Occupational Therapy Psychosocial Interventions for Middle-Childhood Aged Refugee Children in High Income Countries: Focus Group Perspectives

Abstract

Refugee children are at risk of developing psychosocial problems. Occupational therapy practitioners can address some of these problems. Focus groups were held with 17 occupational therapy participants to identify interventions promoting refugee children’s psychosocial wellbeing in middle childhood in high income countries. Four themes emerged: (1) Making the most with what you have, (2) The child in their various environments, (3) Occupational Therapy lens helping to build a bridge between old and new lives, and (4) Sensitivity matters/considerations. Findings indicate research is needed to identify intervention effectiveness and increase use of macro-level interventions. interventions.

Keywords:

• Children
• forced migration
• intervention
• psychosocial

Introduction

An unprecedented number of people have been forcibly displaced as a result of conflict or disaster. The number of refugees¹ has increased to 32.5 million in the last decade (United Nations High Commissioner for Refugees [UNHCR], 2022). Of these refugees, 12.5 million are children (United Nations Children’s Fund [UNICEF], 2022). Between 2010 and 2021, the number of refugee children increased significantly, by 132 per cent, whereas in the same period the number of non-refugee child migrants rose by only 10 per cent (UNICEF, 2022). Children are significantly over-represented among the world’s refugees. While children make up less than one third of the global population, they constitute more than 40 per cent of the world’s refugees (UNICEF, 2022).

According to the UNHCR, more than two thirds of all the world’s refugees have fled from the low and middle-income countries (LMIC) of the Syrian Arab Republic, Venezuela, Afghanistan, South Sudan, and Myanmar. A total of 86% of refugees are hosted in the neighboring developing countries of Pakistan, Ethiopia, Uganda, and Iran. While most countries that host refugees are LMIC, high-income countries (HIC) have seen increasing refugee requests. The largest number of new asylums claims registered in HIC have occurred in the United States of America (USA), Germany, and France (UNHCR, 2021).

Addressing the psychosocial needs of refugee children is a growing concern. Evidence suggests that refugee children are at increased risk of developing psychosocial problems when compared to their non-displaced peers (Close et al., 2016). Potential reasons for this increased risk can be attributed to the stressors encountered during displacement and resettlement. These stressors include food insecurity, limited access to health and education, and the possible witnessing or experiencing of violence (Reed et al., 2012). These stressors can make refugee children vulnerable to a range of psychosocial problems. A recent systematic review including refugee children reported prevalence rates of 19–53% for Post-Traumatic Stress Disorder (PTSD), 10–33% for depression, 9–32% for anxiety, and 20–35% for emotional and behavioral problems (Kien et al., 2019). These conditions may affect children’s emotional regulation, learning, self-esteem, and hope for the future, potentially impacting their development, wellbeing, and ability to successfully integrate into their host country (Brunzell et al., 2016; Brymer et al., 2008).

Psychosocial interventions can be broadly defined as non-pharmacological interventions having a psychological or social aim, which can improve symptoms, global functioning, quality of life, and social inclusion (Barbui et al., 2020). Working with refugee children is an (re-)emerging area of occupational therapy practice (Trimboli & Halliwell, 2018), and has a limited evidence base to guide occupational therapy practitioners providing intervention to this population. Of the existing evidence, occupational therapy intervention research has mainly focused on interventions with adults, with the notable exception, a study by Copley et al. (2011), which was conducted with adolescents.

Occupational therapy practitioners are well-placed to address some of the psychosocial needs of refugee children due to their skills and the occupational lens they use. Occupational therapy practitioners have skills to conduct context-specific interventions. These skills ensure that the occupational needs and rights of displaced people are respected, protected, and fulfilled (World Federation of Occupational Therapists [WFOT], 2014, 2019). Additionally, occupational therapy provides a unique perspective as the profession respects occupational strengths by valuing previous life roles and occupational participation and adaptation. Furthermore, occupational therapy addresses occupational injustices resulting from a lack of equitable opportunity and resources to engage in meaningful occupations due to systematic barriers (Townsend, 1999; WFOT, 2014).

Occupational therapy practitioners risk being marginalized within healthcare delivery due to an inadequate scientific evidence base (Pain et al., 2015). There is an urgent need for increased occupational therapy research with forcibly displaced people to help guide occupational therapy practitioners when selecting and administering intervention approaches to an ever growing population of those being forcibly displaced (Blankvoort et al., 2018; Trimboli et al., 2019). Given the lack of a research base to guide occupational therapy practitioners providing interventions to refugee children, occupational therapists, occupational therapy researchers, and occupational therapy students with experience working with and/or researching refugee children were consulted in this study to identify which interventions are currently being used to promote children’s psychosocial wellbeing, and to identify considerations that need to be addressed when administering psychosocial interventions to this population. These findings will help establish an evidence base to guide current and future occupational therapy practitioners and occupational therapy students providing intervention services to forcibly displaced children.

