Learning Problems in Children of Refugee Background: A ... · of Refugee Background: A Systematic Review Hamish R. Graham, MBBS, MPH, FRACP, ... complex dynamic, a child enters a

REVIEW ARTICLEPEDIATRICS Volume 137 , number 6 , June 2016 :e 20153994

Learning Problems in Children of Refugee Background: A Systematic ReviewHamish R. Graham, MBBS, MPH, FRACP, a, b Ripudaman S. Minhas, MD, MPH, FRCPC, c, d Georgia Paxton, MBBS, BMedSci, MPH, FRACPa, e

abstractCONTEXT: Learning problems are common, affecting up to 1 in 10 children. Refugee children

may have cumulative risk for educational disadvantage, but there is limited information on

learning in this population.

OBJECTIVE: To review the evidence on educational outcomes and learning problems in refugee

children and to describe their major risk and resource factors.

DATA SOURCES: Medline, Embase, PubMed, Cumulative Index to Nursing and Allied Health

Literature, PsycINFO, and Education Resources Information Center.

STUDY SELECTION: English-language articles addressing the prevalence and determinants of

learning problems in refugee children.

DATA EXTRACTION: Data were extracted and analyzed according to Arksey and O’Malley’s

descriptive analytical method for scoping studies.

RESULTS: Thirty-four studies were included. Refugee youth had similar secondary school

outcomes to their native-born peers; there were no data on preschool or primary school

outcomes. There were limited prevalence data on learning problems, with single studies

informing most estimates and no studies examining specific language disorders or

autism spectrum disorders. Major risk factors for learning problems included parental

misunderstandings about educational styles and expectations, teacher stereotyping and low

expectations, bullying and racial discrimination, premigration and postmigration trauma,

and forced detention. Major resource factors for success included high academic and life

ambition, “gift-and-sacrifice” motivational narratives, parental involvement in education,

family cohesion and supportive home environment, accurate educational assessment and

grade placement, teacher understanding of linguistic and cultural heritage, culturally

appropriate school transition, supportive peer relationships, and successful acculturation.

LIMITATIONS: Studies are not generalizable to other cohorts.

CONCLUSIONS: This review provides a summary of published prevalence estimates for learning

problems in resettled refugee children, highlights key risk and resource factors, and

identifies gaps in research.

aDepartment of General Medicine, Royal Children’s Hospital, Melbourne, Australia; bCentre for International Child Health, University of Melbourne, Melbourne, Australia; cDepartment

of Pediatrics, St. Michael’s Hospital, Toronto, Canada; dDivision of Developmental Pediatrics, Department of Pediatrics, University of Toronto, Toronto, Canada; and eMurdoch Childrens

Research Institute, Parkville, Victoria, Australia

To cite: Graham HR, Minhas RS, Paxton G. Learning Problems in Children of Refugee Background: A Systematic Review. Pediatrics. 2016;137(6):e20153994

by guest on April 18, 2020www.aappublications.org/newsDownloaded from

GRAHAM et al

BACKGROUND

Conceptual Framework and Terminology

Learning problems are common,

affecting up to 1 in 10 children.1

They may reflect impairments in

intellect, difficulties in a specific

learning domain, behavioral

problems, or difficulties in social

interaction; comorbidities are

common.1 Bioecological system

theory recognizes that a child’s

development occurs in the context of

interactions between different layers

of their “ecology” (eg, individual

attributes, caregivers, family, school,

community, society).2 Integrating

this bioecological perspective

with neurocognitive research

provides an understanding that

learning problems arise from the

interaction of neurodevelopmental

predispositions with environmental

factors and life experience in a

dynamic process.3 This perspective

acknowledges both risk factors

for failure and resource factors

that contribute to developmental

resilience, 1, 3 and it recognizes that

the expression (and experience) of

learning problems will vary across

the life span and between individuals,

communities, and societies.1, 3

For clarity of reporting, we use

contemporary clinical categories

from developmental pediatrics to

describe the prevalence of learning

problems and broad categories to

describe their determinants (negative

risk factors and positive resource

factors). We use the term refugee-

background to describe children

granted humanitarian protection or

seeking asylum and children from

refugee-like backgrounds who have

migrated through other channels

(eg, family reunion).

Refugee Children and Learning

In 2015, the United Nations High

Commissioner for Refugees (UNHCR)

reported the highest numbers of

forcibly displaced people ever

recorded.4 Globally, there are

currently almost 60 million displaced

people, including 13.9 million people

newly displaced in the past year,

19.5 million refugees, and 1.8 million

people who have lodged claims for

asylum.4 More than half of refugees

are children, and the number

of unaccompanied or separated

children seeking asylum is the

highest since records began

(34 300 in 2014).4

Learning and development are

particular concerns for children of

refugee background.5 Displacement

has long-lasting effects on children

and caregivers, often involving

exposure to trauma and disruption

of family structures.6 Relocation

brings additional stressors, as

families negotiate their needs

within foreign social structures and

with limited supports.6 Within this

complex dynamic, a child enters a

new educational environment and

must negotiate multiple transitions,

including transitions in family,

friendships, schooling, community,

language, culture, and identity.6

Although educational success is

critical to overall well-being in

refugee children, 6 there are limited

data on educational outcomes or

learning problems in this group.

Understanding learning problems

and educational needs is essential

to respond to the increasing

populations of forcibly displaced

children and families.

The aim of this study was to review

evidence on educational outcomes

and learning problems among

refugee children, to describe major

risk and resource factors, and

to highlight areas for additional

investigation.

METHODS

We completed a systematic review

by using the search, selection,

extraction, analysis, and reporting

methods described by Arksey and

O’Malley’s framework for scoping

studies.7, 8

Inclusion and Exclusion Criteria

Inclusion and exclusion criteria

were broad, in keeping with the

study question and scoping review

methods. We included studies

if they involved interventional,

observational, or qualitative studies

relating to the prevalence or

determinants of learning problems

in children of refugee background,

available in English. We defined

“determinants” as any demographic,

individual, family, school, or other

factors reported to be associated with

learning problems or educational

outcomes. We excluded single case

reports and non–peer-reviewed

papers.

Data Sources

We completed searches of Medline,

Embase, PubMed, CINAHL, PsycINFO,

and Education Resources Information

Center (ERIC) in January 2015 (see

Supplemental Information), with the

support of a research librarian for

the time period 1996 through 2015

(Table 1). In addition, we searched

key websites, reviewed reference

lists, and contacted people through

refugee health networks in Canada

and Australia.

2

TABLE 1 Medline Search Query

The following search query was used on January 20, 2015 to search Medline; similar search terms used

for the other databases (Embase, PubMed, CINAHL, PsycINFO, ERIC):

1. (exp Refugees/ or “Emigrants and Immigrants”/) and (Learning/ or Learning problem$.af. or exp

Learning Disorders/ or (cognition disorders/ or mild cognitive impairment/) or (exp “attention defi cit

and disruptive behavior disorders”/ or child behavior disorders/ or exp communication disorders/ or

developmental disabilities/ or exp learning disorders/ or intellectual disability/) or Stress Disorders,

Post-Traumatic/)

2. limit 1 to (english language and “all child (0 to 18 years)”), 1996–present.


PEDIATRICS Volume 137 , number 6 , June 2016

Data Extraction and Synthesis

We systematically extracted data

using a standardized data charting

form, which included information

on study type, location, population,

research methods, outcome

measures, and key findings.

We adopted Arksey and O’Malley’s

descriptive analytical method

for data analysis and reporting, 7 including numerical summary of

included studies to describe the

current state of the literature and

narrative synthesis of findings

using broad categories to describe

educational outcomes, learning

problems, and important risk and

resource factors.

