Culture and Migration: Psychological Trauma in Children and Adolescents

Abstract

Important development in the knowledge of migration, forced migration and asylum-seeking, its association with psychological trauma in childhood and adolescence, as well as in the intergenerational legacies of trauma in the family, have occurred in recent years. Trauma must be considered within a culture, because it is the cultural context that shapes the life experiences including the ones that are considered traumatic. Certainly migration has an impact on the family and a massive interference in the child's psychological development and mental health, which can be severe if related to acculturative stress or traumatic states. Young infants can develop insecure, ambivalent, or disorganized attachment; their lack of basic trust in their surroundings can result in negative effects in their exploratory behavior and autonomy, which may be reflected in disorganized behavior. Older children and adolescents may present increased externalized aggressive behavior and/or internalized anxiety and depressive behavior. Therefore, the models for trauma treatment in childhood must integrate the individual's actual psychological development with elements of the original and host cultures, including societal belief systems, community, neighborhood, family, and individual aspects. The way these elements interrelate and the risk and protective factors related to the child's resilience and psychological resources to overcome primary or secondary traumas must also be taken into account, are discussed in depth in this article.

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Assessment and Treatment
Traumatology
16(4) 142 –152
© The Author(s) 2010
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DOI: 10.1177/1534765610388304
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Culture and Migration: Psychological
Trauma in Children and Adolescents
Elizabeth Batista-Pinto Wiese1,2
Abstract
Important development in the knowledge of migration, forced migration and asylum-seeking, its association with psychological
trauma in childhood and adolescence, as well as in the intergenerational legacies of trauma in the family, have occurred in recent
years. Trauma must be considered within a culture, because it is the cultural context that shapes the life experiences including
the ones that are considered traumatic. Certainly migration has an impact on the family and a massive interference in the child’s
psychological development and mental health, which can be severe if related to acculturative stress or traumatic states. Young
infants can develop insecure, ambivalent, or disorganized attachment; their lack of basic trust in their surroundings can result in
negative effects in their exploratory behavior and autonomy, which may be reflected in disorganized behavior. Older children and
adolescents may present increased externalized aggressive behavior and/or internalized anxiety and depressive behavior. Therefore,
the models for trauma treatment in childhood must integrate the individual’s actual psychological development with elements of
the original and host cultures, including societal belief systems, community, neighborhood, family, and individual aspects. The way
these elements interrelate and the risk and protective factors related to the child’s resilience and psychological resources to
overcome primary or secondary traumas must also be taken into account, are discussed in depth in this article.
Keywords
culture, migration, psychotrauma, trauma, childhood
“…despite the tears of trauma, children’s souls are full of hope.”
(Lewis & Ippen, 2004, p. 41)
Every year, thousands of migrant and refugee families seek
mental health treatment in countries of the European Union.
Many of these families, from different origins and cultural
backgrounds, are victims of war, ethnic conflicts, economic
disasters, political caprices, or international migratory move-
ments, coming to Western Europe in search for a better present
and future. The condition of being a migrant is often burden-
some, especially in the case of forced migration of asylum
seekers and refugees, and the combined effects of these experi-
ences can result in problematic consequences for the mental
health of parents and children, bringing extra complexity to
their psychological condition, and having negative effects on
parents–children interaction (Wiese & Burhorst, 2004, 2007).
This article aims at scrutinizing some aspects of the rela-
tionship between culture, migration, acculturative stress, and
psychological trauma in childhood and adolescence. First,
social and psychological aspects related to voluntary and
forced migration are considered, discussing the specific con-
sequences they bring to parenting and filiation. Second,
acculturation and assimilation processes related to migration
are discussed, focusing on the way they can be affected by
traumatic experiences, which can be associated especially
with forced migration, leading eventually to the development
of Posttraumatic stress disorders in children and adolescents.
Finally, some relevant aspects of the psychological assessment
and treatment of these disorders in migrant and refugee chil-
dren and adolescents are discussed.
Culture and Migration
Migration1 is a sociological event which takes place in a his-
torical and political context. The reasons for migration vary,
and in general, when someone moves to live in another country,
he or she faces economic, linguistic, administrative and legal
difficulties, and often social exclusion.
The migrant has left his original place, where he built the
first and fundamental cultural and psychological identifica-
tions, moving to another place, in search of a better life. As
1Roosevelt Academy, International Honors College of Utrecht University,
Middelburg, the Netherlands
2Institute of Psychology, University of Sao Paulo, Brazil
Corresponding Author:
Elizabeth Batista-Pinto Wiese, Noorwegenlaan 9, 4318 CB, Brouwershaven,
the Netherlands
Email: e.wiese@roac.nl

Wiese 143
a consequence, he or she can suffer the loss of the primordial
world of his existence, to face a long, and frequently difficult
process of acculturation to the new culture. Thus migration
can be seen as a courageous and complex act, which affects
the person’s life, bringing many changes in the family history
and in the individual cultural identity.
Before discussing the development of cultural identity,
especially in children and adolescents, some basic questions
will be reviewed: What is culture? How does culture influ-
ence the person’s psychological functioning? How is culture
transmitted?
