Bennouna et al. Conflict and Health
(2019) 13:47
https://doi.org/10.1186/s13031-019-0233-x
RESEARCH
Open Access
Ecologies of care: mental health and
psychosocial support for war-affected
youth in the U.S.
Cyril Bennouna1, Maria Gandarilla Ocampo2, Flora Cohen2, Mashal Basir3, Carine Allaf4, Michael Wessells3 and
Lindsay Stark2*
Abstract
Background: Youth resettling to the U.S. from conflict-affected countries in the Middle East and North Africa
(MENA) face countless challenges. As they cope with their experiences of armed conflict and forced migration,
these girls and boys must also adjust to the language and social norms of their new society, often encountering
prejudice and discrimination along the way. Previous studies indicate that schools can play a central role in
facilitating this adjustment while also promoting mental health and psychosocial wellbeing. This qualitative study
aims to understand the lived experiences of MENA newcomers resettled in Austin, Texas and Harrisonburg, Virginia
and to assess how schools, families, and communities support their mental and psychosocial wellbeing.
Methods: We held six focus group discussions across the two cities with a total of 30 youths (13–23 years) from
Iraq, Syria, and Sudan. We also conducted semi-structured interviews with 30 caregivers and 27 key informants,
including teachers, administrators, service providers, and personnel from community-based organizations.
Results: Guided by Bioecological Theory, our thematic analysis identifies several means by which various actors
work together to support resettled adolescents. We highlight promising efforts that seek to enhance these
supports, including sheltered instruction, school-parent collaboration, peer support programming, social and
emotional learning initiatives, and integrated mental health centers.
Conclusion: While this study underscores the resilience of newcomers and the value of local support systems, it
also reflects the importance of investment in schools, mental health systems, and resettlement programs that can
enable newcomers to achieve their full potential.
Keywords: RefugeeMental health and psychosocial supportYouthAcculturationEducation
Introduction
The United States has a long history of welcoming immigrants fleeing armed conflict and persecution. From
1975 to 2018, the U.S. Refugee Resettlement Program
welcomed an estimated 3.4 million refugees around the
country [1]. The Trump Administration, however, has
substantially reduced the resettlement program in recent
years, resettling 30,000 people in FY 2019, and planning
to limit admissions further to 18,000 in FY 2020 [2]. Typically, two of every five refugees resettled to the U.S. is
under 18 years old [3].
* Correspondence: lindsaystark@wustl.edu
2
Brown School at Washington University in St. Louis, Missouri, USA
Full list of author information is available at the end of the article
Resettled children and adolescents face a number of
difficulties due to their pre-migration and displacement
experiences, often including exposure to violence, family
separation, and lost years of education, among other
hardships. Many of these girls and boys struggle with
psychological distress resulting from repeated exposure
to adversities and the loss of their social supports [4]. As
they cope with these adversities, resettled girls and boys
may also struggle to learn the language and social norms
of their new society [5]. When they begin reintegrating
into schools, these newcomers have to compete with
students who, for the most part, have spent the majority
of their lives in American schools.
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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While parents struggle to support their children’s adjustment, they also face their own difficulties, including
finding and keeping gainful employment, navigating access to transportation and public services, and managing
households [6, 7]. Even those with higher educational
achievement and skills training in their home countries
tend to struggle to find well-paying jobs after resettlement,
as U.S. employers often do not recognize their advanced
degrees or employment credentials [8]. Since parents work
long hours, and children typically pick up conversational
skills more quickly than their parents, many family responsibilities fall on older children [9].
Nevertheless, a sizeable proportion of girls and boys
resettled to the U.S. overcome these challenges, often
through a variety of protective and promotive factors
that foster resilience [10]. These protective factors span
the individual, family, community, and societal levels. A
range of mental health and psychosocial support
(MHPSS) programs aim to help newcomers by preventing suffering, reinforcing strengths, promoting psychosocial wellbeing, and treating mental disorders [11]. In
principle, MHPSS systems should consist of four layers
(or “tiers”) of support, including: [1] the universal
provision of basic services in a safe, participatory, and
socially responsible manner that promotes mental health
and psychosocial wellbeing [2]; strengthening family and
community supports [3]; focused services from nonspecialized workers (e.g. psychosocial first aid); and [4]
specialized support from mental health professionals
(e.g. Trauma-Focused CBT) [11, 12].
Schools play a central role in supporting young people’s
adjustment to their new homes through a variety of academic, social, and emotional supports [5, 13]. School-led
social and emotional learning (SEL) initiatives focus on
helping youth “develop the ability to recognize and manage
emotions, develop caring and concern for others, make responsible decisions, establish positive relationships, and
handle challenging situations effectively” [14]. More
broadly, schools can deliver multi-layered MHPSS directly
to students or connect students and families to appropriate
services. A growing literature has documented that schoolbased SEL and other multi-layered MHPSS activities can
promote resilience among resettled children and adolescents, but more research is needed to understand how
schools, and school systems, work with students, families,
and communities to deliver such supports [15–17].
According to data from the U.S. State Department,
which classifies refugees according to seven geographic regions, individuals from what it titles the Near East and
South Asia constituted the single largest regional group of
refugees admitted to the U.S. between 2008 and 2017, ranging from 35.1 to 51.6% of all admissions [18]. Although
the number and proportion of refugees from this region
have diminished substantially in recent years under the
influence of the Trump Administration’s travel bans and
new admissions ceilings, 33.6% of arriving refugees in
2018 came from the Near East and South Asia region [18].
Despite constituting such a large proportion of newly arrived refugees in the U.S. over the past decade, the experiences, needs, and capacities of students resettled to the
U.S. from the MENA region have been largely overlooked.
