706 European Journal of Public Health

.........................................................................................................
The European Journal of Public Health, Vol. 29, No. 4, 706–713
ß The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
doi:10.1093/eurpub/cky232 Advance Access published on 30 October 2018
.........................................................................................................
Systematic Review and Meta-Analyses
.........................................................................................................
Resilience and protective factors among refugee
children post-migration to high-income countries:
a systematic review
Charles Marley, Beatus Mauki

School of Health in Social Science, Section of Clinical Psychology, The University of Edinburgh, Edinburgh, UK

Downloaded from https://academic.oup.com/eurpub/article/29/4/706/5149703 by guest on 21 January 2024

Correspondence: Charles Marley, School of Health in Social Science, Section of Clinical Psychology, Medical School, The
University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, UK, Tel: +44 (0) 1316513982, Fax: +44 (0) 1316513971, e-mail:
charles.marley@ed.ac.uk

Background: Increasing numbers of children have been forced to flee and seek asylum in high-income countries.
Current research indicates that focussing on resilience and protective factors is an important long-term goal for
positive mental health and psychological functioning of refugee children. Methods: We performed a systematic
review of quantitative literature regarding psychological and contextual factors that contribute to resilience in
refugee children residing in high-income countries. Our procedure followed guidelines from the Centre for
Reviews and Dissemination. Results: We identified a number of protective factors as related to positive
outcomes. They are drawn from several ecological domains and include age, self-esteem, maintenance of
cultural identity, social support, belonging and safety and innovative social care services. A key overarching
point reported by the studies we reviewed was that for refugee settlement specific policies and approaches to
be beneficial, they were required to be embedded within a positive socially inclusive society. We also identified
several limitations across the reported studies. Conclusion: The factors we identified would assist clinicians to
adopt a resilience-focussed approach. However, a continued pre-occupation with psychopathology was evident
across the studies, which we argue as holding back the development of resilience-focussed approaches.
.........................................................................................................

Introduction
efugee children face numerous adverse experiences both pre and
Rpost-migration, including traumatic events1, travelling long
distances under dangerous circumstances2, complex legal
procedures and hostile refugee policies in the host country3, social,
cultural and language differences4 and discrimination during the
resettlement process.5 Despite this, many refugee children display
positive outcomes in the host country.6
We consider this phenomenon by focussing on the resilience
factors that assist refugee children to withstand adversity.
Resilience is an evolving construct, continuously informed by
scientific advances7; for this review, we operationalize resilience as
a capacity of an individual to maintain stable psychological func-
tioning throughout the course of adversity.8 Thus, we conceptualize
resilience as distinct from recovery.8 We consider resilience to reflect
the ability to maintain a stable equilibrium; individuals may
experience transient perturbations but generally exhibit a stable
trajectory of healthy functioning across time.8 In contrast, we
consider recovery to connote normal functioning temporarily
giving way to psychopathology, before returning to pre-adversity
levels.8 We also consider resilience as idiographic in nature; the
outcome of complex interactions between resilience, risk and
protective factors across multiple levels of ecology. Thus, resilience
requires consideration of the interaction of resilience ‘factors’—
individual differences empirically associated with resilient
outcomes—with risk and protective factors—external characteristics
empirically linked with negative and positive outcomes.8
The position we outline above is in line with resilience researchers’
assertion that more effort needs to be directed towards identifying
protective factors for individuals and social groups.9 It also corresponds
with a shift in mental health research from a focus on individual deficits
to one which aims to identify and understand risk and protective
factors and their role in the attainment of healthy outcomes.a
Accordingly, clinical practice informed by these approaches require
practitioners to consider the interaction of individual characteristics
with multiple factors situated across the various levels of ecology of
the child/young person10 and to understand their influence on
individual pathways to positive outcomes despite adversity.11
Despite this, clinical practice regarding refugee children remains
pre-occupied by the trauma model.6 As Ungar et al.12 argue, the
dominant trauma model overlooks ecology and, by considering
the ecological system in which children are imbedded, we can
promote positive developmental outcomes despite adversity. To
achieve this aim, approaches to clinical practice need to consider
the complexity of risks and protective factors and the multiple
reciprocal relationships within the individuals’ environment
alongside symptom reduction approaches.13 Research informed by
the construct of resilience has shifted the understanding of individ-
uals as centres of change to the consideration of individuals as an
important part of a complex system.12 By considering the individual
this way, it is difficult to understand individual functioning without
involving the context in which they live.14
Aims of the review
Approaches to resilience should consider a broad range of risk and
protective factors and their interaction across the various levels of
context.15 As Kazdin16 argues, health practitioners focus on the
short-term goal of symptom reduction as the primary criterion for
a good outcome. But, as Fonagy et al.17 asserts, long-term goals must
go beyond symptom-based approaches and focus on the transac-
tional aspects of child development. By taking an approach
informed by the construct of resilience, researchers and clinicians
 Resilience and protective factors among refugee children 707

