A Cultural Development and Psychopathology Approach

The developmental psychopathology research has long been focusing simultaneously on adaptation and maladaptation processes in response to the contextual challenges faced by the individual (Sroufe, Reference Sroufe1990). Throughout the course of development, as a product of the interplay between multiple domains of functioning (genetic, neurobiological, physical, psychological, and social), these processes can lead to normal and abnormal developmental patterns. Thus, one of the key focuses of developmental psychopathology perspective is the processes underlying stability and change across the life span (Sroufe, Reference Sroufe2009). Second, developmental psychopathology perspective is concerned with how these processes lead to either normative or abnormal (e.g., psychopathology) developmental outcomes. Third, developmental psychopathology perspective emphasizes a multiple levels of analysis framework in which the organism's functioning at one level (e.g., genetic) always transacts with functioning at another level (e.g., maltreatment) in predicting a developmental outcome (e.g., dissociation; Cicchetti & Dawson, Reference Cicchetti and Dawson2002; Yaylaci, Cicchetti, Rogosch, Bulut, & Hetzel, Reference Yaylaci, Cicchetti, Rogosch, Bulut and Hetzel2017).

Although the role of culture has long been recognized in the field of developmental science including developmental psychopathology, it has not been adequately integrated into theoretical, empirical, as well as intervention-related studies and applications (Causadias, Reference Causadias2013). Recently, Causadias (Reference Causadias2013) called for a field of research that integrates cultural processes into the domain of developmental psychopathology: cultural development and psychopathology. Cultural development and psychopathology considers the development of individual-level and societal-level cultural processes, how these cultural processes transact with biological processes over time, and how they lead to normal and abnormal developmental outcomes. Thus, this newly emerging field focuses on the intersection between culture, development, and psychopathology. Most importantly, cultural development and psychopathology research aims at improving culturally valid assessment and interventions, which is an urgent need in the field.

In order to identify the processes of adaptation and maladaptation leading to developmental outcomes of Syrian refugee children, we need to understand the challenges they face and the developmental processes and outcomes within their particular contexts, including culture. These contexts are changing dynamically, as they undergo potentially traumatic experiences in presettlement (e.g., war-related changes and seeking refuge) and the developmental process of acculturation as an adaptation to intercultural contact in postsettlement (Berry, Phinney, Sam, & Vedder, Reference Berry, Phinney, Sam and Vedder2006). In addition, it is important to remind that cultural processes exist both at distal contextual levels, such as the social level, and within the proximal levels, such as the individual level. At the social-level, the members of the community constantly renegotiate culture (practices, meanings, and behaviors), and in turn shape multiple domains of functioning at the individual level (i.e., cognitive, social, emotional, behavioral, and biological; Rogoff, Reference Rogoff2003).

Risk and Resilient Functioning in the Face of Trauma

Although refugee children can often stay resilient in the face of significant adversities (Betancourt et al., Reference Betancourt, Newnham, Layne, Kim, Steinberg, Ellis and Birman2012), studies conducted with refugee children and youth indicate a high prevalence of mental health problems due to forced migration-related factors (Montgomery, Reference Montgomery2011) such as length of stay and number of relocations (Nielsen et al., Reference Nielsen, Norredam, Christiansen, Obel, Hilden and Krasnik2008). Elevated levels of posttraumatic stress disorder, depression, anxiety, traumatic grief, somatization problems, and behavior problems have been documented in the literature (Attanayake et al., Reference Attanayake, McKay, Joffres, Singh, Burkle and Mills2009; Betancourt et al., Reference Betancourt, Newnham, Layne, Kim, Steinberg, Ellis and Birman2012), as well as the risk for developing future psychopathology of various kinds (Shaw, Reference Shaw2003). It is also indicated that these problems are persistent over years (Ehntholt & Yule, Reference Ehntholt and Yule2006). Among refugee children, unaccompanied ones are at higher risk for psychopathology and engage lesser with services compared to refugee children with parents (Keles, Friborg, Idsøe, Sirin, & Oppedal, Reference Keles, Friborg, Idsøe, Sirin and Oppedal2016; Michelson & Sclare, Reference Michelson and Sclare2009).

