Upholding the Human Rights and Well-Being of Refugee Children Through Effective Clinical Care

INTRODUCTION

Refugee children, adolescents and their families are a growing population globally. Based on United States law and the1951 Refugee Convention,¹ refugees are defined as “migrants seeking entry from a third country who are able to demonstrate that they have been persecuted, or have reason to fear persecution, on the basis of one of five protected grounds: race, religion, nationality, political opinion, or membership in a particular social group”.² An important aspect of having a designation as a refugee is experiencing forced displacement (see Figure 1), defined as migration that occurs as a result of persecution, armed conflict, generalized violence, or human rights violations.³

Figure 1:

Defining Refugee, Displaced People, Asylum Seekers, Migrants

The United Nations 1951 Convention on the Status of Refugees is a legal code regarding the rights of refugees at an international level and it also defines under which conditions a person should be considered as a refugee and thus be given these rights. The Convention specifically provides protection to forcibly displaced persons who have experienced persecution or torture in their home countries and serves as the primary basis for refugee status determination internationally. However, some countries also utilize other refugee definitions, thus, can grant refugee status not based exclusively on persecution and can include other reasons for forced displacement. Increasingly, the term climate refugee is used for individuals experiencing forced displacement due to environmental disasters that have severely and negatively affected their home countries or region. Climate refugees are not included in the Convention definition of refugee; nonetheless this group often face traumatic experiences, poor health outcomes and need clinical and social services supports. This can especially be the case for children, women and families already living in poverty or who are otherwise disenfranchised.⁴ Over 40% of refugees are children, and almost one in three children living outside their country of birth is a refugee person seeking safety.⁵ These numbers encompass children whose refugee status has been formally confirmed and legally defined, as well as children in refugee-like situations (e.g., children from Central America, Palestinian children in the West Bank or Gaza) who may or may not be fully recognized as a refugee based on international legal definitions.

Vulnerabilities and Trauma

The following are just some examples of the types of traumatic and violent situations that can lead to displacement for refugee children their families and communities:

• Sudanese refugee children witnessing traumatic events prior to departure from their home country, during attacks by the Sudanese military, that include instances of sexual violence, as well as of individuals being beaten, shot, bound, stabbed, strangled, drowned, and kidnapped.⁶

• Refugee children in Australia experiencing severe pre-migration traumas, including the lack of food, water, and shelter, forced separation from family members, murder of family or friends, kidnappings, sexual abuse, and torture.⁷

• Displaced unaccompanied child migrants from Central America fleeing some of the country’s most violent cities.⁸

Regardless of legal status, forcibly displaced children face significant vulnerabilities throughout their journey and these need to be of attention in trauma informed and evidence-based care.

Vulnerabilities to Exploitation and Oppression.

Refugee children, particularly those without documentation and those who travel alone, are vulnerable to abuse and exploitation. Examples of this includes experiences of being trafficked, engaged in forced and exploited labor as minors.⁹ Although many communities around the world have welcomed refugees, forcibly displaced children and their families often face discrimination and social marginalization in their home, in transit, and in the destination countries.¹⁰ For example, destination countries often bar refugee children and their families from accessing education, healthcare, social protection, and other services that are available to the citizens of that nation. Many destination countries also lack intercultural supports and policies for social integration. Because of these experiences, providers supporting refugee children and their families will need to consider the possible traumatic experiences and human rights violations that may need attention, including the need for legal protections and legal counsel.

Legal Protections.

The United Nations Convention on the Rights of the Child (UNCRC), the most widely ratified human rights treaty in history (although not by the United States), includes four articles that are particularly relevant to refugee children involved in or affected by forced displacement, which are:

• The principle of non-discrimination (Article 2) states that children have the right to not be discriminated against due to race, ethnicity, religion, or other identity.

• Best interests of the child (Article 3) states that children should be provided with the living situations, supports and services that best promote their well-being, health, education and relationships with their family and others.

• Right to life and survival and development (Article 6) includes the importance of education, shelter, and social support—among other supports for healthy development.

States Parties to the Convention are obliged to uphold its articles, regardless of a child’s migration status. In 2015 Somalia ratified the Convention, bringing the total to 196 countries that have become States Parties to the Convention, leaving only the United States yet to ratify it.¹¹ While the US signed the treaty it has not been ratified, and unlikely to receive the needed votes to do so in a divided Senate with polarized positions on child rearing and parochial education. Nonetheless, the protection of children, their well-being and development, rights regarding protection from human trafficking and involvement in armed conflict, are central principles for the care of refugee, migrant children in the United States and worldwide.