RESULTS

Database searches retrieved 2454

results: Medline 365, Embase

511, CINAHL 278, PsycINFO 543,

ERIC 601, and PubMed 156. After

exclusion of duplicates and addition

of 49 records from other sources,

2021 articles were identified for

screening. Two investigators (H.R.G.,

R.S.M.) independently screened all

titles and abstracts according to

predefined inclusion criteria, then

reviewed 98 full-text papers for

inclusion. Thirty-four articles were

included in the final analysis (Fig 1,

Table 2).

Summary of Included Studies

Overall, 34 studies reported on

learning problems in 29 cohorts of

refugee children; half (17/34) were

published since 2010 (Table 3, Fig 2).

The majority (25/34, 74%) reported

results from cohorts in Australia

(11 studies), the United States (7

studies), or Canada (7 studies), with

only 1 study from a low- or middle-

income country (Thailand). Studies

included participants from diverse

regions of origin, and 14 (41%)

included mixed cohorts of children

from multiple regions. Most studies

(30/34, 88%) reported on adolescent

refugees, with 13 studies including

primary school–age children and a

single study on preschool children.

Twenty (59%) studies used

quantitative (or mixed) methods and

reported on educational outcomes

(n = 8), prevalence of learning

problems (n = 14), and risk and

resource factors (n = 9); the

remaining 14 (41%) studies used

qualitative methods and reported on

risk and resource factors.

Educational Outcomes

Eight studies reported educational

out comes for refugee children,

all at secondary school

level10, 18, 23, 28, 30, 33, 35, 40 (Table 4).

Six studies from North America

and Europe reporting on 1197

refugee-background youth from Sub-

Saharan and North Africa, Eastern

Europe, Middle East, Asia, and Latin

America found they had similar

educational outcomes to their peers,

including similar rates of high school

completion (although often at an

older age).10, 18, 30, 33, 35, 40 One study

of 19 unaccompanied minors who

migrated to the United States from

Sudan reported superior performance

to peers, with 100% high school

completion and 79% progression

to college.28 Conversely, a study

involving 102 youth who migrated

from North Korea to South Korea

reported lower academic performance

relative to native-born peers.23

Prevalence of Learning Problems

Fourteen studies provided prevalence

data on developmental or learning

problems in children of refugee back-

ground10, 14, 16, 17, 20, 23–25, 29–31, 34, 39, 41

(Table 5). No studies reported on

autism spectrum disorder, specific

language impairment, dyscalculia, or

dyslexia.

3

FIGURE 1PRISMA 2009 fl ow diagram of literature.


GRAHAM et al 4

TABLE 2 Summary of 34 Included Studies on Educational Outcomes and Learning Problems in Refugee Children (1996–2015)

Author Place of Origin Population Method Outcomes

Agbenyega& Klibthong (2013), 9 Australia

Sub-Saharan Africa

(countries not specifi ed)

25 refugee-background

families with a child

attending preschool

Qualitative. Semistructured

interviews with parents

and teachers.

Preschool experiences of

parents and educators.

Berthold (2000), 10 USA Cambodia 144 refugee-background

Khmer secondary school

students, born outside US

(age 14–20 y, mean 16.35 y,

50% male)

Mixed methods. In-depth

interviews, questionnaires

with adolescents and

parents.

Educational outcomes (grade

point average), exposure to

violence, PTSD, depression,

school behavior problems,

perceived social support.

Bitew et al (2008), 11 Australia Ethiopia 16 refugee-background

secondary school students

(age 16–20 y)


interviews with students.

Student experience of school,

cultural differences, needs,

interests.

Bitew et al (2010), 12 Australia Ethiopia 16 refugee-background


(age 16–20 y), 10 teachers,

10 parents


interviews with students,

parents, and teachers.

Parental contact with school,

academic assistance

to child, education

and awareness of

Australian school system,

cultural differences and

expectations.

Brown et al (2006), 13 Australia Sudan 8 refugee-background youth

(age 15–20 y)

Qualitative. Individual

interviews and focus

groups with students.

Subjective school experiences,

and challenges.

Correa-Velez et al (2010), 6

Australia

Sudan, Ethiopia, Liberia,

Uganda, Iraq, Afghanistan,

Iran, Kuwait, Bosnia,

Croatia, Burma


students attending English

language school (age

11–19 y) (68% Africa, 27%

Middle East)

Qualitative. Interviews and

questionnaires with

students.

Subjective health and

wellbeing, and wide range of

determinants.

Daud & Rydelius (2009), 14

Sweden

Iraq, Egypt, Morocco, Syria 80 refugee-background

children (age 7–16 y, 50%

male)

Cross-sectional. Standardized

tests (eg, WISC-III, SDQ),

interviews with students

and parents.

ADHD, PTSD, IQ, ODD, CD.

Daud et al (2008), 15 Sweden Iraq, Egypt, Morocco, Syria 80 refugee-background

children (age 7–16 y, 50%

male)


tests and questionnaires

(eg, WISC-III, SDQ),

interviews with children.

Trauma, PTSD, IQ, self-esteem.

Derluyn & Broekaert (2007), 16 Belgium

41 countries (13% Angola, 7%

DRC, 7% Afghanistan, 7%

Nigeria)

166 recently arrived

“unaccompanied refugee

minors” (age 12–19 y, 63%

male)



(eg, CBCL, SDQ), children

and social workers.

Behavioral profi les.

Fazel & Stein (2003), 17 UK Balkans, Kashmir, Afghanistan 101 refugee-background

children (age 5–18 y) (plus

202 age- and gender-

matched “minority” and

“white” peers)


questionnaire (SDQ)

completed by teachers.


Fox et al (2004), 18 USA Vietnam, Cambodia, Laos 237 refugee-background

students (age 6–17 y, mean

11 y, 47% male)



(eg, Self-Perception Profi le

for Children) with students.

Educational outcomes (GPA),

self-esteem, depression.

Hatoss et al (2012), 19

Australia

Sudan 30 refugee-background youth

from 6 schools (plus 227

peers)

Qualitative. Focus groups

plus online survey with

students.


aspirations, and challenges.

Kira et al (2012), 20 USA Iraq, African American 390 children and adolescents

recruited from the

community (age 11–17 y,

mean 13.6 y, 46% male,

52% Iraqi refugee)



(eg, Cumulative Trauma

Scale, WISC-IV) with

adolescents.

Trauma, PTSD, IQ.


recruited from the



52% Iraqi refugee)





adolescents.

Trauma, PTSD, IQ.


PEDIATRICS Volume 137 , number 6 , June 2016 5



recruited from the



52% Iraqi refugee)





adolescents.

Trauma, PTSD, IQ, race

stressors, bullying

victimization.

Lee et al (2012), 23 South Korea North Korea 102 refugee-background


(age 13–22 y, mean 17 y,

67% male)



(eg, CBCL) with students.

Educational outcomes,

behavioral profi les.

Mace et al (2014), 24 Australia 24 countries (21% Burma,

11% Afghanistan, 11% Iran)

332 children seen at a

refugee health clinic (mean

age 9.5 y)

Cross-sectional. Retrospective

clinic chart review.

Medical, psychological,

developmental, and learning

issues.

Mollica et al (1997), 25

Thailand

Cambodia 182 refugee-background

adolescents (age 12–13 y),

and their parents


tests, questionnaires, and

interviews (eg, CBCL) with

adolescents and parents.

Trauma, behavioral profi les.

Naidoo (2009), 26 Australia Africa (countries not

specifi ed)

77 preservice teachers and 9

supervisors working with

the Refugee Action Support

Program


group interviews with

teachers and supervisors.

Teacher experiences and

perceptions of students,

student academic progress

and results.