To answer the first question—What is culture?—we
adopted the definition from Bates and Flog (1990): “Culture
is a system of shared beliefs, values, customs, behaviors, and
artifacts that members of a society use to cope with one another
and with their world, and that are transmitted from generation
to generation” (p. 466).
In reply to the second question—How does culture influence
the person’s psychological functioning?—we point to the ideas
of Droždek (2007) that “culture impacts the regulation and
expression of emotions, sets limits of tolerance of specific and
strong emotions, and provides lay theories and strategies about
handling emotions” (p. 7).
Adding to these ideas, Lewis and Ippen (2004) explained
that culture provides the “. . . psychic structure for relationships
among members of a social group while simultaneously helping
them to make meaning of the physical world” (p. 13). Besides,
culture also provides a cultural envelope around the person,
which is a collective identity that can bring magical and power-
ful components of the group, assuring, since early childhood,
the maintenance, countenance, inscription, and transmission
of basic cultural elements, through the child’s interaction with
the parents and other attachment and role-model figures, mod-
eling the child’s cultural-identity development.
Therefore migration, with its profound influences on family
history, can cause ruptures in the external cultural framework
which, as consequence, can also cause ruptures in the internal
psychological cultural framework of the person (Devereux,
1970; Nathan, 1986), affecting his or her psychological and
cultural identity. Due to the mutual influence between cultural
and psychological structures, after migration the person’s ref-
erence systems and categories used to understand the world
and the relationships are no longer the same, determining
profound individual identity changes, and even modification
in the cultural transmission from parents to children.
To discuss the third proposed question—How is culture
transmitted?—one must understand that culture is transmitted
to the new generation in the day-to-day interactions with adults
and other children who dispose of a complex cognitive, emo-
tional, social, and behavior structure, which will determine
an explicit and implicit knowledge, common to all individuals
of a given group. This structural cultural knowledge is trans-
mitted from one generation to another, throughout the processes
of parenting and filiation, also called transgenerational
transmission.
Parenting, or the complex process of becoming a parent of
a specific child, is based on the recognition of the child as the
bearer of a psychic heritage, which holds the parent’s culture,
conscious dilemmas, and unconscious conflicts that can exist
in the family line: the transgenerational mandate. This mandate
has as metaphorical paradigm —The Tree of Life—a transgen-
erational transmission which tends to be a family myth that
defines the axis of the life mandate imposed on the descendant
(Lebovici, 1996, 1998). This heritage is transmitted to the child
through the care and the daily parent–child interactions, being
the child’s reality built on his or her first relationships with the
caretakers.
In the parents–child interaction real and fantasmatic
exchanges happen, and complex and reciprocal identifications
are produced, in which the experience modifies the symbolic
and vice-versa. These early interactions are constituted (Stern,
1985, 1995) by series of operational acts (care techniques),
corporal and sensorial acts (mother–infant physical contact),
language acts (words said to the child), and psychic acts (con-
sisting of maternal representations). This circle of influences
is quickly expanded to the father and other attachment figures
for the child.
To mirror the parenting process, explained above, comes
the filiation process, of being a son or daughter of specific
parents. This part of our identity is also developed through the
child–parents interactions, in which the child progressively
acquires his or her psychological and cultural structuring. These
two structures—psychological and cultural—are developed
concomitantly, and although they are independent, they main-
tain permanent exchanges with one another. The bond these
developmental processes establish in childhood, linking psy-
chological and cultural elements, is kept vivid and operational
throughout the person’s existence, due to the permanent
exchanges between the individual and his or her cultural envi-
ronment (Nathan, 1986).
Therefore, to bring a child into the world is, for migrant
parents, an important step in their own migratory history. Preg-
nancy and birth periods are, for example, especially vulnerable
ones for these parents, as they are mostly affected by the migra-
tion plans in their minds (reasons, conditions, experiences,
feelings, hopes). Other important elements that influence the
adjustment to the culture are the following: The number of
years spent in the new country; the cultural differences between
the country of origin and the new one; the social, educational,
and economic conditions; and the support (or lack of support)
from the partner, family, and community.
Through their child, the migrant parents will possibly have
more opportunities for contact with the host society, its culture,
and demands. This exposure places them in a paradox: A pro-
cess of being parents among parents in a new cultural and
social group that possibly has different values and practices
related to educating and raising children than those of their
original culture (Sayad, 1999). As a consequence, migrant
parents can be torn from their original group values. Then
they also have the challenge of adjusting to the host society,

144 Traumatology 16(4)
which often expects them to behave the same way as the other
members of that society. This expectation in the case of occi-
dental Western societies in general includes the challenge of
raising the children in a culture with predominantly individu-
alistic cultural values, which can bring extra conflicts when
they come from cultures of predominantly collective values.
