Running head: MENTAL HEALTH OF SYRIAN REFUGEE

Treatment of Psychological Disturbances of Syrian Refugee Children

Christan Mulder
Western Washington University

MENTAL HELATH OF SYRIAN REFUGEE

Treatment of Psychological Disturbances of Syrian Refugee Children

More than 4 million people have fled from Syria over the past 5 years to escape war and
in search of safety. Aside from those whom have fled; many individuals remain displaced within
the country (Hassan et al., 2016). This is considered to be the largest refugee crisis since World
War II, with nearly half of the refugees under the age of 18 and approximately 40% under the age
of 12 (Sirin & Rogers-Sirin, 2015). This graph represents the 3 year growth of applications in
Europe from Syrian asylums. As the graph demonstrates the huge growth spike in the year 2015
(Regional Refugee Response, 2016).

The children displaced by the war in Syria are at high risk of developing psychological
problems as a result of multiple traumatic experiences. The most commonly reported experiences
from Syrian children include: witnessing a family member being killed or the child themselves
being physically abused (Sirin & Rogers-Sirin, 2015). During migration frequently reported
traumatic experiences include being separated from a parent and being forced to leave their home
(Betancourt et al, 2012). Current research indicates a variety of interventions that work to reduce
the psychological effects of war trauma on the Syrian refugee child. This paper will introduce

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you to the mental health concerns of a Syrian refugee child, explore current treatment and
highlight recommendations for this vulnerable population.
The Refugee Journey
The refugee journey is often divided into three phases. The first phase beings with
the individual or family either contemplating or planning migration. For the people of Syria, this
phase is not always planned as many leave their home urgently when there is imminent danger.
The premigration phase is characterized by chaos and changes in daily activities (Crowley,
2007). During this phase the children of Syria must cope with the anticipation of leaving their
home, school and friends all in the midst of life within a war zone.
The second phase of the journey is migration. During migration the refugees are actively
traveling to a new location. The end location may be predetermined but often times is not
(Crowley, 2007). This phase is tremendously frightening for the children of Syria as many risk
their lives crossing dangerous waters in old and overcrowded boats. Over two million children
have fled from Syria and nearly 11,000 children crossed the Syrian border to neighboring
countries on their own (United Nations Childrens Fund, 2016). The dangerous migrations
commonly lead to separation of families and children from their caregiver. The chances of
experiencing behavioral and emotional problems are much higher for a child that arrives to the
resettlement location unaccompanied (Crowley, 2007). During migration many Syrian families
have been required to stay in refugee camps either temporarily until they can return back home
or it is safe to continue on their journey. Often there is inadequate food and water available due
to the large number of Syrian refugees seeking assistance and shelter. In addition, many children
continue to witness acts of violence while staying in the refugee camps (Betancourt et al., 2014).
Although these camps are highly beneficial in many respects during the refugees journey, its

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important to minimize the chance of further exposure to trauma or witnessed violence for
children as continued high stress is detrimental during the resettlement (Jensen et al., 2014).
The final phase is post migration where individuals and families begin to start over living
in a new place. Syrian children attempt to make new friends and adapt to their new living
environment. Emotional support for the child during this time is often inadequate due to
extremely high levels of stress of their parents (Crowley, 2007). There are multiple contributing
factors during resettlement that increases a refugee childs risk for psychological disturbance.
These factors include attending a new school, changes in daily routines and, the potential for
discrimination and isolation within the new country (Jensen, T., Skardalsmo E., & Fjermestad,
K., 2014)