Nykiel-Herbert (2010), 27 USA Iraq 12 Kurdish refugee-

background primary

school students (age

8–11 y)

Mixed-methods program

evaluation. Class

observation, unstructured

narrative recording,

refl ective practice

techniques, review of

academic records reported

by teachers, caregivers,

and students.

Educational outcomes (literacy,

math), student experience,

teacher experience and

perspectives.

Rana et al (2011), 28 USA Sudan 19 youth who had migrated as

“unaccompanied refugee

minors” (89% male, mean

age 15 y at resettlement

and 22 y at interview), 20

(foster) parents


interviews of youth and

parents.

Educational outcomes (school

completion), determinants

of educational resilience.

Rousseau, Drapeau, & Platt

(2000), 29 Canada

Cambodia, Honduras,

Guatemala, El Salvador

158 secondary school

students (76 Cambodian,

82 Central American)

(mean age 14 y) (plus 67

Quebecois youth)



(eg, CBCL), interviews with

parents and students.

Behavioral profi les, risk

behaviors.

Rousseau & Drapeau (2000), 30 Canada

Cambodia, Honduras,

Guatemala, El Salvador

158 secondary school

students (76 Cambodian,

82 Central American)

(mean age 14 y)




parents and students,

and review of academic

records.

Educational outcomes

(French, English, math),

trauma, behavioral profi les,

acculturation, parental

depression, and English

profi ciency.

Rousseau et al (1996), 31

Canada

Cambodia, Vietnam,

Honduras, Guatemala, El

Salvador


primary school students

(100 from Southeast Asia,

56 Central America (mean

age 10.5 y, 56% male)




teachers and parents,

review of academic

records.

Behavioral profi les, parental

and teacher perceptions.

Shakya et al (2010), 32 Canada Afghanistan, Burma, Sudan 57 refugee-background

youth recruited from the


51% male, mean time since

migration 1.9 y)

Qualitative. Focus groups and

interviews with youth.

Educational aspirations,

challenges, barriers, youth

strategies, vulnerability,

empowerment.

TABLE 2 Continued


GRAHAM et al

A single Australian study reported

on the prevalence of sensory

impairment (vision, hearing) and

developmental delay in a mixed

cohort of 332 children attending

a refugee health clinic: 7.5% had

a visual impairment, 3.3% had a

hearing impairment, and 6.9%

had developmental delay, most

commonly language (5.7%) or gross

motor (2.1%).24

Two studies from the United States20

and Sweden14 provided information

on intellectual impairment, using

cognitive testing to investigate the

impact of trauma on intelligence.

These studies reported that among

more than 400 Iraqi-background

and African American adolescents,

half (49.4%–56.3%) had low or

borderline IQ scores on the Wechsler

Intelligence Scales for Children

(WISC). Mean IQ for the US cohort

was 84 points (WISC, Fourth Edition

[WISC-IV]), 20 consistent with

WISC-IV results for African American

and other minority populations in the

United States.20

Ten studies reported on behavioral

profiles of refugee children, with

varying results.16, 17, 23, 25, 29–31, 34, 39, 41

A Canadian study of 156 primary

school–age children from Southeast

Asia and Central America reported

an association between problems

identified through behavioral

profiles (especially “externalizing

problems”) and adverse educational

outcomes;31 however, this

association was not found in a

similar adolescent cohort (n =

158).30 Overall, behavioral and

emotional problems were more

common in refugee-background

children compared with their

6


Slodnjak, Kos, & Yule (2002), 33 Slovenia

Bosnia-Herzegovina 430 refugee-background

youth (age 14–15 y) (plus

195 age- and gender-

matched peers)


questionnaires and

interviews with students

and parents or guardians

(eg, War Trauma

Questionnaire).

Teacher-reported school

outcomes and behavior.

PTSD.

Sourander (1998), 34 Finland Somalia, Ethiopia, Thailand,

Vietnam, Angola, Nigeria,

Burma, Iraq, Zaire

46 unaccompanied minors

(age 6–17 y, mean 14.1 y)

(80% from Somalia)


questionnaire (CBCL) of

children completed by

support worker.


Stermac (2012), 35 Canada Multiple (countries not

specifi ed)

219 immigrant youth from

“war-zone” countries (eg,

former Yugoslavia, Middle

East, eastern Africa),

217 from non–war-zone

countries, 222 Canadian-

born (age 18–20 y,

migrated >8 y before)

Cross-sectional. Telephone

survey with youth.

Educational outcomes (math,

language, overall grade),

self-assessed language

ability, work habits,

perceived supports.

Tlhabano & Schweitzer

(2007), 36 Australia

Sudan, Somalia 14 refugee-background youth

(age 16–26 y)

Qualitative. Structured

individual interviews with

youth.


challenges, and aspirations.

Uptin et al (2013), 37 Australia Burma, Burundi, Sudan, DRC,

Sierra Leone, Togo


youth (age 16–19 y), and 1

Sudanese youth worker


interviews and focus

groups with youth and a

youth worker.

School perceptions and

experience.

Usman (2012), 38 Canada Sierra Leone, Liberia 10 refugee-background

primary school students

(Grades 3 and 4)

Qualitative. Interviews with

children, parents, and

teachers. Observation in

classroom and home.

Students’ linguistic heritage,

perspective of teachers on

communication disorders,

teacher approaches to

communication disorders.

Wiegersma et al (2011), 39

Netherlands

Multiple (countries not

specifi ed)

267 children living in asylum

seekers’ centers (age

4–16 y)


tests and interviews with

parents and children (eg,

SDQ).


Wilkinson (2002), 40 Canada Yugoslavia, El Salvador,

Afghanistan, Azerbaijan,

Iraq, Vietnam, Somalia,

Guatemala, Pakistan

91 refugee-background youth

(age 15–21 y) recruited

from immigration registry,

and 123 of their parents

Qualitative. Structured

interviews with youth and

parents.

Educational outcomes (based

on grade placement,

secondary school and

postgraduate enrollment

and completion).

Ziaian et al (2013), 41 Australia Afghanistan, Iran, Iraq, Sudan,

Liberia, Bosnia, Serbia


children and youth (age

4–17 y)


tests and interviews with

youth (eg, SDQ).

Behavioral profi les, mental

health service utilization.

CBCL, Child Behavior Checklist; DRC, Democratic Republic of the Congo; GPA, grade point average; SDQ, Strengths and Diffi culties Questionnaire.

TABLE 2 Continued



peers, especially in young children

(<10 years old).16, 17, 23, 25, 34, 39,

“Internalizing problems” (ie, anxious,

depressive, and overcontrolled

behavior) were more common

than “externalizing problems”

(ie, aggressive, hyperactive,

noncompliant, and undercontrolled

behavior).16, 17, 23, 25, 34, 39, However,

there is considerable variation in

prevalence estimates, with some

studies reporting no difference to

peers29, 30, 41 and multiple studies

finding marked variation between

self-report, teacher report, and

parent report.16, 25, 29, 39, 41

One study examined the prevalence

of attention-deficit/hyperactivity

disorder (ADHD), involving 80

Middle Eastern refugee children

and adolescents in Sweden.14 There

was high prevalence of ADHD

in students whose parents had

experienced trauma (65% male,

30% female) but low prevalence

in those whose parents had not

(5% male, 10% female).14 Most

(90%) children with ADHD also met

criteria for posttraumatic stress

disorder (PTSD); and lower IQ was

a risk factor for both ADHD and

PTSD.14

Two studies reported on the

prevalence of oppositional defiant

disorder/conduct disorder (ODD/

CD).10, 14 In the Swedish cohort

of adolescent Iraqi refugees, the

prevalence of ODD/CD was 7.5%

in those whose parents had been

exposed to trauma and 0% in

those whose parents did not have

trauma exposure.14 A US study of

144 Khmer adolescents found 30%

had been reported at school for

misconduct (eg, carrying a weapon,

physical assault, swearing, stealing)

and that misconduct was associated

with higher exposure to trauma,

male gender, and lower academic

outcomes.10 The Khmer cohort had

high levels of premigration trauma

(99%), clinical depression (63%),

and PTSD (33%).10

7

Risk and Resource Factors

Twenty-five of the 34 studies (73.5%)

provided qualitative information on

determinants of learning in refugee

children. We describe major risk

and resource factors by using broad

categories: individual child and home

environment, school environment,

migration and trauma experience, and

sociocultural environment (Table 6).

