A systematic review of socio-ecological factors contributing to risk and protection of the mental health of refugee children and adolescents

Florian Scharpf, Elisa Kaltenbach, Angela Nickerson, Tobias Hecker

Clinical Psychology Review, Volume 83, 101930 (2021)



Child development can be viewed as a dynamic process arising from complex interactions between different levels of the ‘social ecology’ (individual, family, school, community, society). This socio-ecological framework can help conceptualize the stressful experiences faced by refugee children, as well as the protective resources they may draw on.

This systematic review investigates the factors contributing to the mental health of refugee children and adolescents from a socio-ecological perspective. The review covers studies in both high-income countries (HIC) and low- and middle-income countries (LMIC). Of 63 selected studies, 41 were conducted in HIC and 22 were conducted in LMIC. Refugee children came from 53 countries in: Africa (21 countries), Asia (17), Middle and South America (10), and Eastern Europe (5). The most frequent countries of origin were Syria, Iraq, Afghanistan, Iran, Burma, Somalia, South Sudan, and Eritrea. 15 studies included unaccompanied refugee minors.

The review identifies the following factors across different socio-ecological levels (individual, family, community, society/culture) and stages of the refugee experience (pre-, peri- and post-migration):


  • Cumulative exposure to traumatic events prior to migration was related to increased mental health problems (PTSD, depression, anxiety, and externalizing problems). Traumatic events involving severe interpersonal violence and family members as victims were associated with worse mental health outcomes. In the case of unaccompanied refugee minors, pre-migration trauma continued to impact mental health years after arrival in the host country.
  • Girls were at a higher risk of internalizing problems and PTSD, while boys were at an increased risk of externalizing problems.
  • Education is pivotal for the wellbeing and development of conflict-affected children. A longer period of schooling prior to arrival in the host country was a protective factor associated with fewer PTSD symptoms and fewer emotional and behavioral problems. Additionally, better school performance (both self-perceived or parent reported) is a protective factor associated with higher psychological wellbeing.
  • An increased duration of stay in camp settings was associated with exacerbated mental health problems.
  • Previous symptoms of depression and anxiety are a risk factor for the development of later PTSD symptoms.
  • Avoidant coping strategies (i.e. avoiding engagement with problems and distressing emotions through behavioral and cognitive efforts) is associated with PTSD and depression.
  • An individual’s resilience (defined as an ability to bounce back from stress, or a set of interpersonal and intrapersonal strengths) is a protective factor that leads to higher levels of wellbeing.


  • Loss of a parent or separation from immediate family members is a risk factor for psychological disorders, while the presence of at least one biological parent is a protective factor. In two studies in LMIC, adolescents who had lost one or both parents were more likely to have PTSD and higher levels of internalizing problems. Previous and current separation from immediate family members was associated with a diagnosis of PTSD. Although the integrity of the whole family unit appears to be crucial, other findings indicate that the presence of at least one biological parent is already protective.
  • Higher socioeconomic status appears to be a protective factor in resource poor settings such as refugee camps. Post-migration socioeconomic status could be particularly relevant in very poor settings. In resource-poor settings, such as refugee camps, low socioeconomic status may also be an indirect risk factor for children’s wellbeing as it increases their risk to be engaged in child labor, which was associated with higher levels of depression.
  • A link between parents’ own mental health problems and refugee children’s mental health has been found across a variety of cultural and socioeconomic settings.
  • Negative parenting behaviors and parental abuse are risk factors for mental health problems in refugee children. Parenting styles perceived as negative (low in emotional warmth and support, harsh, rejecting and controlling) were associated with higher levels of internalizing and externalizing problems. Children and adolescents’ self-reported experiences of abuse by parents were associated with higher levels of mental health problems including PTSD, depression, anxiety, and attention deficit hyperactivity disorders symptoms.
  • Warm parent-child relationship and a more cohesive and supportive family life are protective factors. Positive parenting (supportive and emotionally warm) was linked to lower levels of emotional and behavioral problems. A more positive (warm and stable) family life was associated with lower levels of anxiety, and higher connectedness with family (perceived understanding, care and respect) predicted lower levels of internalizing problems in some settings. A family environment that encouraged the direct expression of emotions was related to decreased risk for PTSD in some settings.

Community (evidence almost exclusively from HICs)

  • Support from mentors and peers, and close relationships with friends are protective factors. Lower support from mentors and peers increased the risk of PTSD and depression (mentors) as well as anxiety (mentors and peers) after stressful life events. The importance of having supportive and understanding friends for children’s mental health was underlined by findings from two studies.
  • Schools can play a vital role for the adjustment and wellbeing of resettled refugee children and youth, as they not only provide opportunities of learning and academic progress, but also constitute the context in which a major part of socialization and acculturation processes take place. Feeling accepted and supported by teachers and fellow students at school was associated with lower levels of aggressive behavior, emotional dysregulation and psychological distress and with higher levels of wellbeing. On the other hand, perceived discrimination by teachers and peers was related to more emotional and behavioral problems in one study and being bullied by peers at school was associated with lower levels of self-esteem and happiness.

Society and culture (evidence almost exclusively from HICs)

  • Post-migration detention as a form of placement appears to be especially harmful to children’s wellbeing.
  • An integrative acculturation style, i.e. being engaged both in the host and heritage culture, appears to be associated with refugee youth’s higher wellbeing. (Acculturation refers to “the dynamic process of psychological and behavioral change that arises from a prolonged confrontation with a new culture’s norms, customs and values”.)
  • Higher exposure to daily post-migration hassles and acculturation stressors is a risk factor for mental health problems. Higher cumulative exposure to daily hassles in the host country was associated with higher levels of mental health problems. Higher exposure to acculturative stressors in the host country, in particular perceived discrimination, was associated with worse mental health outcomes.
  • Resettlement in a poor region appears to be a risk factor for mental health issues. Living in proximity to ongoing war and/or in poorly developed regions may perpetuate children’s feelings of insecurity and helplessness.
  • Being placed in living arrangements characterized by lower support, e.g. semi-independent care or reception centers, puts unaccompanied refugee minors at an increased risk for mental health problems compared to more supportive arrangements, e.g. foster care.
  • Acceptance of asylum claims in the host country appears to be protective, marking the end of a period of uncertainty and offering a long-term perspective.

The contributing factors at the family and community levels (e.g. parental mental health problems, maladaptive parenting and peer support) are for the most part in line with established evidence from non-refugee populations. The review also identifies a number of factors that are unique to refugee children and adolescents, at least those resettling in HIC, such as acculturation, discrimination, placement type (for unaccompanied refugee minors) and the asylum decision.