would be enabled to move from an exclusive focus on pathology to
the promotion of protective factors.15 Such a refocus would provide
the factors required for enhancing individual developmental
trajectories, which would act as a future protective factor in the
face of further adversity. Consequently, our review aims to investi-
gate psychological and contextual factors that contribute to
resilience in refugee children residing in high-income countries.
Identification of protective factors that sustain normative develop-
ment despite exposure to traumatic experiences will be useful for
health practitioners adopting a clinical approach for supporting
refugee children informed by the construct of resilience.
Methods
Our approach to this systematic review follows the structure and
efficacy (reflecting competencies and characteristics of the child or
youth); (iii) self-esteem; (iv) quality of life.
Literature search strategy
Our literature search was conducted within several electronic
databases: Psych INFO; CINAHL PLUS; EMBASE; Ovid Medline;
Applied Social Science Abstracts; Social Services Abstracts and
Sociological Abstracts. The databases cover a wide area of psycho-
logical, medical, nursing, applied social studies and sociological
research. Our search was implemented within the titles, abstracts
and key words. We supplemented the electronic search by hand
searching the reference lists of the final pool of papers included in
our review. The search strings are outlined in Supplementary table
S2.

Downloaded from https://academic.oup.com/eurpub/article/29/4/706/5149703 by guest on 21 January 2024

method provided by the Centre for Reviews and Dissemination.18
The guidelines provide an internationally accepted framework for
undertaking systematic reviews. A summary of the CRD protocol
guidance used to develop the steps of this review are in
Supplementary table S1.
Selection criteria
Study design
Our review focusses on papers providing primary data. The rationale
is to extract relevant empirical validated predictors of positive
outcomes in the face of adversity for refugee children. The papers
reporting studies that we included in our review are composed of
randomized control trials, observation and cohort studies and pre-
and post-design studies. The study designs included for review were
based on guidance provided by the CRD18 and the Evidence-Based
Working Group19 on study designs and grades of evidence.
However, the guidance has attracted criticism for creating the
assumption that systematic reviews are only applicable to
empirical quantitative data.20 We return to this point in the
discussion. The final sample of papers we included for review
cover a 15-year period between 2000 and 2015. This time period
reflects current conflict situations in countries such as Afghanistan,
Syria, Ukraine, Iraq, Somalia, Sudan, Libya and Egypt.
Search overview
We retrieved a total of 735 potentially relevant published papers
through our search strategy. We reduced the 735 papers to 85
through a process of screening keywords, title and abstracts for
key terms relevant to our review focus and in line with the
inclusion and exclusion criteria. Screening was completed by one
author, with a selection of the papers considered by the second
author as a reliability check. From the 85, we selected a pool of 39
published papers for full reading. From the 39 papers, 13 were
excluded because they did not report resilience-related outcomes.
A further 12 were excluded because they fell below the study
design threshold outlined by the Evidence-Based Working
Group,19 and 3 were excluded because they were above the sample
age restriction. The review process is shown in figure 1.
Results
Characteristics of the included studies
Our final sample consisted of 11 published papers and their reported
studies. All papers reported studies that focussed on western high-
income countries. The combined sample of 2959 refugee children
came from Somalia, Balkans, Iraq, Middle East, Cambodia, Sudan,

Population
The papers included for review report studies with children 18 years
and under, in accordance with the UN Convention for the Rights of
the Child. Studies with broader age categories were included only if
the mean age was 18 years or younger. The final sample of papers all
report studies with young refugees forcibly displaced to western
countries. The term refugee is operationalized as any child or
young adult who has applied for asylum under the 1951 Geneva
Convention. The countries receiving refugee children were defined
as high-income countries per the World Bank classification.21

Study focus
Our review considered papers that reported studies of the impact of
interventions for refugee children. For our purposes, intervention
was defined as anything that aimed to better the lives of refugee
children. Adoption of this wide definition was to allow for
inclusion of papers that covered multiple levels of ecology. To be
included for review, we required papers to report studies that
considered protective, resilience and risk factors affecting refugee
children.

