Introduction

With the increasing refugee population worldwide, there is a need for more research into the most effective counselling therapies to support traumatised refugee children and adolescents. This literature review examines the current research and literature in regard to the issues refugee children and adolescents face and how counsellors can best support them and the most effective therapies for this cohort. According to the UNHCR, “refugees are people who have fled war, violence, conflict or persecution and have crossed an international border to find safety in another country (2022e, para. 1). In recent years the number of refugees worldwide has increased substantially (Taylor & Sidhu, 2012; UNHCR, 2022b). Many of these refugees are being rehomed in Australia, with the yearly intake of refugees being set to increase (Higgins, 2022). Around half of these refugees are children and many have experienced significant trauma (UNHCR, 2022b; Velu et al., 2022). PTSD is also more common in refugee children and adolescents (Velu et al. 2022). According to Imig et al., “unlike other newly arrived families, these people have likely suffered forced displacement, loss of material wealth, years in refugee camps, loss of or separation from loved ones and the resulting trauma” (2021, p. 40). Untreated trauma and PTSD can lead to issues such as anxiety, substance abuse, depression and panic disorder (Velu et al., 2022). As the number of refugees increases and more of these students enter Australian schools, counsellors need to be informed of the most effective therapies to treat these traumatised students and the mental health issues they may be presenting with. There is a wealth of research and evidence into the most effective therapies for treating traumatised adults experiencing PTSD (Australian Government, 2020). However, research is lacking into what the most effective therapies are to treat traumatised refugee children and adolescents (Genç, 2022).TF-CBT is widely considered to be one of the most effective therapies for treating trauma-related issues such as PTSD in adults, however, there has been little research into the therapy’s effectiveness in treating refugee children and adolescents TF-CBT is widely considered to be one of the most effective therapies for treating trauma-related issues such as PTSD in adults, however, there has been little research into the therapy’s effectiveness in treating refugee children and adolescents. (Kar, 2011; Sullivan & Simonson, 2016). Research suggests that expressive therapies are most commonly used to treat traumatised refugee students, however, Sullivan and Simonson (2016) suggest these therapies are not as effective as TF-CBT (Sullivan & Simonson, 2016). Together this implies a gap in the research and that more research needs to be undertaken into how effective TF-CBT is in treating traumatised children and adolescent refugees.

Analysis of the Problem

The problem of people being displaced due to events such as war and pestilence is by no means a new problem. However, the number of refugees is increasing significantly (UNHCR, 2022b). After being rehomed, many of these minors, who have often experienced trauma, are in need of support from counsellors, especially within schools where they will be spending a significant amount of time. Research into the most effective counselling therapies and strategies to support the wellbeing of these vulnerable and often at-risk students is needed, yet does not seem to be in an abundance.

The UNHCR found that of all the world’s refugees, around half of them are under the age of 18 (UNHCR, 2022b). Many of these children have been separated from their families, experienced trauma, and been subjected to violence, war, exploitation, trafficking, abuse and neglect (UNHCR, 2022a). In 2011 there were 15.4 million refugees worldwide (UNHCR, 2022b). Since then, that number has almost doubled (UNHCR, 2022b). The UNHCR estimates that 2 million refugees will require resettlement in 2023, which will have risen from 2021, with 1.47 million people requiring rehoming (UNHCR, 2022c). Of all of the refugees resettled by the UNHCR in 2022, 37 percent were for those with legal and protection needs, 32 per cent had been subjected to violence and/or torture and a further 17 per cent were women, children and adolescents at risk (UNHCR, 2022d). The global refugee problem is not a new issue, however, it is clear that the number of refugees continues to rise each year and these vulnerable people, many being children and adolescents, are in need of support from counsellors.

Australia has a long history of accepting and rehoming refugees, and since 1945 over 800 000 refugees and displaced people have been resettled in the country (Phillips, 2015, para. 1). The Australian Red Cross (2022) noted that, in 2018-19, Australia granted 18,762 refugee and humanitarian visas, with the preponderance of people coming from Afghanistan, Syria, Iraq, Democratic Republic of Congo and Myanmar. According to the Australian Government (2021), in 2021 to 2022, Australia allocated 13 750 places to the refugee program. Furthermore, since February 2022 the Department of Home Affairs has allocated over 8 600 visas to Ukrainian people (Australian Government, 2022). Over the next four years, Australia will add an additional 16 500 places for Afghan refugees through their humanitarian program (Higgins, 2022). Higgins (2022) noted that the new intake of Afghan refugees will increase Australia’s yearly refugee and humanitarian intake to 17 875 places. As a consequence of Australia’s increased refugee intake, the number of these potential at-risk students enrolling into schools will increase.

