PTSD and emphasize the need for successful intervention programs.
Although TST-R appears to be a beneficial method of intervention for refugee children and adolescents, more information is needed to confirm its effectiveness on a global level. Each refugee population's circumstances should be taken into account in addition to the cultural sensitivity of each individual when providing care for refugee children and adolescents.
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© 2022 Dr. Fabiana Franco. All rights reserved.
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Karatzias, T., Shevlin, M., Fyvie, C., Hyland, P., Efthymiadou, E., Wilson, D., ... & Cloitre, M. (2017). Evidence of distinct profiles of posttraumatic stress disorder (PTSD) and complex posttraumatic stress disorder (CPTSD) based on the new ICD-11 trauma questionnaire (ICD-TQ). Journal of Affective Disorders, 207, 181-187.
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Murray, K. E., Davidson, G. R., & Schweitzer, R. D. (2010). Review of refugee mental health interventions following resettlement: Best practices and recommendations. American Journal of Orthopsychiatry, 80(4), 576–585.