Girls and boys from countries such as Syria and Iraq may
have unique experiences with resettlement in the U.S.
owing in part to high levels of discrimination against individuals from the Middle East and North African (MENA)1
region in the years following the terrorist attacks of September 11, 2001 and the subsequent Global War on Terror [19, 20]. Anti-MENA sentiment perpetuated by mass
media and policymakers has contributed to a climate of
overt prejudice and discrimination against MENAidentified individuals in the U.S. [19]. In 2017, for example, anti-iIslamic offenses comprised 18.7% of all
religion-based hate crimes, a steep increase from 2% before September 11, 2001 [21, 22]. Furthermore, Muslims
report higher perceived discrimination than their Christian counterparts [23].
Additionally, individuals from the MENA region may
face acculturation stressors regarding the dominant attitudes, behaviors, and social norms of their new societies.
For example, whereas traditional gender roles may regard women as caregivers more than breadwinners,
women often need to work upon their arrival to the
U.S., potentially shifting parental and spousal relationships. While parenting styles differ across the MENA region, parents accustomed to more authoritarian
parenting styles, and the use of corporal punishment,
may have difficulty adjusting to environments promoting
more permissive or flexible parenting styles [24, 25].
What constitutes “health” can also vary across newcomer groups, especially regarding mental health and
psychosocial wellbeing, which can be highly stigmatized.
Differences of interpretation related to defining, identifying, and responding to idioms of distress complicate effort to communicate about MHPSS transculturally and
can lead to underutilization of available services [25].
Study objectives
This study aims to understand the lived experiences
of MENA newcomers resettled in Austin, Texas and
Harrisonburg, Virginia. In particular, we intend to:
1. Identify common challenges that adolescent
newcomers from the MENA region, and their
1
Including Algeria, Bahrain, Comoros Islands, Djibouti, Egypt, Iran,
Iraq, Israel, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco,
Oman, Palestine, Qatar, Saudi Arabia, Sudan, Syria, Tunisia, United
Arab Emirates, and Yemen.
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families, encounter regarding acculturative stress
and psychosocial adjustment; and
2. Assess how individuals, schools, families, and
communities currently support the mental and
psychosocial wellbeing of adolescent newcomers
from the MENA region, including the perceived
strengths and limitations of these supports;
By documenting the experiences of this often-neglected
sub-population and locating the possible mechanisms
through which they adapt to their new schools and communities, we hope to inform future research efforts to
quantify the MHPSS needs and capacities of conflictaffected newcomers from the MENA region. This study
should also provide guidance for the development of programs and policies aiming to strengthen the environment
of care for these newcomers.
Conceptual framework
The Bioecological Theory of Human Development provides a useful starting point for studying how the different
supports in an adolescent’s life influence their outcomes
after resettlement [26, 27]. The theory holds that human
development takes place through processes of interaction
between the individual and the “persons, objects, and symbols in its immediate external environment” [27]. These
processes, which can include for instance studying, problem solving, and caring for others, are in turn influenced
by the characteristics of the person and the context and
time in which they live. Scholars and practitioners working with populations affected by armed conflict have usually focused on the ways in which contextual factors at
various ecological levels influence young people’s outcomes (Fig. 1). Factors in an adolescent’s microsystem, or
immediate environment, include their interactions with
family members, peers, educators, and service providers.
The relationships between these different microsystems—
for instance, how family members interact with the
school—constitute the individual’s mesosystem. Factors in
an adolescent’s exosystem, meanwhile, influence the adolescent indirectly, such as a parent’s relationship with their
workplace. Finally, the macrosystem includes factors at the
broadest levels of society, such as policies, political ideology, prejudice, and social norms, which influence adolescents through the micro-, meso-, and exosystems.
Scholars have adapted the Bioecological Theory in various ways to study resilience [28, 29], acculturation [30],
and ethnic trauma [19], and to assess the educational
Fig. 1 Adapted Illustration of the Bioecological Theory (Bronfenbrenner, 1979; Bronfenbrenner & Morris, 2006)
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needs of resettled refugees [31, 32]. In line with several of
these authors, we distinguish between pre-migration,
transmigration, and post-migration social ecologies [31].
This change of social ecological context is the defining
feature of migration, and although it may confer a range
of benefits both to the individual and the welcoming society over time, the acculturative stress that accompanies
migration and resettlement may also compromise an adolescent’s mental health and psychosocial wellbeing [19, 33,
34]. The context of reception in the receiving community,
including its degree of openness, provision of support, acceptance of newcomers, and opportunity structures, can
mitigate or exacerbate this acculturative stress [35].
Methods
Setting
Data collection took place in Austin, Texas and Harrisonburg, Virginia. We selected these sites purposively to
reflect two cities of varying sizes with a relatively high
number of families from conflict-affected MENA countries. In order to provide a setting where participants
could engage with the research comfortably and openly,
moreover, we selected two districts/divisions where the
study sponsor, Qatar Foundation International (QFI),
had strong partnerships and where school leadership
expressed an interest in using research findings to inform future programming efforts.
According to 2017 estimates, Harrisonburg has a population of 54,215, compared to Austin’s 950,715 [36]. While
updated estimates are not available by city, Harrisonburg
and Austin have historically been leading sites of resettlement in their states. Virginia welcomed some 14,672
(2.1%) of the 697,862 refugees resettled in the U.S. since
2008, while Texas welcomed 69,832 (10%) [2]. In 2015,
some 28.1% of refugees and special immigrant visa (SIV)
holders resettled in Virginia were from the MENA region,
compared to 19.5% in Texas and 15.6% nationally [37].
Iraqis represent by far the largest national group resettled
from the MENA region. Since 2008, Virginia has resettled
some 5450 Iraqis and Texas resettled 18,915 [38].
Harrisonburg has often been considered an exceptionally
hospitable place for immigrants in Virginia [39]. In 2016,
the City Council passed a resolution declaring Harrisonburg
a “Welcoming America” city, making it part of a national
network of communities working together to improve the
context of reception for immigrants and refugees [40].