The Queensland Government (2021a) also noted that refugee students have often witnessed and experienced traumatic events such as death, war, famine, violence, poverty and abuse. As a consequence of witnessing or experiencing traumatic events, their mental health and wellbeing may be affected for many years after the events (Queensland Government, 2021a). Refugee students may experience PTSD, anxiety and depression; this is especially likely on arrival and during the transitional adjustment to their new homes and schools (Naidoo, 2013; Queensland Government, 2021a). It is likely they will also experience acculturation difficulties such as language differences and differences in cultural norms (Naidoo, 2013; Queensland Government, 2021a). In Queensland state schools, it is often the guidance officer’s responsibility to support the transition and wellbeing of these students (Queensland Government, 2021b). All the evidence suggests that these students are at risk of developing mental health issues, and it is clear that effective support must be provided to them by counsellors, especially school counsellors who will have direct access to support these students.

Ziaian et al. (2018) conducted research into the interconnections between the mental health of refugee children and adolescents and their schooling experience. They conducted a mixed methods approach and assessed the mental health of 495 child and adolescent refugees and also explored the educational experiences of 85 students in 13 focus groups (Ziaian et al., 2018). The Children’s Depression Inventory (CDI) and the Strengths and Difficulties Questionnaire (SDQ) were used to assess the students’ mental health (Ziaian et al., 2018). The results highlighted that these students, who had an increased risk of developing mental illness, were in need of extra support at school, although were not receiving this support (Ziaian et al., 2018). The lack of parental support and also the high demand from parents for these students to do well at school was also highlighted (Ziaian et al., 2018). Furthermore, Ziaian et al. (2018) noted that there have been some studies on the mental health and experiences of refugee students, however, it is a neglected area of research. Additionally, the study did not indicate if any of the participants were receiving counselling support and if so, what therapies were being used. Research from Due et al. (2016) further suggests that there has been even less research into the education and wellbeing of primary-aged refugee students.

Together this implies that there is a gap in the research and that more research needs to be undertaken in this area. It is well known that refugee students have often experienced trauma and are at a higher risk of mental health issues, however, more systematic research is needed into the most effective therapies to support these students.

Genç (2022) conducted a systematic review of the most effective therapies for treating refugee children and adolescents who had experienced trauma and PTSD. The study looked at the effectiveness of TF-CBT, EMDR, Narrative Exposure therapy (NET), Art Therapy, Mein Weg (My Way) and Multimodal Trauma-Focused treatment (Genç, 2022). Of all the therapies and studies reviewed by Genç (2022), TF-CBT and EMDR are perhaps the most widely used therapies for trauma and PTSD in adults and also endorsed by the World Health Organisation and the Australian Government as being highly effective therapies for treating PTSD (Genç, 2022; Phoenix Australia, 2020). Both TF-CBT and EMDR are proven to be effective trauma treatments for minors (de Roos et al., 2020; Lewey et al., 2018). However, little research has been conducted into their effectiveness in children and adolescent refugees. All studies and therapies reviewed showed positive results in the reduction of trauma and PTSD symptoms such as anxiety and depression (Genç, 2022).

One study reviewed by Genç (2022) on the effectiveness of NET, also showed promising results. Park et al. (2020) assessed the effectiveness of NET on young Korean’s suffering from PTSD, depression and insomnia. Participants in this study showed significant reduction in symptoms (Park et al., 2020).

Studies of EMDR, another proven therapy in the treatment of trauma-related symptoms and PTSD were also reviewed by Genç (2022). Again, this therapy has been proven to be highly effective with minors, although there is little clinical research into its effectiveness in treating traumatised children and adolescent refugees (Genç, 2022; Lewey et al., 2018).

Lempertz et al. (2020) assessed the effectiveness of EMDR with 10, 4–6-year-old refugees who had experienced war in their home country (Genç, 2022). A pre-test-post-test study was used and based on teacher and parental ratings, there were children aged 4–6 years who had experienced war in their home country (Lempertz et al., 2020). Based on their parents’ and teachers’ ratings, there was a substantial reduction in PTSD symptoms (d = 0.93) after the EMDR interventions (Lempertz et al., 2020).