Displacement, Migration, and Trauma

There are several situations and circumstance that place refugee children at particular risk. These include human trafficking and exploitation, dangers in detention centers and refugee camps. All these adverse events can be traumatic and contribute to poor mental health, including post-traumatic stress, anxiety, depression, and substance use disorders. Therefore, the assessment of refugee children and adolescents should include screening and identification of these experiences and the offering of evidence-based trauma treatment and social services and supports.

Trafficking

Trafficking occurs by definition when smugglers illegally move a migrant into another country, essentially a modern day slave trade that is a pervasive issue for children travelling both with and without their families.¹² In the U.S, programs offer safe homes and treatment for trafficked young people, including vulnerable groups such as girls belonging to single-parent households, unaccompanied children, children from child-headed households, orphans, girls who were street traders, and girls whose mothers were street traders. Globally, girls under age 18 have been the main targets of sexual exploitation.¹³ Although boys are also targets, risk of sexual exploitation and abuse is higher for girls, and these experiences can have far-reaching effects on the physical and mental health. Children can also become victims of exploitation in the labor market, forced to work long hours, with minimum pay. Unaccompanied children may resort to dangerous jobs to send money back to their families of origin and to meet their own survival needs, rendering them at risk of labor exploitation.

Experiences of detention

Experiences of detention include when children are detained in prisons, military facilities, immigration detention centers, welfare centers, or educational facilities during the migration process. While detained, migrant children are often deprived of a range of rights, such as the right to physical and mental health care, privacy, education, and leisure.¹⁴ Unfortunately, many countries do not have a legal time limit for detention of minors, leaving some children incarcerated or detained for indeterminate time periods. Some children are even detained together with adults and subjected to a harsher condition, treatment, and regimens. Such poor conditions have been the center of human rights litigation in the United States and globally, including the Flores Agreement in the U.S.¹⁵ which outlines the type of provisions of healthcare, education and leisure children need to be provided. It also declares that a child or minor under 18 should spend minimal time in detention and urges their expedient placement with family or other appropriate setting in the community.

Refugee camps

Refugee camps are holding areas that can be found internationally and often operate at levels below acceptable standards of environmental health; overcrowding and a lack of wastewater networks and sanitation systems are common. Girls and sexual and gender minorities (e.g., trans women) at refugee camps may also be targeted and experience sexual assault¹⁶. Militia forces may also try to recruit and abduct children. With poor infrastructure and limited support services, refugee camps are often unable to protect children from these dangers.

Host Country Experiences (Post-Migration)

Only a minority of refugees who travel into new host countries and are allowed to start a new life there. Most refugees around the world are living in refugee camps or urban centers waiting to be able to return home.³ For those who are starting a new life in a new country there are two main options, seeking asylum or undergoing refugee resettlement.

Seeking Asylum or Special Immigrant Juvenile Status.

Asylum seekers are people who have formally applied for asylum once arriving in another country and who are still waiting for a decision on their status. In most situations, they need to apply for asylum within one year of arriving in the host country. Unaccompanied minors may face difficulties throughout the asylum process. Many children do not have the necessary documents for legal entry into a host country, leading them to avoid officials due to fear of being caught and deported to their home countries.¹⁷ Without documented status, unaccompanied children often face challenges in acquiring education and healthcare in many countries. In the US, once they have received a positive response on their application for asylum, they will obtain legal permanent residence in the United States. Special Immigrant Juvenile Status (SIJS) is an immigration classification available to certain undocumented immigrants under the age of 21 who can demonstrate that they have been abused, neglected, or abandoned by one or both parents. Therefore, SIJS is another way for immigrant youth under twenty-one to apply for and obtain legal permanent residence in the United States.

Refugee Resettlement.

Third country resettlement refers to the transfer of refugees from the country they have fled to another country that is more suitable to their needs and that has agreed to grant them permanent settlement. However, only a handful of nations prioritize this option and specifically consider children as a special category of refugees who are prioritized for resettlement.¹⁸ The U.S. Office of Refugee Resettlement (ORR) currently works with state and local service providers to provide unaccompanied children with resettlement and foster care services. This service is guaranteed to unaccompanied refugee minors until they reach the age of majority or until they are reunited with vetted sponsors, which may be family or other adults identified by their families.