Ehntholt and Yule (Reference Ehntholt and Yule2006) identify several risk and protective factors influencing refugee children's psychological functioning. According to their review of the literature, significant risk factors are fourfold: trauma-related, individual characteristics, family, and postmigration environment. Trauma-related risk factors include exposure to war-related traumatic events and the unknown fate of missing family members. War-related trauma exposure, in turn, depends on the number of traumatic events, the severity of the trauma, perception of the degree of personal threat, and level of personal involvement. Risk factors related to individual characteristics include preexisting vulnerability of the individual such as previous behavior problems or physical illness. At the family level, poor parental mental health (e.g., maternal distress), incarceration or political persecution of the father, or lack of accompanying family members constitute risk. Finally, in the postmigration environment, low levels of social support, financial difficulties, unemployment, social isolation, discrimination, language problems, and asylum-seeking procedures are listed as difficulties. Protective factors included individual-level dispositions such as good temperament, high self-esteem, better adaptation skills, having positive beliefs, and family-level characteristics of cohesion, adaptability, and high social support in the postmigration environment (Ehntholt & Yule, Reference Ehntholt and Yule2006).

These above-mentioned risk and protective factors vary for different groups of refugee children, as refugees do not constitute a homogenous group. There are about 51.2 million people across the world who are forcibly displaced,Footnote ² and annually, 25,000 unaccompanied minors seek asylum across 80 countries (Vostanis, Reference Vostanis2016). Naturally, there is an immense variation of background and experiences within this population. Following the breakout of the civil war in Syria, the number of refugees is alarmingly increasing worldwide in recent years, and more attention is necessary to the specific contexts of Syrian refugee children's experience. From a cultural development and psychopathology perspective, it would be problematic to assume a unitary course of development for all refugee children. Patterns of adaptation and maladaptation should be identified based on their particular context and cultural processes.

Most up-to-date data on this issue are mainly from exploratory studies and nongovernmental humanitarian organizations (e.g., United Nations High Commissioner for Refugees). Initial findings indicated high levels of emotional and behavioral issues, with almost half of them having clinically significant anxiety or withdrawal symptoms, and two-third of them having fearfulness (Cartwright, El-Khani, Subryan, & Calam, Reference Cartwright, El-Khani, Subryan and Calam2015). Stress factors for children included discrimination, fears related to war, worries about family members they left in Syria, their traumatic experiences, concerns about education, violence in the family, parental stress, economic difficulties, and confinement to home (United Nations Women, 2013). Among these factors, confinement and harassment were more likely to be expressed by girls, whereas boys more commonly reported physical abuse and bullying. Another major challenge is having to take on roles and responsibilities that are not suitable for their developmental capacity (United Nations High Commissioner for Refugees, 2013). However, evidence shows that with social support provided by family, community members, and service providers, adolescents’ distress, depression, and fearfulness can be significantly reduced in time (International Medical Corps, 2014).

Research also demonstrated that Syrian refugee adolescents experience considerable postmigration related stress, such as social isolation, discrimination, and harassment. A qualitative investigation conducted in Lebanon and Jordan showed that Syrian refugee adolescent girls faced significant levels of physical and social isolation, discrimination, and harassment (Mercy Corps, 2014). Adolescent boys, in contrast, suffered from discrimination, bullying, and physical violence within their social life. These boys reported feeling humiliated due to being exploited as child laborers under conditions that lack adequate safety and decent payment. They also reported having a sense of humiliation as the tension between the Syrian community and the host community escalates because of refugees’ taking on employment opportunities (Mercy Corps, 2014). A study conducted in Jordan demonstrated that adolescent girls struggle with more problems and they are also more likely to experience sadness compared to boys (International Medical Corps, 2014). These results might suggest that female gender can be a risk factor predicting more difficulties among Syrian refugee adolescents.