Therefore, migration brings important modifications in the
psychological and cultural developmental processes of chil-
dren, adolescents, and adults, affecting the individual’s cultural
identity. In general, after some time, migrants do not maintain
their original culture in its totality, as they bring mainly local
or regional variants, which include a selection and mixture of
cultural elements (Berting, 2009). Besides, in case of migration,
the parents exposed to a new culture in the acculturation pro-
cess, can lose their confidence in the external social and cultural
framework, and may feel that the outside world is no longer
safe, and even develop a certain degree of confusion in the
way they perceive the world (Moro & Nathan, 1995); as a
consequence, these parents may transmit their kaleidoscopic
perception to the child, generating anguish and insecurity.
Therefore, it can be stated that the parents’ migration brings
an extra vulnerability factor for the child, because its being
in between different cultures, frequently with conflictive values
and beliefs, may result in difficulties in the cultural identity
development, which can bring an acculturative stress or be
traumatic to children and adolescents, with extra risks for their
psychological development.
The Migrant Child’s
Acculturation Process
After migration, the person’s psychological adjustment to envi-
ronmental and cultural changes has the tendency to take place
progressively. This adjustment process has the aim to move to
a less conflicting position in between the culture of origin and
the new culture.
Acculturation can be defined as a prolonged contact between
individuals or groups of different cultures and the resulting
change, such as the adoption of certain aspects of either or both
cultures (Sam & Berry, 2006). The acculturation process occurs
after migration or even after a temporary stay in another country,
when people need to make adjustments to the culture of the
host country. So it presumes an interactive process of change,
which involves both the migrant and the host society.
For some people, the acculturation process can be smooth
and quick, whereas for others it can take very long and imply
struggling with stress, eventually even leading to the develop-
ment of health problems. These individual differences in the
acculturation process seem to be related to demographic
factors, like age, intrapersonal factors, as personality and atti-
tudes, and interpersonal factors, like social and cultural con-
texts (Wiese & Burhorst, 2007).
For Berry (2005), the different strategies for acculturation
have the following components: Attitudes and behaviors. Atti-
tudes are related to the person’s opinions and beliefs, whereas
behaviors refer to the daily life practices. As these two com-
ponents often do not harmonize, individuals often experience
a discrepancy between their opinions/beliefs about, and their
behaviors toward life events.
Berry (2005), in 1970, proposed descriptors for the adjust-
ment process of migrants to a new country, its culture and
social life, including fundamental acculturation processes,
which have several layers and phases: Integration, assimilation,
separation, and marginalization. Integration is a strategy that
implies the maintenance of the original culture, whereas in
parallel, interacting with the host culture. Assimilation is the
complete adoption of the host culture, without the maintenance
of the original cultural identity. Separation implies in holding
on strongly to the original culture, rejecting the host culture.
Marginalization defines the position of having no possibility
to keep the original culture, but, at the same time, not develop-
ing the cultural identity of the host culture. These strategies
are important, as they contributed a great deal to the research
of adjustment processes in immigrants (Ward, 1997).
For the migrant, acculturation can be a mourning process,
because it can imply a loss of what is familiar, such as language,
home, relationships, places, and weather. The acculturation pro-
cess for children and adolescents, in general, is much more rapid
than for adults, and can lead to a strong integration to the host
society, incorporating practices and values of the new group.
In the integration process, the perceived difference between
the original and the host culture, termed as cultural distance,
seems to interfere in the cultural adjustment process (Shupe,
2007), but its effects in children can have great variability. In
this particular aspect, it seems that the parent’s attitudes toward
the host culture are also very important, and can favor or make
more difficult the development of the new cultural identity
for the child and adolescent (Sam & Berry, 2006).
Besides cultural distance, also social factors and personality
characteristics seem to influence how individuals cope with
the stressors in their environment (Taylor, 2009). The culture
learning theory places emphasis in the learning experience of
living in a new country, rather than in the adjustment to it
(Furnham & Bochner, 1986). This theory implies that social
skills are basic elements in the adjustment of a host culture,
and consequently social support systems are vital in the accul-
turation process.
Cohen and Wills (1985) also emphasized social support as
an important element to buffer the negative effects of stress.
In addition, social support can also have an effect in alleviating
the physiological damaging of stressful experiences (Cohen
& Wills, 1985), and existing stress can be exacerbated by lack
of social support (Taylor, 2009).
Figure 1, illustrates graphically some influences on the
acculturation process.
Acculturation is, in general, a long and difficult adjustment,
which often leads to (and frequently aims to achieve) some
form of assimilation to the new culture, in a process that can
take even several generations. This process has many phases,
characterized by different levels of integration in the

Wiese 145
culture—including bi and multiculturalism—in several aspects
of the cultural and social life. Eventually, if the acculturation
process leads to a complete assimilation of a new generation,
it includes the establishment of a new cultural identity (presup-
posing the loss the original culture of the parents), with its ethnic
identification, values, language, beliefs, and practices.
The acculturation process to a new culture, which is mostly
done by the first and second generations, involves complex
interactions in several dimensions: Affective, cognitive, social,
and cultural. It can bring many difficulties and psychological
suffering to parents and children, but can also give opportunity
to develop new coping strategies and creative solutions, as well
as foster resilience.