Outcome measures
To be included for review, papers were required to report studies
that employed outcome measures of the following factors: (i)
resilience or ability to prosper irrespective of adversity; (ii) self- Figure 1 Flow chart of literature review strategy
708 European Journal of Public Health
Ethiopia, Afghanistan, Iran and the former Yugoslavia. The host
countries included the UK, Sweden, Demark, USA, Australia,
Canada, Netherlands, Croatia and Austria. The age range of the
samples was between 6 and 19 years; however, Montgomeryb and
Bertholdc had a wider range of 11–23 years. For further details,
please see table 1 below.
Quality assessment
The Scottish Intercollegiate Guidance Network22 stipulates that
rating studies helps to distinguish research that is methodologically
weak from that which is strong. Several criteria were developed by
adapting the Scottish Intercollegiate Guidelines Network guidance
for examining the methodological quality of the studies reported.
Eight domains were considered relevant to this review.
Supplementary figure S1 provides detail regarding the quality
assessment criteria.
Summary of quality assessment of the studies that
were selected
Most of the studies achieved above average methodological quality
with three falling below average. The highest rated achieved a meth-
odological score of 75% (see table 2 below for full summary). Most
of the studies achieved the maximum rating (4 points) on research
designa,b,e,f,g,h,k and selection biasa,b,c,d,e,g,h,i,j criteria. Several studies
included populations from non-clinical settings, including
schoolf,g,h,i,e local community settings;c,j,b residential settingsd and
a social services department.k Only one study utilized a clinical
sample.a Most of the studies displayed several methodological
strengths, particularly the clarity of their aims and hypotheses in
relation to resilience and protective factors.
A small number of studies were limited methodologically by using
non-standardized measures.j,e,f The remaining studies employed
standardized measures with validity and reliability based on
western population samples. Thus, most studies lacked information
on the cross-cultural validity of their measures, with some of these
not translated to the language of the study population.a A majority
presented the demographic background of their sample and reported
the number of withdrawals and drop-outs, allowing for consider-
ation of confounder variables, attrition and sample size. However,
some studies utilized small sample sizesi,k and sampling procedures
that could be influenced by a desire for social acceptability.g
The main methodological issue noted across the reported studies,
however, was the use of measures for considering psychopathology
rather than measures for considering resilience or positive outcomes.
Only 2f,h of the 11 papers that the authors reviewed report studies in
which the researchers had used measures of resilience and explicitly
focussed on positive outcomes in the face of adversity. We view this
finding as highlighting a continued pre-occupation with trauma and
associated negative outcomes. The remaining nine studies utilized
standardized measures of ‘negative’ outcomes, such as anxiety, de-
pression and trauma symptoms. This focus extended into their the-
oretical framing, with most studies considering refugee children who
displayed negative outcomes to detriment of those doing well despite
adversity. The two studies that adopted a positive focus, utilized
measures of resilience and well-being and focussed on positive
adjustment. The first, by Correa-Velez et al.f report on a longitudinal
study of refugee settlement and well-being. The study utilized the
World Health Organisation Quality of Life questionnaire to consider
subjective health and well-being. The second study, by Kovacev et
al.,h utilized the Adolescent Self-Perception Profile and the Social
Support Scale for Children to consider positive constructions of
global self-worth, positive peer relationships and perceived social
support in order to examine the impact of acculturation on psycho-
social adjustment.
Despite the largely negative outcome focus and theoretical
framing of the majority of the reported studies, it was possible to
extract several factors connected to resilience and well-being despite
adversity. These are presented in accordance with an adapted version
of the Centres for Disease Control and Prevention’s (CDC) Social
Ecological Model.l The CDC model is adopted as an organizing
framework as per its application by UNICEF,m the WHOn and
other public health-related reviews.o The CDC model uses a four-
level concentric model—individual, relationships, community and
society—to understand violence and the effect of prevention
strategies. Our adoption of this model for organizing the findings
from our review is based on its preventative focus and its emphasis
on intervention at multiple levels being more likely to promote
positive outcomes than any single intervention.
Summary of identified resilience factors derived from
the papers reviewed
Downloaded from https://academic.oup.com/eurpub/article/29/4/706/5149703 by guest on 21 January 2024
Individual level protective factors
Individual level factors include personal characteristics—such as age,
gender education etc.—and can provide a focus for strategies aimed
at promoting attitudes, beliefs and behaviours that predict positive
outcomes. We identified a number of characteristics within this
sphere as promoting positive outcomes, including age, levels of
self-esteem/self-efficacy and maintenance of cultural identity.
Regarding age, Hodes et al.k suggest that younger refugee children
display better outcomes than older children faced with adversity.
The authors utilized a cross-sectional design, considering unaccom-
panied asylum-seeking minors and found that increased age was
associated with psychological and emotional disturbances.
The paper by Daud et al.a considered the effects of levels of refugee
children’s self-esteem on their outcomes and demonstrated that self-
esteem, prosocial behaviour and intelligence were associated with
adaptive abilities in the face of adversity. The study examined
resilience among children whose parents suffered from PTSD
compared to a non-traumatized control group. The results show
that children of non-traumatized parents scored higher on IQ
tests, emotionality and prosocial behaviour. Similarly, the paper by
Kia-Keating et al.g reported that higher self-efficacy was associated
with lower psychological disturbances among Somali adolescents
resettled in the USA. Their study examined children’s sense of
school belonging and perception of social functioning following
adversity. The findings indicate that refugee adolescents who
experience high-levels of self-efficacy, commitment and involvement
in their schools had lower levels of psychological and emotional
difficulties.
The final individual level factor relates to attitude to accultur-
ation. In the study reported by Kovacev,h refugee adolescents who
held positive attitudes towards the host culture alongside positive
attitudes towards their traditional culture displayed positive psycho-
logical adjustment. The study examined how different modes of ac-
culturation and perceived social support were related to adolescent
refugee psychosocial adjustment, as measured by global self-worth
and peer social acceptance. The authors concluded that adolescents’
acculturation attitudes significantly influenced their psychosocial
adjustment via their perception of social support.
Relationship level protective factors
The relationship level considers close relationships, focussing on
factors such as immediate social circle, family cohesiveness, profes-
sional relationships and the role they play in contributing to positive
outcomes. Strategies at this level may include parenting approaches
or mentoring and peer programmes. At this level, the study by
Bertholdc investigated the extent to which social support given to
Khmer refugee adolescents from their peers predicted their level of
adjustment after exposure to multiple adversities. Their findings
indicate that peer support was associated with positive outcomes
despite adversity. The study also considered the role of family
Table 1 Study characteristics