In a study by Özer, Sirin, and Oppedal (Reference Özer, Sirin and Oppedal2016), 311 (%56 girls) Syrian refugee children residing at a camp in Turkey were examined. The children were aged between 9 to 18 (mean age 12.4) at the time of data collection, which was in 2012. In addition, at the time of the assessments, the children were in the camp for about half a year. The mean number of children in their families was six. For 85% of the children's families, Turkey was the first destination after fleeing Syria. The majority of children were from the cities of either Idlib or Aleppo in Syria. Of children's fathers, three-fourth of them completed high school or higher education. Of interest here, 20% of the children reported that they did not experience war in Syria. The authors discussed the possibility that parents might have protected their children from the effects of the civil war or they might have left the country before the conflict had escalated in their vicinity. Seventy-four percent of the children reported that they experienced the death of a loved one. Thirty percent of them reported having experienced separation from their family members, and 60% reported feeling that their life was in danger. Overall, about 50% of the children reported witnessing six or more frightening events, which was interpreted as an alarmingly high number compared to the norms. Majority of children reported having supportive relationships (71% of the girls, and 61% of the boys). However, symptoms of posttraumatic stress disorder (PTSD) were prevalent, with 45% of the children having reported symptoms above the clinical cutoffs. Sixty percent of the children had depressive symptoms. Twenty percent of them reported depression above clinical levels, and somatic complaints were most frequently endorsed. The only gender difference observed was in levels of depression, where more girls were found in the clinical range compared to boys (54% vs. 26%). Psychosomatic complaints were also found to be high among children (65%), especially in the head and back. Twenty-two percent of the children exhibited aggression. Overall, the authors concluded that mental health problems were extremely high, compared to what would be expected from a normal population, and these problems were significantly interfering with children's normal daily functioning. In addition, for most children, more than one of these problems were observed, suggesting a high co-occurrence of symptoms.

One potential problem with these findings has to do with the representativeness of the sample. The families and the children who volunteered for the study are likely to be better functioning refugees compared to children and families in the camp who did not volunteer. Thus, the sample may not be representative of the Syrian refugee children residing in camps in Turkey, and the findings may not adequately reflect the functioning of children. Another problem with this kind of research is that most statistical findings were evaluated from an ethnocentric perspective. That is, the participants’ scores were interpreted based on the norms established for Western populations, and may not adequately reflect the degree to which they indicate maladaptation. There is limited information on the development and mental health of children in Syria prior to the war, and the baseline functioning of this population is largely unknown. This lack of cross-cultural psychometric equivalence has been criticized in the literature as a general problem in psychology (Poortinga, Reference Poortinga2016), and it is also relevant for the literature on refugee children.

From a practical perspective, in order to identify potential children at risk (who require extensive psychological assessment and intervention), valid screening and measurement tools (i.e., brief questionnaires and interviews) are essential. As increasing numbers of refugee children are entering European countries and neighboring regions of Syria, clinicians and practitioners apply mental health screening and measurement tools widely regardless of established cultural validity. The relevancy and applicability of these tools need to be established. The assessment of trauma and mental health among refugee children should be culturally sensitive. In addition, these tools need to be developmentally sensitive, covering children's reactions to trauma depending on age/developmental level. In terms of validation of tools, preschool-age children seem to be especially overlooked (Gadeberg, Montgomery, Frederiksen, & Norredam, Reference Gadeberg, Montgomery, Frederiksen and Norredam2017). Development of culturally appropriate and developmentally valid screening and measurement is an urgent need to detect and ameliorate refugee children's mental health issues adequately.