MENTAL HEALTH AND SYSTEMS OF CARE

Unaccompanied refugee children tend to display more behavioral problems and emotional distress than refugee children who have caretakers. Parental well-being plays a crucial role in enabling resettled refugees to transition into a new society. A child separated from caretakers during the process of resettlement faces increased risk of developing a mental health problem,¹⁹ including posttraumatic stress disorders. Distress may be further exacerbated by forced migration to a foreign country and the uncertain legal process of achieving refugee status protections or asylum determination. Migration and resettlement, particularly when these include separation from primary caregivers, are disruptive to development with potentially negative consequences for relational attachment and risk for internalizing and externalizing symptoms.²⁰ Research has shown that family reunification, formation of healthy social networks and supportive community connections, and provision of social services and professional support have contributed to successful resettlement of refugee children.²¹ However, refugee children are particularly vulnerable to stigma regarding mental health problems prior to and during their resettlement.²² Complicating matters, differences between parental and host country values and culture can create a rift between a refugee child and their family, make difficult their adaptation to a new society, and impede parental help seeking.

Caring for the mental health of refugee children must include attention to traumatic experiences, displacement, family trauma and separations, and address social supports, educational needs, and community isolation. Additionally, mental health care should help promote cultural adaptation to host country and assist with overcoming barriers to care. Table 1 identifies important examples of risk factors to address and protective factors that should be identified, assessed, and integrated into care planning to support strengths and promote well-being.

Table 1:

Risk and protective factors for refugee child mental health

	Risk Factors	Protective factors
Before Travel	Exposure to violent and potentially traumatic events Torture Poverty History of mental health problems Female, trans-gender and non-binary gender identity	Higher educational attainment Financially stable
During Travel	Exposure to violence and life-threatening events Family separation Human trafficking and exploitation Female gender	Direct Route Family support
During Resettlement	Food insecurity Barriers to specialized care Inadequate or poor living conditions Uncertainty of asylum process	Basic needs met Quick asylum process Legal support Educational support Emotional supportive and regulating environments
Integration	Social isolation Unemployment Discrimination Acculturation stress Family conflict Downward social mobility	Supportive social networks Sense of belonging in host country Ethnic identity and culturally supportive organizations including faith based

Overcoming Barriers to Care

There are many potential barriers to receiving mental health services. Structural and cultural factors that can delay refugee children and their families from seeking medical and/or psychological help. Cultural barriers can include (not exhaustive):

• Fear of discrimination and stigmatization

• Denial of mental illness as defined in the Western context

• Fear of the unknown consequences following diagnosis such as deportation, separation from family, and losing children

• Mistrust of Western biomedicine

There are also structural barriers to care, for example:

• Heightened instances of mental health complications in refugee populations for which providers have little training and may be inclined to over-pathologize culturally bound symptoms or trauma symptoms.

• In the case of children, a lack of collateral information about previous behavioral health symptoms prior to the trauma of migration makes comprehensive care difficult.

• Time constraints: medical appointments are restricted to a small window of opportunity (specific and limited appointment schedules), making it difficult for facilitating engagement or even access to care.

Additionally, language and cultural differences can complicate a refugee’s understanding of mental illness and mental health services.²³ Since children and adolescents have a greater capacity to adopt their host country’s language and cultural practices, they are often used as intermediaries between service providers and their parents.²⁴ This may result in increased tension in family dynamics where culturally sensitive roles are reversed. Traditional family dynamics in refugee families disturbed by cultural adaptation tend to destabilize important cultural norms, which can create a rift between parent and child. These difficulties can cause an increased risk for depression, anxiety, and other mental health concerns in culturally adapted adolescent refugees. Relying on other family members or community members to relay clinical information has equally problematic results when they unintentionally exclude or include details relevant to comprehensive assessments and care planning.

Important strategies for overcoming barriers to care include practicing cultural humility, providing social supports and including helpers such as community workers who can support and accompany families. This includes using the services of trained language interpreters²⁴ (which may be especially limited for some languages or dialects) and practicing family driven care that may include their preference for consulting with religious leaders or organizations as intermediaries. Religious leaders are especially helpful especially when they can serve as cultural-religious brokers on topics related to trauma and mental health.