Genç (2022) reviewed four studies on the effectiveness of TF-CBT with young refugees. Although being one of the most commonly used and effective therapies for traumatised children and adolescents, he found only four studies showing the effectiveness of the therapy in this cohort. All studies showed positive results (Genç, 2022). Being such popular and effective treatments for the general population suffering from trauma-related issues, the question remains as to why so little research has been conducted on this therapy with child and adolescent refugees.

Due to the lack of research in this field, only 20 experimental studies were reviewed (Genç, 2022). Although there is a wealth of evidence in the effectiveness of these treatments in treating trauma-related mental health issues in adults, there is very little research on how effective these treatments are in child and adolescent refugees (Genç, 2022). However, some have criticized these western based therapies as not being effective for refugees due to not being culturally appropriate (Genç, 2022). According to Genç (2022), although some culturally sensitive trauma treatment interventions have been used with refugees, there is limited research into their effectiveness on refugee students.

There is, however, overwhelming evidence of TF-CBT’s effectiveness as a trauma-related intervention for children and adolescents. Karr (2011) noted that TF-CBT has undergone rigorous testing and is considered the best choice for treating children with PTSD. Refugee students come with multifaced problems and face many added barriers such as xenophobia, prejudice, language barrier and discrimination due to their race and religion (Genç, 2022). To further Karr’s argument of TF-CBT’s efficacy in treating trauma-related issues, the Australian Government, the American Psychological Association and the World Health Organisation advocate TF-CBT as one of the most effective therapies in treating PTSD (Balbo et al., 2019; Phoenix Australia, 2021). De Roos et al. (2020) also suggest TF-CBT’s effectiveness in treating PTSD in children. What is lacking in the research is how effective these therapies such as TF-CBT are in treating traumatised refugee children and adolescents.

Together this implies that there is a clear gap in the research as refugee students come with further complications and differences from the general population …there is a clear gap in the research as refugee students come with further complications and differences from the general population.. Therefore, the effectiveness of these therapies within this cohort needs to be further examined. Evidently, with Australia’s increased support of accepting refugees, many of whom will be minors and having experienced varying degrees of trauma, the number of these refugees entering schools will also increase. The literature clearly suggests that there is more research needed into the most effective counselling therapies and strategies, and to support the wellbeing of these vulnerable students. To reduce psychological harm and improve the wellbeing among refugee children and teens, research into the most effective treatment modalities is essential (Genç, 2022). Clearly, further research into an already proven and effective therapy such as TF-CBT in treating refugee students would be beneficial.

Impact of the Problem

As previously stated, refugee students may experience numerous issues such as PTSD, anxiety, depression, acculturation difficulties, language barriers and discrimination, which can all significantly impact the mental health and wellbeing of these students (Genç, 2022). Research has provided insight into just how devastating the traumatic events experienced by refugees can be, and If these issues are not addressed with the appropriate treatments, the impacts can be detrimental (De Deckker, 2018).

De Deckker (2018) agrees that refugee students have likely experienced horrific trauma which is not only difficult for the student to deal with, but it can also be daunting and challenging for school counsellors to deal with. There is now a substantial amount of research demonstrating how traumatic events can have a significant negative influence on one’s neurological development, leading to challenges with learning, behaviour, forming relationships, and emotional control (De Deckker, 2018). There are several types of trauma, all of which refugee students may suffer from acute trauma, chronic trauma and developmental trauma (De Deckker, 2018). Unfortunately, many refugee students have experienced chronic trauma, in which they were exposed to traumatic events, repeatedly and over longer periods of time (De Deckker, 2018; Unterhitzenberger & Rosner, 2016). De Deckker (2018) noted that chronic trauma experiences can have a significant negative impact on how one’s cognitive and bodily functions work and respond to their environment. In contrast to other researchers, De Deckker (2018) suggests that counselling the students in the school setting may not always be appropriate due to factors such as being enclosed in small rooms. He also suggests that the cultural appropriateness of talking therapies needs to be considered (De Deckker, 2018). However, Cohen et al. (2017) and Karr (2011) argue that this can be mitigated with minor culturally appropriate adjustments being made to TF-CBT. Cohen et al. (2017) further suggest that TF-CBT can be used with people from all cultures.