As research is not able to document pre- versus post-conflict functioning of Syrian children, how can we discuss the real impact of conflict on Syrian refugee children? In an effort to answer this question, Jabbar and Zaza (Reference Jabbar and Zaza2014) came up with comparison groups that might represent the baseline of Syrian children. Specifically, they investigated 120 Syrian refugee children (aged 7–12) from the Zaatari refugee camp at the Jordanian–Syrian border, and compared them with two reference groups with the same age and gender composition. One group was 120 Jordanian children in Ramtha district, who were similar to Syrian children of Zaatari in terms of socioeconomic and cultural characteristics. These children did not directly experience violence, but were close enough to the border to hear guns and explosions. The other reference group was 120 Jordanian children in Amman, who were not exposed to violence at all. The results suggested that the Zaatari children were significantly more depressed than the two comparison groups. Among the comparison groups, Ramtha children were more depressed than Amman children. As for anxiety symptoms, Zaatari and Ramtha children did not significantly differ from each other, and both groups exhibited more anxiety than Amman children. These authors draw attention to these findings that indicate detrimental risk not only for the children who experience violence firsthand but also for those living nearby these hostilities. Among Syrian refugee children in the Zaatari camp, there were no gender differences in anxiety or depression scores. However, significant age differences were found. Older children (aged 10–12) presented more symptoms than younger ones (aged 7–9), as consistent with prior findings in the literature (Werner, Reference Werner2012). These findings demonstrate that both boys and girls who are exposed to conflict and violence are at risk for symptoms, and older children are more affected than younger ones (Jabbar & Zaza, Reference Jabbar and Zaza2014).

Parental Factors, Parenting, and Developmental Considerations

Although premigration trauma and perimigration stress has an impact on child psychopathology (Ziaian, de Anstiss, Antoniou, Sawyer, & Baghurst, Reference Ziaian, de Anstiss, Antoniou, Sawyer and Baghurst2011), this impact is mostly significantly mediated by parental psychopathology and reduced parenting quality/capacity (Reed, Fazel, Jones, Panter-Brick, & Stein, Reference Reed, Fazel, Jones, Panter-Brick and Stein2012). Especially for children exposed to armed conflict, the role of the family is very important (Thabet, Ibraheem, Shivram, Winter, & Vostanis, Reference Thabet, Ibraheem, Shivram, Winter and Vostanis2009). Effective parenting can play a protective role on refugee children's mental health outcomes (Panter-Brick, Grimon, & Eggerman, Reference Panter-Brick, Grimon and Eggerman2014). With their supportive presence, parents can act as protective shields during traumatic experiences; however, when parents’ management of stress is poor, they may further exacerbate children's difficulties and undermine their adaptation following stressors such as war and conflict (Elbedour, Ten Bensel, & Bastien, Reference Elbedour, Ten Bensel and Bastien1993). The experience of refuge might dramatically change several aspects of parenting, including quality of parent–child interactions, warmth, and confidence in parenting (Betancourt, Meyers-Ohki, Charrow, & Tol, Reference Betancourt, Meyers-Ohki, Charrow and Tol2013). There is also evidence supporting the moderating role of family factors, such as maternal attachment, on the effects of resilience-building psychosocial interventions on refugee children (Diab, Peltonen, Qouta, Palosaari, & Punamäki, Reference Diab, Peltonen, Qouta, Palosaari and Punamäki2015). Yet, we still know little about the specific parenting difficulties and needs of refugee parents.

Williams (Reference Williams2010) proposes a four-stage ecological model to describe the changes refugee parents experience: (a) parenting in the country of origin, (b) parenting in preflight contexts, (c) parenting during flight and forced migration/refuge, and (d) parenting in resettlement to the host country. Parenting is dynamic, constantly changing during these stages. Multiple contexts in each stage influence parent's experience, reshaping values, cultural practices, and perceptions. Yet, parenting is mostly a neglected aspect of the refugee experience. From a practice perspective, work with refugees typically focuses on humanitarian aid. However, parenting-related struggles start at the very early stages of refuge, and the parents’ role is essential in supporting the child's experience across all stages. Interventions can work better when they support parents early on and when they are tailored to the specific stages and contexts of refugee parents’ experience (Williams, Reference Williams2012).

The effectiveness of parenting interventions is well established in the literature. However, there is sparse research evidence documenting the effectiveness of parenting interventions among refugee families in preflight and flight phases (i.e., pre-resettlement) as most research has been concentrated on refugee families who are resettled, typically in high-income countries (Williams, Reference Williams2010). The pre-resettlement stage is both a time when the primary caregiver's role is paramount to ensure children's positive adaptation and a time in which parenting-related challenges rise immensely. Yet, little is uncovered about how to support parents through this process (Williams, Reference Williams2010). There is an urgent need for understanding phase- and context-specific parenting challenges of Syrian refugee families. Toward responding to this need, both large-scale quantitative data and exploratory qualitative data will be informative to identify targets for intervention and to alleviate risk for adverse developmental outcomes among Syrian refugee children.