Program Case Example: Refugee Immigrant Assistance Center (RIAC), Community Counseling Services

RIAC Community Counseling is a community-based mental health and social support program created to serve the unique needs of refugees and immigrants. An important innovation of RIAC is that it is embedded in a refugee resettlement agency. This was planned intentionally, to improve access to services by offering a “one-stop” services approach. The clinic is staffed by multi-cultural and multi-lingual clinicians and case-managers, all who possess lived experience and professional expertise in refugee and immigrant mental health issues as well as a deep understanding of the cultural needs of the populations served. The program serves children and adults, and multigenerational families, providing resettlement services and case management and mental health services, and includes a psychiatrist, a nurse practitioner, and social workers. RIAC serves as a placement site for clinical internships for local psychology and social work schools, and they have academic partnerships with local universities, which additionally facilitates academic and research partnerships. For example, RIAC has served as a site for research on Trauma Systems Therapy for Refugee Youth. Clinical services include group therapy, individual therapy, psychopharmacology, and school-based consultations to support teachers and school counselors serving refugee students and families. There are specialized programs for men, women, and young adults, designed to address trauma, and age and gender specific concerns.

TREATMENT OPTIONS

The evidence-base for treatments that are specifically helpful for the youngest refugee children is limited. One evidence-based therapy for refugee families of infants and young children is Child-Parent Psychotherapy (CPP), an intervention model for children 0–5 years old who have experienced traumatic events and has been extensively studied in culturally diverse families.²⁵ It integrates attachment, psychodynamic, developmental, trauma, social learning, and cognitive behavioral theories. Therapeutic sessions focus on supporting the relationship between a child and their caregiver to restore the child’s cognitive, behavioral, and social functioning and includes contextual factors that may affect the caregiver-child relationship (e.g., cultural norms and socioeconomic and immigration-related stressors). Parent–Child Interaction Therapy (PCIT) is an evidence-based approach originally intended to treat disruptive behavior problems in children 2–7 years old, but in the last 40 years it has been studied internationally and found to be an effective intervention for many behavioral and emotional issues including posttraumatic disorders.²⁶ PCIT includes supporting child-directed and parent-directed interactions. Therapists instruct and coach caregivers in play therapy and operant conditioning skills with the objective of encouraging warm, secure caregiver–child relationships.

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT)

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) was developed as an evidence-based treatment approach and is based on traditional Cognitive Behavioral Therapy for traumatized children. It is a flexible component-based treatment model made up of both individual and joint child and parent sessions.^27,28 A meta-analysis²⁹ including four studies of TF-CBT provided evidence of TF-CBT’s effectiveness in decreasing trauma symptoms and sustainment of these results during follow-up assessment among refugee children participants. However, the authors conclude that despite TF-CBT effectiveness for trauma symptoms treatment, there is still limited evidence to suggest that TF-CBT is effective for all refugee children due to the pilot nature of the studies, and its underutilization in traumatized refugee children from different cultural backgrounds. They called for future studies to be conducted TF-CBT interventions with diverse refugee children to provide more empirical support for its effectiveness.

Trauma Systems Therapy—Refugee—

Trauma Systems Therapy—Refugee—TST-R^30–32 is a phase-based model of care that includes both individual and/or home-based support depending on the child’s needs. TST interventions address both a child’s self-regulation and social environment. In TST-R, services are often embedded in school systems to reduce barriers to seeking care based on evidence that refugee families are more likely to seek help in a school setting. Of note, cultural brokering, the inclusion of a cultural expert is an essential component of the TST-R model. A cultural broker is incorporated into each of the four tiers. The broadest level of care includes community engagement activities focused on developing trust between communities and providers and providing education about culture, mental health, and community needs. Throughout these activities, efforts are made to de-stigmatize mental health services and help seeking. The second level of care focuses on preventative skills-based groups for refugee youth that focus on increasing self-regulation skills, decreasing acculturative stress and increasing social support, factors known to be associated with better mental health among refugee youth. The third and fourth levels of care focus on youth who demonstrate significant mental health needs and integrates emotional regulation and other cognitive behavioral therapy skills. Youth receive community-based, linguistically, and culturally sensitive care and families receive legal assistance and resettlement services as needed.

