Forcibly displaced children and families are among the most vulnerable groups in the world, now with an unprecedented 30 million children displaced by conflict and a peak of 19 million children internally displaced.1  Public health crises, such as the coronavirus disease 2019 (COVID-19) pandemic, highlight the preexisting refugee crisis, placing them at greater mental health risk. Although children are not the highest risk cohort to suffer serious illness from COVID-19,2  pandemic-related policies, health precautions, and psychosocial stressors are potentially damaging for vulnerable children and families such as forcibly displaced youth. Basic public health measures, such as social distancing, hand hygiene, and self-isolation, are difficult to implement in camps, settlements, and homes because of overcrowded living situations, poor access to basic sanitation, and lack of access to health services, leaving displaced children at risk for contracting disease. Many forcibly displaced families are understandably distrusting of government requests for public health measures because they are fleeing governments that are the cause of violence and armed conflict.3  These psychosocial stressors can lead to a worsening of mental health, especially when combined with a history of potentially traumatic events that cause forced migration. In this article, we describe the synergistic impact of government policy responses and psychosocial stress on the mental health of forcibly displaced children and families and recommend risk mitigation strategies to improve safety, psychosocial environments, and mental health for this populations. The term “displaced” will be used for reader ease, with definitions of forcibly displaced persons in Table 1.

TABLE 1

Definitions of Forcibly Displaced Persons

Definition
Asylum seeker An individual who is seeking international protection; whose claim has not yet been finally decided on by the country in which (s)he has submitted it 
Refugee (1951 Convention) A person who, owing to a well-founded fear of persecution for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country 
Internally displaced person Persons or groups of persons who have been forced to flee their homes because of armed conflict, generalized violence, violations of human rights or natural or human-made disasters, and who have not crossed an internationally recognized state border 
Unaccompanied child Children who have been separated from both parents and other relatives and are not being cared for by an adult who, by law, is responsible for doing so 
Definition
Asylum seeker An individual who is seeking international protection; whose claim has not yet been finally decided on by the country in which (s)he has submitted it 
Refugee (1951 Convention) A person who, owing to a well-founded fear of persecution for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country 
Internally displaced person Persons or groups of persons who have been forced to flee their homes because of armed conflict, generalized violence, violations of human rights or natural or human-made disasters, and who have not crossed an internationally recognized state border 
Unaccompanied child Children who have been separated from both parents and other relatives and are not being cared for by an adult who, by law, is responsible for doing so 

Definitions are from ref 16.

Displaced children seeking safety face complicated and rapidly changing government responses to migration. Some governments have used the pandemic to exert migration-control policies, citing public health containment measures to prevent the spread of the virus.4  In April 2020, 91% of the world’s population lived in countries with restrictions on newcomers into the country, with 39% of people living in countries that were completely closed to nonresidents.5  With many resettlement, relocation, and repatriation mechanisms suspended, there are no alternatives for refugees and migrants trying to escape.6  Those needing to flee violence now have nowhere to go and add to the already 45.7 million people who are internally displaced.7  Suspended search and rescue operations and border closures leave displaced youth and families stranded, with children facing potential separation from families. Of concern are discriminatory policies against displaced families, with changes in status determination procedures for asylum seekers, redistribution of detainees across facilities, lack of appropriate medical care, and overcrowded and unsanitary immigration detention conditions across the world.8 

Before the pandemic, displaced children were already vulnerable to mental health problems and psychosocial stressors, with high levels of anxiety, depression, and posttraumatic stress.9  They were managing cultural bereavement (grief from the loss of cultural identity and social systems), traumatic and/or ambiguous loss of loved ones, fractured families with changing roles, acculturative stress, and uncertainty (of safety, housing, and legal status)10  and now have the additional stress of the pandemic. Necessary public health strategies, such as closures of school and afterschool programs and religious and community gatherings, can eliminate normal means of coping and social support. Reduction in nonurgent health care and social services that provide basic social, emotional, and health needs can threaten safety and worsen daily life stressors for children and families globally. Although these restrictions may have been necessary for reducing the transmission of COVID-19, the most vulnerable children, such as those forcibly displaced, are experiencing decreased protections against risk of violence, abuse, and exploitation.11  These psychosocial stressors of disrupted education, family stress, social isolation, increased abuse, and uncertainty about the future can all exacerbate mental health.12 

All children’s experiences are shaped by the environment in which they are embedded. Socioecological interventions that build on strengthening the communities in which children live, although challenging in humanitarian settings such as refugee camps and detention centers, should be promoted.13  Clinicians can help to improve the social environment for youth and families by engaging with community programs that have the trust of displaced persons. In addition, they can use inclusive communication strategies that address the unique needs of displaced youth and advocate for children’s rights to health and safety, both within the United States and in humanitarian settings (refer to Table 2 for a list of strategies).

TABLE 2

Strategies to Mitigate Risk of Adverse Mental Health for Forcibly Displaced Children During the COVID-19 Pandemic