Several factors related to parental functioning can be discussed in the case of Syrian refugee parents. When overall maternal physical and mental health is considered, the literature indicates high adversity. For instance, most Syrian refugee women do not receive adequate antenatal care during their pregnancy, which can potentially lead to higher fetal mortality, maternal mortality, and a range of adversities during children's prenatal development (Benage, Greenough, Vinck, Omeira, & Pham, Reference Benage, Greenough, Vinck, Omeira and Pham2015). Especially in countries where the resources are disproportionately sparse in contrast to the number of refugees hosted, such as Turkey or Lebanon, these public health concerns might become more significant. In addition, access to family planning is documented to be limited among Syrian refugees, and the number of unplanned births is likely to be higher compared to other groups (Benage et al., Reference Benage, Greenough, Vinck, Omeira and Pham2015). Research also indicates that Syrian refugee women are more likely to have PTSD symptomatology compared to men, which raises issues related to maternal mental health, and maternal caregiving. A cross-sectional study conducted in a tent city in Turkey (n = 352) showed that the frequency of PTSD among the participants was 33.5%. However, female gender, history of previous psychiatric diagnosis, family history of psychiatric problems, and experience of at least two traumas predicted more likelihood of having PTSD (71%; Alpak et al., Reference Alpak, Unal, Bulbul, Sagaltici, Bez, Altindag and Savas2015).

In addition to parents’ psychopathology, there is preliminary research focusing on parenting-related difficulties. In a recent qualitative study, Syrian refugee parents (n = 27, ages 22–45) in northern Syria and southern Turkey (who reside in camps or in housing outside camps) were examined (El-Khani, Ulph, Peters, & Calam, Reference El-Khani, Ulph, Peters and Calam2016). The study consisted of eight individual interviews and four focus groups with five or six mothers in each group. The researchers aimed at exploring the challenges faced by Syrian refugee parents in three major areas: (a) changes and difficulties parents experience, (b) coping mechanisms parents use, and (c) challenges parents request support about. Parents’ number of children varied between one and seven, and their duration of stay varied from “just arrived” to a maximum stay of 8 months. The authors used a data-driven approach to thematic analysis.

The results revealed three major set of challenges: environmental, child specific, and parent specific. As for environmental challenges, the study indicated adverse living conditions where unmet basic needs, perceived chaos of their daily lives, and safety issues were major parenting challenges reported by Syrian refugee parents. Perceived chaos resulted from a lack of predictability in their lives, which further led to a feeling of loss of control. Safety concerns resulted from lack of familiarity with the surrounding people and led to restrictions on children's activities (e.g., playing outside). As for child-specific challenges, negative changes in behavior (e.g., violent and anxious play behavior) and communication patterns (e.g., talking back, not listening, etc.), difficult emotions (e.g., anger, sadness, and lack of motivation and interest), and signs of trauma (e.g., regressive behaviors, bedwetting, and fear of loud noises and bright lights) are found as important sources of parenting distress. From a cultural perspective, it was noted that misbehavior such as disobedience to parents is perceived as offensive and disrespectful. Parents described Syrian culture as putting considerable emphasis on children's respect for and obedience to their parents. As for parent-specific challenges, parents’ own emotional distress (e.g., feelings of anxiety, anger, and abandonment), feelings of guilt (overusing harsh discipline or poor caregiving), lack of confidence, and past traumatic experiences (e.g., exposure to violence and fear) were reported as sources of difficulties related to parenting (El-Khani et al., Reference El-Khani, Ulph, Peters and Calam2016).