Church World Service (CWS) manages refugee resettlement
in Harrisonburg, connecting recent arrivals to housing, basic
services, education, and employment. The rate of refugee resettlement had fallen sharply at the time of data collection,
especially among families from the MENA region, owing to
the new ceiling on arrivals imposed by the Trump Administration as well as the travel ban [41]. Harrisonburg City Public Schools (HCPS) serves some 6000 students, of whom a
little under half (46%) were born outside the U.S. After
Spanish, Arabic (9% of students) and Kurdish (6% of students) are the most common foreign languages [42].
Austin has been a central example of American cities
struggling with state-led efforts to reduce immigration
and refugee resettlement in recent years. In 2016, for example, the State of Texas formally withdrew from the
federal Refugee Resettlement Program, leaving cities and
their networks of nongovernmental organizations
(NGOs) to support incoming refugees alone [43]. Until
2018, Refugee Services of Texas (RST) and Caritas of
Austin worked together to serve newcomers, but the latter organization ended its resettlement program in 2018,
owing to a drastic reduction in refugee arrivals [44].
Austin Independent School District (AISD) serves some
81,650 students, of whom some 27% are English language learners (ELLs) [45]. After Spanish, Arabic is the
most common home language, and there were some 75
Arabic-speaking students from conflict-affected countries enrolled in 13 of AISD’s 14 high schools in 2018,
according to internal data.
Participants
Three groups of participants were eligible for participation
in this study, including: 1) youth enrolled in high school
(13–23 years) that were either born in conflict-affected
MENA countries or born during their family’s displacement
from such a country; 2) the caregivers of these youths, including parents and siblings; and 3) key informants responsible for services, programming, or policy related to the first
two groups. Key informants included teachers, guidance
counselors, school district/division administrators, case
workers, therapists, and NGO personnel.
In Harrisonburg, the study team worked with a division official to develop a list of potential key informants
to recruit purposively. The administrator helped recruit
and schedule school key informants, while the study
team contacted non-school key informants directly via
email. All key informants provided written consent. The
interviewers also asked each key informant to recommend other participants. For caregivers and youths, the
study team worked with school personnel and a representative from CWS to develop a list of potential participants that had agreed to be contacted by the research
team. The researcher and a trained Arabic interpreter
then contacted adult caregivers by phone to explain the
study purposes and to inquire about their interest in the
study. Those who expressed interest were mailed a study
information form in English and Arabic. The form also
included the option to decline to be contacted further.
Of the 25 families contacted, 17 participated, one declined, and the rest could not be reached. A researcher
and interpreter then visited each family that expressed
interest in order to present the study, answer questions,
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and complete written informed consent (including consent for adults to participate and consent to invite their
youths to participate). Youths were then invited to the
public high school and they completed written informed
assent in the absence of their parents in order to ensure
their participation was voluntary.
In Austin, the study team worked with AISD’s Refugee
Family Support Office to develop a list of potential key informants, caregivers, and youths. The research team contacted key informants directly by email or phone and all
key informants provided written consent in person. Key
informants were also asked to suggest other potential participants. An Arabic interpreter trained by the research
team contacted all potential family participants and those
who agreed were mailed adult participant and parental
consent forms. Of the 48 families contacted, 14 participated, eight refused, five consented but did not show up
for data collection, and the rest could not be reached. The
research team and interpreter visited all families who
expressed an interest in participating to complete written
informed consent. Youths were invited to a public high
school where they completed written informed assent.
Data collection
The research team conducted a scoping study in Harrisonburg in February 2018 and in Austin in March 2018 in order
to coordinate with school partners, identify potential participants, contextualize data collection instruments, and plan
data collection. Data collection took place in both locations
throughout July 2018 and consisted of semi-structured interviews with caregivers and key informants and schoolbased focus group discussions (FGD) with youths. In twoparent homes, parents were often interviewed together,
though it was common for only the mother to be available.
Key informant interviews sometimes included two participants, while FGDs, which were stratified by gender, included
five students per session, on average.
Interview questions for caregivers focused on displacement and resettlement experiences, acculturative stressors,
engagement with schools and healthcare, sources of support, and perceptions of children’s adjustment (Table 1).
Interview questions for key informants were tailored to participants’ job responsibilities, but focused centrally on challenges faced by newcomers and the supports in place to
reinforce student strengths and promote positive outcomes.
Focus groups discussed the interactions that conflictaffected students from the MENA region had with educators, parents, and peers, and students. Students also
provided their own definitions of what it meant to feel supported and proposed ideas for improving school- and
community-based support systems. Caregiver and youth
sessions were assisted by an Arabic interpreter trained in
best ethical and methodological practices for interviewing
youths affected by armed conflict. The study team did not
ask about participants’ refugee or citizenship status. The researchers recorded all data collection sessions using an
audio recording device, unless the participant requested
otherwise, and also kept detailed field notes. A team transcribed the audio files, including the interpreter’s Arabic-toEnglish translation. The research team reviewed, edited, and
de-identified all transcripts in English.
Ethical considerations
Recognizing the ethical complexities of collecting data with
populations affected by armed conflict and forced migration, and particularly adolescents, the research team took
Table 1 Examples of Interview and FGD Questions
Adult Caregiver Interviews
Adult Professional Interviews
1 How do students in this school make new friends?
What are some places where you can meet new
friends? What are some things that would make
people not become friends? How do friends
support one another?
Adolescent FGDs
What was your experience of arriving to the U.S.
like? Please describe some of the ways you first felt.
What kinds of support did your family receive from
thegovernment or other organizations when you
first arrived? What are some additional kinds of
support that you receive from yourcommunity?
What would you say it is like for
a refugee student of Arab background
to attend school in this district? How
do you think their experiences in
the school compareto those
of other students?
2 Who are some of the adults in theschool that you
would go to if youwanted to speak about your
future? What would you do if you were worried
that you had a health issue? For instance, if you felt
too tired or if you felt sad? Is there someone in the
school you would speak with?