Education and School

Refugee children may experience disruptive schooling in their country of origin, or they may have received no formal education at all (UNHCR, 2022). Studies of migrant children globally found that experiences of discrimination in school negatively impacts mental health.¹⁰ In the US, children’s challenges in making up learning loss related to displacement is exacerbated by racial bias in the educational system and limited educator training in child mental health and behavioral responses that result from trauma.³³ Misunderstandings based on cultural beliefs and lack of trauma-informed training form the context of behavioral issues that teachers and school staff are not always well prepared to understand or to respond to. Trauma can impede the ability to learn³⁴ and can cause fear towards people in positions of authority (such as teachers and principals).

High-quality education (evidence-based learning curriculum, well-trained instructors with documented qualifications, physical environment, higher teacher-student ratios) with inclusive practices (flexible and responsive to the local stakeholders) led by supportive teachers helps refugee children feel safe in the present, achieve success in school, and enables them to be productive in the future.^35,36 School dropout rates are highest for migrant children with a trauma history,³⁷ and may also be influenced by self-perceptions of limited academic ability, othering from peers and educators, and/or a lack of educational preparation prior to entering the host-country school. Refugees may also experience school pushout in cases where educators are unprepared or unwilling to support the needs of migrant students.³⁸ There are several important cultural considerations for schools to think about in serving refugee children and their families, some examples include:

• Facilitating caregiver involvement - when caregiver involvement and support are lacking, a child’s academic success decreases substantially. Refugee parents or guardians are often unable to help their children with homework due to language barriers. Caregivers often do not understand the concept of parent-teacher meetings and/or never expect to be a part of their child’s education due to pre-existing cultural beliefs.

• Youth cultural assimilation—can cause alienation of youth from their parents and country of origin and create barriers and tension between the parent and child.

• Refugee youth face higher rates of bullying,³⁹ including social and individual rejection or hostile discrimination, that can cause additional trauma when refugee children are treated cruelly by their peers and adults. A review of antibullying interventions identified decreased internalizing symptoms,⁴⁰ and a clinical trial found that having peers of similar migrant backgrounds empowered vulnerable youth and decreased victimization.⁴¹

• Behavioral issues - caused by the adjustment issues and survival behaviors learned in refugee camps or during other adverse experiences can create ongoing school problems if not identified and skillfully addressed in a trauma informed way. Within racially biased educational systems, clinical symptoms are too often simply interpreted as conduct problems.³³

Curriculum Case Example for Supporting Educational Outcomes and Related Recommendations

In response to an intensive needs assessment of a refugee community in New England seeking to support children’s well-being and academic success, a parent support intervention curriculum was co-developed by the authors and community leaders from African countries and Bhutan.⁴² The intervention was informed by a learning collaborative with the community and by results from interviews with youth, caregivers, mental health professionals, educators, law enforcement and justice agencies, social services workers, government officials, and clergy. Key education themes included the mismatch of expectations of parent involvement in US schools with more rigid boundaries for parental involvement in home countries, as well as limited confidence in helping with homework due to language and content barriers, and acculturation stress. Children who experienced trauma symptoms were unlikely to have teachers who accurately interpreted the meanings of their behaviors or knew how to respond. Most distressing for parents was that corporal punishment accepted in home countries would lead to social services reporting in US schools. Thus the 12-week parenting support intervention included modules that described expectations and policies of US schools and social service agencies, ways to support academic success that didn’t require content knowledge, alternative approaches to discipline, and strategies for family communication that incorporated attention to acculturative stress. For implementation of the intervention, a bilingual community liaison was hired to facilitate meetings between parents, teachers, and school counselors. Evaluation results showed improved behavioral and academic outcomes for the children and high satisfaction ratings from caregivers.⁴²

Other recommendations for school success include:

• Course materials should be appropriate for the specific learning needs of refugee children and provide for a wide range of skills in order to give refugee children strong academic support.

• Educators should spend time with refugee families to assess previous educational experiences of the child and help to place the child in the correct grade level and to provide any necessary accommodations.

• Teachers in the United States often have little experience with the trauma that refugees often face. Therefore, educational resources and training for educators and school counselors can be helpful.

• Refugee children thrive in classroom environments where all students are valued and invited to share their cultural heritage. A sense of belonging, as well as ability to flourish and become part of the new host society, are factors predicting the well-being of refugee children in academics.

• Extracurricular resources that can be provided to refugee children include supplementary curriculum enrichment resources that reflect their cultural values, videos in parental language on school awareness, informational leaflets, and handbooks, as well as trauma-informed resources that serve to benefit refugee youth and parental involvement in the school.