The study also pointed at an important problem of parenting in the refugee context: Syrian refugee parents reported to be adopting negative, harsh, or physical ways of disciplining (e.g., shouting, hitting, and threatening) due to their perceived incompetence in gaining children's compliance. They reported that they had not been using this kind of discipline very often back in Syria. Considering previous research demonstrating a high prevalence of child maltreatment in refugee populations (Lustig et al., Reference Lustig, Kia-Keating, Knight, Geltman, Ellis, Kinzie and Saxe2004), child maltreatment is an important issue that needs to be attended to in the case of Syrian refugee families. Thus, targeting parenting challenges can potentially be an effective means for preventing child maltreatment. Tentative recommendations were implicated on developing parenting interventions based on the findings of the study. The authors suggested that interventions for parents need to be context sensitive and tailored to respond to the presettlement challenges Syrian parents experience. Interventions need to address parenting challenges via promoting a sense of control and self-efficacy ameliorating psychological well-being of the parent, providing guidance on how to cope with stress, and how to engage in positive family communication. By creating positive changes in the parent, these interventions can lead to positive changes in the child (El-Khani et al., Reference El-Khani, Ulph, Peters and Calam2016).

This study provides preliminary insight about the Syrian refugee parenting experience, and is a necessary step toward future large-scale quantitative research (El-Khani et al., Reference El-Khani, Ulph, Peters and Calam2016). A cultural development and psychopathology perspective necessitates adequate exploratory research prior to assuming applicability of existing measures and models to diverse populations and contexts. For a deeper understanding of diverse cultural contexts, a mixed-method approach that includes both quantitative and qualitative paradigms is recommended (Causadias, Reference Causadias2013). Yet, caution must be taken when interpreting the results as there are major limitations of the study. As it is generally the case in the parenting literature, the sample did not include fathers. Engaging fathers in parenting research has been a common difficulty (Cabrera, Volling, & Barr, Reference Cabrera, Volling and Barr2018), which can be even more difficult in the context of refugee families. Fathers might be unavailable to the researchers or they might be minimally involved in parenting compared to mothers. However, fathers’ role is particularly important in the adaptation of immigrant children, and it should be considered carefully (Leyendecker et al., Reference Leyendecker, Cabrera, Lembcke, Willard, Kohl and Spiegler2018). Another limitation of the study is the small sample size, which can be observed as a general problem in the literature on Syrian refugee parents and children, due to challenges with collecting data (engaging participants, access issues in the camps, etc.).

Not all children seeking refuge are as fortunate to have parents and family members. Some refugee children are unaccompanied minors, who have no parents, relatives, or anyone who is legally obliged to care for them. Other refugee children are separated children, who have been separated from their parents or caregivers. The literature on these children indicate higher risk compared to accompanied children, including higher distress and elevated PTSD scores. These children miss a very important protective factor, presence of parents, and this renders them vulnerable to traumatic experiences, abuse, and exploitation (Bronstein & Montgomery, Reference Bronstein and Montgomery2011; Derluyn & Broekaert, Reference Derluyn and Broekaert2008; Missing Children Europe, 2017).

Processes of Resilience

Motti-Stefanidi (Reference Motti-Stefanidi2018) discusses risk and resources for the resilience of immigrant youth at three levels: societal context, proximal context, and personal attributes. At the societal level, he considers factors within the macrosystem, such as cultural beliefs, ideologies, ethnicity, and social class. The proximal level consists of immediate contexts, such as family, school, and neighborhood, where the youth experiences direct interactions with others. Personal attributes refer to individual-level attributes that have an impact on the individual's adaptation, such as personality, motivation, and self-efficacy. When the adaptation of Syrian refugee youth in Turkey is considered, several risk, protective, and promotive factors come into view at each of these levels.

At the societal level, there are several potential risk and protective/promotive factors. Under the “temporary protection” status, the state provides Syrian refugees services that can act as promotive factors. Registered Syrians have free access to public healthcare and education, in addition to having a work permit. On the contrary, Syrian refugees’ “temporary” status can be an obstacle for their integration. “Temporary protection” is an ambiguous status. It is not recognized under international law. Although the holders of this status can receive services as a demonstration of the state's “hospitality” (Kirişci, Reference Kirişci2014), none of them are considered as Syrian refugee's rights.