People have different views on mental health.
What does mental health mean to you? Is mental
health something that you speak about sometimes
in your family?
What has your experience been
working with the families of
refugee youth from
Arab backgrounds?
3 What does it mean for a school to support a
student? What do schools do to make students feel
safe? What do schools do to make students feel like
they belong?
How would you describe your relationship with
his/her school? For example, do you attend
meetings at the school? Are you in touch with any
teachers or counselors? What has contributed to
this relationship being the way it is?
What has been the role of the
school administration/service
team/organization in supporting
refugee students from Arab
backgrounds to integrate into
their new communities? How
would you say these strategies
are working? What would you
change about these current
strategies and why?
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several measures to promote voluntary, meaningful, and
safe participation [15, 46]. Such measures included: 1) partnering with schools and community NGOs that could provide safe research space, make referrals in case of acute
needs, and protect participant confidentiality; 2) engaging
with interpreters from the MENA region; 3) training everyone involved in data collection on ethical conduct; and 4)
de-identifying and securing participant data. Furthermore,
the research team considered informed consent and assent
an ongoing process that required open communication and
accessible, child-friendly research instruments [47].
The research protocol was approved by the Institutional Review Boards (IRB) at Columbia University’s
Mailman School of Public Health (IRB-AAAR7830),
AISD’s Department of Research and Evaluation (R18.62),
and the Superintendent of Schools at HCPS.
Analysis
The research team analyzed the data using thematic analysis and constant comparative method [48, 49]. The lead
analyst reviewed all transcripts to develop initial codes related to the research objectives and questions. He then
compared these codes to the relevant literature and developed analytic memos and an initial codebook. After incorporating feedback from the principal investigator and
research team, the lead analyst then applied the codebook
to a sample of the data and refined the codebook further.
The researchers then recruited a team of coders with backgrounds in public health, social work, psychology, and refugee resettlement and trained them on the study protocol
and codebook. Together, the research team finalized the
codebook with 56 codes and built inter-coder reliability
(ICR) using Dedoose’s Training Center (Additional file 1).
Once coders had established an ICR of at least 66.7% on
tested codes, they were assigned a batch of transcripts to
code using Dedoose. The lead analyst reviewed coding applications and resolved ambiguities in coding application.
Through an iterative process, the lead analyst and principal
investigator identified eight themes in the data and compared these to the empirical and theoretical literatures related to Bioecological Theory, acculturation, adolescent
SEL, and the mental health and psychosocial wellbeing of
forced migrants (Additional file 1).
Results
We conducted interviews with 27 key informants and 30
caregivers across the two cities, as well as six FGDs with
30 youths (Table 2). Key informants included eight
teachers and high school principals, nine district/division
staff, and 10 NGO personnel from resettlement organizations and community-based organizations. Altogether,
the study engaged youths and caregivers from 31 households, the majority (68.3%) of whom came from Iraq,
with a sizeable minority from Syria (18.3%) and Sudan
(13.3%) (Table 3). It is important to note that within
these national identities there was considerable ethnic
and religious diversity. The Iraqi group, for example, included participants identifying as Kurds, Yazidis, and
Turkmen. Families had complicated migration histories,
often having spent years in refugee camps or settlements
in countries such as Jordan, Turkey, Egypt, and Libya.
At least four families had fled the Iraq war for Syria, only
to encounter that country’s civil war. Ongoing displacement and uncertainty about their final destination left
many families precarious during this period, sometimes
interrupting children’s education for years at a time. Several children had been born in displacement, spoke local
languages, and partially identified with their country of
refuge. Participants frequently remained separated from
their extended family members, and in at least one case,
an immediate family member had been prevented from
traveling to the U.S. following the Trump Administration’s various travel bans.
Adjustment challenges
The families we interviewed had lived in the U.S. for
anywhere between 2 and 9 years, with a median of 4
years. Adults usually worked long hours in manual and
low-skilled jobs, such as food processing, construction,
and transportation, despite often coming from more
skilled professions in their countries of origin. Youths
and especially adults described considerable difficulty
learning English, which undermined their career opportunities and ability to engage with public services, such
as healthcare and education. As one father explained:
Table 2 Number of Participants by Study Group and Location
Key informants
Caregivers
FGDs
Total
10
10
3
23
Harrisonburg
Sessions
Total participants
10
14
17
41
Females
6
8
9
23
Males
4
6
8
18
Sessions
15
10
3
28
Total participants
17
16
13
46
Females
12
9
3
24
Males
5
7
10
22
25
20
6
51
Austin
All sites
Sessions
Total participants
27
30
30
87
Females
18
17
12
47
Males
9
13
18
40
Note. Two adolescents participated in both caregiver interviews and FGDs, so
the total number of unique participants is 85.
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Table 3 Countries of Origin for Adolescent and Caregiver Participants
Austin
Harrisonburg
All sites
Participants
Percentage
Participants
Percentage
Participants
Percentage
Iraq
16
55.2
25
80.6
41
68.3
Syria
8
27.6
3
9.7
11
18.3
Sudan
5
17.2
3
9.7
8
13.3
Total
29
100
31
100
60
100
[W] ithout the language, everything will be difficult.
My intention was that when I come to U.S., I work in
the same field—in construction. But because my
language wouldn’t help me, so I couldn’t work in the
same field (Austin, Father, Sudan, A2.008.1).
Although schools, resettlement agencies, and youths
themselves helped caregivers communicate across languages, caregivers did not always understand or agree
with the policies, practices, and pedagogical approaches
of their children’s new schools. As one boy explained
about his parents, for instance:
They don’t know much about school, especially the
systems and stuff. So, all, everything they want is like
to ask that we are fine […] but they really don’t know
what’s exactly going on in the school (Harrisonburg,
Boy, Iraq, H3.016.1).