This study focuses on middle childhood, the period that spans early childhood to adolescence. This age range is typically considered as the ages between approximately 6 to 12 years. A key psychosocial characteristic of this developmental stage is children beginning to develop a sense of self, by becoming more aware of their own abilities and limitations (Long et al., 1967). Children in middle childhood generally show increasing independence from parents and family and start to form stronger and more complex friendships, including with peers (Collins, 1984). They also become more skilled at understating social cues and navigating social interactions (Collins, 1984). Children also become better at managing emotions and expressing themselves in appropriate ways (Denham, 2007). Middle childhood is regarded as an optimal age for targeting psychosocial development and its associated behaviors, emotions, and relationships due to the self- and social- learning that takes place during this period (DelGiudice, 2018). The aims of this study are thus to identify interventions occupational therapists are currently implementing to promote refugee children’s psychosocial wellbeing, and considerations that need to be addressed when administering psychosocial interventions to these children.

Methodology

Research design

This study used a qualitative research design. This approach is useful when exploring complex concepts that are understood contextually (Denzin & Lincoln, 2008). A focus group format for data collection was chosen as it allowed in-depth information to be gathered. Thematic network analysis methodology was used to examine subjective perspectives of participants and provide insights on psychosocial interventions used and considerations for implementing those interventions with refugee children that could be translated into practice in HIC (Attride-Stirling, 2001).

Ethics

Ethics approval was obtained from Curtin University (HRE2019-0792-05).

Participants and recruitment

Both purposive and snowball sampling were used to recruit focus group participants. Purposive sampling facilitated a broad representation of relevant viewpoints, while snowball sampling was used as it was foreseen that participants would be hard to find due to the (re-)emerging nature of working with displaced populations within occupational therapy (Morgan & Krueger, 1998). A set of screening criteria was used to ensure adequate experience and qualification of the research participants. Participants were required to be occupational therapists, occupational therapy researchers, or occupational therapy students with at least one month of direct intervention delivery involvement or research experience with refugee children in middle childhood in HIC in the last 10 years. Given that working in forced migration is a (re-)emerging occupational therapy area of practice, a short time frame of experience was selected (Trimboli & Halliwell, 2018). Participants were located internationally and self-reported their occupational therapy qualifications and experience. Invitations to participate were sent to online professional and student occupational therapy groups in the areas of forced displacement, mental health, and migration. Two invitations were sent to these groups (two weeks apart) to maximize participation. An online scheduling tool was used to allocate participants to a group according to their availability, with a pre-determined number of four to eight participants for each group to enable diversity in the information provided and comfort with sharing their thoughts and experiences (Guest et al., 2017).

Focus group procedures and data collection

Prior to commencing the focus group, participants provided written consent, and identified their age, gender, current role, length of time in practice, the role in which they had provided intervention or conducted research in the topic area, length of time working in the topic area, and the country in which they worked in the topic area using Qualtrics Design XM^TM (Qualtrics, 2021). Three focus groups of 60–90 minutes were then held online in English and video-recorded using WebEx® (Cisco, 2021). English was not the first language for some of the participants. The moderator was able to offer language support by translating in German, Spanish, and Italian if required. The moderator is fluent in the aforementioned languages. The other language that would have required language support is Greek, however, the participants from Greek speaking countries were fluent in English. To facilitate the discussion, the first author acted as the moderator for each focus group. The last author acted as the observer of the group process in one of the focus groups.

A semi-structured schedule of questions was emailed to the participants prior to the focus groups to enable reflection, and then used to stimulate discussion on which occupational therapy interventions were used, and what intervention considerations comprised of (See Supplementary material). Verbatim transcriptions were undertaken for each focus group. Of the three focus groups, one had five participants, one had four participants, and the remaining focus group had seven participants. One participant had to leave her focus group meeting early and emailed written responses for the remaining questions. One participant could not attend any of the focus groups and provided written responses to the questions. All participants were given the opportunity to provide additional written information following the focus groups; one participant provided a more detailed answer to one of the questions, and two participants provided resources to programs they had referred to in the focus group.

Data analysis

Participant’s demographic data were analyzed using Qualtrics (Qualtrics, 2021). Focus groups were transcribed verbatim using Rev transcription services (Rev, 2021) and checked for accuracy by the first author. Focus group participants were then provided with the transcript for member checking. One participant made changes to her transcript to better reflect what she had meant to say.

Written responses were included in the data analysis with the focus group transcripts, and all the data were analyzed using thematic networks (Attride-Stirling, 2001). NVivo 11 was used to organize and code the focus group data (QSR International Pty Ltd., 2018). Data immersion occurred with the first three authors reading all the transcripts multiple times to identify general impressions. Thematic networks analysis was used as it provides a robust guide to analyze qualitative data and facilitates transparency of the analysis through the visual representation of the identified themes in the thematic network maps (Kiger & Varpio, 2020).

The thematic networks analysis began by author one devising a coding framework based on recurrent issues in the text, using quotes as examples, and discussing the emergent phrase ideas and concepts using coded text segments with the other authors. Once agreement of the codes was reached, the first author then coded the remaining focus group transcripts. To ensure consistency, the codes were regularly reviewed through group discussions with suitable quotes that exemplified the category for each theme. This iterative group process allowed refinement of the themes over a series of meetings and four rounds of data analysis. Basic themes were developed from the codes, which reflected the participants’ language, and were then grouped into common ideas forming organizing themes. Organizing themes added meaning and context to basic themes. From these organizing themes, four global themes were developed to summarize the data (Attride-Stirling, 2001). An example of the theme development process for one theme is outlined in Figure 1. Participant validation was sought by emailing participants so they could verify the global themes and their descriptions and provide any additional information they thought relevant. Audit trails were kept during the data analysis process to ensure trustworthiness (Creswell, 2014).

