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Helping refugee children thrive: what we know and where to next
  1. Karen Zwi1,2,
  2. Lisa Woodland3,
  3. Sarah Mares4,
  4. Santuri Rungan2,
  5. Pamela Palasanthiran1,2,
  6. Katrina Williams5,
  7. Susan Woolfenden2,
  8. Adam Jaffe1,2
  1. 1 University of New South Wales, Sydney, New South Wales, Australia
  2. 2 Sydney Children’s Hospitals Network, Sydney, New South Wales, Australia
  3. 3 District Executive Unit, South Eastern Sydney Local Health District, Sydney, New South Wales, Australia
  4. 4 School of Psychiatry, University of New South Wales, Sydney, New South Wales, Australia
  5. 5 Royal Children’s Hospital, Melbourne, Victoria, Australia
  1. Correspondence to Dr Karen Zwi, University of New South Wales and Sydney Children’s Hospitals Network, Randwick, Sydney, NSW 2031, Australia; Karen.zwi{at}

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Australia offers a small but well-regarded refugee programme offering extensive support to the 13 750 refugees settled in the country each year, after the processing of their protection claims by the United Nations. Since 2015, a further 12 000 resettlement places have been allocated to Syrian and Iraqi refugees.1 Globally, there are an estimated 65 million people around the world currently displaced, half of whom are children under 18 years of age.2 These children are exposed to cumulative risks associated with poor developmental and social–emotional health outcomes.3–6

Successful settlement of refugee children and their families is of global importance and presents a challenge to health professionals in implementing known evidence to optimise development and social–emotional health in childhood and to produce a better chance of lifetime good health and success, including mental health, employment and socioeconomic status.7–9 With a well-coordinated and evidence-based response, there is potential to produce excellent outcomes for displaced children. Presented here is a summary of findings from a body of evidence developed in our local setting in regional Australia to inform future service development for displaced children. We argue that there is an urgent need for further investment in long-term outcomes and make recommendations on how we can continue to develop the evidence base to support optimal well-being for displaced children in Australia and other high-income settings.

What is known

For health professionals to provide safe, high quality, culturally responsive care to refugee populations, an understanding of the multiple barriers to care is required. Specific strategies and tools to empower families can improve clinician–patient relationships, service delivery and health outcomes.10

We have shown that accessible healthcare for refugees is achievable through community-based models that include primary care, refugee health nurses and specialised paediatric refugee referral services and has the added value of integrating the whole family into universally available, mainstream healthcare.11 In one regional area of Australia, between 2007 and 2012, general practitioners (GPs) conducted physical health and pathology examinations on 367 (97%) refugee children. Of 188 children, 88% were screened within 1 month and 96% within 6 months of arrival.12 Families in this model maintained high levels of contact with their GPs, who had easy access referral pathways to specialist paediatricians for children with chronic disease or complex medical or psychosocial issues. Few families accessed local early childhood nursing services for preschool children’s developmental surveillance.13 High-quality healthcare is important considering the general paediatric and infectious morbidity among refugees screened. Fifteen per cent had a chronic disease, and, similar to other Australian children, 13% were obese or overweight.13 14

Evidence about refugee children’s development and social–emotional well-being trajectories over time is limited. Studies on refugee school-aged children, largely retrospective, show equivalent education outcomes to Australian born peers but do not measure social–emotional well-being unless children have mental health symptoms.15–21 Our longitudinal study of refugee children shows that developmental and mental health outcomes can be appropriately assessed once immediate health needs have been addressed.12 Our research team conducted assessments on 61 refugee children (<15 years) recruited between 2010 and 2014, at 13 and 31 months after arrival (years 2 and 3 assessments). Children retained in the study were similar to those not recruited and lost to follow in terms of gender, WHO region of origin and language spoken at home.13 22 23 Furthermore, the study sample had similar proportions of WHO region of origin to the overall Australian refugee intake over the 2009–2013 financial years (figure 1).

Figure 1

WHO region of origin for the study sample and the overall Australian refugee intake.

The Strengths and Difficulties Questionnaire (SDQ) and Australian Developmental Screening Tool, which have normative Australian data, are acceptable to families and can be administered by refugee health nurses working with interpreters.22 24 25 Encouragingly, in preschool children, the 27% who had mild developmental problems in year 2 were all normal by year 3.13 Most school-aged children exhibited improvement in social–emotional well-being over time without specific psychological interventions and were comparable to the Australian population at all timeframes.13 24 25 Therefore, most children had developmental and well-being outcomes within the normal range by year 3, with a minority having persistently poor social–emotional outcomes.13

Risk and protective factors that potentially impact on child health can be measured by parent completion of a structured questionnaire (measuring access to health services, socioeconomic resources and community support) and the Social Readjustment Ratings Scale, which measures stressful life events in the previous year.22 23 26–28 Despite major life upheaval, there were significant positive changes over time in these families (table 1).23 However, at years 2 and 3 after arrival, parental employment remained 10% lower (3%; 13%) than the regional average and was at a lower skill level as compared with prearrival employment.23

Table 1

Changes in risk and protective factors over time at year 2 and year 3

For employment, study status and English language proficiency, data given by the primary respondent about themselves and their partners were summed.