In the different aspects of the acculturation process parents
frequently have more difficulties in, for example, mastering
the new language, presenting a strong accent while speaking
it, and maintaining their original eating habits and customs, as
well as many other aspects which show their strong relationship
with the culture of origin. Children that are born in the host
country or migrated very young, frequently speak the language
without accent, and closely identify with the host culture, which
can eventually lead to rejecting aspects of their parents' original
culture.
It must be emphasized that the acculturation process ideally
should include democratic participation, with equal opportuni-
ties and rights, and the acceptance of cultural diversity in an
atmosphere of mutual respect and tolerance (Hollands, 2001).
Unfortunately, even in Western Europe, this is not always the
case (Wiese & Burhorst, 2007).
The acculturation process turns out to be even more complex
when the forced exile of refugees is considered. Mestheneos
and Ioannidi (2002), in a study carried out in fifteen member
states of the European Union, by the European Council on
Refugees and Exiles (ECRE) Task Force on Integration, pro-
posed that integration should be measured using objective
indicators to compare the refugees’ position with that of the
dominant majority, including access to jobs, education, housing,
political representation, and participation. These authors out-
lined the obstacles for refugee integration: long delays in the
legal asylum-seeking procedure before obtaining refugee status;
loss of social status as they have to learn the local language and
have to be re-qualified or have to learn new social and profes-
sional skills; the lack of consideration of cultural differences
and different forms of racism and assumptions of superiority;
dealing with welfare state systems with either very bureaucratic
or inflexible procedures, overgenerosity or enforced depen-
dence; living in shared houses or marginal neighborhoods;
and barriers in finding permanent employment in jobs com-
mensurate with their abilities and training.
If acculturation, with its doubts and conflicts, is a very com-
plex process for adults, its implications are even more com-
plicated for children and adolescents, because the fact that they
are in a period of intense change in their psychological devel-
opment makes them more vulnerable (than adults) to the influ-
ences of the external environment, especially when exposed
(primarily or secondarily via parents) to stressful or traumatic
experiences. Therefore, during this process, children can quite
often have their development positively or negatively affected
in different levels and aspects, with important consequences
for their future. Besides that, children from migrant parents
have the difficult challenge to build a bridge between the former
family culture and the host culture, and to develop a new cul-
tural identity, with bicultural or multicultural influences.
It is, therefore, not easy to measure the impact of life events
like migration on the psychological functioning of individuals,
especially children. The consequences of the harsh change of
environment that exile brings can manifest itself a long time
after the event and affect the entire family. The migrant child
has to develop cognitively, culturally, socially, and emotionally
in a transcultural situation. The child must build a cultural struc-
ture in the separation between two worlds of different natures,
one related to its family culture—the world of affection—and
another, to the outside world—the world of rationality and prag-
matism. This frequently results in many conflicts in the interac-
tion with the environment (Moro, de La Noë, & Mouchenik,
2004). To these children, migration can be a knot in the family
history that constitutes a source of phantoms, which are built
in the mirror of the parents’ phantoms, frequently rich and cre-
ative but also often psychologically disturbed (Wiese, 2007).
To better explain how culture may influence the child’s
reactions to extreme stress, Aptekar and Stöcklin (1997),
described the following paths: (a) Mediating the child’s
responses to the stressful experiences, that range from a benign
reaction to the development of Posttraumatic stress disorder—
PTSD; (b) Being used by the child as a means to cope with
stress, as the knowledge of situations can help to transform
circumstances into opportunities; (c) Giving conditions that,
Figure 1. Elements that influence the cultural identity

146 Traumatology 16(4)
unfortunately, can predispose to stigmatization of children in
specific difficult circumstances.
Baum (1990) defined stress as a “negative experience that
is associated to threat, harm or demand” (p. 660), explaining
that this emotional experience is “accompanied by predictable
biochemical, physiological, cognitive, and behavioral changes
that are directed either toward altering the stressful event or
accommodating to its effects” (p. 653). When stress is pro-
longed, it turns into chronic stress, which can severely affect
mental and physical health. Chronic stress also includes per-
ceived threats, harm, or demands and the organism’s responses
to them, which persist mostly because the stressor remains.
This can be the case in the event of migration and accultura-
tion difficulties.
Therefore, one possible consequence of the difficulties
brought by migration, is the development of acculturative stress,
which is defined as “one kind of stress, that in which the stressors
are identified as having their source in the process of accultura-
tion” (Berry, Kim, Minde, & Mok, 1987, p. 492). This term,
acculturative stress, was initially proposed by LeVine (1963),
as part of the culture-adjustment process after moving to a dif-
ferent country, and starting to live in a new cultural context,
where many stressors can be experienced, resulting from cul-
tural, social, and psychological changes (Berry et al., 1987).
Another risk related to acculturation is the development of
a Posttraumatic stress disorder —PTSD. This possibility will
be considered in the acculturation process, especially in case
of forced migration, great cultural distance, severe discrimi-
nation experiences, lack of professional and social support,
and other difficulties. It is important, in that case, to take into
account that “the cultural context phenomenologically shapes
the lived experience of both children’s development and their
experience of trauma. The meaning of trauma is often culture
specific” (Lewis & Ippen, 2004, p. 14).