Figure 1. Theme development.

Results

Participant demographics

Seventeen international female participants took part in this study. Demographic data can be found in Table 1. All participants met inclusion criteria and were either practicing occupational therapists or occupational therapy researchers. No occupational therapy students were recruited. A majority of participants identified their current role as practicing occupational therapists, followed by occupational therapy researchers. Two participants identified their current role as being educators.

Table 1. Demographic data.

n = 17	N (%)
Current role
Practicing Occupational Therapist	11 (64.7)
Occupational Therapy Researcher	4 (23.5)
Other	2 (11.8)
Years in practice
<5	4 (23.5)
5–10	3 (17.7)
10+	10 (58.8)
In what role(s) were psychosocial interventions conducted (n = 21)
Student practical / fieldwork	2 (9.5)
Volunteer	2 (9.5)
Clinical	6 (28.6)
Researcher	5 (23.8)
Other	6 (28.6)
HIC where interventions or research were conducted (n = 17)
USA	5 (29.4)
Australia	3 (17.7)
Germany	3 (17.7)
Cyprus	2 (11.8)
Switzerland	2 (11.8)
Greece	1 (5.9)
Ireland	1 (5.9)
Not reported	1 (5.9)

Participants were asked in what role(s) they provided psychosocial interventions or conducted research with refugee children in HIC and could select more than one response. Most participants had conducted psychosocial interventions in roles as clinicians, researchers, or volunteers. ‘Other’ roles included clinical practice supervisors, a settlement and community services lead, and a school liaison officer. A majority of participants were from English speaking HIC. One participant had provided intervention in two countries.

Psychosocial intervention approaches used within occupational therapy

A wide variety of intervention approaches, including programs and activities were used by focus group participants to promote psychosocial well-being with middle childhood refugee children in HIC. These can be found in Table 2. The interventions were mainly directed at the refugee children, followed by the refugee children’s parents, their teachers, and lastly their peers. All the interventions were provided in community-based settings, including refugee centers, homes, schools, and leisure or sports centers.

Table 2. List of occupational therapy intervention activities.

Occupational therapy intervention activities identified

Counseling (including Cognitive Behavioral Therapy (CBT)) Creative arts, such as coloring in, drawing, painting, and creating kites Education of teachers by providing them with information on why and how to support refugee children that may be experiencing occupational performance difficulties Facilitating structure and routines in the host country Gardening (with parents) Handwriting skills Holistic circus therapy Mindfulness Money management with older children, using local currency Music (drumming) Preparing children to enter new communities such as at school and leisure-based facilities through education and practice Public transport training Reestablishing preexisting roles and activities from the country of displacement, including chores with the refugee children and their parents Sensory de-sensitization (to clicking pens, drumming). Sports including skiing, golf, capoeira Angola, ultimate frisbee (including with peers) Supporting / educating parents to take back some of their parenting role Teaching children what the appropriate behaviors within a school environment are Teaching the refugee children and their families on personal hygiene issues and how to use water Unstructured play (‘messy play’) Yoga

Programs identified

‘Settling in Kit’ (A kit that supports a program designed to provide early intervention for newly arrived students with refugee background to adjust to life in Australia and recover from traumatic aspects of their refugee experiences) (Service for the Treatment and Rehabilitation of Torture and Trauma Survivors, n.d.) PAR FORE program (A program based around the principles of Perseverance, Accountability, Resilience, Fellowship, Opportunity, Respect, and Empowerment) (Par Fore, 2013) Rock and Water course (Encourages self-awareness, and increased self-confidence and social functioning) (Rock and Water Program Gadaku Institute, n.d.) Techniques for Tough Times (A curriculum and training for educators teaching life skills to at-risk students) (Vandenakker & Threet, 2014)

Thematic analysis

Four major themes emerged from the data. These were: (1) making the most with what you have; (2) the child in their various environments, (3) occupational therapy lens helping to build a bridge between the old and new life; and (4) sensitivity matters/considerations.

Theme 1: Making the most with what you have

This theme relates to the barriers and limited resources that study participants identified when attempting to deliver psychosocial interventions to middle childhood refugee children, even in HIC, and the creative and pragmatic solutions that some participants implemented to address these issues (Figure 2).

Figure 2. Making the most with what you have.

Barriers to providing occupational therapy interventions to refugee children included restrictive government policies affecting the therapists’ access to children, and organizations’ lack of awareness of the role and potential of occupational therapy to provide services to refugee children. One participant identified that in her country the healthcare system appears to have a lack of understanding that occupational therapy can provide psychosocial support to people from a refugee background:

… it would be important that, for example, our country [sic] that the healthcare system understand that there are OTs [Occupational Therapists] who are able to do psychosocial support, because I, I don’t know how it is in your countries. But here, um, it’s not on their top list that OTs [Occupational Therapists] should be paid for what they are doing. So, most of the OTs [Occupational Therapists] are doing it as volunteers, or in the role of social workers or others. So, it is not really seen.