TABLE 3 Characteristics of 34 Included Studies on the Prevalence and Determinants of Learning

Problems in Children of Refugee Background

Characteristic Number (%)

Country of settlement

United States 7 (20.6)

Canada 7 (20.6)

Australia 11 (32.4)

South Korea 1 (2.9)

Thailand 1 (2.9)

Sweden 2 (5.9)

Finland 1 (2.9)

Belgium 1 (2.9)

Netherlands 1 (2.9)

Slovenia 1 (2.9)

United Kingdom 1 (2.9)

Study population region of origin

Sub-Saharan Africa 9 (26.5)

Middle East and North Africa 6 (17.6)

East Asia and Pacifi c 4 (11.8)

Europe and Central Asia 1 (2.9)

Multiple regions 14 (41.2)

Study population age

Preschool age 1 (2.9)

Primary school age 3 (8.8)

Adolescent 20 (58.8)

Primary school age and adolescent 10 (29.4)

Study outcomes reported

Educational outcomes and prevalence of learning problems 19 (55.9)

Prevention of learning problems 14

Educational outcomes 8

Risk and resource factors (solely) 15 (44.1)

Method

Quantitative cross-sectional 20 (58.8)

Qualitative 14 (41.2)

FIGURE 2Included studies by year of publication.


GRAHAM et al

Individual Child and Home Environment

Two of the 7 studies reporting

secondary school outcomes in refugee

youth found girls achieved higher

results than boys.10, 35 However,

female academic advantage among

refugee youth was less pronounced

than among their nonrefugee peers

and was limited to language subjects

only.10, 35 A Canadian study of 91

refugee youth from 9 countries found

that younger age at migration, greater

length of time since resettlement, and

urban residence were associated with

better secondary school outcomes.40

This study found no association

between self-reported English

language proficiency and secondary

school outcomes, 40 despite Sudanese

youth reporting English language

difficulties as a common barrier to

success.13, 19, 36

Three studies reported ethnic

differences in educational

outcomes.30, 31, 40 A Canadian study

of 156 refugee children in primary

school found that children from

Central America had more severe

learning difficulties reported by

teachers than their peers from

Cambodia and Vietnam, despite

similar objective academic

outcomes.31 Qualitative data from

this study suggested teachers were

influenced by cultural stereotypes,

leading them to identify Latino

children more readily as having

problems.31 Two studies in

Canadian secondary schools

reported lower school failure rates

for Cambodian-background youth

(compared with Central American

youth) (n = 158)30 and superior

outcomes for Yugoslav compared

with other refugee-background youth

(n = 91).40

Six studies reported that Sudanese-

background refugee youth generally

had high academic aspirations and life

ambition and that this was an effective

motivation for success.13, 19, 28, 32, 36, 37

Indeed, their desires to advance their

education, support relatives and

8

friends left behind, and help rebuild

their country were major motivators

for migration and life.19, 28, 32, 37

Seven studies examined parental

involvement in the education of

refugee children.9, 11, 12, 28, 31, 32, 37

Parental support for education was

identified as a protective factor for

refugee adolescents.28 However,

although they valued education

strongly, parental involvement in

TABLE 4 Educational Outcomes in Refugee-Background Children From Studies Included in This

Review

Educational Level Educational Outcomes

Preschool No studies identifi ed

Primary school No studies identifi ed

Secondary school performance

Failing, defi cient, GPA <2.0, % 21.910

Average, good, excellent, GPA >2.0, % 78.110

Mean GPA (secondary school) “Below peer level, ”23 “At peer level”33

0–4 scale 2.77–3.010, 30

0–5 scale 3.6818

Secondary school completion

Completed or on track, % 80–10028, 35, 40

Behind or dropped out, % 0–2028, 35, 40

Postsecondary school

Pursue postsecondary, % 53–8428, 40

GPA, grade point average.

TABLE 5 Estimated Prevalence of Learning Problems in Refugee-Background Children

Learning Problem Estimated Prevalence (%) Sample Size

Sensory impairment (n = 332)24

Vision 7.524

Hearing 3.324

Developmental delay 6.924

Gross motor 2.124

Fine motor 0.924

Language 5.724

Social 0.624

Cognitive 1.824

Specifi c language impairment,

dyscalculia or dyslexia

No studies identifi ed —

Cognitive function

Mean IQ (WISC-IV FSIQ) 8420 (n = 80)14

IQ <84 (WISC-IV FSIQ) 49.4–56.314, 20 (n = 390)20

IQ <70 (WISC-IV FSIQ) 11.120

Behavioral profi les

Total problems in “clinical

level”

CBCL (carer) 25.2–53.816, 23, 25, 34 (n = 102)11

Internalizing problems 13.9–27.316, 23 (n = 166)20

Externalizing problems 11.6–50.816, 23 (n = 182)22

YSR (self) 26.425 (n = 46)26

SDQ (self) 4.4–9.816, 39, 41

SDQ (carer) 9.0–3816, 17, 39, 41

ADHD 47.5 (M 65, F 30) if trauma14 (n = 80)14

7.5 (M 5, F 10) if no trauma14

ODD/CD 7.5 if trauma14 (n = 80)14

0 if no trauma14

Autism spectrum disorder No studies identifi ed —

Behavior problems 30 (M > F)10 (n = 144)20

Mental health problems (from previous systematic reviews and meta-analysis)

PTSD 11 (7–17) (n = 260)

19–5442 (n = 3003)42

Depression (n = 3003)42

CBCL, Child Behavior Checklist; FSIQ, full-scale IQ; SDQ, Strengths and Diffi culties Questionnaire; YSR, youth self-report.



education was limited, with parents

having little contact with school and

providing minimal homework help.11, 12

Parents and teachers perceived

learning problems differently, with

teachers emphasizing language and

family dynamics whereas parents

emphasized the cultural gap of

educational styles and expectations.31

Parents and teachers both recognized

the importance of parent–teacher

communication, 31 but there were

frequent misunderstandings about

education styles, rules, and pathways,

attributed to different cultural

expectations and a lack of familiarity

with education systems.9, 11, 12 Three

studies described the positive effect

of “gift-and-sacrifice” motivational

narratives, whereby parents linked

their struggle with poverty and

migration to the value of educational

opportunity.28, 32, 37

One large US study found a positive

association between parental

education and secondary school

outcomes.35 However, 2 similar-sized

Canadian studies found parental

proficiency in the host country

language to be more important

than parental education per se.30, 40

These Canadian studies also found

no association between household

income and secondary school

outcomes, suggesting that education

was prioritized regardless of the

family’s socioeconomic status.30, 40

However, financial stress was

reported as a major risk factor

for secondary school dropout by

unaccompanied minors, who cited

unique challenges such as obligations

to earn and send money back to

family.28

Three studies reported that family

cohesion and supportive home

environment were associated with

better secondary school outcomes

(particularly for girls).6, 24, 30 Two

studies reported on the association

between parental physical and

mental health and secondary school

outcomes, with 1 finding a positive

association40 and the other finding no

association.30

School Environment

Eleven studies reported on

school transition for refugee

children.28, 31, 40, 11, 13, 32, 36, 37, 26, 27, 38

Accurate educational assessment

and grade placement were major

determinants of educational

success11, 32, 40 but were often

inaccurate.31, 38 Inadequate

appreciation of a child’s educational

experience was reported to result

in inappropriate grade placement

and expectations13, 28, 32, 36, 37, 40 and to

impair remedial educational efforts.38

This discrepancy resulted from either

expectations that were too high (ie,

failing to account for the impact of

interrupted education)13, 36, 40

or too low (ie, failing to recognize

previous learning).28, 37 Teacher

ignorance of linguistic heritage

has resulted in misunderstandings

(eg, misinterpreting respectful

whispering as being shy, unsure,

inattentive, or disrespectful),

misdiagnosis, and counterproductive

remediation attempts (eg, group

reading and public correction creating

a feeling of inadequacy and reinforced

withdrawal).11, 38 Conversely,

teachers’ understanding of a child’s

cultural heritage was associated with

enhanced learning at both primary38

and secondary11 school level.