In the USA, Denmark and Sweden protective factors associated with well-being have been examined using a population-based approach with longitudinal study design. In these studies, between 27 and 131 refugee children and/or youth have been participants, followed up for 6–12 years. Findings include that subjects were highly resilient, mental health outcomes improved over time and postmigration stressors were more predictive of psychological problems than adverse experiences before arrival. In the 38 children (62%) from our original longitudinal study, specific protective factors at year 2 for normal social–emotional well-being at year 3 were originating from Africa, the child’s father present on arrival and reduced stressful life events in the past year; the latter included changes in schooling or residence, death of a close family member, major change in financial state and marital separation (table 2).23 When considered cumulatively, four or more protective factors predicted better social–emotional well-being (P<0.006).23

Table 2

Protective factors for normal Strengths and Difficulties Questionnaire (SDQ)at year 3

Some factors that are protective could be enhanced postarrival, such as stability in the child’s schooling or residence, creating opportunities to improve the outcomes of refugee children. Importantly, children with fewer than four protective factors are likely to benefit from proactive follow-up with interventions aimed at increasing protective factors, thereby buffering risk and improving outcomes.2 3 6 14 19

Significant international criticism has been directed at Australia’s policies in relation to asylum seekers who arrive by boat and are subject to mandatory detention, off-shore processing and denial of resettlement in Australia.1 29 Immigration detention is known to be a pre-eminent risk factor for adverse social–emotional well-being.12 18 30–39 In the Australian context, we found parent-completed SDQ scores of 38 children aged 4–15 years in our longitudinal study group, none of whom had been detained, indicated better social–emotional well-being compared with 48 children detained on remote Christmas Island, assessed during the Australian Human Rights Commission 2014 National Inquiry into Children in Immigration Detention.40 The differences were significant for social–emotional well-being scores in all age subgroups, in the total sample (P<0.0001) and in four of five SDQ subscale scores (P<0.0001). SDQ scores for the children in detention resembled scores of a mental health clinical population.24 25 41–43 In children with similar levels of prearrival adversity, these results present a compelling argument that detention itself contributes to the high level of social–emotional distress. To optimise health and well-being, not detaining asylum seeker children postarrival is likely to be one of the most powerful interventions available to host countries.

What is needed for care and services

Refugee children are known to be highly resilient and we may be able to optimise well-being even in the most vulnerable through clinical and public policy intervention. Of most interest are those postarrival factors associated with well-being that are modifiable. Based on the findings of our work and other studies, recommendations that are likely to contribute to improved health and well-being of refugee and asylum seeker children settling in Australia and other high-income settings include the following.32 38 44–56

  1. At the child level:

    • provide access to postarrival health screening and long-term access to care for mental and developmental health conditions, chronic disease and weight management;

    • provide regular review and proactive follow-up for children with fewer than four protective factors;

    • promote engagement with early childhood centres for developmental surveillance and early intervention;

    • develop targeted resilience-building adolescent programmes addressing social and educational support.

  2. At the family level:

    • support access to family centred primary healthcare and refugee nurses;

    • promote access to mental health services to address psychological morbidity and premigration trauma;

    • support families to remain intact, including support for couples and family reunification.

  3. At the community level:

    • settle families in close proximity to welcoming, inclusive communities;

    • facilitate stable settlement with minimal relocations;

    • support education with stable schooling and school-based peer support;

    • remove financial stress through employment (assisted by promoting English proficiency, recognition of overseas qualifications and facilitating local work experience) and/or access to economic resources;

    • reduce exposure to racial discrimination and postmigration violence.

  4. At the national level:

    • promote a sense of belonging for refugee communities;

    • promote policies that allow reunification of families;

    • promote long-term stable settlement by removing immigration detention and temporary protection policies for asylum seekers (to remove prolonged uncertainty);

    • promote independent research of the health impacts of Australian and international policies that subject asylum seeker children to immigration detention.

What is needed to increase evidence that will improve well-being

We acknowledge that the evidence presented here is based largely on observational research in our specific setting and sample attrition may have biased our findings. Generalisation to other settings, especially where health and social supports are not provided by resettlement governments or with different refugee populations, may not be appropriate. The next steps are to promote widespread research access to refugee and asylum seeker populations to further understand pathways to resilience and to assess the impact of specific interventions that the evidence suggests are likely to be effective in improving outcomes. National and international data repositories are required, with networks of research trials using standardised approaches to assessment and monitoring. High level evidence with economic analysis is required to evaluate interventions that enhance educational outcomes, employment and social inclusion.23 48 57 Fundamental to this research is working in close collaboration with policy makers and key service providers to ensure optimal translation of findings into sustainable practice.

Successful settlement of refugee children and their families is an issue of global importance. There is potential to produce excellent outcomes, especially considering that most refugee children are doing well. Australia and other high-income countries have the capacity to provide and evaluate the level of care required to produce optimal lifelong outcomes.


Primary healthcare and the refugee nurse support system is funded by Australian Federal and State governments, respectively. Specific funding for the longitudinal follow-up study was provided by Foundation Markets Foundation for Children (AUD$158 000 July 2009–June 2011) and the South Eastern Sydney Multicultural Health Service (AUD$80 000 July 2012–June 2013).



  • Contributors KZ takes public responsibility for the entire work, from idea to complete manuscript. All authors meet the following criteria for authorship: substantial involvement and contribution to the idea or the study question, or to the study design, or to the fieldwork component, or to the analysis, or to the interpretation of study findings; writing drafts of the manuscript, or reviewing drafts or revisions critically with substantial input and approval of the final version of the manuscript.

  • Funding This study was funded by Foundation Markets Foundation for Children.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Ethics approval Ethics approval for the community sample in these studies was granted by the Human Research Ethics Committee Northern Hospitals Network, South Eastern Sydney Illawarra Area Health Service (HREC Reference Numbers 08/084 and 09/163), including approval to compare this sample with the detention sample on 21/6/2017. The research involving the detention sample in this study was assessed by the South Western Sydney Local Health District Human Research Ethics Committee (HREC/15/LPOOL/556), which was satisfied with provisions to protect the rights of participants. All participants gave their informed consent prior to their inclusion in the study.

  • Provenance and peer review Not commissioned; internally peer reviewed.