Poppitt and Frey (2007) explored the acculturation stress of Sudanese refugee youths living in Brisbane. 20 of these students participated in structured interviews and results revealed that acculturative stress was related to language barriers, parental control and cultural differences in Australia compared to their home countries (Poppitt & Frey, 2007). Research from Ziaian et al. (2018) also suggested parental control as being a factor to acculturation stress. The results from Poppitt and Frey’s (2007) study also showed that there was a need for culturally specific counselling practices in schools. However, previous studies from Cohen et al. (2017) and Karr (2011) have shown that only minor cultural adjustments need to be made to trauma-focused therapies such as TF-CBT for them to be effective with all people from all cultures. This implies that counsellors must be making these adjustments. Poppitt and Frey (2007) also found that language barriers were a main contributing factor to the participants’ acculturation stress and also noted that there was a hesitancy of any of the participants to use professionals such as counsellors when needed. Silove et al. (2007) similarly noted this hesitancy in the refugee population to seek mental health assistance from professionals. In a study of Vietnamese refugees, Silove et al. (2007) noted that only a small number of Vietnamese refugees with PTSD consulted a mental health specialist and Australians with PTSD were three times more likely to consult a mental health specialist than Vietnamese refugees. According to Poppitt and Frey (2007) adolescents from Sudan would be assisted in achieving a level of cultural integration and setting attainable objectives if proper English language support and counselling techniques that consider cultural differences were funded. Although Poppitt and Frey’s (2007) study highlighted valuable data, more participants would be needed to show a clearer picture of acculturation stress and also consideration of the participants’ ages should be taken into account.

Sullivan and Simonson (2016) conducted a systematic of school based mental health intervention for traumatised refugees. They found many of these vulnerable students were often experiencing substantial psychological distress, however, were not receiving adequate support (Sullivan & Simonson, 2016). They identified three main types of therapies being used: TF-CBT, creative expression, and multitiered or multimodal therapies (Sullivan & Simonson, 2016). All therapies used showed to have positive results and the most commonly used withing was creative expression and play therapy (Sullivan & Simonson, 2016). Sullivan and Simonson noted that, ‘creative expression interventions were the most commonly used but had the least consistent results’ (2016, p. 523). However, the systematic review highlighted that TF-CBT showed the most consistent positive outcomes when treating traumatised students (Sullivan & Simonson, 2016). The question remains as to why creative expression therapies such as art and music therapy are being more commonly used with these students over TF-CBT when the evidence suggests TF-CBT is more effective. Sullivan and Simonson’s (2016) research was limited in the fact that other relevant studies may have been overlooked and the sample of articles reviewed was small. The review of a broader range of studies may have potentially strengthened their research and highlighted more prominent conclusions.

Potential Benefits

Prior research suggests that more studies need to be undertaken in order to find the most effective therapies for treating traumatised refugee students. TF-CBT would be an obvious choice to research the therapy’s effects on these students as it is already an approved trauma treatment for the general population including minors (Balbo et al., 2019; de Roos et al., 2020; Phoenix Australia, 2021). If studies were to suggest that this therapy is just as effective in treating refugee children and adolescents, the benefits would be significant. Counsellors would then have more evidence to use these therapies with these clients. This would add to previous studies that recommended trauma therapies such as TF-CBT as being more effective in treating traumatised refugee students than some of the more commonly used therapies such as expressive and art therapies. School counsellors could also use this research to advocate to their line managers the effectiveness of TF-CBT, in situations when this is not a recommended therapy for use at schools. If results prove that TF-CBT is an effective treatment for this cohort, and the therapy is the more commonly used, there would be improvements in mental health, wellbeing and educational outcomes. However, the main benefit would be to show how beneficial TF-CBT is in treating traumatised refugee students, and if the research suggests positive outcomes, the therapy could be used to successfully support the wellbeing of these vulnerable students who deserve to be happy and successful after being displaced from their homes and subjected to trauma. Furthermore, this research could also open possibilities for further research on the effects of other trauma-focused treatments such as EMDR and NET on this cohort.

Potential Future Research

Potential future research into how counsellors can support the wellbeing of child and adolescent refugees could be based on the following research questions: How effective is TF-CBT in treating traumatised refugee children and adolescents? Is there a difference in the effectiveness of TF-CBT in children (5-9) and adolescents (10-17)? As there have been very few studies in this area, the research methods will be based on the following similar studies, whilst improving on the gaps in these studies.

According to a systematic analysis of effective therapies for young refugees by Genç (2022), only 4 studies were found on the effectiveness of TF-CBT in young refugees. Gormez et al. (2017) conceded a pre and post-test study of 32 traumatised Syrian refugees aged between 10 and 15. 8 sessions of CBT were conducted in a school setting and post-test results showed significant reduction in trauma-related symptoms (Gormez et al., 2017). However, it should be considered that this was a small test group and also a small age range was tested.

