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Article 68

Refugee Children’s Fears and Coping Mechanisms

A Preliminary Investigation

Monica Leppma & Judit Szente

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Paper based on a program presented at the 2013 ACES Conference, Denver, CO, October 18.

Acknowledgement

The present study was supported by the Toni Jennings Exceptional Education Institute Special Initiative Award Grant from the University of Central Florida (2010-2012). The authors would like to acknowledge the research assistants involved in the study: Jacklyn Keller, Lauren Perez, Francis Jacamo, and Kristin Shoemaker for their data collection and analysis.

There is evidence that refugee children are at considerable risk for mental health problems (Fazel & Stein, 2002) because they have potentially experienced stressors such as exposure to war and violence, loss of their home, malnutrition, detention, and separation from their family (Birman et al., 2005). The most recent statistics indicate there are over 15 million refugees worldwide (U.N. Refugee Agency, 2011). The U.N. Refugee Agency defines a refugee as a person who is outside his or her country of nationality or habitual residence; has a well-founded fear of being persecuted because of his or her race, religion, nationality, membership of a particular social group or political opinion; and is unable or unwilling to avail him- or herself of the protection of that country, or to return there, for fear of persecution (2011). In 2011, approximately 38% of the refugees seeking to re-settle in the United States were children (Martin & Yankay, 2012).

Despite research indicating the need for psychological and social services, information is lacking as to the clinical needs of refugee children (Betancourt et al., 2012; Villalba, 2009). Moreover, children are an understudied and underserved population in the mental health field, especially refugee children, who are particularly vulnerable (Betancourt et al., 2012). Refugees experience stress and trauma while in their own country (e.g., surviving war, terrorism, or disasters; Szente, Hoot, & Taylor, 2006), while fleeing to a new country, and then while settling into their new home country. The period of settling in is often referred to as a period of “secondary trauma” (Fazel & Stein, 2002, p. 366). Research indicates that approximately half of newly arrived refugee children exhibit symptoms of anxiety (Fazel & Stein, 2002), which is a fear-related disorder. Many of these children’s fears may be symptoms of post-traumatic stress disorder. Fear and anxiety may also manifest as worry, irritability, sleep disturbances, or somatic issues such as headaches or abdominal pain (Fazel & Stein, 2002).

The Foundation for Child Development (2010) indicated that immigrant children face many challenges that may inhibit their potential. The process of adapting to a new environment seems to be more difficult for refugee children due to possible hardships prior to coming to their new home country and their effect (i.e., fear) on their development. Experiencing adversity combined with significant changes can leave children feeling vulnerable, anxious, or fearful (Szente, Taub, & Leppma, 2013).

Fear is a natural process throughout childhood development. Adaptive fears foster self-preservation or motivation. Maladaptive fear responses, however, may hinder normal development to the point of becoming debilitating (Robinson & Gladstone, 1993; Robinson, Rotter, Fey, & Robinson, 1991). Excessive fear inhibits children’s ability to concentrate and learn (Moses, Aldridge, Cellitti, & McCorquodale, 2003). Failure to address such maladaptive and excessive fears creates the potential for anxiety disorders or other mental illness. Thus, understanding refugee children’s fears, and their attempts to cope, provides valuable information for addressing their mental health and developmental needs.

Several studies have been conducted in the past with both children and adults in order to study children’s fears (e.g., Bayer, Sanson, & Hemphill, 2006; Burnham, 2009; Driessnack, 2006; Elbedour, Shulman, & Kedem, 1997; Gebeke, 1994; Lahikainen, Kirmanen, Kraav, & Taimalu, 2003; Lahikainen, Kraav, Kirmanen, & Taimalu, 2006; Ollendick, Langley, Jones, & Kephart, 2001; Robinson, Robinson, & Whetsell, 1988; Robinson et al., 1991); however, results vary greatly. In addition, fear studies from the 19th through the 21st centuries indicated that children’s fears are affected by current events, situations, and social and political circumstances such as war, terrorism, or natural disasters. According to Moses at al. (2003), “the most common fears children experience during these times are fears about separation, abandonment, physical danger or injury, and death. …During a time of war, children’s assumptions are shattered. They no longer believe that they or their families are safe” (p. 9). Thus, it remains important to continuously study the changing nature of children’s fears and determine the best methods for fostering internal resources and resilience.