Study Place Population Study method Sample size Age range Measurement tools Protective factors

Bean et al.d Netherlands Various countries Correlational 582 12–18 CBCL, TRF, SLE, HSCL-37A, RATS Individual, family, and community
Bertholdc USA Cambodian Correlational 76 11–19 PSS-fa and PSS-Fr scales, PRBS, HTQ; SCECV, Family and community
LA PTSD index, CES-DC
Correa-Velez et al.f Australia Ethiopian, Afghanis, Correlational 97 11–19 WHoQoL, BREF. Community and society
Iranian and Kuwaiti
Daud et al.a Sweden Iraqi Correlational 80 6–17 DICAR, WISC-III, ITIA, SDQ Individual, community and society
Geltman et al.j USA Sudanese Descriptive survey 304 18 years of age HTQ, CHQ Community, society and family
Hodes et al.k UK Various countries Correlational 113 13–18 HTQ, IES, BDSR. Family and society
Kia-Keating et al.g USA Somalian Correlational 76 12–19 MSPSE, DSRS, WTSS, UCLA-PTSD RI, PSSM Individual and community
Kovacevh Australia Yugoslavian Cross-sectional survey 83 12–19 GSW, PSA, AAS. Family and community
Montgomeryb Denmark Middle Eastern Correlational 131 11–23 YSR/YASR Individual and family
Rousseau et al.i Canada Cambodian Longitudinal 67 14–16 BAS, CBCL, FES, YSR. Family and community
Sujoldzic et al.e Austria Bosnian Cross-sectional 1282 15–18 Absence of school scale, RADS, SES, FAS, Community and society
Perceived discrimination scale, peer
violence scale, adult violence scale
family connectedness scale, school
connectedness scale, neighbourhood
scale, religious commitment scale.

AAS (Acculturation Attitude Scale); BAS (Bahavioural Acculturation Scale); BDSR (Birleson Depression Self-Rating); CBCL (The Child Behavioural Check List Guardian Report); CES-DC (Centre for
Epidemiology Studies Depression Scale for Children); CHQ (Child Health Questionnaire); DICAR (Diagnostic Interview for Children and Adolescents); DSRS (Depression Self-Rating Scale); FAS (Family
Influence Scale); FES (Family Environmental Questionnaire); GSW (Global Self-Worth); HSCL37A (The Hopkins Symptoms Check List 37 Adolescents); HTQ (The Harvard Trauma Questionnaire); IES
(Impact of Event Scale); ITIA (The ‘I Think I Am’ Scale); LA PTSD (The Los Angeles Post-traumatic Stress Disorders Index); MSPSE (Multidimensional Scales of Perceived Self-Efficacy); PRBS (Personal
Risk Behaviours Scale); PSS-Fa (Perceived Social Support from the Family); PSS-Fr (The Perceived Social Support from Friends); PSA (Peer Social Acceptance); PSSM (Psychological Sense of School
Membership); RATS (The Reaction of Adolescents to Traumatic Stress); RADS (Reynolds Adolescent Depression Scale); SCECVLA (Survey of Children’s Exposure to Community Violence); SDQ (The
Strengths and Difficulties Questionnaire); SLE (The Stressful Life Events); TRF (Teacher’s Report Form); UCLA-PTSD RI (University of California at Los Angeles Post-traumatic Stress Disorder Reaction
Index); WTSS (War Trauma Screening Scale); WHOQOL (World Health Organisation Quality of Life-Bref); WISC-III (The Wechsler Intelligence Scales for Children); YABC (Young Adult Behavioural
Check List); YASR (Young Adult Self-Report: Aged 17); YSR (Youth Self-Report: Less than age 17).
Resilience and protective factors among refugee children
709

Downloaded from https://academic.oup.com/eurpub/article/29/4/706/5149703 by guest on 21 January 2024

710 European Journal of Public Health

Table 2 Quality assessment scoring

References Study designa Selection biasa Demo-graphicsa Confoundinga Outcome measuresa Attritiona Samplea Generalizabilitya Total

Bean et al. (2007) 2+1 2+2 1 1 1+0 2 2 0 14/24

Berthold et al., (2000) 1+2 2+2 1 1 1+0 2 1 0 13/24
Correa-Velez et al. (2010) 2+2 1+2 1 1 0+0 0 1 0 10/24
Daud et al. (2008) 2+2 2+2 2 1 1+0 1 0 0 13/24
Geltman et al. (2005) 1+0 2+2 0 1 0+0 1 2 1 10/24
Hodes et al. (2008) 2+2 1+2 1 1 1+0 1 1 0 12/24
Kia-Keating et al. (2007) 2+2 2+2 2 0 1+2 1 1 0 15/24
Kovacev et al. (2004) 2+2 2+2 2 2 1+0 1 1 0 15/24
Montgomery et al. (2010) 2+2 2+2 2 2 1+0 2 1 2 18/24
Rousseau et al. (2004) 1+1 2+2 1 0 0+0 0 1 0 8/24
Sujoldzic et al. (2006) 2+2 2+2 2 0 0+0 0 2 2 14/24

a: Well-Covered—2 points; Adequately covered—1 point; Poorly Covered; Not Addressed; Not Reported; Not Applicable—0 point (SIGN,
2008).