Thus, migration, either voluntary or forced, independent of
its motivation, can be understood as a potentially stressful
and even eventually traumatic event, specially for children and
adolescents, inducing a long and necessary process of defensive,
adaptive, or structuring modifications, which lead to accul-
turation and identity changes, through bi or multicultural
influences.
Migration Related Trauma in
Childhood and Adolescence
The migration process, especially in the initial phases which
include leaving the country of origin and starting the accultura-
tion process in a host country, can have the status of a severe
psychological wound, a trauma, for some parents and children
(Moro, 2005). Trauma can result in a break in the psychological
protector shield against negative stimuli, exposing the frequently
vulnerable child and putting at risk his mental health. This
trauma, is mostly not developed in a single isolated experience
but by repeated occurrences that often happen in a close
intrafamilial setting, in primary or secondary traumatization
(in this last case, when the parents are traumatized).
There are strong predictors of trauma: (a) The exposure to
an extreme traumatic stressing event, to the person and/or his
or her family, being the following the most frequent: Threat
to, witnessing or learning about forced separation from family,
unexpected violent death, life-threatening events, physical
violence or serious harm or injury to physical integrity (for
example: inappropriate sexual experiences considering the
age); (b) The psychological distress related to the traumatic
situation, considering the severity, duration, and proximity of
the experience. The trauma is long-lasting when there is a
human stressor imposing the situation. Other variables such
as personality variables, preexisting mental disorders, and fam-
ily and social support must also be considered.
The trauma that is discussed here is of a specific type, based
mostly on the minority status of a group of people, and on
legacies of intergenerational ethnic and/or cultural conflicts
related to migration, which can even present more severe
characteristics and consequences in the case of the forced
migration (as war, genocide, rape, racism, and discrimination)
of refugees.
Within this approach, taking into account voluntary and
forced migration experiences and their consequences for a
psychological trauma in children, there are two important con-
cepts that we must consider: vulnerability and risk of psycho-
pathology in a critical period. Vulnerability is a state of least
resistance to harm and aggression. To illustrate this vulnerabil-
ity, Anthony, Chiland, and Koupernic (1982) took the image
of three dolls: One of glass, the second of plastic, and the third
of steel. If dropped, the doll made of glass will probably break,
the second, of plastic, will be damaged with a scar, and it is
possible that the third, of steel, will remain unaffected. There-
fore, the doll that is dropped will break or be harmed with more
or less facility depending on the material it is made of.
This metaphor for the concept of intrinsic vulnerability will
take into account that the damage depends on the kind of surface
on which the doll is dropped, which is a metaphor for the
concept of environment. The damage to the doll is also related
to the force applied when dropped. These are related to the
circumstances of the fall, as for example, the aggression that
was involved in the situation and the exposure to harm. Taking
this image as a metaphor for trauma vulnerability, it can be
understood that the psychological symptoms and disorders
after the exposure of traumatic events depend on the interaction
of three categories of factors: The intrinsic vulnerability of the
child, the social and family environment, and the circumstances
related to the situation. To these can be added the possibilities
of treatment that the child has at his disposal following the
trauma, and how the specific family culture considers the events
and deals with their consequences (Moro, 2005).
This notion of vulnerability can be better conceived when
we think that the child is part of a complex, interactive family
system. The child’s interactive system consists of the nuclear

Wiese 147
family, and frequently also of the extended family and its culture,
as well elements of the outside world such as school and health
care, in a dynamic process which can bring favorable or unfavor-
able influences to the child’s psychological development. The
rupture of one element of that system can effect changes in the
whole interaction process, and lead to changes in the child’s
functioning and his psychological development.
The second concept mentioned above applied to trauma in
children, is the critical period of psychopathological risk,
which has practical consequences on prevention and interven-
tion. This concept refers to the level of psychopathological
risk in the different periods of human development, proposing
that the effects of trauma can influence the child’s develop-
ment in such a way as to increases the risk of psychological
disorders, not only in childhood but also later, in adolescence
or adulthood.
In the case of a child of migrants, a vulnerability can be
determined when the psychological functioning is such that
minimal internal or external variations can lead to large dysfunc-
tions, and often suffering, blockages, inhibitions or reduced
development of his psychological resources and potentials
(Moro, 2005). This notion of vulnerability is mainly clinical,
therefore it is very complex and difficult to quantify, because
it allows for varied modes of expression which can have mul-
tiple causes. This fragile condition is often manifested as real
or latent sensitivities and weaknesses with variable traits.
Besides the traumatic experiences that can be associated
mostly with forced migration, also in voluntary migration, the
transcultural situation in which the child of migrant parents
grows up, having to structure a cultural identity built on a split
between two different worlds, can bring more insecurity and fra-
gility. To grow up, this child must create several splittings (Moro,
2005): on the topographical level—within versus without—
(for example, between family and school relationships); on the
temporal level—before versus after (the event of migration);
on the spatial level—there versus here (at home, in the treatment
setting and with friends); and, on the ontological level—the
same versus the other (contexts with same or different religion,
habits, and clothes). These splittings are necessary to enable
the child to move around in two different cultural worlds, in
a transcultural situation, and to adjust to the double reference
universe he is exposed to, but they can also be sources of inhibi-
tions and anxieties, as they can be structured and become mecha-
nisms for psychological functioning, in a form of ego-splitting,
with severe consequences for mental health.