As refugee children go through the resettling process, it is important that people in the child’s support system understand their fears and coping mechanisms as they adjust to their new environment (Szente, Taub, & Leppma, 2013). The purpose of this study was to explore any effects that refugee status had on normal fear development. The present study is intended to address a gap in the literature because to date there is no research that focused on refugee children’s fears from both children’s and parents’ perspectives and on examining refugee children’s coping strategies. The present study is also unique in the way that it employs a variety of instruments that are designed to examine children’s self- reported and projected fears from drawings and a series of interviews.

Method

Participants

A convenience sample of 18 refugee children between the ages of 6-13 was selected for this study. In addition, one parent for each child was also asked to participate. Refugee children and their parents were identified for this study through the co-author’s existing collaboration with a non-profit program that aids refugees in the resettling process in the area.

Institutional Review Board approval was obtained for the study, and the caregiver consent and child assent processes took place through collaboration with the non-profit refugee resettling program. The children represented the following five countries: Haiti, Cuba, Sudan, Venezuela, and Vietnam. Their ages ranged from 6 to 13 (M = 9.64) and represented both genders (8 male, 10 female). The participants were attending public schools and received services from the same refugee youth program in a city in the southern United States. Their length of stay in the United States ranged from 5 months to 6 years with a mean residency of 28 months.

Instruments

Qualitative measures (semi-structured, open-ended interviews) were utilized with children and parents. When conducting any assessment with children, it is recommended that interviewers obtain information using multiple methods and multiple sources (Leppma & Jones, 2013). Accordingly, we designed the study to use a draw-and-tell approach, along with a picture-aided semi-structured interview, to seek information directly from the child participants. Using a draw-and-tell approach for exploring children’s fears provides unique insight into how children describe and experience fear (Driessnack, 2006). Picture-aided interviews assist children in discussing fears that may be more difficult to identify or verbalize (Lahikainen et al., 2003). In addition, we obtained information about the child participants from their parents, utilizing a semi- structured interview and a demographic questionnaire.

Child Participants

Draw-a-picture/semi-structured interview. Each child had choice of white/manila paper (8 x 11 inches) and choice of pencil, markers, and crayons. First, each child was asked to draw any picture that they wanted and tell about their picture. This was done to help put the child at ease by beginning the interview with a positive, creative activity (Moses et al., 2003). After they completed their drawing and reflection, each child was also “asked to think about a time when he or she was most afraid” (Driessnack, 2006, p. 1419) and draw it. If the child hesitated, parts of a semi-structured interview (Lahikainen et al., 2003) were used:“All people, even adults are sometimes afraid of something, although they may be afraid of different things than children. …What things are you afraid of?” (p. 86). Children were then asked to (a) tell about their picture, (b) tell about how they felt in that picture, and (c) tell about what they thought would make them less scared. Finally, children were asked to draw/write their names on their drawings.

Picture-aided semi-structured interview. The child being interviewed was shown a series of six pictures (black and white drawings) with (a) a child’s face that is the same sex and age as the child being interviewed; and (b) a child of differing sexes and in different settings. Questions such as: “This child is the same age as you are. He/she is afraid. What is he or she afraid of?” were asked (Robinson et al., 1988, p. 86). If a child did not respond, no further encouragement was given. If the child responded, additional questions included: “How afraid is he/she?; How does the child know that s/he is afraid?; What does s/he do when s/he is afraid (say, do, think, etc.)?; and What can s/he do to be less afraid?” Responses were recorded on Response Sheets. The validity of this instrument was demonstrated by Robinson et al. (1988). The reliability of the instrument is reported as .79 (Robinson et al., 1988).

Parent Participants

Semi-structured interview. Parents were asked to describe the following: (a) What their child seemed to be afraid of; (b) How often fear manifested in actions (What types of actions? What did the child do, look like, say, etc. before, during, and after the fearful situation?); (c) Ways the child was coping with fearful situations; and (d) Types of traumatic experiences of the child (victim, witness, etc.).

Demographic questionnaireEach parent was asked to complete a Demographic Questionnaire indicating their child’s age, gender, ethnicity, country of origin, SES, birth date, grade, maternal/paternal education level, length of time in the United States, prior educational experiences of the child, child’s level of English, and number of people in the family.