Low teacher expectations of refugee-

background children were reported

to be common in both primary and

9

TABLE 6 Risk and Resource Factors Infl uencing Learning Outcomes for Refugee Children

Risk Factors Resource Factors

Individual child and home environment

Male gender10, 35 Female gender, 10, 35 younger age at migration, 40

greater length of time since resettlement, 40 and

urban residence40

Latino30, 31 (North American context) Cambodian or Vietnamese, 30, 31 Yugoslav40

English (new) language diffi culties13, 19, 36 High academic aspirations and life ambition13, 19,

28, 32, 36, 37

Financial stress28 Parental involvement in education11, 12, 28

Parental misunderstandings about educational

styles and expectations9, 11, 12, 31

“Gift-and-sacrifi ce” motivational narratives28, 32, 37

Parental education35 (or no association30, 40)

Parental profi ciency in the host country language30,

40

Family cohesion, supportive home environment.6,

24, 30

Parental physical and mental health40 (or no

association30)

School environment

Teacher ignorance of linguistic heritage11, 38 Accurate educational assessment and grade

placement11, 13, 28, 31, 32, 36–38, 40

Low teacher expectations28, 31, 37, 38 Teacher understanding of cultural heritage11, 38

Cultural stereotyping by teachers28, 31, 32, 37, 38 and

peers6, 11, 28, 37

Teachers who believed in child11, 28, 37

Lack of friends28, 37 Culturally appropriate transition program26, 27, 38

Bullying and racial abuse6, 9, 11, 19, 28, 32, 37 Supportive peer relationships6, 11, 13, 28, 37

Migration and trauma experience

Past experience of trauma, 15, 20–22 particularly

abandonment trauma21 and bullying

victimization22

Past experience of trauma33, 35, secondary trauma

(eg, parental war experience)21

Current or past forced detention24

Postmigration trauma (eg, bullying, racial

abuse)10, 15, 20–22, 30, 35, 41

Sociocultural environment

Positive acculturation (whereby there is selective

adoption of new country culture while

maintaining a strong connection with culture

and country of origin)28, 30, 31


GRAHAM et al

secondary schools, 28, 31, 37, 38 with the

risk that such expectations would

become a self-fulfilling prophecy.38

Refugee-background youth reported

demotivation from low teacher

expectations and appreciated

teachers who believed in them

and encouraged them to pursue

challenging academic programs.11, 28, 37

Cultural stereotyping of refugee-

background children by

teachers was associated with

prejudiced assessments,

relationships, expectations, and

behavior.28, 31, 32, 37, 38

Three studies reported on school-

based interventions to facilitate

school transition for refugee

children.26, 27, 38 These studies support

the use of intentional transition

programs, culturally relevant

classroom techniques (eg, student-

driven gender segregation, student–

student interaction and assistance)

and explicit attention directed to low

teacher expectations.26, 27, 38 One study

involving a teacher-as-tutor program

reported benefits for both students

(accelerated academic progression)

and teachers (informed beliefs and

attitudes), who became allies in

helping students overcome broader

educational barriers and challenges.26

Five studies reported on the school

social environment in relation to

school success.6, 11, 13, 28, 37, Refugee

youth consistently report that

supportive peer relationships are

academically protective6, 11, 13, 28, 37;

however, difficulty forming such

relationships is the norm, resulting

in significant loneliness and

emotional stress.6, 13, 28, 37 Sport is a

common locus for successful peer

relationships, especially for boys, but

can both encourage and distract from

academic endeavor.13, 28, 37 Cultural

stereotypes strongly influence

social relationships, to the academic

advantage of some and detriment

of others (eg, African boys may be

expected to play sports but

not expected to succeed

academically).6, 11, 28, 37

Six studies found that overt

personal racism, bullying, and

abuse were common, and more

subtle discrimination was the

norm for refugee children and

adolescents, and this discrimination

negatively affected their educational

experience.6, 9, 11, 19, 28, 32, 37 Adolescents

reported feeling identified primarily

by their appearance (especially skin

color) and having to come to terms

with “embodying difference, ” often

experiencing this “otherness” for the

first time when arriving at school.37

Parents of preschool children

reported differential treatment and

derogatory race-based language from

teachers, whereas teachers reported

exclusion by other children.9

Migration and Trauma Experience

Ten studies reported on

the impact of trauma on

learning.10, 15, 20–22, 24, 30, 33, 35, 41 Three

studies involving 793 refugee-

background youth from multiple

countries reported that PTSD

and exposure to war trauma had

negligible10, 35 or positive33 impact on

school outcomes. Canadian students

from war zone countries had similar

academic outcomes to those from

non–war zone countries, and they

had higher academic expectations,

lower truancy, and greater high school

completion rates than their Canadian

peers (although often finishing at older

ages).35 Adolescents from Bosnia–

Herzegovina in Slovenia with greater

trauma exposure and symptoms of

PTSD tended to have higher academic

performance compared with matched

Slovenian-born peers.33

Conversely, 4 studies involving a

total of 319 traumatized children and

adolescents from Cambodia, Iraq, and

the Middle East found that cognitive

function was detrimentally affected

by trauma.15, 20–22 Daud et al15

described intergenerational effects

of trauma on Swedish refugees

from the Middle East, with children

of traumatized parents scoring

lower on cognitive tests despite no

direct experience of trauma (and

independent of whether they had

PTSD). Three studies involving the

same cohort of 200 Iraqi refugee

adolescents in the United States

reported that different types of

trauma had different effects on

cognitive testing (WISC-IV).20–22

“Abandonment trauma” had the

largest impact on all domains (equal

for either maternal or paternal

abandonment), whereas “personal

identity trauma” (eg, personal

assault or rape) affected working

memory, and “survival trauma”

(eg, life-threatening accident)

affected processing speed. “Collective

identity trauma” (eg, genocide or

discrimination) had no impact on

cognitive test results, whereas

“secondary trauma” (eg, parental war

experience) improved reasoning,

processing speed, and working

memory21. “Bullying victimization”

was associated with lower test scores

over and above other traumas.22

Two studies involving 302 refugee

youth from a variety of countries

reported that parental experience

in a refugee camp and parental

separation had no association with

secondary school outcomes.30, 40

Qualitative data from resettled

Sudanese-background refugee youth

demonstrated that thoughts of war

continued to disturb their daily lives,

including their ability to concentrate

and learn.19

Although premigration trauma

is common, there is increasing

recognition that postmigration

trauma is also common and may

have greater impact on both

learning10, 30, 35, 41 and cognitive

function.15, 20–22 Postmigration

trauma exposure was a significant

predictor for behavior problems

and academic failure in a cohort of

Khmer adolescents in the United

States, whereas premigration

trauma exposure did not correlate

with behavioral or educational

outcomes.10 The Australian refugee

health clinic study found that current

10 by guest on April 18, 2020www.aappublications.org/newsDownloaded from


or past mandatory immigration

detention was a significant predictor

for learning and psychological

difficulties among newly arrived

children.24

Sociocultural Environment

Three studies reported better

primary and secondary school

outcomes among refugee children

with greater levels of successful

acculturation (whereby there is

selective adoption of new country

culture while maintaining a strong

connection with culture and country

of origin).28, 30, 31

DISCUSSION

Our review of educational outcomes

and learning problems in refugee-

background children highlights the

complexity of examining learning

in refugee children and identifies

important gaps in the literature.