Therefore, in their cultural and psychological structuring,
children of migrants may build mechanisms of cleavages to
deal with their unstable contexts. These mechanisms determine
the specific vulnerabilities of these children. In that theoretical
frame, Moro (2005) named them as the exposed children.
The psychological functioning of being an exposed child
can be accompanied by a denial of the filiation, meaning the
denial of being the son or daughter of his or her parents. As a
consequence of this mechanism, the child of migrants, raised
in a new country and under the influence of a different culture,
can be perceived as a foreigner within the family, by the parents
for example, or by the extended family; (Moro & Nathan,
1995). This means that his or her behaviors, ideas, opinions,
habits, attitudes, and expressions, for example, can be differ-
ent from what the family would expect or recognize as part
of their cultural background. To explain this foreignness of
the child, the family or even the child him- or herself, can
create fantasies, representations from cultural myths or leg-
ends which can persist and be transmitted to other generations
(Moro & Nathan, 1995).
Besides the child’s direct exposure to traumatic experi-
ences, it is also important to consider the risk of secondary
trauma—when the parents are traumatized—because trauma
can affect the attachment basis, bringing direct consequences
to the child’s life and development.
In infant mental health, the clinical treatment of mothers
and babies indicates that babies of traumatized mothers seem
to perceive, directly or indirectly, their mother’s traumas, as
they leave strong traces in their interactions (Wiese, 2007).
This mechanism of a secondary trauma can affect the child’s
psychological developmental processes and influence his
future as adolescent and adult. A consequence of the parents’
trauma can be the development of a disturbed affective parent–
child communication. In these cases, the parents often are
unable to deal with the child’s needs, and can behave in a
frightened/anxious way toward the child.
Therefore, it can happen that after the exposure to traumatic
events, the child may show heterogeneous and complex mani-
festations and symptoms. Thus, the same circumstances and
situations can have many different effects in infants (Lebovici,
1989). Yet, in the etiology of trauma, it is also necessary to
consider the child’s psychological development at the moment
of the traumatic experience, when several affective impressions
were encoded. For the migrant child, these vulnerabilities can
determine lower resistance to traumas, in comparison with
children who are raised within their own parents’ culture.
In the case of forced migration of refugees, several studies
(Anderson, 2001; Farwell, 2001; Lie, Lavik & Laake, 2001;
Lustig et al., 2004; Maloney, 2000), investigated how these
children cope with their new situation, showing consequences
of the adaptation to the new society, including depressive symp-
toms. Maloney (2000) discussed in a transatlantic workshop
about unaccompanied asylum-seeker children, comparing poli-
cies and practices in North America and Europe, with several
child-friendly practices and recommendations. Anderson (2001)
described a qualitative research about the social situation of
refugee children, based in many interviews, carried out by the
German Youth Institute between 1997 and 2000, concluding
that these children live in a state of constant uncertainty with
regard to future and life planning, which increases psychologi-
cal pressure in their daily lives. Farwell (2001) did an ethno-
graphic research, based in interviews with key informants, about
33 youth recently repatriated to Sudan, describing the sources

148 Traumatology 16(4)
of traumas and coping strategies, and suggesting the need of
planned interventions to provide psychological support to that
population. Lie and colleagues (2001), in a study conducted in
the Psychosocial Centre for Refugees, in Norway, showed that
the exposure to life-threatening events, physical violence, and
forced separation from the family are strong predictors of psy-
chological distress. Lustig and colleagues (2004), made a broad
literature review of studies conducted between 1990 and 2003,
addressing the mental health of refugee children and adoles-
cents, concluding that this group of young people suffers from
significant conflict-related exposures, including preflight stress
and stress in resettlement, and associated traumas.
Research done in relocation countries, using psychological
tests, indicated an increased level of psychological distress
among migrant children (Lavik, Christie, Solberg, & Varvin,
1996; Mollica et al., 1993; Resnick, Kilpatrick, Dansky, Saun-
ders, & Best, 1993; Vrana & Lauterbach, 1994). Other
research showed that the children’s self-regulating ability
depended largely on the emotional state of their caretakers
(parents mostly), therefore, the asylum-seeking children and
adolescents without caretakers may have a greater risk of
psychiatric disorder following trauma exposure (Loughry &
Flouri, 2001; Lustig et al., 2004; Sourander, 1998).