Data Collection

Four undergraduate students were trained to assist in the data collection procedures. University faculty held regular meetings with the research assistants throughout the data collection process to reflect on and discuss the progress. The interviews were conducted in the refugee families’ homes, and the children and parents each participated independently. The total interview time was 1.5 hours on average. University faculty accompanied the research assistants whenever possible. The official caseworkers for the families were also present during the interviews and were able to provide translations when necessary. If at any point in the study a child or parent felt uncomfortable or uneasy to answer a question, s/he was allowed to stop participating.

Data Analysis

Participants’ responses to the interviews were recorded on corresponding Response Sheets. Frequency distributions technique was used to make comparisons within the study (Gladstone, 1990) to allow for a systematic arrangement of individual measures. The fear object with the highest frequency was included on the top of the list, followed by the next highest frequency, etc. Once the frequency tables were created, content analysis of the responses was performed and the responses were analyzed by cultural groups, age, and gender.

Results

Data analysis resulted in eleven different fear themes: Animals (26%), Imaginary/Cultural Creatures (16%), NA (15%), Lack of Safety (12%), Dark (13%), Other (2%), Lack of Basic Needs (1%), Being Alone (2%), Nature (5%), Scary Movies (5%), and Verbal Arguments/Disagreements (3%). Animals included snakes, dogs, crocodiles, frogs, rats, turtle, lion, bear, tiger, rabbit, and alligator. Imaginary/Cultural Creatures included ghosts, monsters, zombies, zombie cats, evil spirits, and dragon. NA indicated the child did not give an answer or said, “I don’t know.” Lack of Safety included kidnapping, being chased, bad things, someone escaping from jail, someone hurting the child, getting hit by a car, falling, hiding, doing drugs, and police. Results further indicated that the top 5 most frequent children’s fear themes were: Animals (26%), Imaginary/Cultural Creatures (16%), NA (15%), Dark (13%), and Lack of Safety (12%). The following sections indicate the fear themes broken down by category. Table 1 delineates the top fear themes by country, gender, and age group.

Table 1

Top Five Fear Themes by Percentage for Country, Gender, and Age

Note: -- denotes no other fears identified

Children’s Fear Themes by Country

Haiti. Results for Haitian children indicate that their most frequent fears are as follows: Animals: rats, snakes, dogs; Imaginary Creatures: monsters, zombie cats, zombies, dragon, evil spirits; Lack of Safety: someone chasing the child, doing drugs; Nature: rain, trees falling on child; and Other: thinking, something the child was looking at.

Sudan. The most frequent fears for Sudanese children are: NA; Lack of Safety: someone hurting the child, getting hit by car; Dark; and Verbal Arguments/ Disagreements: parents shouting.

Cuba. The most frequent fears for Cuban children are: Animals: elephant, rabbit, snake, turtle, lion; NA; Dark: being in the dark alone, being outside at night; and Lack of Safety: hiding, falling, someone chasing the child, bad things, someone escaping from jail.

Venezuela. Data for Venezuela indicate the following most frequent fear themes: Animals: snakes, crocodile, bear; Imaginary/Cultural Creatures: ghosts; and Scary Movies.

Vietnam. The most frequent fear themes for the fifth cultural group, Vietnamese children, are as follows: Imaginary/Cultural Creatures: monster, ghosts; Dark; Lack of Safety: kidnapping; Nature: thunder, lightning, rain; Animals: tiger, alligator; and NA.

Children’s Fear Themes by Gender

Data suggested that the top five fear themes for both genders were the same: Animals, Dark, Lack of Safety, Imaginary/Cultural Creatures, and NA; however, their order and percentages were different. The top five fear themes for females were Animals, NA, Dark, Lack of Safety, Imaginary/Cultural Creatures. The top five fear themes for males were Animals, Imaginary/Cultural Creatures, Lack of Safety, NA, and Dark.

Children’s Fear Themes by Age

Data for both age groups (6-9 and 10-13 years of age) resulted in similar results. The top five fear themes for 6-9 year olds were Animals, NA, Imaginary/Cultural Creatures, Lack of Safety, and Dark. The top fear themes for the adolescent group were Animals, Dark, Lack of Safety, Imaginary/Cultural Creatures, Other, and NA. Although the order and percentages were different, there were four common fear themes within the top five most frequent themes for both age groups: Animals, Lack of Safety, Imaginary/Cultural Creatures, and Dark.

