Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors

Mina Fazel, Ruth V Reed, Catherine Panter-Brick, Alan Stein

The Lancet, Volume 379 (2012), Pages 266–82


This paper examines the individual, family, community, and societal risk and protective factors for mental health in children and adolescents who are forcibly displaced to high-income countries.

The systematic review covered 44 studies from high-income countries, with 5,776 displaced children and adolescents. They included children from Bosnia, Cambodia, Central America, Chile, Croatia, Cuba, Iraq, the Middle East, Somalia, Sudan, Vietnam, and the former Yugoslavia, who were either internally displaced or resettled in Australia, Belgium, Canada, Croatia, Denmark, Finland, the Netherlands, Sweden, the UK, and the United States. Mental health outcomes measured in these studies were generally grouped as: (a) internalizing or emotional problems, including depression, anxiety, and PTSD; and (b) externalizing or behavioral problems. A meta-analysis was not undertaken due to clinical and methodological heterogeneity in the research.

The review identifies the following risk and protective factors, at individual, family, community, and societal levels:


  • Exposure to violence is associated with an increased likelihood of mental health disorders in refugee children. Psychological problems in refugee children can arise from: personal experiences of pre-migration violence; direct and indirect exposure to post-migration traumatic events; and cumulative exposure to traumatic events.
  • In about half the studies, the prevalence of depression and internalizing problems was higher in girls than in boys.


  • Familial experiences of adverse events affect children’s psychological functioning. Some types of parental experiences are more strongly associated with children’s mental health problems than are children’s own experiences, particularly if parents have been tortured or are missing.
  • Being unaccompanied on arrival in the host country increases the risk of psychological disorders. Unaccompanied children who had at least one family member living in the host country had lower scores for internalizing difficulties and PTSD. Accompanied children subsequently separated from their relatives were also at risk of poor mental health. Children whose relatives were in difficult circumstances (e.g. imprisoned), and those who had difficulty contacting their relatives had worse psychological functioning.
  • Children in single-parent households were at greater risk of psychological disorders. Boys living with both parents had lower rates of psychological symptoms than boys living in other family arrangements. Fewer changes of family structure were protective for boys. Adolescents living with both parents had lower internalizing scores in mid-adolescence, whereas those in single-parent households reported greater feelings of competence.
  • Family cohesion and perception of high parental support were associated with fewer psychological difficulties in children than were poor family support or cohesion.
  • Good parental mental health, particularly in mothers, is an important protective factor.
  • Socioeconomic status might provide some protection, because access to material and social resources could enable an early flight from conflict and reduce cumulative exposure to adversity.


  • Perceptions of acceptance or discrimination in host countries are highly relevant. Low peer violence and discrimination were positively linked to self-esteem. Boys were more likely to report discrimination than girls, and this difference was predictive of poorer psychological functioning.
  • High perceived peer support was associated with improved psychological functioning.
  • Living and socializing alongside other people of the same ethnic origin seems to provide protection from psychological illness, particularly while in foster care.
  • A perceived sense of safety at school has been associated with low risk of PTSD, and an increased sense of school belonging was shown to protect against depression and anxiety. This sense of belonging is important because of the potential for interventions to improve school learning and social environments.


  • Frequent changes of residence in a host country were predictive of poor mental health in children and adolescents in some studies.

In their conclusion, the authors note that cumulative adversities usually worsen health outcomes, exerting more powerful effects than any factor alone. The most harmful factor was exposure to violence—whether experienced personally, witnessed, or feared—and the loss of family support by death or violence. The authors emphasize that post-migration factors provide opportunities for high-income countries to intervene directly to achieve improved outcomes for refugee children. At the same time, the possibility of intervention by governments and non-governmental organizations in high-income countries to keep negative exposures to a minimum in countries of origin and countries of transit should not be neglected.