Overall, there are limited data

on the prevalence of learning

problems in refugee children, with

single studies informing most of

the estimates. There are almost no

studies describing children resettled

in developing countries, despite

the fact that 86% of refugees live in

developing countries.4

Most studies examined outcomes

in adolescent cohorts, there were

few studies on primary school

aged children and only a single

study involving preschool children,

which is concerning given the

importance of early identification for

effective intervention.43 Notably, no

studies reported the prevalence of

autism spectrum disorder, despite

higher rates in other immigrant

populations44–47 and a postulated

association with low vitamin D

levels, 48 which is well described

in resettled refugee populations.49

Similarly, there were no studies on

language impairment, dyscalculia, or

dyslexia, and only 1 study examined

any contribution from sensory

impairment. Only 1 study examined

the prevalence of ADHD, although

these authors highlighted the overlap

in ADHD and PTSD symptoms, which

is an area of particular diagnostic and

therapeutic uncertainty. The majority

of studies were cross-sectional;

the lack of longitudinal data is

a significant limitation, because

learning outcomes and contributing

factors may change over time (both

positively and negatively).

Implications for Practice

Despite significant data gaps, our

review has important implications

for health professionals, educators,

refugee support agencies, and

policymakers.

First, children of refugee background

should be expected and supported to

achieve school outcomes comparable

to those of their peers. Despite

limited data on the preschool or

primary school population, evidence

suggests refugee-background youth

have similar pass rates, completion

rates, and grade point averages to

their peers.10, 18, 28, 30, 33, 35, 40

Population data from other

immigrant populations have often

shown an academic advantage for

migrants compared with native-born

peers after adjusting for variables

such as socioeconomic status, the

so-called immigrant paradox.50, 51

Although the data on refugee-

background children are insufficient

to draw similar conclusions, many

of the same resource factors apply:

strong family ties (although a

significant minority experience

family loss or dislocation),

prioritization of education, “gift-and-

sacrifice” motivational narratives, 52

isolation from negative peer and

social influences, bilingual advantage,

and possible migration bias toward

healthier, wealthier, and more

educated parents.53 This finding

of academic resilience is echoed in

reviews on mental health of refugee

children, 42, 54–59 particularly the

examples of “positive deviance, ”

where children have better mental

health than would be predicted from

their life experiences and social

situation.

Evidence on the impact of trauma

on cognition and school outcomes is

mixed, with several studies indicating

that premigration trauma (and

symptoms of PTSD) has negligible (or

positive) effects on school outcomes.

Possible explanations for this effect

might be survival of past traumatic

experiences contributing to greater

resilience (eg, past trauma becoming

part of individual motivational

narratives), teachers being more

supportive to students who display

signs of PTSD, or survival bias (where

only the most resilient successfully

migrate).

Our review identified substantial

data on educational risk and resource

factors for refugee-background

children (Table 6). Major risk

factors included experience of

trauma, racism, and bullying;

parental misunderstandings about

educational styles and expectations;

and teacher stereotyping, low

teacher expectations, and poor

awareness of linguistic heritage.

Resource factors included high

academic and life ambition, parental

motivational narratives and

involvement in education, family

cohesion and supportive home

environment, accurate educational

assessment and grade placement,

teacher understanding of linguistic

and cultural heritage, culturally

appropriate school transition,

supportive peer relationships, and

successful acculturation. The risk

and resource factors identified in

our review share commonality to

those reported in previous reviews

on resilience in refugee children58

and the educational needs of refugee

students.60 It is clear that, although

premigration experiences do

influence refugee children’s learning,

the most important determinants

of success are located in the

postmigration context, and many of


GRAHAM et al

these are modifiable in the country of

settlement.

Recommendations

Health professionals, educators,

social support agencies, and

policymakers all have important

roles in providing the individual,

family, community, and structural

support necessary for refugee-

background children to succeed.

Health professionals must identify

potential learning problems early

and work with schools to support

vulnerable children throughout their

educational and social transitions.

Pediatricians have a particular role

in these areas and should tailor their

developmental and educational

assessments to address particular

risk and resource factors. Alongside

health screening and medical

care, this support may include

contributing to accurate grade

placement (including age assessment

where needed), acknowledging

cultural and linguistic heritage,

valuing past educational and life

experience, affirming educational

aspirations, encouraging parental

involvement in school, reassuring

and educating families about

additional language acquisition,

encouraging maintenance of

the families’ first language, and

explicitly inquiring about learning

difficulties, racism experience, and

bullying. Given that some problems

become apparent only after time

in mainstream schooling (and

the dynamic nature of risk and

resource factors), longitudinal care is

important. Clinicians need to revisit

serial screening for school-related

problems as children and families

move through their social and

developmental transitions.6

Educators and schools must provide

inclusive and culturally safe school

environments and be aware that

school represents a major transition

for refugee-background students

and their families.60–62 Positive

supports include dedicated transition

programs, enhancing teacher

linguistic and cultural understanding,

proactively addressing bullying and

racial discrimination, encouraging

parental involvement in school,

incorporating past educational and

life experiences for appropriate

grade placement and individualized

learning plans, and promoting

appropriately high academic

expectations. The finding that

refugee-background students

experience high levels of school-

and peer-based racial abuse and

discrimination is disturbing, and

this will affect not only learning, but

health, well-being, and acculturation

more broadly.6, 49

Support agencies and policymakers

must recognize the importance

of migration transition supports,

including linguistic and educational

transition programs. In the early

postsettlement period, supporting

access to health professionals and

educators who are experienced in

working with refugee-background

children and families is likely to be

of benefit, alongside education and

support for parents to engage with

their children’s schools.

Researchers also have a role in

advancing our understanding of

learning and educational outcomes

in refugee-background students. Key

evidence gaps include longitudinal

assessments of educational and

vocational outcomes and the

influence of risk and resource factors

over time, evaluation of learning in

preschool and primary school–age

populations, directed research

with new population groups, and

comparative evaluations of resettled

populations in different countries

and contexts. Research is also needed

into the validity of assessment tools

in refugee-background populations.

The tools we use to assess

intelligence, behavior, and social and

emotional well-being are culturally

bound, having been developed and

validated in certain population and

language groups (usually European

or North American) and cannot

be assumed to be valid in other

populations.63 Although some of

these tests have been adapted for

use in other specific populations (eg,

WISC tests), they are not validated

for most of the population groups

who become refugees63 or for use

with interpreters. Despite these

obvious limitations, such testing

may be mandated by education

systems when learning problems or

intellectual disability is suspected.

Clinicians working with refugee

children often grapple with

understanding the meaning and

application of cognitive, behavioral,

or language assessments and

deciding which diagnostic labels

most accurately describe clinical

presentations. These clinical

dilemmas highlight the role of

the developmental history and

longitudinal care in supporting

refugee-background students with

learning problems. Additional

research is needed to develop

culturally appropriate assessment

tools, address language difficulties

in assessments, and develop a

nuanced understanding of behavioral

phenotypes in children of refugee

background.

Our review has several limitations.