While most parents in both cities expressed largely
positive feelings about their schools and communities, a
number also shared concerns about the potential “bad”
influence of other students on their children, what they
perceived as a permissive disciplinary environment, and
the use of technology such as computers for education.
In Harrisonburg, for example, where students were given
laptops to take home, parents sometimes felt that these
laptops created a barrier between children and their parents, who could not always monitor or participate in
computer-based educational exercises. Meanwhile, parents in Austin were sometimes confused that their children did not bring home textbooks. As one parent
explained:
I don’t understand. What’s the idea of keeping these
books in the school, not bringing them home with the
students so at least the parent can have knowledge
and […] at least have an idea of what their children
are studying (Austin, Mother, Iraq, A2.011.1)?
For students, the most salient challenge, beyond language
acquisition, was learning to navigate the school system.
Most students described an initial sense of disorientation
when they began school, not only because of their English
level, but also because they were not accustomed to multiple
class periods, were not aware of the full range of programs
and extra-curricular activities on offer, and did not have
enough background contextual information to follow their
courses. As a male student from Iraq explained about his
History teacher in Harrisonburg: “He would say some stuff
that a U.S. person would know, but I had no idea what they
were and he expected everyone to already know that part,
so he would jump from place to place” (H3.016.1).
Beyond academics, students in both sites described experiences with bullying and microaggressions on the
basis of their accents and their ethnic or religious identities, which often inhibited their sense of belonging. In
Harrisonburg, for instance, a 16-year-old girl from Iraq
told a story of being on a school bus when she first arrived. In her words: “I didn’t really know English. I
couldn’t speak very well and there was [an] American
boy [ …] he was talking about my religion in a bad way
and talking about me that I’m wearing hijab” (H3.003.1).
Several girls remembered peers mocking their religious
garments or trying to remove their hijabs.
Although students in both sites almost always described school staff as respectful, educators were not always knowledgeable of students’ cultural backgrounds.
This lack of understanding inhibited educators’ ability to
reach newcomers in meaningful ways and sometimes led
them to commit painful microaggressions against their
students. In Austin, a 17-year-old girl from Iraq
recounted a time her substitute teacher used her as an
example of “cultural change,” as she had supposedly
stopped wearing a hijab after arriving to the U.S. The
girl was not only offended for having been singled out in
class, but also because she had never actually worn a
hijab. As she explained, “I found it kinda rude because
you can’t just like assume that ‘oh yeah, she took it off
and whenever she got here’” (A3.002.1). These stories go
well beyond religious garments. Arab boys described being called “terrorists” by their peers and several informants described fights along ethnic lines in their
schools, whether between Arabs and Kurds, between
MENA students and Latinx students, or within the
MENA group.
In addition to the difficulties of adjusting to their new
society, families faced ongoing hardships related to their
pre-migration and transmigration experiences, including
ongoing family separation and mental and psychosocial
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distress. While most parents did not feel comfortable discussing mental health and psychosocial wellbeing, a few
adults and youths described symptoms such as depressive
feelings, anxiety, sleeplessness, and aggressive behavior.
While many youths and caregivers continued to struggle with these various challenges, they also described
several means by which they had adapted to life in the
U.S. in the years following their resettlement. In their efforts to overcome their adversities, girls and boys drew
on a rich ecosystem of supports. In keeping with Bioecological Theory’s emphasis on the importance of relationships in child and adolescent development, the
remainder of this section describes the various ways in
which key actors in an individual’s social ecologies—
families, peers, schools, and communities—worked independently and together in both sites to protect newcomers, reinforce their coping strategies, and promote
their mental health and psychosocial wellbeing.
Family
Parents used a variety of strategies to ease their children’s adjustment to life in the U.S. Several took a strict
approach to parenting, especially with girls, imposing
rigid rules to promote educational achievement and
mitigate what they considered social risk. An Iraqi
mother in Harrisonburg said of her daughters, for instance, “I advise them to keep only one friend because of
conflict or problems” (H2.009.1). Both parents went on
to explain that they considered their daughters to be at
greater risk of harm than their son and that such advice
was a matter of safety and preserving tradition.
Parents described varying degrees of strictness, with
some banning or limiting social media use, others
restricting social and extra-curricular activities, and still
others attempting to act as a gatekeeper between their
children and their children’s friends. One Iraqi mother
in Austin discouraged her children from becoming
friends with other Iraqis struggling to adjust to school.
In her words, “I’ve tried to keep my children away from
them because, as you know, the good things spread and
the bad things also spread” (A2.015.1). Instead, she
pushed her children to befriend native English speakers.
As she explained, “I always encourage them to fit into
the new society, to have communication, under my control and my supervision.” Another Iraqi couple described
a painful tension they felt between wanting to become
more flexible with their children so as to allow them to
fit in with the broader community, and not wanting to
lose their children’s respect (H2.010.1 and H2.011.1).
In addition to keeping their children safe and guiding
their social development, many parents also considered
it their responsibility to maintain their children’s connection with their national or ethnic heritage. As an
Iraqi mother in Harrisonburg explained about her
children, “we want them to learn about all the traditions
[ …] And, and we taught them to speak Arabic, to write
Arabic, and to read Arabic” (H2.003.1). A Sudanese
mother in Harrisonburg echoed this sentiment, but
noted the challenge of this undertaking. In her words,
“we speak Sudanese [ …] we try to teach them the culture, Sudanese culture, traditions, but they are refusing
everything” (H2.005.1). She went on to explain that “The
school already teaches them in a new culture,” making it
difficult to keep their Sudanese heritage relevant and exciting for them. She commented that schools could play
an important part in encouraging students to maintain
and celebrate their heritage.