Downloaded from https://academic.oup.com/eurpub/article/29/4/706/5149703 by guest on 21 January 2024

unity, demonstrating that family unity and parental support were
associated with positive outcomes despite adverse events.
The Berthold findings were confirmed by Montgomery,b who
demonstrated that refugee children who experienced positive inter-
actions with their mothers displayed positive outcomes despite
experiencing traumatic events. The Montgomeryb study also found
parental education to act as a protective factor. Utilizing a longitu-
dinal approach, the study indicated that refugee children who
adjusted well after traumatic experiences had fathers with high edu-
cational levels, indicating that resources within the family promoted
resilience for refugee children.
The study by Rousseau et al.i identified a supportive family en-
vironment as a protective factor. The study examined the extent to
which family environment, gender and acculturation determined the
mental health of refugee adolescents. The findings showed that
Cambodian children within supportive family environments who
used adaptive strategies from their traditional culture while
incorporating strategies from the host culture displayed positive
outcomes. Relatedly, the study by Geltman et al.j indicated that
social support from the same ethnic origin offered protection
from psychological stress among refugee children, especially for
those in foster care.
Community level protective factors
The community level is concerned with settings, such as schools,
workplaces and neighbourhoods, in which social relationships
occur, and seeks to identify the characteristics of these settings
that are associated with positive outcomes. Strategies at this level
focus on the social and physical environment—e.g. reduction of
social isolation, school-level interventions or strategies for
improving housing and financial prospects. One of the papers
reported on the study of a school-based intervention for
promoting a sense of safety and belonging. The study by Geltman
et al.j focussed on Sudanese refugee children, reporting perceived
sense of safety and belonging at school as a protective factor. The
findings were supported by Kia-Keating et al.g and Sujoldzic et al.,e
who also demonstrated school connectedness as a protective factor.
The study by Correa-Velez et al.f focussed on the communities in
which refugee children resided, demonstrating that community
support predicted adaptive psychosocial functioning. They
reported that those who experienced social inclusion within the
host country maintained substantial well-being. Similarly, the
paper by Bean et al.d reported that high-support living arrangements
among refugee children promoted positive adaptation for unaccom-
panied refugee children. Additionally, the Geltman et al.j paper was
supportive of the findings of these two papers, reporting that refugee
children can thrive if the resettlement effort takes a comprehensive
approach that includes community engagement and innovative
social care interventions.
Societal level protective factors
The societal level considers the broad societal factors that help create
a climate in which positive outcomes can be achieved. These factors
include social and cultural norms and governmental policy. The
findings at this level were limited to the studies reported by
Sujoldzic et al.e and Correa-Velez et al.f The study by Sujoldzic et
al.e investigated whether socioeconomic status, discrimination and
social cultural context determined psychological well-being among
Bosnian adolescents. The reported findings suggest that psycho-
logical well-being among adolescent refugees in Bosnia and those
in Austria and Croatia is determined by the socioeconomic
conditions and availability and usage of health services. The study
by Correa-Velez et al.f outlined earlier considered factors that
promoted a sense of belonging, reporting that settlement specific
policies and programmes were only effective if embedded within a
broader socially inclusive society. The thrust of their argument is
that refugee policies and societal culture need to be positively
focussed on refugee settlement for beneficial outcomes to be
maximized.
Discussion
We argue, in line with previous researchers, that understanding
children’s adjustment in the face of adversity requires a careful
examination of which factors predict positive outcomes.13 In line
with this position, our review investigated the factors that predicted
positive outcomes for refugee children in the face of adversity. Our
findings reveal that protective factors for refugee children span
multiple domains, including individual, family, school, community
and society levels. The individual level characteristics highlighted as
important by our review included age,k self-esteem/efficacy and
maintenance of cultural identity.g These characteristics are known
to be important for multiple social groups, but need to be seen as
one level within a holistic consideration, rather than the sole focus of
practitioners and researchers.c
Previous papers have argued that refugee family members are a
source of stress for adolescents, citing parental pressure to maintain
previous traditions and cultural values rather than absorbing the
contradictory western values as impacting negatively on
outcomes.23 Conversely, the papers we reviewed portray a different
reality in that family members were not a source of stress, with
family connectedness and cohesivenessj and supportive relation-
shipsc,a related to positive adjustment. This correlation has been
documented by other researchers24 but a focus on parental and
family dysfunction may be limiting further exploration of the
family as a protective factor.25 Thus, not only do the findings of
our review emphasize parental well-being is a protective factor, they
also add to the weight of Ungar’s25 argument for a focus on positive
family functioning to aid our understanding of positive outcomes in