Impact on Mental Health

Psychological disturbances and emotional disorders have been reported as the most
prevalent and significant clinical health problem among Syrian refugee children (Jensen et al.,
2014). Many studies have reported post-traumatic stress disorder (PTSD) as the most commonly
observed mental health disturbance in Syrian refugee children. This is characterized by
repeatedly re-experiencing a trauma through nightmares, behaviors associated with
hypervigilance such as decreased sleep, anger, poor behaviors; as well as avoidance of situations
or experiences relating to the trauma or experience (Crowley, 2007). A research study analyzed
data between the years 2004-2010 from The National Child Traumatic Stress Network (NCTSN)
database from a sample size of 14,088 child refugees and found that 30.36% of the sample size
exhibited signs of PTSD based on clinician ratings (Betancourt et al., 2012). Depression and
anxiety follow close behind PSTD from the NCTSN study with 27% demonstrating signs of

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these mental health disturbances (Betancourt et al., 2012). A second study conducted on Syrian
children who now reside in Turkey, all presented with high rates of emotional and behavioral
problems. Nearly half of the children surveyed had significant reports of anxiety or withdrawal
and nearly two-thirds were scared on a daily basis (Betancourt et al., 2012).
Education
Prior to resettlement many refugee children of Syria experienced a disruption in their
education, and many do not have access or ability to attend school once they have relocated.
Access to school became difficult prior to leaving Syria for many children as schools all over the
country were demolished and burned to the ground at the start of the war (Sirin, S., Rogers-Sirin,
L.,2015). Limited capacity of schools have contributed to low enrollment numbers of Syrian
refugee children. Many families are offered free or reduced cost schooling but struggle with
small associated costs including transportation (Sirin, S., Rogers-Sirin, L.,2015) Some Syrian
child refugees begin working right away upon resettlement in order to assist the family in
meeting basic needs which eliminates the time the child is available to attend school (Sirin, S.,
Rogers-Sirin, L., 2015). Neighboring countries hosting the Syrian refugees including Lebanon,
Jordan and Turkey are experiencing a shortage of teachers and inadequate supplies. The teachers
are struggling to meet the needs of the traumatized Syrian refugee children and most have never
received training on mental health disturbances. In addition, there have been reports of bullying
and violence in the schools against the Syrian refugee children; furthering emotional distress
(Sirin, S., Rogers-Sirin, L., 2015).Outcomes for refugee children are much greater when they are
able to attend school. In addition to obtaining an education, attending school provides time for
the child to grow, learn and adapt to their new environment (Stein, 2002). The teacher may serve
as emotional support for the child who may not be receiving adequate support at home during

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this transition. Schools also provide resources for the refugee child that he or she may otherwise
not have access to without attending school. For many refugee children, the school becomes an
anchor, for education, social, emotional and psychological support (Stein, 2002).
The refugee children from Syria have experienced prolonged periods of trauma
and have been witness to multiple violent acts during war. Individual therapy, group therapy and
school based treatment or interventions should all be available to the child (Betancourt et al.,
2014). Schools provide an excellent place for communication and play between children,
especially among the Syrian children living inside refugee camps. The dynamics of a school
setting provide an excellent way for refugee children to receive psychosocial support. Some may
even consider school to provide the refugee child with a sense of identity and is a vital part in
their integration by becoming an anchor, not only for education but also for social and emotional
development (Stein, 2002).
Treatment
There are a variety of interventions that have been used to address the
psychosocial needs of the Syrian refugee children. Activities that involve art and music have
been highly effective. Coloring, dance, and drama sessions are used in schools and inside refugee
camps. The primary goals of these activities include allowing for self-expression and building of
self confidence in the child. Psychologists are also able to identify some psychological problems
by analyzing the childs drawings (Jabbar & Zaza, 2014). A group of Syrian children living in
Istanbul between ages 7-12 were surveyed to examine if art therapy is an effective intervention to
reduce symptoms of depression or anxiety and if it reduces occurrences of PTSD. Four different
questionnaires were used addressing PTSD, Anxiety, traumatic experiences and depression. Data
was collected prior to the art therapy session and after the art session. Scores were significantly