Limited resources were identified by most participants as having an impact on providing occupational therapy services to refugee children. Some participants identified that they were the sole occupational therapist working or volunteering with refugee children, and this resulted in challenges, such as when providing interventions to large groups of children. A lack of funding to conduct interventions was identified by many participants, with one person identifying the effect this had: “… and you need to get funding is [sic] very fatiguing and can challenge your sense of I do have something valuable to contribute here”. This lack of funding had an impact on some participants being able to access appropriate language services and spaces to conduct intervention sessions. Limited financial resources were identified as being a contributing factor to refugee families not being able to afford the cost of transport to access the intervention site or afford the cost of the intervention itself. Affording the costs of some of the leisure activities and sports that were practiced in HIC were also identified as barriers to participation:

And yet, at least in (country), which is a very high-income country, the standard of occupations of children’s [sic] are pretty high, like, for example, doing ski [sic]

Despite the barriers and resource limitations identified, some participants identified creative solutions they have used to attempt to address these challenges, such as needing to be flexible and adapting goals depending on the political climate and the resources available. For example, one participant highlighted that: “… you need to see what other resources and who is around to support and help”. Using students and volunteers to administer interventions under occupational therapy guidance was identified as a potential solution:

It’s 30 minutes of activity that an occupational therapy student does. It’s the way we’ve always done it.

Occupational therapists can and should leverage their impact with volunteers and links to other stakeholders where possible – e.g., programs could involve a creative element like story, and involve stakeholders from the arts, volunteers mentoring story development, libraries hosting an event or exhibition etc.

Working with other professions, such as teachers, and referral to other health professionals were also identified as strategies to deal with working as a sole therapist, and to address sustainability issues, particularly when the psychosocial needs that have been identified are outside occupational therapy’s scope of practice.

Theme 2: The child in their various environments

This theme relates to not only intervening with the child themselves, but also considering the wider physical environment of the child including the home, the school, and the broader community. The interventions also involved other stakeholders including the refugee child’s family, their teachers and peers, and community service providers. All the occupational therapy intervention activities reported were conducted in community-based settings (Figure 3).

Figure 3. The child in their various environments.

Within the home environment, participants identified that it is important to consider the needs and wishes of parents, as well as actively supporting parents in their new surroundings:

… I feel like interventions that are not directly geared towards the family, um, directly would have less chances of being successful. Because, um, you, you know, the child is part of, um, you know, a unit that is integrating as a whole in the community. And it’s not just the child and, you know, specific area of occupation, such as school or play or leisure like activity, you need the parents to understand like the nuances of the new communities that they are, um, being integrated in.

The school was identified as a suitable environment in which to conduct occupational therapy interventions. Reasons for using the school included that it provides a consistent environment, and opportunities to work with, and educate, teachers and peers on how best to understand and support refugee children in their migratory transition and in their student role in a new country. As one participant outlined in relation to a handwriting project they were involved in:

… it was an interesting little project in terms of providing a skill-based thing for students, but also, I’m, I’m building the capacity of the teaching staff to actually understand what was missing.

Opportunities to participate in the broader community, such as sport and leisure-based activities, were deemed important. Participants also identified that parents needed support with navigating the community to enable their children to participate in activities outside of the home and school environment.

Theme 3: Occupational therapy lens helping to build a bridge between old and new lives

This was the theme with the most support that emerged from the focus groups and refers to how participants considered the pre-migration roles and routines of the refugee child and their family, and how transition and participation into the resettlement country could be facilitated by drawing on the child’s and their family’s preexisting strengths. This theme specifically considered; 1) the activities and intervention approaches participants used, 2) the goals that participants identified that they facilitated with all the stakeholders, and 3) the unique contribution of occupational therapy when providing interventions to refugee children in HIC (Figure 4).

Figure 4. OT lens helping to build a bridge between the old and new lives.

Participants identified many activities and some programs they facilitated, or were aware of being used, with the stakeholders (Table 2). Unless otherwise specified, the interventions were conducted with the refugee children. The intervention approaches used included health promotion, early intervention, counseling, education, and skill development.

Participants identified that occupational therapy goals needed to be client-centered, developmentally appropriate, and trauma-informed. These goals included facilitating occupational performance, participation, socialization, and a sense of belonging. Some participants provided examples of team-based sports as activities that could be used to promote the goals of participation, socialization, and to foster a sense of belonging. One participant reported using ultimate frisbee, a sport that was new to both the refugee children and their peers, as a way of engaging all the children:

It’s interesting in terms of with the frisbee, looking at like a sport that no one has any experience of. Yeah, like, yeah, as you said, that leveling.

Providing opportunities to have fun for the refugee children was considered important by many participants. Reasons identified for this included that these children may have been deprived of opportunities for fun and “just being a child” when fleeing. Additionally, one respondent stated that refugee children are sometimes expected to take on additional responsibilities within the host country, particularly as their language abilities improve faster than that of their parents. Some participants identified that supporting and educating parents to take back some of their parenting role, which may have been lost in the transition process, was important.