Specifically, Syrian refugees, both residing in the camps and those living outside camps, have free access to primary health services (e.g., immunization programs; follow-up of pregnant women, babies, and children; reproductive care; and counseling provided by community health centers) and secondary health services (provided by field hospitals and polyclinics).Footnote ³ When more advanced treatment is necessary, refugee patients are referred to public hospitals where they receive free care (Ekmekci, Reference Ekmekci2017). However, Turkey already had serious issues about its healthcare system, and the unexpected and dramatic influx of refugees from Syria further complicated these issues. For instance, among all European Union member states, Turkey has the smallest number of medical doctors per capita and was not well prepared to deal with high-risk health issues of refugees (Ekmekci, Reference Ekmekci2017). Despite those health measures put into place, Syrian refugees still struggle with access issues due to limitations of the health system, such as lack of awareness of the staff on Syrian's health coverage, overcrowded hospitals, overwhelmed personnel, and language barriers. In addition, communicable diseases pose a risk for both Syrians and local residents due to a high percentage of Syrian children who are not vaccinated (Kirişci, Reference Kirişci2014).

For Syrian refugees carrying a passport or residence card, admission to public schools is possible. However, the language barrier usually becomes a challenging issue for Syrian children in the Turkish education system. For Syrian children in the refugee camps, temporary education centers are established, where teachers and community leaders residing in the camps facilitate children's learning. For those who live in the cities, the Turkish public school system is an option. Still, a significant proportion of Syrian children in Turkey do not receive an education. As for working conditions, it is important to note that Syrian refugees can sometimes be employed for cheap labor without social security, which results in decreased job opportunities for both Syrian refugees and local residents.

As another societal-level factor, the cultural distance, which refers to the perceived dissimilarity between the immigrant's culture of origin and the host culture (Motti-Stefanidi, Reference Motti-Stefanidi2018), is likely to be narrower between Syrian and the local culture when compared to the cultural distance between Syrian culture and the cultures in Euroamerican societies. Turkey and Syria share many regional similarities, including traditions, values, religious beliefs and practices, family life, food, and language. Most Syrian refugees come from Northern Syria regions, where local residents have close social and familial connections (Kirişci, Reference Kirişci2014). Common religious beliefs serve as a reference point for the justification of the “open-door” policy for Syrians. There is a discourse supported and endorsed by the government around identifying the local residents of Turkey with the “ansaar,” those local people of the city of Madina, who hosted the Prophet Muhammad and the first generation of Muslims when they sought refuge from persecution. Through this identification, local residents are encouraged to welcome and support Syrian refugees. There is a vibrant civil society activism doing charitable work to help the families of the killed or wounded during the atrocities in Syria, such as establishment of orphanages, soup kitchens, refugee sites, schools, and so on. These dynamics help decrease cultural distance and serve as protective factors for the adaptation process of Syrian refugee youth. Literature on Muslim immigrant youth in Europe document acculturative challenges related to Islamophobic sentiments and discrimination in European countries. Negative developmental outcomes were observed in cases where the minority youth perceives the mainstream culture as rejecting their religious heritage (Phalet, Fleischmann, & Hillekens, Reference Phalet, Fleischmann and Hillekens2018). Considering a narrower cultural distance, these challenges and related negative outcomes (e.g., radicalization) would be less likely to emerge for the Syrian refugee youth in Turkey.

Despite factors that facilitate developmental adaptation, there are also cultural dissimilarities that widen the cultural distance. For instance, Turkish civil law does not allow polygamous marriages and child marriages, while marriages of Syrian women with already married local men as well as underage marriages of young girls have been issues that raised social tension lately. Turkish law does not permit registration of babies born in these marriages, and these women and their children face social stigmatization. However, the dire situation of the Syrian refugees put them at risk for sexual and financial exploitation (Kirişci, Reference Kirişci2014). These dynamics fuel negative stereotyping and discrimination toward Syrian refugees.