the face of adversity. Further, the findings of the reported studies in
our review counter the idea of refugee families as more problematic
for children’s development when compared to families in the host
community.26 They also affirm Ungar’s25 assertion that family
relational resources contribute to a positive bond, enabling
children to thrive in the face of adversity.
Further factors identified by our review as protective included
peer support,c the education systemj,g and ‘acculturation’.h A
number of the papers we reviewed reported peer support from the
host community as an important factor in positive adjustment.c,a,e
However, only Kovacevh made attempts to understand the possible
mechanisms at work, linking peer support to the way adolescent
refugees view themselves. What the author suggests is that peer
support may challenge hostile discourses surrounding refugee
children within the host society, allowing for a sense of belonging
to develop. However, these mechanisms require further consider-
ation through alternative research approaches that would allow con-
sideration of mediating and moderating variables.
The findings from the Kia-Keating et al.g and Kovacevh in this
review show that a sense of school connectedness was protective.
This was also demonstrated by Montgomeryb who highlighted im-
provement in the mental health of refugee children who were active
in educational engagements. Rousseau and Guzder27 support these
findings by arguing that school-based prevention programmes
become a significant factor in enhancing mental health of refugee
children. However, some researchers contend that few programmes
that focus on mental health for refugees exist in schools and those
that exist focus on treatment rather than building resilience.2 Kia-
Keating et al.g state that educational support for refugee children
needs a comprehensive approach based on an ecological perspective.
Hamilton et al.28 support this view, arguing that researchers need to
adopt an ecological multicultural perspective that focusses on the
entire experience of refugee children.
School should not be considered an absolute protective factor for
refugee children, however. Several studies report that refugee
children who come to western countries experience incidents of
racism and discrimination at school which impact on their
capacity to develop relationships with peers in their host society.29
This was also demonstrated by Correa-Valez et al.f who found that
one of five participants had encountered bullying because of their
ethnicity, race and/or religion. Given that the findings by Geltman et
al.j associate positive adjustment with refugee children’s perception
of safety at school, an area considered of utmost importance for
researchers and clinicians is how the education system manages
bullying and discrimination.4
We identified alignment with the values of a host society to be a
protective factor.h However, previous studies have found maintain-
ing traditional values to be a protective factor, while the adoption of
host society values met with poorer psychological functioning.30
This discrepancy is further illustrated by Ellis et al.31 who highlighted
that male refugee children who adopted American culture values
demonstrated positive adjustment, whilst female refugee children
who maintained their traditional values also displayed positive
outcomes. The Geltman et al.j paper included in our review
further complicates matters; their study of Sudanese children
living with an American family presented features of emotional
and psychological disturbances, whereas the Sudanese children
who were living with Sudanese families displayed improved psycho-
logical functioning. However, the Kovacevh paper included in our
review suggests it may be the particular adjustments and particular
traditional values maintained that predicted psychosocial adjust-
ments. This position fits with Ungar’s25 assertion that children
have their own constructions of resilience and protective factors
that differ across cultural contexts. The point we take from Ungar
is that both traditional and host society values matter in building
resilience and protective factors and that these variables are not
fixed, but in continual dynamic interaction.
Resilience and protective factors among refugee children 711
Societal level factors indicated as assisting refugee children in host
society included community engagement/acceptance of refugees and
innovative social care services.d,f,j,e There was an awareness that in-
novative health care services may also promote positive outcomes;
however, we were unable to locate empirical investigations of
innovative health care interventions specifically designed for
refugee children during the data collection process. The lack of con-
sideration reflects the criticism of Angel et al.32 who argue that cross-
cultural understandings psychological needs of refugee children are
lacking due to the dominance of western models of mental health,
particularly relating to trauma.
Limitations
The studies we reviewed highlight several methodological issues
affecting research about resilience with refugee children. One of
Downloaded from https://academic.oup.com/eurpub/article/29/4/706/5149703 by guest on 21 January 2024
the limitations we identified is a reliance on cross-sectional study
designs. To counter this, we recommend that future research should
consider adopting mixed design methods that merge qualitative and
quantitative approaches for exploring resilience and protective
factors. Our rationale is that mixed design methods integrate
positivist and interpretivist approaches, minimizing the occurrence
of bias in the research outcomes.33 For instance, some researchers
suggest the influence of school on resilience-building for refugee
children in the host countries is not objectively measurable.34
However, the papers in our review suggest that the influence of
schools in resilience-building for refugee children in the host
countries can be measured objectively.g,b This contradiction
highlights the challenges concerning resilience factors among
refugee children in schools, as well as ways in which they can be
investigated and understood. Because of these challenges, Tusaie and
Dyer35 assert that using both quantitative and qualitative methods
for resilience-informed research studies would enable measurement
of positive outcomes despite adversity alongside the investigation of
the individualized dynamics of resilience that are at work. The im-
plication of adopting this methodological approach has 2-fold
advantages: (i) it involves dynamic and interactive perspectives for
understanding resilience factors and (ii) it provides a holistic per-
spective that considers the experiences of refugee children.
Another limitation we identified in the reviewed papers related to the
measurement of resilience and its cross-cultural relevance. For instance,
some reviews evaluated resilience as positive outcomes despite adver-
sity,c,j,b or absence of psychopathology,a,k or well-being,d,f,e with others
referring to resilience as psychosocial adjustment.g,h We believe this
challenge relates to the cross-cultural relevance of measures employed
for a population that is comprised of ethnically and culturally diverse
subpopulations. Some of the papers included in our review have
responded to this challenge by making a choice to assess a specific
subgroup through convenience sampling.j However, other researchers
argue that using specific subpopulations is not a satisfactory solution as,
even within one country itself, children are diverse in their
socioeconomic and individual subjective experiences.36 There is also
an attempt to downplay the influence of cultural differences on
refugee research. For instance, the European Commission argues that
the data collected from refugee populations show that cultural variables
do not indicate more variation in mental health than socio-demo-
graphic factors. We believe that research informed by the construct of