Within this global theme, the occupational therapy lens helped to build a bridge between old and new lives, and there was significant discussion around the refugee child’s, and their parent’s, previous and current roles, and routines. Examples included reactivating lost or forgotten roles in the transition to the host country (e.g., the refugee child doing chores, the family gardening for self-subsistence), helping parents to understand their and their children’s roles within the new community, establishing routines and structure to facilitate transitions for the children (i.e., into school) and establishing healthy routines at home (i.e., sleep).

The unique contribution of occupational therapy within forced migration included using activities and occupations as a therapeutic tool, as more well-known verbal processing therapies may not be suitable due to language or trauma issues:

… as X (participant) was saying, it is about the occupation for … or activity-based interventions, isn’t it? That is what is unique to us that we can use activities and occupations as a therapeutic tool, which another discipline mightn’t be. You know, and I think especially with refugee children, with, with their background of trauma, um, talking therapies are going to be hard for them.

One participant suggested that non-occupational therapy staff lacked clinical reasoning when selecting interventions for refugee children:

… And then going back to what we had earlier, that refugee program I worked [sic] and they originally planned on us going with them on, like these adventure trips to the zoo or to that or that. And we just immediately felt that “No, we’re not going to do that. These kids just arrived in (Country); they do not want to be separated from their family.

Additionally, a unique contribution of occupational therapy intervention included using a strength-based approach to facilitate participation, particularly with activities that were already familiar to the refugee child, to facilitate attempting new experiences:

… as an OT, we’re focusing on various occupations and various activities and tasks, but throughout them all, I suppose, our approach is the way that we scaffold success. So, whether we are providing different resources or the way that we use ourselves in the activity with the children so that they have an experience of success, particularly success in, in maybe activities that they’re more familiar with. So, we can then build on that. But I think the success is important for their sense of safety and competence, so that they then have [sic] the comfortable enough to try something new. Um, and I think that’s something that we can, we can add, just in the way that we are with them. And praise, I think, for that psychosocial sense of, sense of self and self-esteem, to try new things.

Theme 4: Sensitivity matters/considerations

Participants identified many contextual factors that required careful consideration when providing meaningful and relevant occupational therapy interventions to refugee children and their parents (Figure 5).

Figure 5. Sensitivity matters/considerations.

The importance of building trust and rapport with the refugee child and their parents, and providing interventions in a trauma informed way to minimize the likelihood and effect of re-traumatization, was identified as paramount by many participants:

… um, and so I would definitely, yeah, agree and echo that thought that any intervention that we provide would need to be very, um, very mindful of trauma

Cultural awareness was a consideration that multiple participants referred to. Discussions included what activities or toys may be inappropriate when working with people from other cultures and needing to be conscious of not imposing Western values on the refugee children and their family. An example of a potentially inappropriate toy was playing with a train when this choice of toy may not be familiar to the refugee child. To combat the issue of appropriateness, one participant stated that a child’s family was always consulted when new therapy groups were being created:

… and so, if we wanted to run a new group, we had to go to them (family) first to ask if it was okay um, rather than making assumptions about culturally what eh, what these folks that outsi-[sic], people like us should be teaching their children

Considering culture, gender, and discrimination was also identified as necessary by many participants. One participant reported that some female clients may not feel comfortable working with male occupational therapists: “Cultural factors (e.g., male OTs [Occupational Therapists] working with female Muslim clients)”. Not only did participants identify that refugee children and their families may be discriminated against and bullied in their resettlement country, but some participants also reflected on how their own (sub-conscious) biases and practices could result in power imbalances and (un)conscious behaviors. For example, one participant referred to the need to be aware of “white savior” behaviors to foster agency of those displaced, and trust in the therapeutic relationship.

Considering the needs and priorities of the stakeholders was also a topic of discussion. The impact of not knowing the host country language, particularly for parents, was identified as a barrier that needed to be addressed to enable parents the opportunity to participate in the community, particularly in their child’s school environment. A strategy that was utilized by one school to facilitate communication was having newsletters translated into languages of the families using Quick Response codes. Challenging financial situations were discussed by some participants and included the family’s limited finances impacting on their ability to afford transport and the intervention activities. Some participants also identified that families may have more pressing priorities than coming to an intervention session.

Lastly, participants acknowledged that working in forced displacement, particularly with survivors of trauma, was a demanding area of practice due to issues such as burnout and vicarious trauma. Some participants spoke about how it was necessary to be sensitive to one’s own needs, and highlighted the importance of self-care, which included regular debriefing with peers:

…But I think in order to provide, um, really helpful interventions and, and a positive psychosocial wellbeing, we also need to create a community of practitioners that can support these interventions. So, in, in my last job, um, when, when you’re doing this work, it can be very taxing. And there’s a lot of secondary trauma that that happens with the practitioners. And so, um, for example, what we did is… And not everyone participated, it was sort of voluntary, but every Thursday morning, for example, we met as a clinical group for an hour and a half and just shared difficult cases, successes, different interventions, trainings, we really kind of came together, and I see so much wisdom in this group

Discussion

This study collected data from a group of occupational therapists, occupational therapy researchers, and occupational therapy students who have had direct intervention delivery involvement or research experience in forced migration and occupational therapy interventions aimed at improving psychosocial wellbeing for middle childhood refugee children in HIC. Despite the high numbers of refugee children in HIC, there is a paucity of literature regarding possible interventions occupational therapy practitioners use to support psychosocial wellbeing of this group.

