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Visions Journal

A reminder that this article from our magazine Visions was published more than 1 year ago. It is here for reference only. Some information in it may no longer be current. It also represents the point of the view of the author only. See the author box at the bottom of the article for more about the contributor.

War Trauma in Refugees

Red flags and clinical principles

Claudia María Vargas, PhD

Reprinted from "Trauma and Victimization" issue of Visions Journal, 2007, 3 (3), pp. 12-13

We know that the wounds from war are not confined to the battle field. Refugees from conflict zones often continue to experience trauma from persecution, imprisonment, torture and resettlement for a long time. Thus, it is important to understand the challenges of refugee families and communities.2 This piece identifies some red flags for post-traumatic stress disorder (PTSD) according to age, gender and culture, and provides some guiding principles for mental health workers in caring for refugees.*

Psychological distress from war is harmful to refugee children and adults regardless of racial or cultural background. Refugees may experience a sense of helplessness and despair. The most common mental health issue for refugees is post-traumatic stress disorder and related symptoms of depression, anxiety, inattention, sleeping difficulties, nightmares, and survival guilt.3-12

Red Flags


Trauma can look very different across the developmental stages. Here are some of what we know are danger signs:

  • Birth to five years. Young children have difficulty explaining their trauma, but display their trauma by clinging to their mothers, trembling and uncalled for crying. They may also show their trauma through play and inappropriate behaviours for their age like thumb-sucking, nail-biting, bedwetting, frightened facial expressions, fear of darkness or sleeping alone, and little social interaction.13-14 According to the research, parents may not recognize possible trauma, because they mistakenly assume “the child wasn’t looking when it happened” or “was too little to know.”9

  • Six to 11 years. Children at this age may become anxious, depressed, angry, unable to concentrate or socialize with peers, and may refuse to go to school. Others may experience sleeping difficulties, nightmares, fear of the dark, and physical ailments like vomiting, headaches or stomach aches. This age group is three times more likely to suffer from PTSD than adolescents, because they are at a younger stage of development.15-16

  • Adolescents. Adolescents may be affected for a long time.13 They can feel as if they are frozen in the past, with no prospect of a future.17 Their trauma shows in school difficulties, eating disorders, alcohol abuse, teenage pregnancy, thoughts about suicide, or general ‘acting out.’ Most at risk are those who have lost family and community connections.18

  • Adults. Traumatized adults tend to suffer from hypervigilance, emotional numbing and flashbacks or re-experiencing the trauma.1 They may startle easily, show the fight-or-flight response or a heightened sense of awareness, and suffer from nightmares, emotional detachment from oneself and others, and distorted emotions and perceptions.19-21 They may abuse drugs or alcohol, and become depressed, hostile and suicidal.


Girls tend to internalize the trauma and become anxious, withdrawn and depressed. Boys tend to externalize trauma and are more likely to and be inattentive, impulsive and hyperactive, or to engage in violent activities.19 However, findings are inconclusive regarding gender differences.

More important than gender, however, for youngsters is family separation, the murder of a parent (more likely to be the father, since more refugee men are murdered than women), parents’ emotional well-being, experience of torture by a family member, or the number and intensity of traumas.15-16,19,22


Findings point to commonalities in the human experience of emotional and physical pain and suffering across cultures.23-25 The expression of trauma may differ: e.g., Soviets tend toward alcohol abuse,26 while Ethiopians describe physical symptoms such as “burning all over, a tight feeling in the neck, and ‘insects crawling under the skin.’”27 Vietnamese have the think-too-much problem, and Latin Americans have “nervios” (nerves).26 However, we need to be careful about stereotyping. The suffering is universal.

Some Principles of Care**

Multidisciplinary care

Refugees may have faced many health challenges, physical injuries, hunger, diseases and emotional trauma. It is essential to provide medical and mental health care, as well as the housing, schooling, and employment needs essential to life in their new homeland.

Complementary therapies

Survivors of torture have been shown to suffer intense and prolonged pain, and they have a greater risk of developing chronic pain and other health problems.28 Treatment of chronic pain from injuries that damaged nerves, muscles or bones may need more than one type of therapy, starting with medical care. Complementary therapies such as psychotherapy and body work appear to help the emotional and physical healing process.28-29

Family-centred care

Since PTSD affects the whole family, it is important to learn its effects on all family members. Professionals who are family-centred are sensitive to the different ways families cope with loss and sorrow, and to their need to maintain their culture and language. These practitioners value cultural diversity and uniqueness across families and explore the need for community supports and reconnecting families with their cultural communities.1,28-31

Strengths model

Refugees face many challenges—a different language, culture and world view—but they also bring with them many strengths. As survivors of persecution and cultural and family losses, they are motivated to succeed and create a better life for themselves and their children. Amidst the pain and trauma, clinicians need to recognize their strengths.32

Cultural responsiveness

War trauma can affect future generations, as illustrated by the suffering of Indigenous and persecuted groups.33-34 There is a need for cultural competence based on respect, trust, empathy, care and understanding of the socio-political and historical forces that led refugees into exile.26,28-29,33 A culturally welcoming and safe environment is essential. Culture-sensitive care embraces cultural healing practices, including the role of spirituality and the mind–body–spirit connection.

* The essay is based on a review of international studies on PTSD in refugee children, complemented with interview data of service providers in Canada and the United States. The information gathered has been shared with respondents.

** The Vancouver Association of Survivors of Torture developed the VAST Therapeutic Principles of Care. See footnote reference 17.

About the author
Claudia is an Adjunct Associate Professor in the Pediatrics department at Oregon Health and Science University. Dr. Vargas has worked and done research on refugee services and disabilities in Canada and the United States.
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