Comparisons of Children’s Self-Reported Fears and Parents’ Views of Children’s Fears

The individual comparisons indicate that there is a 33.3% match between the parent’s and the child’s views of the fear object (in 6 out of 18 cases). In the majority of cases (66.7% - 12 out of 18 families), there is a difference between what the parents think their children are afraid of and what the child reports as his/her fear object. For example, 66.7% of parents believed their children were afraid of the dark, when in fact only 33% of children reported fear of the dark in their Draw-and-Tell interview.

Children’s Coping Mechanisms

The most common coping strategy themes were NA (26%), Leaving (e.g., running away, going somewhere else; 15%); Interacting with Fear (e.g., talking to fear, making friends with or loving fear, fighting or yelling at the fear; 14%); Imagining Fear not Being There (e.g., closing eyes, imagining fear is not there, imagining good things instead; 9%); Family (help from a relative; 9%); Prevention (e.g., staying away from fearful object; 7%); Self Comfort (e.g., telling self not to be afraid or cry; 5%); Animals (e.g., getting a dog or lion; 5%); Light (e.g., turning on light; sun will help; 5%); Hiding (4%); and Asking for Help (e.g., calling someone or 911; 2%).

Discussion

The various fear themes fell within the categories described in previous studies (e.g., Bayer et al., 2006; Burnham, 2009; Driessnack, 2006; Elbedour et al., 1997; Gebeke, 1994; Lahikainen et al., 2003; Lahikainen et al., 2006; Ollendick et al., 2001; Robinson et al., 1988; Robinson et al., 1991). The top five most frequent fear themes for all cultures, genders, and ages combined were: Animals, Imaginary/Cultural Creatures, NA, Dark, and Lack of Safety. When separated by cultures, Venezuelan and Haitian children feared Animals the most, indicating a higher than average total frequency (60% and 32% respectively). Haitian children and Vietnamese children feared Imaginary/Cultural Creatures the most (32% and 23.5% respectively). When looking at the NA theme, Sudanese and Cuban children indicated it the most (44% and 22% respectively). In terms of the Dark fear theme, Sudanese and Vietnamese children indicated higher than average frequencies (22% and 23.5% respectively). Similarly, Sudanese and Vietnamese children indicated more frequencies than the average for the Lack of Safety fear theme as well (22% and 18%). Further analysis of previously experienced traumatic events such as man-made or natural disasters could help explain these findings.

Data analyzed by gender illustrated that boys reported Imaginary/Cultural Creatures such as zombies, ghosts, and dragons (21%) and Scary Movies (7%) with a lot more frequency than girls (9% and 0% respectively). On the other hand, girls reported Dark (17%), Lack of Basic Needs (4%), and Verbal Arguments/Disagreements (4%) with more frequency than boys (9%, 0%, and 0% respectively).

Regarding the two age groups (ages 6-9 and 10-13), there was a minor difference among the top five fear themes. Younger children appeared to have more NA responses that may be the result of shutting down earlier by the picture card interviews. In addition, younger children were more afraid of Being Alone (6%) and Scary Movies (6%) than older ones (0% and 0%) and reported more NA responses (19% and 11% respectively). Children aged 10-13 reported Lack of Basic Needs (4%) and Other (11%) themes more frequently than those of ages 6-9 (0% and 0%). Similar to the above, additional analysis of previous traumatic experiences may help explain these findings.

The findings indicated that only 33% of the parents knew the source of their children’s fears. The remaining 67% of parents either did not know whether their child was afraid of anything or thought of another fear object for them. This result is similar to the literature indicating that parents often underestimate the prevalence and intensity of their children’s fears (Barrett et al., 1991; Klein, 2009).

Lustig et al. (2003) recommended that counselors explore refugee children’s coping strategies in order to build on their strengths and resilience. The stress associated with being a refugee can be mediated by improving coping strategies, belief systems, and social relations (Lustig et al., 2003). In the present study, 10 various ways of coping strategies were identified. All these strategies, except NA, fit within the four factors of coping style identified by the Program for Prevention Research (1999): Active, Avoidant, Distraction, and Support Seeking. Active coping strategies identified by participants included leaving, interaction with the fear, prevention, and self-comfort. Avoidant strategies identified included imagining the fear not being there and hiding. The Distraction strategy identified was using light. Finally, Support Seeking strategies included relying on family, animals, and asking for help.