Parents and older siblings also tried to take an active role
in adolescents’ educational lives, with differing degrees of
success. Caregivers typically attempted to motivate adolescents by focusing on career objectives, particularly specialized, high-income professions such as medicine and
engineering, which were especially difficult to achieve for
those newcomers who had missed years of schooling and
had arrived at an older age. For some parents, this encouragement was enough, as they felt incapable of engaging
with schools meaningfully themselves, and trusted their
children to navigate the system on their own. When asked
about her son’s college options, for instance, a mother from
Iraq responded, “We don’t go into details. We don’t know.
He knows better about college” (H2.012.1). In a male FGD
in Harrisonburg, several students described a similar parental detachment, explaining that as long as they continued to
receive fair grades and did not get into trouble, their parents did not engage much in their educational lives. These
students were usually at a disadvantage in school, compared
to those with parents who took more active roles in their
children’s education. Some newcomer parents, for example,
described monitoring their children’s report cards, helping
with homework, and keeping in constant contact with
teachers, whether by phone, email, mobile phone applications, or routine visits to schools. Parental involvement with
schools seems to have been influenced not only by parenting style, but also parental education, English language ability, free time, and student performance.
Peers
Students took great comfort in one another’s friendship
and support. Girls and boys in both cities consistently remembered the peers that welcomed them on their first
days of school. Peers oriented newcomers to their new environment and introduced them to their classmates, promoting a sense of belonging. Although schools did not
usually institutionalize formal, peer-led orientations, students who had been welcomed when they first arrived
often made sure to help new arrivals in turn. As an Iraqi
girl in Austin remembered, “I know how lost I was, so I
really don’t want other people to be lost [ …] I’m planning
Bennouna et al. Conflict and Health
(2019) 13:47
to do a thing like with [a recently arrived] family that I’m
‘gonna teach their kids English, help them with homework” (A3.002.1). When possible, newcomers usually
made friends with other Arabic-speaking students at first,
who interpreted for them in class, taught them some English, and helped them to understand their course schedules and academic and extra-curricular opportunities.
Students who did not have other Arabic-speakers in their
schools tended to have more initial difficulty adjusting. In
Austin, for example, an Iraqi girl remembered being the
only Arabic-speaker in her school in the following terms:
I was like the only Arabic girl and I had recently
moved towns. And the town was like most populated
with like, Latinos and like Latinas, and so they weren’t
very nice that I didn’t speak Spanish. And they would
like speak behind my back. And I got like very—I got
angry, and sad, and it didn’t, like, do well for me
(Austin, Girl, Iraq, A3.014.1).
Relationships between MENA students and students of
Latinx origin tended to be especially tense when the latter
constituted a large proportion of the ELL group and drew
a majority of the resources and attention from the schools.
For the most part, however, MENA students in both cities
quickly made friends with non-Arabic-speaking ELLs in
their classes. Moreover, as their English improved and
they began to take classes with the general student body
or to participate in extra-curriculars, many became friends
with U.S.-born students as well. For most newcomers,
supportive friends were those who were genuinely interested in learning about them and their background, who
withheld judgment and laughter when they struggled in
class, and who stood up for them when other peers bullied
them. An Iraqi girl in Harrisonburg, for instance,
recounted a time when her friends defended her against a
male classmate who repeatedly followed and harassed her.
As she remembered, “when he comes around, they were
just yelling at him or trying to fight with him, and he was
just leaving after that” (H3.003.1).
School and community
Schools and communities took numerous measures to support youths and their families. Harrisonburg’s Newcomer
Program offers one model of support to ease students’
school adjustment. In this program, newcomers from every
background received sheltered instruction through English
immersion courses as well as cross-cultural orientation
classes until they reached a basic level of language proficiency. In order to promote friendships outside of the newcomer community, students also took some substantive
(e.g. math) and elective (e.g. art) courses with the general
student population. Teachers and students alike considered
the Newcomer Program useful for learning basic English,
Page 9 of 13
building a supportive community of peers, and acclimating
to the school environment more broadly. As a Sudanese
girl remembered, “they put me [in] Newcomer and the
teacher [was] always caring and helping and stuff”
(H3.004.1). Notwithstanding the program’s considerable
strengths, staff still thought it could be improved. One key
informant explained that students graduating from the
Newcomer Program often still lacked sufficient English
proficiency to keep up with students in the more advanced
classes at the school. As the informant explained:
They have the academic chops; they have the
motivation; they have the work ethic. Where, if we
would scaffold the language appropriately, they could
be succeeding like crazy in these courses. But those
[advanced classes] are the classes where we see the
least diversity (H1.08).
In Austin, resettled families were dispersed around the
city, which complicated efforts to coordinate specialized
supports across the school district and led to considerable variation in how schools welcomed newcomers.
The high school with the highest concentration of refugees did not offer a class designed for refugees or newcomers but, instead, students were enrolled in a
standard English as a Second Language (ESL) class, with
all other ELLs. The teacher of that class also supported
the school’s faculty to meet student need, whether
through professional development sessions, adjustment
of lesson plans, or coaching.
Austin’s Refugee Family Support Office was central to
the city’s ability to respond to the needs of its resettled
students and their families. This district office worked
across AISD’s departments and schools, as well as several
outside organizations, to provide a range of supports. The
team, which consisted of a small staff representing the
most common refugee language groups, worked closely
with schools at every level. Although its central function
was to deliver language services, the office also oversaw
school registration for refugee students, coordinated
tutoring activities, collaborated with resettlement agencies
to meet basic needs, collected data on student and family
needs, conducted professional development around the
district for school faculty and service providers, and informed district policies to improve the context of reception for refugee students. Of course, each of these
activities presented its own sets of challenges. With students spread across such a large number of schools, for
example, the office struggled to monitor needs throughout
the district. As one respondent explained, “there’s a lot of
things we don’t even know about until we find out, you
know, months later” (A1.03). For their part, school
personnel did not always have the time or incentive to attend professional development sessions, making it difficult
Bennouna et al. Conflict and Health
(2019) 13:47
to diffuse best practices for monitoring and responding to
newcomer needs.