resilience would be hindered by following the argument of European
Commission and that future research should continue to focus on
cultural differences as promoting well-being. Thus, there remains a
challenge for researchers to incorporate cultural diversity and cross-
cultural understanding of mental health into the research process.37
A final limitation that we identified was the continued focus on
psychopathology. From the 11 papers we included in our review,
only Correa-Velez et al.f and Kovacev et al.h adopted a resilient
outcome focus, utilizing measures to consider positive affect and
adjustment of refugee children who faced adversity. In contrast,
the remaining nine papers utilized various measures of
712 European Journal of Public Health
psychopathology, focussing on the continued appearance of mental
health problems within the sample to the detriment of those doing
well despite adversity. This limitation demonstrates the pre-
occupation with negative outcomes6 raised in our introduction.
We believe this to be particularly problematic as it can be
considered to individualize the impact of contextual factors,
allowing their impact on refugee children to remain unconsidered.
As Ungar et al.12 argue, such a focus overlooks ecology; if we only
look for negative outcomes, and overlook context, we will continue
to only see refugee children through this particular deficit-informed
lens.
The review we present also suffers from some methodological
drawbacks. The papers we included for review were restricted to
English language publications, potentially reducing the number
relevant papers for review. Further, the studies reported in the
paper we reviewed appeared to base their outcome measures upon
western conceptions of resilience. As Sleijpen et al.38 assert, most
psychometric scales used to measure resilience levels for refugees
are designed for western populations, meaning the questions and
focus may be confusing for refugee children. A final limitation of
our review is that, in focussing on quantitative studies, we may have
inadvertently added to the assumption that evidence from systematic
reviews can only be gleaned from quantitative studies.20 Our focus
on quantitative studies was based on the aim of providing a first step
towards a useful framework for conceptualizing the factors that can
aid refugee children in the face of adversity through extracting em-
pirically validated protective factors. However, by excluding quali-
tative studies, arguably we limit the possibility of a richer
exploration of how refugee children understand their experiences
in the face of adversity. The addition of a review of qualitative
evidence could enhance the findings of our review by offering an
account of the various factors and developmental processes that
affect refugee children’s psychological well-being at different ages
and stages of development. Such an approach may also illuminate
mediating and moderating processes in processes and ecological
domains associated with contradictory outcomes.
Conclusion
Our review sought to investigate psychological and contextual
factors that contribute to resilience in refugee children. Our over-
arching aim was to identify factors that sustain normal development
despite exposure to traumatic experiences and to promote the
adoption of a resilience-focussed clinical approaches for
supporting refugee children. The papers we reviewed report several
protective factors across various ecological domains, including age,
levels of self-esteem/efficacy, maintenance of cultural identity, social
support from peers and family, sense of belonging and safety in
school and community and innovative social care services.
However, a key overarching point reported in our reviewed papers
was that for refugee settlement specific policies and approaches to be
beneficial, they were required to be embedded within a socially
inclusive society. We identified several limitations across the
studies reported, including a reliance on cross-sectional designs,
the dominance of a western conception of resilience, a lack of
culturally specific assessment measures and a continued focus on
psychopathology. We argue that these particular limitations are
holding back the development of resilience-focussed clinical
approaches and potentially allowing for individualization of the
impact of negative contextual factors on refugee children.
Supplementary data
Supplementary data are available at EURPUB online.
References a–o are provided in the Supplementary References.
Acknowledgements
We would like to thank the editor and anonymous reviewers for
their insightful critique on the initial draft of this article.
Conflicts of interest: None declared.
Key points
 The more refugee children are exposed to adversity, the
more their adaptive abilities depend on the quality of their
environment, available resources and ways to access
resources.
 Refugee children flourish if provided a safe environment
that takes a comprehensive approach that includes the
Downloaded from https://academic.oup.com/eurpub/article/29/4/706/5149703 by guest on 21 January 2024
local community and innovative social services and
resilience-focussed intervention.
 Refugee settlement policies and approaches promote
positive outcomes if embedded within a positive, socially
inclusive society.
References
1 United Nations Development Program (UNDP). Overcoming Barriers: Human
Mobility and Development. New York: UN Development Project, 2009.
2 Fazel M, Doll H, Stein A. A school-based mental health intervention for refugee
children: an exploratory study. Clin Child Psychol Psychiatry 2009;14:297–309.
3 Fazel M, Stein A. The mental health of refugee children. Arch Dis Child 2002;87:366–70.
4 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. The Lancet
2012;379:266–82.
5 Goldin S, Levin L, Persson LÅ, Hägglöf B. Stories of pre-war, war and exile: Bosnian
refugee children in Sweden. Med Confl Surviv 2001;17:25–47.
6 Schweitzer R, Greenslade J, Kagee A. Coping and resilience in refugees from the
Sudan: a narrative account. Aus N Z J Psychiatry 2007;41:282–8.
7 Leppin AL, Gionfriddo MR, Sood A, et al. The efficacy of resilience training
programs: a systematic review protocol. Syst Rev 2014;3:20.
8 Bonanno GA. Loss, trauma, and human resilience: have we underestimated the
human capacity to thrive after extremely aversive events? Am Psychol 2004;59:20.
9 Rutter M. Resilience reconsidered: conceptual considerations, empirical findings,
and policy implications. In: Shonkoff J, Meisels S, editors. Handbook of Early
Childhood Intervention. Cambridge: Cambridge University Press, 2000.
10 Masten AS. Ordinary magic: resilience processes in development. Am Psychol
2001;56:227.
11 Schoon I. Risk and Resilience: Adaptations in Changing Times. Cambridge:
Cambridge University Press, 2001.
12 Ungar M, Ghazinour M, Richter J. Annual research review: what is resilience within
the social ecology of human development? J Child Psychol Psychiatry
2013;54:348–66.
13 Sroufe LA, Egeland B, Carlson EA, Collins WA. The Development of the Person: the
Minnesota Study of Risk and Adaptation from Birth to Adulthood. New York:
Guilford Press, 2009.
14 Sameroff AJ. Developmental systems and psychopathology. Dev Psychopathol
2000;12:297–312.
15 Luthar SS, Brown PJ. Maximizing resilience through diverse levels of inquiry:
prevailing paradigms, possibilities, and priorities for the future. Dev Psychopathol
2007;19:931–55.
16 Kazdin AE. Developing a research agenda for child and adolescent psychotherapy.
Arch Gen Psychiatry 2000;57:829–35.
17 Fonagy P, Cottrell D, Phillips J, et al. What works for whom?: a critical review of
treatments for children and adolescents. New York: Guilford Publications, 2014.
18 Centre for Reviews and Dissemination. Systematic Reviews: CRD’s Guidance for
Undertaking Systematic Reviews in Health Care. York: University of York, 2009.
Available at: http://www.york.ac.uk/inst/crd/index_guidance.htm.