Occupational therapists recognize the importance of engagement in meaningful occupations to promote well-being and mitigate the negative impact of occupational deprivation. In this study, participants identified a rich diversity of intervention activities and approaches that could be used to promote psychosocial well-being, which depended on contextual issues such as the intervention goal, available resources, and the needs and priorities of all the stakeholders. Broad categories of intervention identified within this study included creative arts, education, social skills training, facilitating sport opportunities, and play. Whilst none of these interventions have been shown to be effective to our knowledge within the occupational therapy literature for forced migrants, some of these interventions have been identified as promising within the broader health literature (Trimboli et al., 2021). The interventions that were identified as promising within the broader literature included meditation and relaxation (Catani et al., 2009), however the study by Catani et al. (2009) was conducted in a LMIC, thus findings can’t be generalized to HIC. CBT was reported as being used by one of the focus group participants and CBT has been found to have a large effect on between-group analysis using the Strengths and Difficulties Questionnaire (SDQ) with children in middle childhood who have been forcibly displaced to a HIC (O’Shea et al., 2000). However, the study by O’Shea et al. (2000) should be interpreted with caution as the authors combined CBT with family therapy, and a randomized control trial design was not used. Play was frequently referred to by the focus group participants; however, play was described in a general sense, or as ‘messy’ play, rather than using structured play. Whilst there is no evidence for the effectiveness of unstructured play with refugee children, when structured play in the form of Child-Centered Play Therapy (CCPT)² was provided in a randomized control trial to forcibly displaced children located in a HIC, improvements in Post-Traumatic Stress Disorder (PTSD) symptoms were identified (Schottelkorb et al., 2012).

Many challenges were identified when providing interventions to refugee children in HIC. Some of these challenges were linked to resource constraints, and highlight that even in HIC, resources are an issue. This finding is not particularly surprising as health is generally recognized as an underfunded area, particularly in mental health sectors (Bannister, 2021). Low-cost intervention solutions were identified by some participants, such as students conducting their fieldwork placement at refugee centers. Whilst these solutions enable refugee children to have access to interventions, short-term solutions do not address the sustainability of providing ongoing input. Given that refugee children are also likely to experience further developmental changes as they transition into adolescence, continued support may be required. Focus group participants identified the importance of considering the child within different environments in theme 2, including the school. Thus, a potential solution to address sustainability issues may be using existing organizations, such as schools, to provide consistency and ongoing psychosocial well-being monitoring.

Literature suggests that teachers administering psychosocial interventions under the support of health professionals in school environments in HIC can be effective in promoting psychosocial wellbeing (Fazel & Betancourt, 2018; Tyrer & Fazel, 2014). Occupational therapists can play a role in training and supporting teachers to be lay counselors, thus enabling the teachers to administer psychosocial interventions in countries that use community-based models of practice. Lay counselors can be staff or volunteers who provide psychosocial support, but who do not have a mental health background or formal degree in counseling (Connolly et al., 2021). Although existing literature has not yet looked at the role occupational therapy can play in supporting teachers as lay counselors, research incorporating other health professionals such as school nurses to support teachers in HIC is promising (Fazel et al., 2009; Rousseau et al., 2005). Further research could consider occupational therapy’s role in providing psychosocial interventions to refugee children in school environments and supporting teachers to become lay counselors.

However, a potential limitation of providing interventions in the school setting is the potential exclusion of family. Results from this study identified that family should be considered in intervention planning, and interventions should be conducted in a variety of environments, including the home, such as to promote the child’s participation in family routines. Additionally, parents were identified as needing some support to understand the nuances of the community to allow their children to participate. Thus, it is imperative a way is found to ensure that family are included in conferences and meetings about their children with the educators, occupational therapists, and relevant stakeholders, with an interpreter if required. This will however depend on the country’s and school’s policies regarding education support and practices. The multifaceted challenges facing refugee children and their families warrants comprehensive psychosocial support through which the needs of both the children and their families should be identified and addressed (Fazel & Betancourt, 2018).

This study identified that occupational therapy interventions were conducted in many physical environments in the community, and with different stakeholders. The need to consider both the ‘environment’ (i.e., where the interventions took place), and the ‘person’ (i.e., with various stakeholders), when providing interventions to refugee children aligns with existing occupational therapy practice models, for example, the Canadian Model of Occupational Performance and Engagement (Polatajko et al., 2007) the Person-Environment-Occupation model (Law et al., 1996), or the KAWA model (Iwama, 2006). These approaches are also congruent with the WFOT Position Statement in Human Displacement (revised) (WFOT, 2014) and occupational therapy’s role within community mental health settings in some HIC, such as the USA (Castaneda et al., 2013). Additionally, providing community-based interventions delivered in informal settings such as schools and leisure centers, rather than medical establishments, can offer non-stigmatizing and potentially more culturally appropriate services to refugees. Refugee families may be more likely to accept services in community-based settings given the increased likelihood of having a pre-established relationship with some of the people, such as in schools (Beehler et al., 2012).