Both Austin and Harrisonburg employed liaisons from the
MENA community, as well as other immigrant communities. Beyond simple language support, these individuals often
tutored and mentored students, ran extra-curricular activities, and helped schools communicate and coordinate with
caregivers, including at times visiting parents during their
work lunch breaks to discuss their children’s progress. A girl
in Harrisonburg described her school liaison in the following
terms: “When we came to this country like totally lost, and
you don’t know, just don’t know what to do. And she’s just
right there for you. She opens the way” (H3.005.1). In Austin, several actors from local universities and NGOs provided additional language and academic tutoring and
mentoring for students.
Both cities had recently taken concerted steps towards
strengthening SEL in their schools. Harrisonburg had integrated SEL into its curricula and launched programs
around restorative justice, cultural competency, traumainformed care, bullying prevention, and community outreach. In order to provide additional SEL support to
newcomers, in particular, Harrisonburg High School
launched the Peer Leader Program, together with local
partners. In this program, newcomers participated in
weekly sessions to share experiences and advice, help
welcome new arrivals, and plan activities to engage the
broader community. Students participated in a number
of additional enrichment opportunities as well. For example, students completed a two-day workshop led by
the Center for International Stabilization and Recovery,
which, according to one key informant, “focused on how
to be a good listener, how to deal with your own stress,
how to recognize danger signals in other students”
(H1.01). In addition to the Peer Leaders Program, Harrisonburg High School also hosted weekly meetings for
Arabic-speaking girls, as well as a monthly Arabic club,
all led by the Iraqi school liaison.
At AISD, which reportedly had been implementing SEL
in all of its schools as of the 2015–2016 school year, the
district was in the process of implementing its SEL 2.0
strategic plan. According to an informant familiar with
the plan, SEL 2.0 was an effort to recognize “the centrality
of race and equity” and to make “more explicit connections to cultural and linguistic identity” (A1.01). The effort
also included elements of restorative practices, mindfulness, and a focus on building adult SEL capacity. Although
informants did not share specific plans to tailor this SEL
initiative to refugees or the MENA population in particular, members of the Refugee Family Support Office had
begun conducting district trainings related to the effort.
In addition to these social and emotional learning measures, AISD, together with local partners, began integrating
mental health centers into the school system in 2015,
Page 10 of 13
reaching over 40 schools by 2018. The centers took a
multi-layered approach to MHPSS, working with several
departments to deploy preventive strategies, such as promoting trauma-informed care throughout the schools. The
centers also worked with parents and teachers to build referral systems and provided specialized care for students
with acute and chronic needs, such as CBT and TrustBased Relational Intervention. Key informants at the centers acknowledged the particular challenges of working with
populations from conflict-affected countries, not just including language barriers, but also differences in conceptualizing mental health and psychosocial wellbeing and
stigma around these issues. One informant described her
process of trying to destigmatize the issue by referring to
specific symptoms, rather than a diagnostic title, and “to
bring it back to school and school success,” rather than
mental illness and therapy (A1.11). This participant also
noted the importance of reinforcing student strengths and
helping them manage daily stressors, such as job applications, rather than focusing exclusively on addressing underlying traumas through specialized therapy. This informant
recognized the need for greater cross-cultural training and
said that the centers were beginning to work with the Refugee Family Support Office on professional development
efforts.
Discussion
Families resettling to the U.S. from conflict-affected
countries in the MENA region encounter countless challenges as they adjust to their new society. However, our
findings demonstrate that newcomers in Harrisonburg
and Austin adapted readily to their new environment
and engaged with a rich ecosystem of supports, starting
at home and extending through their schools and communities. Guided by Bioecological Theory, our findings
demonstrate the critical importance of system-wide support mechanisms that coordinate the efforts of actors at
every level to work in tandem, rather than apart [24, 25].
Students received direct educational, mental health, and
psychosocial support from numerous actors in their
microsystem, including caregivers, peers, educators, and
service providers. In addition to working directly with
students to reinforce their strengths and address the
challenges of adjustment, these actors also worked together in the mesosystem to enhance the overall supportive ecosystem. Teachers, school liaisons, and tutors
enabled parents to overcome language and access barriers and to become more involved in their children’s
education. Meanwhile, the basic supports from resettlement agencies and other community organizations
helped to relieve stressors affecting adult newcomers in
the exosystem (e.g. related to employment and finances),
allowing them to devote more time and energy to
caregiving.
Bennouna et al. Conflict and Health
(2019) 13:47
Just as resettled families adapted to their new communities, schools also adapted to their new students, creating a more accommodating context of reception.
Specialized personnel with training related to refugees and
MHPSS provided coaching and professional development
opportunities for teachers and counselors, building more
cultural competence and trauma sensitivity. Administrators at the district/division level, for their part, spearheaded initiatives together with community partners and
external donors to formalize programs and policies that
could support students and families across the school system, whether related to refugees in particular, or SEL and
MHPSS more broadly. Such capacity-building efforts have
been crucial to a number of previous initiatives to improve
school-based MHPSS supports for refugees and asylumseekers, and several English-language resources have been
published in recent years to facilitate professional development [15, 50, 51].
While the study did not test the effectiveness of these
various measures for improving student educational performance or mental health and psychosocial wellbeing, it
identified several plausible mechanisms through which
such improvements could take place. For example, students drew on supportive peer groups to adjust to their
new schools, to overcome language barriers and microaggressions, and to gradually create a sense of belonging,
despite continued anti-MENA and anti-refugee sentiment in the macrosystem. Recognizing the protective
and promotive qualities of such relationships with peers,
as well as with family members, educators, and other
members of the community, school decisionmakers in
these two cities had developed multi-layered supports to
build on the strengths of these relationships. By foregrounding SEL and trauma-informed care in the classroom, for instance, AISD aimed to cultivate a more
harmonious school climate capable of preventing intergroup conflict, reducing mental health stigma, and encouraging proactive care-seeking through school mental
health centers (which themselves provided multiple
layers of care). Meanwhile, school liaisons and coordinators worked outside the classroom to bolster parental
strengths and further connect them to the school’s support systems. A growing body of evidence supports such
integrative, holistic MHPSS approaches that address
negative exposures and reinforce strengths across social
ecological levels [19, 52, 53]. Examining the linkages between these various actors also exposed fault lines in the
two cities’ support systems, however, which may provide
useful lessons to guide future interventions and research
undertakings and which have significant implications for
refugee resettlement policy.