In a study conducted in the United Kingdom with refugee
children, Fazel and Stein (2003) showed that more than one
quarter of them suffered from a significant psychological dis-
order and this incidence was three times more frequent than
in English children. In another study on 129 asylum-seeking
and refugee children and adolescents referred to a mental health
facility in the Netherlands, Wiese and Burhorst (2004, 2007)
also reported significant physical and psychological traumatic
experiences in 26% of the children and adolescents with fami-
lies, and in 68% of the unaccompanied minors. Sexual abuse
had a high frequency in unaccompanied minors, especially for
girls (67% compared with boys 14%). The results of that study
indicated that unaccompanied minors had a statistically sig-
nificant higher frequency of symptoms and psychiatric disor-
ders, than asylum-seeking children who were with their
families, indicating the presence of the mother and/or the father
as an important protective factor to children against stress reac-
tions in adverse situations.
The above mentioned studies emphasized the relationship
between traumatic exposure and psychological symptoms in
refugee children, as well as the need for early diagnosis and
treatment to avoid long-term effects of trauma. Also empha-
sized was the highlighting of the high vulnerability of asylum-
seeking children and adolescents.
Epidemiological studies (Nemeroff et al., 2003) also
showed the importance of preventing the psychological effects
of trauma in children, because individuals who had traumatic
experiences in childhood are more vulnerable to the develop-
ment of PTSD in adulthood. Therefore early detection and
intervention in children’s trauma can also help to prevent psy-
chological disorders later in life.
Effects of Posttraumatic
stress disorder—PTSD in
Children and Adolescents
Before the 1950s, there was very little investigation of the
psychological effects of traumatic events in children and
adolescents, being Spencer Eth and Robert Pynoos pioneers
in the field (Beall, 1997). Since that time the field has
expanded enormously, with publication of researches inves-
tigating the different psychological effects of PTSD. In chil-
dren, the reaction of traumatic experiences often includes
nightmares, concentration difficulties, irritability, and hyper-
vigilance. The symptoms can also be psychosomatic, such
as headaches, stomachaches, and other pains, as well as
eneuresis. Affective difficulties are often found: Frequent
crying and depression, withdrawal behavior, and isolation
which can be manifested by avoiding contacts with the peer
group and not wanting to attend school. Other findings are
changes in self-perception, in the relationship to others and
in the interpretation of the social context, fear of being left
alone, changes of eating and sleeping habits, regression to
underdeveloped behaviors, and increase of aggressive behav-
ior (Wiese & Burhorst, 2004, 2007).
Very young children can lose their trust in the caregivers
and develop an attachment disorder, with its consequences for
emotional and social functioning. Frequently, their exploratory
behavior is reduced and they show less autonomy. Their symp-
toms can include irritability and anger, search behavior for the
missing person (in case of separation), lack of age-appropriate
interest, and change in appetite and/or in sleeping patterns,
sadness and emotional withdrawal (Hinshaw-Fuselier, Heller,
Parton, Robinson, & Boris, 2004). It is possible that children
under age eight do not have the traditional symptoms of PTSD
as a consequence of trauma, and present other signs of stress,
such as disorganized behavior, increased aggressive behavior,
or anxious/depressive behavior.
Trauma can affect the child’s and the adolescent’s readiness
to learn and bring mechanisms of hypervigilance, constriction
of exploration, misattribution of hostile intention to others.
The excess preoccupation can affect attention and concentra-
tion processes that are fundamental in the learning develop-
ment, having important consequences in school performance
(Lieberman & Horn, 2004).
Assessment and Treatment of
Acculturative Stress and PTSD in
Migrant Children and Adolescents
The diagnosis and treatment process of acculturative stress
and PTSD related to migration in children and adolescents
include the family system, taking into account the family’s
cultural background and favoring its integration with elements
of the host culture.

Wiese 149
As the children in treatment come from diverse cultural
backgrounds, there is also a concern about the language; it can
be very important to have interpreters or bicultural therapists
participating as mediators in mental health treatment. Although
the child and the parents can appear to have enough knowledge
of the local language, their memories and feelings related to
important events in their lives may be encoded and better pro-
cessed in their native language (Lewis & Ippen, 2004).
It is also important that health care professionals familiarize
themselves with the cultural background of their clients, in
such a way that the differences in language or in cultural back-
ground between the professional and the client are not obstacles
to the effectiveness of the trauma treatment. The consideration
of the cultural meanings of the symptoms and disorders the
child presents is also fundamental in the treatment, as well as
the family’s cultural values and how they can affect the response
to the treatment. The health care professional must also be
attentive to the identification of cultural or environmental ele-
ments in the client, especially those that can cause resistance
to the psychological treatment, and those that can foster the
treatment and show positive elements of resilience.
In order to do that it is necessary to develop individual
treatment strategies, within the specific therapeutic approach.
This way, therapeutic strategies are built, aiming to approach
the child and to help him or her to transform the vulnerability
into strength and to diminish the risk factors for later psychi-
atric disorders, favoring the social and emotional development
process as well as the participation in the host society.
Culture can also become a protective factor for parents. It
gives them strength and a sense of direction in their roles as
parents, and in the case of psychological or psychiatric disor-
ders, culture can provide an envelope to support parent-child
interactions, especially in critical periods. The psychological
treatment can also provide a model to parents and children, to
help them in building a strong bridge between their two refer-
ential worlds, mastering the transcultural risk. For the child of
migrants, any therapeutic approach that does not take into
account the family’s cultural background only contributes to
reinforce the splitting he/she built between the two worlds of
reference, contributing to marginalization.