Ehntholt et al. (2005) evaluated 26 traumatised refugee children in a group setting aged between 11 and 15 using TF-CBT and found a decrease in PTSD symptoms. However, the decrease in symptoms was not maintained in a two month follow up (Ehntholt et al., 2005). Only 6 sessions of TF-CBT were conducted with the patients and this may have been a potential factor for the relapse of symptoms. It can take at least 12 sessions for the remission of PTSD symptoms using TF-CBT (Australian Government, 2020). Furthermore, group sessions may have affected patient outcomes. Van Bilsen (2013) and Hase and Brisch (2022) maintain that the therapeutic relationship between counsellor and client is essential for positive therapy outcomes, something that may be difficult to achieve in group therapy.

Unterhitzenberger and Rosner (2016) conducted a case study using TF-CBT on a 17-year-old refugee girl who had experienced severe trauma. 12 sessions were employed and the results were positive, with a significant reduction in trauma-related symptoms (Unterhitzenberger & Rosner, 2016). According to Genç (2022), in regard to the study results from Unterhitzenberger and Rosner (2016), there was a 90 % reduction in PTSD symptoms, a 75 % reduction in anxiety symptoms and a 67 % reduction of symptoms associated with depression. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) and Children’s Depression Inventory (CDI) were used to assess the outcomes of the study (Unterhitzenberger & Rosner, 2016). Though, being a single case study, limited conclusions of the results could be drawn.

Finally, Unterhitzenberger et al. (2019) used a quasi-experimental design to study the effectiveness of TF-CBT in 26 young refugees. All participants were diagnosed with PTSD and underwent 15 sessions (Unterhitzenberger et al., 2019). The Diagnostic Interview for Mental Disorders in Childhood (DISC) and the Child and Adolescent Trauma Screen (CATS) were used to assess the results (Unterhitzenberger et al., 2019). Positive outcomes were observed and remained consistent 6 weeks and six months after treatments, however, although positive results were shown, as a consequence of the participants’ age range being 15 to 17, the study’s results were limited (Unterhitzenberger et al., 2019).

A potential research method to improve on the studies of these researchers and answer the following questions: How effective is TF-CBT in treating traumatised refugee children and adolescents? Is there a difference in the effectiveness of TF-CBT in children (5-9) and adolescents (10-17)? Would be as follows: a cohort study of 30 refugee students in total, 15 child (5-9) and 15 adolescent (10-17) students who have been identified as suffering from trauma symptoms such as PTSD, anxiety and depression. These students would undergo 12 sessions of TF-CBT over 12 weeks. Quantitative pre and post measures to assess their current mental health would be used using the CDI and the SDQ. Both the CDI and the SDQ assess the mental health and behaviour of patients and are appropriate for children and adolescents (Pearson, 2022; Youth in Mind, 2022). The students would be assessed again 6 weeks after treatment and then 6 months using the same assessments. Data will be analysed using the SPSS software for its ease of use and advanced statistical processing (IMB, 2022; University of Maryland, 2022).

The potential risks of the research must be assessed, such as the participants’ re-exposure to traumatic events, and mitigation strategies must be provided (Bright & Harrison, 2013). As the project will be involving children and adolescents, further considerations and risk assessments must be undertaken, as they are considered part of a vulnerable cohort (Bright & Harrison, 2013). Minors will need additional parental or carer consent and must also have the ability to understand the purpose of the research and their right to decline (Bright & Harrison, 2013). As the participants will be refugees and culturally diverse, consideration of their diversity must be made and culturally approximate adjustments to the therapy must be considered and altered where appropriate (Ægisdóttir et al., 2008). Additionally, the consideration of the researcher’s potential bias toward the research must be carefully considered whilst also respecting the uniqueness and diversity of the participants in a culturally sensitive counselling research approach (Australian Counselling Association [ACA], 2019; Ægisdóttir et al., 2008). Of utmost importance is the wellbeing of the participants and all areas of the research methodology must be carefully planned and approved by the appropriate bodies, before being undertaken (Bright & Harrison, 2013).

Conclusion

As refugee numbers increase worldwide and Australia increases its intake of these vulnerable people, counsellors are in need of current research highlighting the most effective therapies to support the high number of child and adolescent refugees entering the country and schools. This literature review has shown a clear gap in the research around the most effective therapies to support refugee children and adolescents, yet also highlights some recent promising research into TF-CBT as being a highly effective therapy for the treatment of these traumatised youths. Further research into the effectiveness of TF-CBT is needed to provide counsellors with more evidence to support the wellbeing of these vulnerable students.

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