• School policies, expectations, and parent’s rights should be translated into the parent’s native language since many parents do not speak English proficiently.

• Educators need to understand the multiple demands placed on parents (such as work and family care) and be prepared to offer flexibility in meeting times with families. Parents have made the journey to a new country, along with many sacrifices, in hopes of providing opportunity for their child, so educators should not equate challenges in scheduling with lack of caring.

Accurate assessments for refugee children with disabilities are challenging given language barriers that can include limited interpreter options along with lack of cultural responsiveness⁴³ and a dearth of translated and validated disability assessments⁴⁴ and trauma and mental health screening tools⁴⁵ in languages other than English and Spanish. Improved assessments and services are critical for refugee children who are particularly vulnerable to physical and sexual abuse, exploitation, and neglect. Re-assessment may also be required as initial assessments can result in underperformance due to hyperarousal, lack of exposure to standardized testing, and lack of limited educational opportunity as well as cultural mismatch between the child and the examiner. Children are not only often excluded from their education, but also may not be provided the necessary supports for realizing and reaching their full potential.⁴⁶ In refugee camps and temporary shelters, and in schools within the countries they eventually resettle—the needs of refugee children with disabilities are often overlooked or difficult to address. Consultation from child mental health and educational professionals with experience and expertise in working with the special needs of refugee children with disabilities should be sought to ensure necessary supports.

SUMMARY

Refugee children in resettlement and their families have often faced significant traumatic experiences prior to migration and then must navigate the social and psychological stress of adapting to a new country. Forced displacement is increasing due to armed conflict and political violence, and more recently, influenced by climate change. Situations and circumstances pre, during, and post migration have significant impact on the mental health of refugee children. Although there are policies enacted within and between countries to protect children, there is variation in legislation and implementation in the U.S. and elsewhere across the globe. In addition to uneven protections, children and adolescents experience human trafficking and exploitation, and dangers in detention centers and refugee camps. All these adverse events can be traumatic and contribute to poor mental health, including post-traumatic, stress, anxiety, depression, and substance use disorders. Therefore, the assessment of refugee children and adolescents should include screening and identification of these experiences and the offering of evidence-based trauma treatment and social supports to promote their well-being and thriving.

KEY POINTS.

• A refugee minor is a child or adolescent who has lost the protection of their country of origin, has been forcibly displaced and cannot safely return home.

• There are a variety of reasons a child or adolescent and their family experience forced displacement, including facing the direct threat of violence resulting from conflict, targeted violence based on identity, and political violence.

• Stress related to cultural and social adaptation to a host country can negatively affect the psychological health of children, youth, and their families.

• Refugee children can face significant healthcare and educational barriers in a resettlement country, and these should be addressed through systems of care, trauma focused and culturally responsive care approaches.

SYNOPSIS.

Refugee children are often exposed to adversities and traumatic experiences that can harm the mental health and well-being of refugee children. These include human trafficking and exploitation, dangers in detention centers and refugee camps. All these adverse events can be traumatic and contribute to poor mental health, including post-traumatic stress, anxiety, depression, and substance use disorders. Therefore, the assessment of refugee children and adolescents should include screening and identification for these experiences, provision of evidence-based trauma treatment, and social supports to promote their well-being and thriving.

CLINICS CARE POINTS.

• Refugee experiences and mental health needs require screening for and addressing exposure to trauma and exploitation, with referral and provision of mental health services that offer cultural and linguistic access and expertise.

• Refugee mental health services for children necessitate comprehensive services, including medical, mental health, educational and social supports and case management, family supports including resettlement services, employment and housing, and legal services.

• Psychoeducation and evidence-based interventions for the children and caregivers can assist with intergenerational trauma and family well-being.

• Clinicians need to be proactive in improving mental health access and engagement strategies, including promoting approaches that use cultural humility, enhancing cultural awareness and sensitivity of mainstream providers, and facilitating ethnically matched professionals and paraprofessionals.

• Trauma-sensitive approaches emphasize helping school staff understand the impact of trauma on school functioning and seeing behavior through this lens; building trusting relationships among teachers and peers; helping students develop the ability to self-regulate behaviors, emotions, and attention; supporting student success in academic and nonacademic areas; and promoting physical and emotional health.

• Culturally responsive clinics and centers are well positioned to offer interventions designed to address trauma, reduce resettlement stress, and provide case management and preventive interventions that support child and family strengths.