Although our search strategy

involved multiple databases, we

excluded studies that were not

published in peer-reviewed journals

and studies that were not available

in the English language. Inclusion

criteria required a defined refugee-

background population and excluded

studies that may have included this

population but did not identify them

explicitly (eg, Latino immigrants to

the United States). This criterion

was intended to ensure that the data

better represent forced migration

rather than immigrant populations

more generally. Although included

studies involved children from

various backgrounds, many findings

cannot be generalized to other

refugee-background populations.



Many studies used convenience

sampling rather than more robust

selection methods. This limitation is

due largely to the methodological,

ethical, and practical challenges of

working with vulnerable populations

and remains an ongoing challenge to

researchers in this field.

CONCLUSIONS

Success at school is critical to well-

being for refugee-background children.

Published data on educational

outcomes and learning problems in

this population are limited, particularly

for younger children and children

in low- or middle-income countries.

Overall, refugee-background children

should be expected (and encouraged)

to achieve comparably to their peers.

Clinicians and educators have an

important role in identifying risk

factors and also acknowledging

the positive resources that refugee

children and families bring to their

education and countries of settlement.

These findings provide practical

guidance to clinicians and educators

working with refugee children and

families, highlight areas for future

research, and inform interventions and

policy to support refugee children to

achieve their developmental potential.

ACKNOWLEDGMENTS

Thanks to Kate Milner for advice on

developmental tools, Shidan Tosif

and Kelly Jurianz for review of the

manuscript, research librarian Poh

Chua for assisting with the search

strategy, and Thivia Jegathesan for

assistance with proofreading and

manuscript revision.

13

ABBREVIATIONS

ADHD: attention-deficit

hyperactivity disorder

CINAHL: Cumulative Index to

Nursing and Allied

Health Literature

ERIC: Education Resources

Information Center

ODD/CD: oppositional defiant

disorder/conduct

disorder

PTSD: posttraumatic stress

disorder

UNHCR: United Nations High

Commission for

Refugees

WISC: Wechsler Intelligence

Scales for Children

WISC-IV: Wechsler Intelligence

Scales for Children,

Fourth Edition

Dr Graham conceptualized and designed the study, conducted the database searches, reviewed articles for inclusion, and drafted the initial manuscript; Dr

Minhas conceptualized and designed the study, reviewed articles for inclusion, and drafted the initial manuscript; Dr Paxton contributed to the conceptualization

and design of the study and reviewed the draft; and all authors approved the fi nal manuscript as submitted.

DOI: 10.1542/peds.2015-3994

Accepted for publication Mar 21, 2016

Address correspondence to Hamish R. Graham, MBBS, MPH, FRACP, Centre for International Child Health, Level 2 East, The Royal Children’s Hospital, 50 Flemington

Rd, Parkville VIC 3052, Australia. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2016 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no fi nancial relationships relevant to this article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential confl icts of interest to disclose.

REFERENCES

1. Goswami U. Foresight Mental Capital and

Wellbeing Project. Learning Diffi culties:

Future Challenges. London, England: The

Government Offi ce for Science; 2008

2. Bronfenbrenner U. The Ecology of

Human Development. Boston, MA:

Harvard University Press; 1979

3. Oberklaid F, Levine MD. Precursors

of school failure. Pediatr Rev.

1980;2(1):5–11

4. UNHCR. World at War: UNHCR

Global Trends: Forced Displacement

in 2014. Geneva, Switzerland:

UNHCR; 2015

5. Crisp J, Talbot C, Cipollone DB. United

Nations High Commissioner for

Refugees G (Switzerland). Learning

for a Future: Refugee Education

in Developing Countries. Geneva,

Switzerland: UNHCR; 2001

6. Correa-Velez I, Gifford SM, Barnett AG.

Longing to belong: social inclusion and

wellbeing among youth with refugee

backgrounds in the fi rst three years

in Melbourne, Australia. Soc Sci Med.

2010;71(8):1399–1408

7. Arksey H, O’Malley L. Scoping

studies: towards a methodological

framework. Int J Soc Res Methodol.

2005;8(1):19–32

8. Levac D, Colquhoun H, O’Brien KK.

Scoping studies: advancing the

methodology. Implement Sci. 2010;5:69

9. Agbenyega J, Klibthong S. Whole

school initiative: has inclusive

education gone astray? Int J Whole

Sch. 2013;9(1):3–22

10. Berthold SM. War traumas and

community violence: psychological,

behavioral, and academic outcomes

among Khmer refugee adolescents. J

Multicult Soc Work. 2000;8(1–2):15–46


GRAHAM et al

11. Bitew G, Ferguson P, Dixon M. Ethiopian-

Australian students’ experience of

secondary schooling in the Australian

education system in the State of

Victoria. Australas Rev African Stud.

2008;29(1):78–91

12. Bitew G, Ferguson P. Parental support

for African immigrant students’

schooling in Australia. J Comp Fam

Stud. 2010;41(1):149–165

13. Brown J, Miller J, Mitchell J.

Interrupted schooling and the

acquisition of literacy: experiences

of Sudanese refugees in Victorian

secondary schools. Aust J Lang Lit.

2006;29(2):150–162

14. Daud A, Rydelius P-A. Comorbidity/

overlapping between ADHD and

PTSD in relation to IQ among

children of traumatized/non-

traumatized parents. J Atten Disord.

2009;13(2):188–196

15. Daud A, Klinteberg B af, Rydelius P-A.

Resilience and vulnerability among

refugee children of traumatized

and non-traumatized parents. Child

Adolesc Psychiatry Ment Health.

2008;2(7):2

16. Derluyn I, Broekaert E. Different

perspectives on emotional

and behavioural problems in

unaccompanied refugee children

and adolescents. Ethn Health.

2007;12(2):141–162

17. Fazel M, Stein A. Mental health of

refugee children: comparative study.

BMJ. 2003;327(7407):134

18. Fox PG, Burns KR, Popovich JM,

Belknap RA, Frank-Stromborg M.

Southeast Asian refugee children: self-

esteem as a predictor of depression

and scholastic achievement in

the US. Int J Psychiatr Nurs Res.

2004;9(2):1063–1072

19. Hatoss A, O’Neill S, Eacersall D. Career

choices: linguistic and educational

socialization of Sudanese-background

high-school students in Australia.

Linguist Educ. 2012;23(1):16–30

20. Kira I, Lewandowski L, Yoon J, Somers

C, Chiodo L. The linear and nonlinear

associations between multiple types

of trauma and IQ discrepancy indexes

in African American and Iraqi refugee

adolescents. J Child Adolesc Trauma.

2012;5(1):47–62

21. Kira I, Lewandowski L, Somers CL,

Yoon JS, Chiodo L. The effects of

trauma types, cumulative trauma, and

PTSD on IQ in two highly traumatized

adolescent groups. Psychol Trauma.

2012;4(1):128–139

22. Kira IA, Lewandowski L, Ashby JS,

Somers C, Chiodo L, Odenat L. Does

bullying victimization suppress IQ?

The effects of bullying victimization

on IQ in Iraqi and African American

adolescents: a traumatology

perspective. J Aggress Maltreat

Trauma. 2014;23(5):431–453

23. Lee YM, Shin OJ, Lim MH. The

psychological problems of North

Korean adolescent refugees living

in South Korea. Psychiatry Investig.

2012;9(3):217–222

24. Mace AO, Mulheron S, Jones C, Cherian

S. Educational, developmental and

psychological outcomes of resettled

refugee children in Western Australia:

a review of School of Special

Educational Needs: Medical and Mental

Health input. J Paediatr Child Health.

2014;50(12):985–992

25. Mollica RF, Poole C, Son L, Murray

CC, Tor S. Effects of war trauma on

Cambodian refugee adolescents’

functional health and mental health

status. J Am Acad Child Adolesc

Psychiatry. 1997;36(8):1098–1106

26. Naidoo L. A structuration theory

analysis of the Refugee Action

Support Program in greater

western Sydney. Aust J Teach Educ.