First, both school systems struggled with a fundamental
tension between targeted and universal supports, as has
been found in previous studies [15]. On the one hand,
Page 11 of 13
activities that focused too narrowly on certain subpopulations—whether refugees, Arabic-speakers, or immigrants
more broadly—could exacerbate perceived differences between identity groups, undermining newcomer integration
and sense of belonging. Without the proper cultural adaptation, on the other hand, universal supports risk either
failing to reach newcomers or potentially causing harm
[12]. Consistent with the logic of multi-layered MHPSS,
actors in both districts attempted to resolve this tension
by pairing universal initiatives (e.g. system-wide SEL) with
loosely targeted programming for groups with special
needs (e.g. Newcomer Program for all recent arrivals)
[11]. Youth and parents alike appreciated when program
activities were sensitive to their prior experiences and
carefully adapted, without singling them out as refugees.
Some participants recommended greater reflection of
their histories and languages of origin in school and program activities. Such recommendations are supported by a
growing body of evidence indicating that newcomers
benefit from cultural continuity, though more research is
needed in this regard [5].
Second, the complexity of programming and policy efforts, especially in a district as large as Austin, could lead
to service gaps, inefficiencies, and miscommunications
among actors. Furthermore, the demands on teachers and
guidance counselors limited the time they could dedicate
to coordination, professional development, and support
outside the classroom. School liaisons and AISD’s Refugee
Family Support Office emerged as crucial resources, not
only for actors within the school system, but also for those
in the broader community. School districts/divisions
around the U.S. should learn from this coordination
model, which our findings suggest depends on stable
funding, a dedicated and well-trained staff, and sufficient
flexibility to work alongside a broad set of partners.
Finally, despite these various efforts, actors in Austin and
Harrisonburg alike had a limited ability to insulate resettled
families from the stressors of a macrosystem that is increasingly hostile to refugees in general and those from the
MENA region in particular. As described above, students
experienced these stressors in their daily interactions,
through bullying and microaggressions, despite inclusive
school policies. With fewer refugees of MENA origin arriving in the U.S., and reduced budgets for refugee resettlement
offices, key nodes in the support networks detailed in this
study were already undergoing drastic changes at the time
of data collection. Key informants expressed grave concern
for what these changes would mean for refugee families,
both of MENA origin and otherwise. While these same participants remained confident that, by working together, families, schools, and communities could continue to support
newcomers, it is clear that policy interventions at the national and subnational levels will be necessary to sustain and
expand an inclusive context of reception [54, 55].
Bennouna et al. Conflict and Health
Page 12 of 13
(2019) 13:47
This study had several limitations. By recruiting
resettled participants with the help of school districts and
community organizations, we were more likely to include
families that had received the greatest support. Families
which had less contact with these actors (e.g. those whose
children had dropped out of school) may have provided
greater insight into the limits of existing support efforts.
Harrisonburg and Austin were also reputed in their states
for being especially welcoming cities. Future studies
should investigate supports for resettled families in areas
with a less welcoming context of reception, lower ethnic
and linguist heterogeneity, and fewer resources. Finally,
our study did not include a counterfactual group. Future
studies should build on our findings by comparing the
outcomes of students resettled from conflict-affected
countries in the MENA region against the outcomes of
students from other backgrounds.
Conclusion
In a national political context marked by a growing
normalization of anti-refugee sentiment and decreasing
political and financial support for refugee resettlement,
this study suggests that, by working together, families,
peers, schools, and local communities can nevertheless
create a welcoming and caring environment that many
newcomers in this study considered central to their adaptation and sense of belonging. Although resettled students
and families in the study sites struggled with overwhelming pre-migration, transmigration, and post-migration
challenges, they also demonstrated a remarkable commitment to seizing the opportunities of their new society,
investing in their educational and career advancement,
participating actively in their communities, and helping
one another. While this study underscores the resilience
of newcomers and the value of local support systems, it
also reflects the importance of government investment in
schools, mental health systems, and resettlement programs that are necessarily for enabling newcomers to
achieve their full potential.
Supplementary information
Supplementary information accompanies this paper at https://doi.org/10.
1186/s13031-019-0233-x.
Additional file 1. Summary of Codebook.
Acknowledgements
The authors are grateful for the support of the study participants, school and
community partners, and the QFI team. The authors also thank everyone
who worked on translation, interpretation, and transcription.
Authors’ contributions
LS, CB, and MW designed the study. CB and MB conducted field data collection.
CB and LS led data analysis, with contributions from MGO, FC, and MB. CB and
LS led the development of the manuscript, with contributions from MW, MGO
and FC. All authors approved the final manuscript.
Funding
This work was supported by Qatar Foundation International (QFI). The
funders contributed to study design, but did not contribute to data
collection, analysis, publication decision, or manuscript preparation.
Availability of data and materials
The data that support the findings of this study are available upon request.
Ethics approval and consent to participate
Ethical approval was provided by Columbia University’s Institutional Review
Board (AAAR7830).
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Author details
Department of Political Science, Brown University, Providence, USA. 2Brown
School at Washington University in St. Louis, Missouri, USA. 3Mailman School
of Public Health, Columbia University, New York City, NY, USA. 4Qatar
Foundation International, Washington, D.C, USA.
1
Received: 5 June 2019 Accepted: 1 October 2019
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