Considering at which micro- (individual), meso- (organizational) and/or macro- (policy) level(s) to intervene, and consequently, with whom, for the most significant impact is important to consider when delivering occupational therapy interventions, particularly in low-resource practice areas, such as forced migration (Scheer et al., 2020). The intervention activities and programs identified by participants in this study were mainly focused on the micro-level (with the child and their parents), and the meso-level (teachers and to a lesser extent, peers). Possible reasons for this focus at the micro- and meso-level may be that the participants were doing their best prioritizing interventions for refugee children that were most likely to produce a visible and immediate effect, given the limited resources and short duration of intervention, for example, when using students to deliver interventions. Whilst these micro- and meso-level interventions can play an important role in facilitating psychosocial wellbeing in the child’s immediate environment, there was limited discussion of the role occupational therapy can play in macro-level interventions such as targeting policy and engaging in advocacy. The Occupational Therapy Practice Framework: Domain and Process (American Occupational Therapy Association [AOTA], 2020) supports occupational therapy’s role in advocacy and recognizes that occupational therapy intervention can expand beyond direct service provision. Relatively recent occupational therapy frameworks such as the Participatory Occupational Justice Framework (POJF) have been developed to encourage advocacy and facilitate social inclusion by raising awareness of, and addressing, issues of occupational injustices (Townsend & Whiteford, 2005).

Advocacy can take many forms and includes advocating for social and/or political change and transforming policies and services that directly affect displaced people (Burnett, 2003). Advocacy is important to consider in occupational therapy given the impact of restrictive forced migration policies on participation and wellbeing. Boyden (2001) contends that the experience of forced migration is essentially one of exclusion, as involuntary displacement to a foreign and potentially hostile environment constrains the opportunities for participation available to both children and adults. While it is important to equip refugees with tools and strategies to manage their problems at the micro- and meso- level, many of the challenges refugees face are structural and institutional in nature, such as prejudice, discrimination, and restricted access to opportunities for participation. Thus, it is critical that occupational therapists acknowledge the challenges refugees face in their wider context and complement any direct intervention with advocacy to address broader societal and political issues.

An occupational therapy lens can help provide a unique perspective to view how psychosocial wellbeing can be facilitated in a new environment for refugee children. Resettlement poses challenges for refugee children and their family (Soltan et al., 2022), however occupational therapists can help facilitate successful transitions. Some of the participants in this study described a sequential approach over time when working with refugee children by identifying pre-migration roles and routines of the child and their family, followed by recognizing the need to work on some of the skills and competencies for the refugee child to participate successfully in their new host country. Occupational therapists have skills that can prepare and support the child and their family regarding changes in roles, routines, and habits (AOTA, 2018). These skills include educating relevant stakeholders on the children’s needs, teaching skills needed so the refugee child can successfully participate in their new environment, and collaborating with community organizations and services to coordinate resources and accommodations that may be needed, so children can participate successfully in their new environment AOTA, 2018). These skills were all identified by the research participants in this study. The participants additionally identified their role in providing counseling support for refugee children, and their parents.

Client-centered practice and strength-based approaches were identified by participants as important to utilize when working with refugee children and their families. Client-centered approaches focus on relationship building and are foundational to occupational therapy practice (WFOT, 2010). Creating and building relationships is critical when working with people from a forced migration background, who may have had experiences of trauma, which are likely to impact on their ability to feel safe and connected (Bath, 2015). Client-centered practice can help empower refugee children and their family to identify meaningful goals and intervention choices. Empowerment is also a feature of strength-based approaches. Strength-based approaches are used by occupational therapists to work collaboratively with clients to identify their goals, skills, interests, and strengths. These approaches are useful in forced migration as there is a more equal distribution of power between the therapist and the ‘client’, so that the client is empowered to identify and builds on their strengths and enables them to see themselves as competent and resourceful (McCashen, 2005). Strength-based approaches are particularly important in forced migration, as people will likely have experienced adverse conditions during their migration journey that could impact on their sense of competency and agency. By using client-centered practice and strength-based approaches, occupational therapists can work collaboratively with clients and address power imbalances to create meaningful occupational participation opportunities.

Occupational therapists have skills to grade and adapt intervention modalities, based on the client’s need. Many of the interventions identified in this study included intervention activities where there was a reduced demand for verbal comprehension and/or processing skills, such as creative interventions, sports, and play. This noticeable lack of verbal processing approach used by participants with this population is noteworthy, when compared with interventions provided by practitioners from a psychological and psychiatric background (Trimboli et al., 2021). The wide repertoire of intervention activities and approaches that occupational therapy practitioners can provide to address psychosocial wellbeing is one of the strengths of having occupational therapy involved in providing psychosocial interventions to refugee children. Children who aren’t yet fluent in the host country language, and who may have experienced trauma, may feel more comfortable using non-verbal intervention approaches to express and process their emotions and trauma. Despite the acknowledgement of the use of psychosocial interventions through arts and sports, the literature supporting the effectiveness of such interventions is currently limited. Further research exploring the effectiveness of arts and sports-based intervention approaches is warranted.