2009;34(4):40–50

27. Nykiel-Herbert B. Iraqi refugee

students: from a collection of aliens to

a community of learners—the role of

cultural factors in the acquisition of

literacy by Iraqi refugee students with

interrupted formal education. Multicult

Educ. 2010;17(3):2–14

28. Rana M, Qin DB, Bates L, Luster

T, Saltarelli A. Factors related to

educational resilience among

Sudanese unaccompanied minors.

Teach Coll Rec. 2011;113(9):2080–2114

29. Rousseau C, Drapeau A, Platt R. Living

conditions and emotional profi les of

Cambodian, Central American, and

Québécois youth. Can J Psychiatry.

2000;45(10):905–911

30. Rousseau C, Drapeau A. Scholastic

achievement of adolescent refugees

from Cambodia and Central America.

Adolescence. 2000;35(138):243–258

31. Rousseau C, Drapeau A, Corin E.

School performance and emotional

problems in refugee children. Am J

Orthopsychiatry. 1996;66(2):239–251

32. Shakya YB, Guruge S, Hynie M, et al.

Aspirations for higher education

among newcomer refugee youth in

Toronto: expectations, challenges, and

strategies. Refuge. 2010;27(2):65–78

33. Slodnjak V, Kos A, Yule W. Depression

and parasuicide in refugee and

Slovenian adolescents. Crisis.

2002;23(3):127–132

34. Sourander A. Behavior problems and

traumatic events of unaccompanied

refugee minors. Child Abuse Negl.

1998;22(7):719–727

35. Stermac L, Elgie S, Clarke A, Dunlap

H. Academic experiences of war-zone

students in Canada. J Youth Stud.

2012;15(3):311–328

36. Tlhabano KN, Schweitzer R. A

qualitative study of the career

aspirations of resettled young

Sudanese and Somali refugees. J

Psychol Afr. 2007;17(1–2):13–21

37. Uptin J, Wright J, Harwood V. “It

felt like I was a black dot on white

paper”: examining young former

refugees’ experience of entering

Australian high schools. Aust Educ Res.

2013;40(1):125–137

38. Usman LM. Communication disorders

and the inclusion of newcomer African

refugees in rural primary schools of

British Columbia, Canada. Int J Prog

Educ. 2012;8(2):102–120

39. Wiegersma PA, Stellinga-Boelen AAM,

Reijneveld SA. Psychosocial problems

in asylum seekers’ children: the

parent, child, and teacher perspective

using the Strength and Diffi culties

Questionnaire. J Nerv Ment Dis.

2011;199(2):85–90

40. Wilkinson L. Factors infl uencing

the academic success of refugee

youth in Canada. J Youth Stud.

2002;5(2):173–193

41. Ziaian T, de Anstiss H, Antoniou G,

Baghurst P, Sawyer M. Emotional



and behavioural problems among

refugee children and adolescents

living in South Australia. Aust Psychol.

2013;48(2):139–148

42. Bronstein I, Montgomery P.

Psychological distress in refugee

children: a systematic review.

Clin Child Fam Psychol Rev.

2011;14(1):44–56

43. Lazar I, Darlington R, Murray H,

Royce J, Snipper A, Ramey CT. Lasting

effects of early education: a report

from the Consortium for Longitudinal

Studies. Monogr Soc Res Child Dev.

1982;47(2–3):1–151

44. Bolton S, McDonald D, Curtis E, Kelly

S, Gallagher L. Autism in a recently

arrived immigrant population. Eur J

Pediatr. 2014;173(3):337–343

45. Lehti V, Hinkka-Yli-Salomäki S,

Cheslack-Postava K, Gissler M,

Brown AS, Sourander A. The risk of

childhood autism among second-

generation migrants in Finland: a

case–control study. BMC Pediatr.

2013;13:171

46. Haglund NG, Källén KB. Risk factors

for autism and Asperger syndrome.

Perinatal factors and migration.

Autism. 2011;15(2):163–183

47. Dealberto MJ. Prevalence of autism

according to maternal immigrant

status and ethnic origin. Acta Psychiatr

Scand. 2011;123(5):339–348

48. Kočovská E, Fernell E, Billstedt E,

Minnis H, Gillberg C. Vitamin D and

autism: clinical review. Res Dev Disabil.

2012;33(5):1541–1550

49. Paxton G, Smith N, Win AK, Mulholland

N, Hood S. Refugee Status Report.

Department of Education and Early

Childhood Development. Melbourne,

Australia: State Government Victoria; 2011

50. Cobb-Clark DA, Sinning M, Stillman

S. Migrant youths’ educational

achievement: the role of institutions.

Ann Am Acad Pol Soc Sci.

2012;643(1):18–45

51. Coll CG, Marks AK. In: Coll CG, Marks

AK, eds. The Immigrant Paradox

in Children and Adolescents: Is

Becoming American a Developmental

Risk? Washington, DC: American

Psychological Association; 2012

52. Ceballo R, Maurizi LK, Suarez GA,

Aretakis MT. Gift and sacrifi ce: parental

involvement in Latino adolescents’

education. Cultur Divers Ethnic Minor

Psychol. 2014;20(1):116–127

53. Crosnoe R, Turley RN. K–12 educational

outcomes of immigrant youth. Future

Child. 2011;21(1):129–152

54. Porter M, Haslam N. Predisplacement

and postdisplacement factors

associated with mental health of

refugees and internally displaced

persons: a meta-analysis. JAMA.

2005;294(5):602–612

55. Lustig SL, Kia-Keating M, Knight WG,

et al. Review of child and adolescent

refugee mental health. J Am Acad Child

Adolesc Psychiatry. 2004;43(1):24–36

56. Fazel M, Reed RV, Panter-Brick C,

Stein A. Mental health of displaced

and refugee children resettled

in high-income countries: risk

and protective factors. Lancet.

2012;379(9812):266–282

57. Reed RV, Fazel M, Jones L, Panter-Brick

C, Stein A. Mental health of displaced

and refugee children resettled in low-

income and middle-income countries:

risk and protective factors. Lancet.

2012;379(9812):250–265

58. Betancourt TS, Khan KT. The mental

health of children affected by armed

confl ict: protective processes and

pathways to resilience. Int Rev

Psychiatry. 2008;20(3):317–328

59. Fazel M, Wheeler J, Danesh J.

Prevalence of serious mental disorder

in 7000 refugees resettled in western

countries: a systematic review. Lancet.

2005;365(9467):1309–1314

60. McBrien JL. Educational needs

and barriers for refugee students

in the United States: a review

of the literature. Rev Educ Res.

2005;75(3):329–364

61. Brown CS, Chu H. Discrimination,

ethnic identity, and academic

outcomes of Mexican immigrant

children: the importance of

school context. Child Dev.

2012;83(5):1477–1485

62. Kia-Keating M, Ellis BH. Belonging and

connection to school in resettlement:

young refugees, school belonging,

and psychosocial adjustment.

Clin Child Psychol Psychiatry.

2007;12(1):29–43

63. Georgas J. Cross-cultural psychology,

intelligence, and cognitive processes.

In: Georgas J, Weiss LG, van de Vijver

FJR, Saklofske DH, eds. Culture and

Children’s Intelligence: Cross-Cultural

Analysis of the WISC-III. San Diego, CA:

Academic Press; 2003:24–40


DOI: 10.1542/peds.2015-3994 originally published online May 18, 2016; 2016;137;Pediatrics

Hamish R. Graham, Ripudaman S. Minhas and Georgia PaxtonLearning Problems in Children of Refugee Background: A Systematic Review

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