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higher prior to the therapy with depression and trauma and PTSD but did not show any
significant change in anxiety before and after intervention. In general the study concluded that
the therapy was beneficial for depression and in reduction of PTSD but also provided an
advantage for the children to talk about their emotions in a safe environment (Ugurlu, Akca, and
Acarturk, (2016).
As previously discussed, education and attendance at school is a huge component of
mental health treatment for the Syrian refugee children. In 2013 the enrollment rate for children
in school was at 45% inside refugee camps and 58% outside of camps with a combined rate of
55% total children in school (Syrian Refugees Education Country Profile, 2013). Humanitarian
assistance is critical to the refugee child and family as the importance of attending school cannot
be addressed until basic needs are met. The United Nations International Childrens Emergency
Fund and similar organizations provide assistance. They have set up refugee camps that provide
mere basic necessities such as clean drinking water, education programs and limited
psychosocial services. These organizations are experiencing huge funding gaps, lacking nearly
40% of the required funds to meet such basic needs (United Nations International Childrens
Emergency Fund, 2013). A report from the Global Child Protection Group in the year 2013
found that 98% of Syrian children reported psychosocial problems and only 20% of the children
had received some type of psychosocial support.
The diversity among Syrian refugee children can impact assessment of mental health
concerns and also pose concerns in terms of treatment. The Syrian population has a wide range
of religious backgrounds and cultural influences. Children have been taught different coping
mechanisms and there are many different beliefs when it comes to seeking health treatment
especially treatment for mental illness. Language can often pose challenges in addressing issues

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of mental health. Barriers such as language and culture have contributed to low rates of
treatment. In addition, stigma relating to a child requiring or seeking treatment has also been a
barrier (Betancourt et al., 2014). A priority goal for many organizations like the WHO and The
Regional Refugee and Resilience Plan (3RP) is to promote access to health care and
psychosocial support services for all Syrian refugees in a way that is culturally appropriate and
accepting (Regional Refugee Resilience Plan, 2016).
Screening tools have become increasingly popular with schools and other organizations
that assist with child refugees. The mental health screening tool is culturally sensitive and may
assist in determining how at risk a child is for negative mental health outcomes (Crowley, 2008).
The strength and difficulties questionnaire is a screening tool that has been designed for
children ages 3-7, in assessment of mental health of children and has been recommended by
researchers in utilization for child refugees as an initial screening measure (Crowley,2008). In
many instances during the first encounter with refugee families, health care providers or
assistance organizations often do not have enough time with the child to discuss past experiences
or trauma, but are focused on ensuring that basic needs such as food and shelter are available.
Screening tools such as the Strength and Difficulties Questionnaire come in hand during brief
encounters with the refugee children. Current literature suggests that during initial encounters,
education may be provided on the signs and symptoms of PTSD and symptoms they may
experience if a disturbance is present (Crowley, 2008).
Conclusion
Childrens post war traumas present in a variety of ways, and require multiple different
approaches in treatment of psychosocial issues (Fazel and Stein, 2002). Similarly with the Syrian
refugee children who have been subject to multiple encounters of war and witness to acts of

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violence the treatment should be designed and implemented in a variety of ways. Many barriers
exist in appropriate psychosocial care for the Syrian refugee children including lack of funding,
access to education and individual misconceptions or stigma relating to mental health care.
Additional research and studies must be conducted on the Syrian refugee children in order to
increase knowledge and expertise of care with this vulnerable population group. As evidenced by
the discussions in this paper, it is critical that the mental health topic of child refugees in Syria
continue to be of priority and concern.

References
Betancourt, T. S., Newnham, E. A., Layne, C. M., Kim, S., Steinberg, M. A., Ellis, H., & Birman
D. (2012). Trauma history and psychopathology in war affected refugee children referred
for trauma-related health services in the United States. Journal of Traumatic Stress, 25,
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Crowley, C. (2008). Journal of the American Academy of Nurse Practitioners. The mental health
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Youssef, A., Jefee-Bahloul, H., Barkeel-Oteo, A., Coutts, A., Song, S. & Ventevogel, P.
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Review for Mental Health and Psychosocial Support staff working with Syrians Affected
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10.1080/03004430.2014.916074

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