19 Evidence-Based Medicine Working Group. Evidence-based medicine. A new
approach to teaching the practice of medicine. JAMA 1992;268:2420.
20 Thomas G. Introduction: evidence and practice. In: Pring R, Thomas G, editors.
Evidence-Based Practice in Education. Buckingham: Open University Press, 2004.
21 World Bank. World Development Indicator Dataset. Washington, DC: World Bank,
2009.
22 Scottish Intercollegiate Guidelines Network (SIGN). A Guideline Developer’s
Handbook. Edinburgh: SIGN, 2011.
23 Williams CL, Berry JW. Primary prevention of acculturative stress among
refugees: application of psychological theory and practice. Am Psychol
1991;46:632.
24 Connell AM, Goodman SH. The association between psychopathology in fathers
versus mothers and children’s internalizing and externalizing behavior problems: a
meta-analysis. Psychol Bull 2002;128:746.
25 Ungar M. The Social Ecology of Resilience. New York: Springer, 2012.
26 Gilad L. Refugees in Newfoundland: families after flight. J Comp Fam Stud
1990;379–96.
27 Rousseau C, Guzder J. School-based prevention programs for refugee children.
Child Adolesc Psychiatr Clin N Am 2008;17:533–49.
28 Hamilton R, Anderson A, Frater-Mathieson K, et al. Literature Review: Interventions
for Refugee Children in New Zealand Schools: Models, Methods, and Best Practice.
New Zealand: Ministry of Education, 2000.
Resilience and protective factors among refugee children 713
29 Brough M, Gorman D, Ramirez E, Westoby P. Young refugees talk about well-being:
a qualitative analysis of refugee youth mental health from three states. Aust J Soc
Issues 2003;38:193–208.
30 Liebkind K. Self-reported ethnic identity, depression and anxiety among young
Vietnamese refugees and their parents. J Refug Stud 1993;6:25–39.
31 Ellis BH, MacDonald HZ, Klunk-Gillis J, et al. Discrimination and mental health
among Somali refugee adolescents: the role of acculturation and gender. Am J
Orthopsychiatry 2010;80:564–75.
32 Angel B, Hjern A, Ingleby D. Effects of war and organized violence on children: a
study of Bosnian refugees in Sweden. Am J Orthopsychiatry 2001;71:4.
33 Johnson RB, Onwuegbuzie AJ. Mixed methods research: a research paradigm whose
time has come. Educ. Res 2004;33:14–26.
34 Slodnjak V, Kos A, Yule W. Depression and parasuicide in refugee and Slovenian
adolescents. Crisis 2002;23:127.
35 Tusaie K, Dyer J. Resilience: a historical review of the construct. Holist Nurs Pract
Downloaded from https://academic.oup.com/eurpub/article/29/4/706/5149703 by guest on 21 January 2024
2004;18:3–8.
36 Patel V. Cultural factors and international epidemiology: depression and public
health. Br Med Bull 2001;57:33–45.
37 Omeri A, Lennings C, Raymond L. Beyond asylum: implications for nursing and
health care delivery for Afghan refugees in Australia. J Transcult Nurs 2006;17:30–9.
38 Sleijpen M, June ter Heide FJ, Mooren T, et al. Bouncing forward of young refugees:
a perspective on resilience research directions. Eur J Psychotraumatol 2013;4:20124.