The most common coping strategy theme identified in this study was NA (26%), which suggests that children did not know how to be less afraid or what to do to conquer their fears. The next most frequent coping strategies were Leaving the Fear Object (15%) and Interacting with Fear (14%). The types of interactions differed in terms of positive interactions such as talking to the fear, making friends with the fear, or loving the fear as well as negative interactions such as fighting the fear or yelling at the fear. The next two most frequent coping themes were Imagining Fear not Being There (9%) by closing their eyes and imagining good things instead, and Family (9%).

Conclusion and Implications

This study examined refugee children’s self-reported and projected fears, their coping mechanisms, and the relationship between children’s and parents’ views of their children’s fears. The findings suggest that refugee status may affect fear development in children. Eighteen refugee children between the ages of 6 and 13 were included in the study along with their parents. The participants represented the countries of Haiti, Sudan, Cuba, Venezuela, and Vietnam. The limitations of the study include the number of countries represented, the number of participants, and some of the children seemed to shut down very quickly when talking about the picture-aided cards; therefore, no data could be collected for that part of the child interviews. Nevertheless, this is the first study to investigate the fears and coping mechanisms of refugee children through child and parent interviews. Therefore, our findings carry the potential to contribute to the newly growing body of research exploring the mental health needs of refugee children. Moreover, there are several implications suggested by the findings that may ameliorate the assessment and treatment planning process for working with refugee children.

As indicated previously, fear is part of the normal child development process. When the developmental process is combined with prior traumatic events such as experiencing natural or man-made disasters, it is crucial for parents and professionals to create and maintain a safe environment for children. In such environments, we can learn what children are afraid of, listen to their fears, and show respect for children’s feelings. Once we know the source of children’s fears, we can help to provide them “a supportive and safe foundation” (Gebeke, 1994, ¶ 20). To do this effectively, counselors must understand children’s fears in the context of their individual experiences and culture.

Refugee children represent a vulnerable population and are subject to high levels of psychological distress, which may affect their pattern of fear development (Fazel & Stein, 2002). It is important that counselors are prepared to accurately assess and treat fear responses of refugee children. In the present study, both age groups (6 – 9 and 10 – 13) reported Animals as the top fear. However, normative data on fear development indicate that fear of animals generally decreases in school-age children (Robinson et al., 1991). The difference here may be due to the refugee children having experienced significant trauma, and it felt safer to discuss a concrete fear such as animals as opposed to fears related to their actual experience. Therefore, it is important that counselors understand potential variations in fear development to better assist refugee children. Furthermore, when school-age children report animals as their top fear (rather than safety or social-related fears) counselors should consider assessing for a possible history of trauma or loss.

Consistent with previous research (Barrett et al., 1991; Klein, 2009), parents in the present study were unaware of, or underestimated, their children’s fears. This highlights the importance of asking children themselves about their fears. It is essential that counselors allow refugee children to voice and work through their fears. To do this, counselors may need to spend additional time focusing on creating an atmosphere of safety, trust, and open communication that fosters self-exploration of refugee children’s fears as well as allowing for the counselor to explore the world from the child’s perspective (Robinson et al., 2004). The need to spend sufficient time to create a safe atmosphere may account for some of the children in this study shutting down during part of the interview. Future studies may require more than one meeting with refugee children to develop a sense of safety that allows the children to explore their fears more fully.

About one-fourth of the children in this study were unable to provide an answer when asked what they could do to be less afraid. This suggests a need for adults to teach coping skills and foster resilience. A few of the children were able to identify active approaches to managing their fears. Continued exploration of refugee children’s coping skills may help identify specific factors to build resilience in vulnerable children.

Enabling children to voice and work through their fears can start fostering resilience and healing. Such a process is essential before children can successfully adjust to their new school and new life in their new home countries. Learning to overcome fears promotes the development of problem-solving skills, which in turn enables children to become more independent and self-reliant (Stephens, as cited in Simons, 2010). Counselors play a critical role in early detection and treatment of mental health problems in refugee children (Lustig & Tennakoon, 2008) in order to ensure their optimal development.