In the psychological assessment and treatment of trauma-
tized children, the following considerations (inspired in the
general recommendations of the American Psychiatric Associa-
tion, 2004, for the treatment of adults with PTSD, and adapted
by the author of the present article) will be followed: To screen
for recent and remote exposure to traumatic events, and to
secondary trauma; To investigate the response of the child and
of the parents to each traumatic event, as well as the nature
of the event itself; To consider the limitations in making a
diagnosis, related to the age of the child and to the complexity
of the associated circumstances (for example, dissociation may
prevent patients from recalling their trauma; young children
do not express trauma directly and tend to project it); To collect
as much as possible the full history of all salient traumas
(age and duration of the traumas) and factors or interventions
that may have intensified or mitigated the traumatic response.
The mental health assessment phase of migrants may include
medical and/or psychiatric assessment, anamnesis, psychologi-
cal assessment (cognition, neuropsychological development,
and personality), creative observation and assessment, and
family-system assessment. On average, the assessment evalu-
ation takes place in the first 3 months, and should be followed
by 3-monthly follow-up evaluations.
Several specialized psychological tests and instruments
were developed to identify posttraumatic stress reactions in
children (Finch & Daugherty, 1993; Yule & Udwin, 1991).
Among some of these scales and inventories are: The Chil-
dren’s Stress Reaction Index (Frederick & Pynoos, 1988);
Revised Impact Events Scale (Horowitz, Wilner, & Alvarez,
1979), the Children’s Post-Traumatic Stress Disorder Inven-
tory (Saigh, 1989), and also a semistructured interview guide
(Pynoos & Eth, 1986).
In the case of young children (under age 4), the assessment
of the parents–child interaction is very important and can be
done, for example, by the application of the Interaction Assess-
ment Procedure—IAP (Batista Pinto, 2001, 2007; Wiese, 2006,
2007), a special videorecording technique that aims at a detailed
assessment of the mother–child and father–child interaction.
For the infant’s diagnosis, the Diagnostic Classification of Mental
Health and Developmental Disorders of Infancy and Early Child-
hood—DC: 0-3R (2005) is strongly advised.
The Sandplay, as a nonverbal method (Boik & Goodwin,
2000; Kalff, 2003; Wiese, 2007), also seems to be a very
appropriate psychological tool to use with migrants, both in
the assessment and in treatment, providing a very safe situ-
ation for the projection of traumas and conflicts, as well as
their elaboration.
After the diagnostic phase, a treatment plan is established.
Different treatment modalities are proposed to the family
(including for example, play therapy, art therapy, psychomotor
therapy, parent counseling, and others). Several modalities of
psychotherapeutic treatment—individual, parents/child, group
or family—can be offered in different phases, and they can be
effective in various possible approaches: play therapy (Cat-
tanach, 1994; Klapper, Plummer, & Harmon, 2004), attachment
therapy (Brisch, 2002); family ethnopsychotherapy (Moro, de
La Noë, & Mouchenik, 2004); sandplay therapy (Boik &
Goodwin, 2000; Wiese, 2007) and others. The choice of a
specific treatment is preferably decided by a multidisciplinary
team, considering the specializations and specific theoretical
approach of the psychotherapists, and matched with the needs,
issues and feelings of the child and the parents. For some
children and adolescents, there can be a need of intensive
psychiatric care, in-patient or day-clinic treatment, which can
also include a special school, adjusted to the child’s learning
possibilities and actual resources.

150 Traumatology 16(4)
Final Considerations
Several authors have written guidelines (Nader, 1994; National
Center for PTSD, 2006) for the therapist’s attitude towards the
client. Inspired by these, as well as based on clinical experience
with traumatized clients, some principles and guidelines are
suggested by the present author for psychotherapists who work
with traumatized children and adolescents, to foster resilience
and overcome their trauma: be able to talk about the traumatic
events; provide means to express the experiences and feelings
related to the trauma; support the client in positive strategies to
cope with anxiety, anger, and other stress reactions/symptoms;
be consistent and predictable in your relationship with the client
in view of his or her vulnerability; be affectionate and take into
account the context and the culture of the client’s background;
discuss what is expected in the client’s behavior in different
situations and contexts; answer the questions and explain what
is needed; look for signs of reenactment, dissociation, avoid-
ance, and reactivity; empower the client to avoid retraumatiza-
tion; talk to the client about choices giving him or her some
sense of control of his or her own life; ask for help and supervi-
sion if necessary. Most of all, therapists should be aware that
children, in their need to reestablish their connection with the
different cultural worlds they are exposed to and the variety
of persons involved in their lives, can have an extended process
of healing that continues long after the treatment ends.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the authorship and/or publication of this article.
Funding
The author(s) received no financial support for the research and/or
authorship of this article.
Note
1. In this text we chose to use the word migration in its broader
meaning: to move to live in another country of which the person
is not a native.
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