Strategy
Community engagement Partner with professional organizations, such as the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatrists, American Psychiatric Association, American Psychological Association, and ACLU, for specific advocacy-related activities 
 Within the United States Partner with community organizations (such as Catholic Charities, Lutheran Social Services, Freedom for Immigrants, Kids in Need of Defense, and Northwest Immigrant Rights Project) serving the needs of forcibly displaced youth and families 
 Globally Facilitate cross-sector collaboration to maintain continuity of necessary services (child welfare, education, mental health and psychosocial support, and immigration and/or legal) 
 Support family strengthening programs and services to help those with limited education, cultural bereavement, and the potentially retraumatizing experiences due to conflict and migration 
Communication Provide accessible and culturally appropriate child-friendly information on COVID-19 to displaced children and families 
 Ensure public messaging about COVID-19 is inclusive of displaced children and families and includes outreach to those communities that they trust (volunteers, community programs, refugee programs, churches, temples, and mosques) 
 Inquire about access to adequate hygiene, including menstrual health, and prioritize basic needs: clean water, access to toilets, and hygiene 
 Provide basic health education (eg, coughing into elbows, appropriate use of face coverings for children, and physical distancing) 
Advocacy Encourage media to speak up against xenophobia and racism and to support and protect children 
 Advocate to uphold children’s rights to stop deportations, expulsions, and detention of displaced children and families during the COVID-19 pandemic 
 Support pending legislation through calls, letters, and briefings to elected officials to support the well-being of forcibly displaced youth. For example, within the United States: 
 House Bill: Coronavirus Containment Act of 2020 (requires ICE to ensure that test results of foreign nationals are negative for severe acute respiratory syndrome coronavirus 2 before repatriation or removal and for other purposes)17  
 HR 7569: Immigration Enforcement Moratorium Act (for the Department of Justice to stop in-person removal proceedings during the pandemic and to promote fair procedures in immigration courts)18  
 HR 1153: Condemning Unwanted, Unnecessary Medical Procedures on Individuals Without Their Full, Informed Consent (condemns forced, unnecessary medical procedures performed on women at the Irwin County Detention Center)19  
Humanitarian settings Invest more resources into mental health and psychosocial support for migrant children and families and make all efforts to help migrant children and families have access to health care and COVID-19 testing when necessary 
 Collaborate with existing programs and contact points to disseminate COVID-19 public health messages, such as with child-friendly spaces 
 Partner in advocating for safer living and housing conditions to allow for social distancing in transitional spaces like refugee and internally displaced person camps and shelters. If the environments are crowded and prohibit safely distancing, advocate to isolate those with COVID-19 from the individuals with the most high risk (elderly, those with comorbidities, and those with other preexisting conditions) 
Strategy
Community engagement Partner with professional organizations, such as the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatrists, American Psychiatric Association, American Psychological Association, and ACLU, for specific advocacy-related activities 
 Within the United States Partner with community organizations (such as Catholic Charities, Lutheran Social Services, Freedom for Immigrants, Kids in Need of Defense, and Northwest Immigrant Rights Project) serving the needs of forcibly displaced youth and families 
 Globally Facilitate cross-sector collaboration to maintain continuity of necessary services (child welfare, education, mental health and psychosocial support, and immigration and/or legal) 
 Support family strengthening programs and services to help those with limited education, cultural bereavement, and the potentially retraumatizing experiences due to conflict and migration 
Communication Provide accessible and culturally appropriate child-friendly information on COVID-19 to displaced children and families 
 Ensure public messaging about COVID-19 is inclusive of displaced children and families and includes outreach to those communities that they trust (volunteers, community programs, refugee programs, churches, temples, and mosques) 
 Inquire about access to adequate hygiene, including menstrual health, and prioritize basic needs: clean water, access to toilets, and hygiene 
 Provide basic health education (eg, coughing into elbows, appropriate use of face coverings for children, and physical distancing) 
Advocacy Encourage media to speak up against xenophobia and racism and to support and protect children 
 Advocate to uphold children’s rights to stop deportations, expulsions, and detention of displaced children and families during the COVID-19 pandemic 
 Support pending legislation through calls, letters, and briefings to elected officials to support the well-being of forcibly displaced youth. For example, within the United States: 
 House Bill: Coronavirus Containment Act of 2020 (requires ICE to ensure that test results of foreign nationals are negative for severe acute respiratory syndrome coronavirus 2 before repatriation or removal and for other purposes)17  
 HR 7569: Immigration Enforcement Moratorium Act (for the Department of Justice to stop in-person removal proceedings during the pandemic and to promote fair procedures in immigration courts)18  
 HR 1153: Condemning Unwanted, Unnecessary Medical Procedures on Individuals Without Their Full, Informed Consent (condemns forced, unnecessary medical procedures performed on women at the Irwin County Detention Center)19  
Humanitarian settings Invest more resources into mental health and psychosocial support for migrant children and families and make all efforts to help migrant children and families have access to health care and COVID-19 testing when necessary 
 Collaborate with existing programs and contact points to disseminate COVID-19 public health messages, such as with child-friendly spaces 
 Partner in advocating for safer living and housing conditions to allow for social distancing in transitional spaces like refugee and internally displaced person camps and shelters. If the environments are crowded and prohibit safely distancing, advocate to isolate those with COVID-19 from the individuals with the most high risk (elderly, those with comorbidities, and those with other preexisting conditions) 

ACLU, American Civil Liberties Union; HR, US House of Representatives; ICE, Immigration and Customs Enforcement.

A growing number of global programs can serve as models to minimize the impact of the COVID-19 pandemic on displaced children’s mental health. The United Nations Refugee Agency has implemented multilingual telephone lines and training in psychological first aid and has ensured access to medication to families around the world.14  Whole-family and community approaches to children on the move include mental health and psychosocial support messaging to promote mental health through back-to-school campaigns and child-friendly spaces, disseminate positive parenting tips, share parenting and stress management posters in quarantine camps, and play messages that oppose gender-based violence and provide mental health and psychosocial support through community loudspeakers.15  This pandemic is an opportunity to develop strategic relationships and collaborations in social services, health care, and policy reform to transform the environment in which we receive those forcibly displaced from their homes and provide higher impact and humane care for all children and families.

FUNDING: No external funding.

COVID-19

coronavirus disease 2019

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: Dr Song is an associate with the Mental Health and Psychosocial Support Collaborative hosted by Save the Children Denmark and ICF consultant to the US Department of State.

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