It is evident from the results of this study that working in forced migration is a complex area of occupational therapy practice, as there are many contextual issues that need to be considered and addressed when providing meaningful interventions to this population. Occupational therapy in established areas of practice is already considered a complex area of practice due to the several interacting components involved in occupational therapy practice. These components include “the application of theories and bodies of knowledge, specific activities considered part of the occupational therapy process, and a range of interpersonal therapeutic techniques or behaviours” (Pentland et al., 2018, p. 39). However, results from this study indicate that working with forcibly displaced populations could be considered an even more complex area of practice as there are additional considerations required that may not be relevant to other areas of practice. Specific considerations include cultural awareness and providing culturally sensitive practice (considering that most children and their family will come from LMIC), language challenges, and working with potentially traumatized populations within a political landscape. With so many factors to consider, working in this area may appear challenging, however, connecting with, or establishing, formal or informal communities of occupational therapy practice and mentoring systems may be one way of supporting practitioners working in this area of practice.

Occupational therapy research is required to determine the effectiveness of the occupational therapy intervention activities and approaches currently being used for refugee children in middle childhood to ensure that the best possible practice is being provided, particularly given the resource constraints of working in this area of practice. However, there are many methodological and ethical challenges when conducting research with people who have been forcibly displaced that need to be considered and addressed. Literature highlights how power imbalances with people in authority and highly transient forced migration populations are likely to impact the research process (Block et al., 2013; Kaukko et al., 2017). Guidelines for conducting research with refugee populations have been published to facilitate an ethical approach to refugee research (European Commission, 2020) and should be considered when conducting research with this population. Additionally, future considerations for the occupational therapy profession include the need to address macro-level interventions in forced migration. incorporating frames of practice and models of practice that actively consider interventions to address systematic barriers to participation. Lastly, partnering with professions and organizations that are more involved in refugee community advocacy work is warranted.

Limitations

The qualitative nature of focus groups restricts the generalization of these results. The focus groups were held in English, and although the questions were provided prior to the focus groups with time to prepare responses, and the facilitator spoke some other languages, the non-native English speakers may not have felt completely comfortable providing more complex information or responding to the comments of other participants. To try to mitigate this, participants were invited to email the facilitator additional information after the focus groups, and participants could look at the recording transcripts to rectify any issues. Due to the online nature of the focus groups, it was also difficult to observe non-verbal cues, making facilitation challenging. In addition, purposive and snowball sampling was used mainly through social media channels. Using these online recruitment channels may have limited people who do not use social media from participating.

Conclusion

The rise in forced migration is evident. Middle childhood represents a unique opportunity for occupational therapy to promote psychosocial in refugee children who are living in HIC. This study is one of the first of its kind and has identified that occupational therapistsare using a wide range of intervention approaches and activities to promote refugee children’s psychosocial wellbeing in middle childhood in HIC, and that there are numerous considerations that need to be addressed when administering psychosocial interventions to these children. These findings are a first step to helping establish an evidence base to guide occupational therapy practitioners and occupational therapy students who are providing intervention services to refugee children located in HIC. The current occupational therapy literature base does not provide evidence that these interventions are effective, however some interventions have been identified as promising in the wider health literature. Although the evidence base does not currently exist within occupational therapy, the study participants were grounding their interventions in existing occupational therapy models and frameworks. However, occupational therapists have the potential to increase their scope of practice when working with refugee children, by including macro-level interventions, to ensure that systematic barriers to participation and considered and addressed.

Despite the challenges identified of working with refugee children, occupational therapy practitioners and occupational therapy students are currently using creative means to provide services to refugee children to address psychosocial wellbeing. Although the involvement of occupational therapy with refugee populations is a (re-)emerging area of practice, the involvement of occupational therapy services is warranted. The profession of occupational therapy provides a unique perspective by facilitating transitions into the host country by using strengths-based and client-centered approaches, having the potential to work in various environments and with the various stakeholders in contact with the refugee child, and from a multi- systems level. Although occupational therapy practitioners have a vast variety of intervention approaches and activities at their disposal, occupational therapists are urged to develop a coherent evidence-base and engage in research activity to ensure that those interventions that are being administered are effective, and those that are not effective, to be discontinued.

Author contributions

Concettina Trimboli: Conceptualization, Data collection, Data curation, Data analysis, Validation, Methodology, Writing – Original Draft, Writing – Review & Editing, Project administration.

Caroline Fleay: Conceptualization, Data analysis, Writing – Review & Editing, Supervision.

Lauren Parsons: Conceptualization, Data analysis, Writing – Review & Editing, Supervision.

Angus Buchanan: Conceptualization, Data collection, Data analysis, Writing – Review & Editing, Supervision.

Acknowledgments

We would like to thank all the study participants for their time, generosity of responses, and their valuable insights, and Mr Volker Paelke for his help with the figures in this paper.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the Research Training Program (RTP) Stipend Scholarship.

Notes

1 Refugees are defined as people being outside their country of habitual residence, who are unable to return to their country of origin due to a well-founded fear of persecution based on their race, religion, nationality, membership in a particular social group, or political opinion United Nations General Assembly (1951).

2 A developmentally appropriate form of play designed for children experiencing social, emotional, behavioral, and relational disorders.