In the context of refuge, risk and protective factors work in concert with each other. Thus, they need to be considered as interacting mechanisms. For example, a recent study (Çelebi, Verkuyten, & Bagci, Reference Çelebi, Verkuyten and Bagci2017) adopted a risk and resilience framework in order to investigate the identity needs as a potential moderator of the link between perceived discrimination and mental and physical health among Syrian refugees in Turkey. They found that a sense of efficacy and meaningfulness derived from Syrian ethnic identity works as a protective factor against the adverse mental and physical health effects of perceived discrimination. In general, higher perceived discrimination was linked with more negative mental and physical health outcomes. Yet, for those Syrian refugees who had a high ethnic identification and a sense belonging and continuity of their Syrian identity, this link was not found. Syrian refugees who derived a sense of efficacy and meaningfulness from their ethnic identity exhibited lower depression and anxiety. Although this study was conducted on Syrian adults in Turkey, it provides insight into the developmental processes of resilience in the case of Syrian refugee youth. In the literature, uncertainty about one's self, perceived exclusion, and injustice toward one's group are associated with the radicalization of the refugee youth (Verkuyten, Reference Verkuyten2018). Thus, developing a strong and positive ethnic identity can be an important protective factor for experiencing discrimination and related maladaptive functioning. In addition, considering that most Syrian adults represented in this study are parents to children and adolescents, their ethnic identity can be an asset for families and children in the face of various risks such as negative stereotyping, stigmatization, sense of hopelessness, and lack of legal rights (Çelebi et al., Reference Çelebi, Verkuyten and Bagci2017).

At the individual level, children's personal attributes and skills for adaptation need to be considered. Motti Stefanidi (Reference Motti-Stefanidi2018) emphasizes the active role of the youth in negotiating the demands of their culture of origin and those of the host culture during this process. However, based on the discrepancies between the two cultures, the values and expectations could differ between socializing agents in the proximal environment. For example, in a situation where the culture of origin is collectivistic and the host culture is individualistic, parents might set goals toward maintaining family relatedness while teachers might encourage more independence. Kağıtçıbaşı (Reference Kağıtçıbaşı, Masten, Liebkind and Hernandez2012) argues that the ultimate goal here is to develop an autonomous-related self, which accommodates these contradicting demands of both cultures. In some cases, however, the cultures may not be so divergent in terms of individualism versus collectivism. In addition, both the culture of origin and the host culture are dynamically changing across time and context. For example, Syrian culture and Turkish culture are likely to be similar in terms of individualism versus collectivism. Although both cultures are heterogeneous, where various subcultures can be observed, both Syrian and Turkish cultures value family relatedness while being in a process of change toward individualism observed in younger generations. Thus, the Syrian refugee youth may not be facing a dramatic challenge in terms of shifting from collectivism to individualism. For Syrian youth in Turkey, the process of acculturation involves developing an authentic cultural self and has its own unique dynamics that future research needs to uncover.

Individual-level resilience can be supported in various ways. When a safe environment is provided, developmentally normative processes can function as self-correcting mechanisms (Cicchetti & Tucker, Reference Cicchetti and Tucker1994). For example, play can be an essential mechanism of coping with stress and developing resilience for refugee children. The International Institute for Child Rights and Development and Right to Play Lebanon initiated a program focused on the role of play in Syrian refugee children's psychosocial recovery and resilience in various cities in Lebanon (Cook, Reference Cook2017). The outcomes of the program demonstrated that play has an overarching impact on the resilience of Syrian refugee children. Specifically, play facilitated developmental pathways of positive psychosocial outcomes, including recovery from trauma, learning, compassionate action, social justice, and prosocial competition among children. Diverse forms of play, each of which linked to unique aspects of psychosocial well-being, were introduced. Due to adverse living conditions, children reported being restricted in terms of their ability to play. They also reported boredom and elevated levels of aggression. As a recommendation for future Right to Play applications, the study pointed at the importance of increasing cultural relevance of their program, via more clearly focusing on Syrian values and incorporating more culturally specific play practices. Although it was not a longitudinal investigation to predict future outcomes, the author concluded that the observed positive impact of play on protective factors could be maintained over time. In the long run, they are likely to function as promotive factors at the individual level, with sustained coping skills and an increased ability to thrive in difficult circumstances (Cook, Reference Cook2017).

Finally, it is important to note that Syrian children who are not officially registered are not discussed here. Unauthorized status constitutes a serious risk for youth development as documented in other contexts such as the United States (Yoshikawa, Suárez-Orozco, & Gonzales, Reference Yoshikawa, Suárez-Orozco and Gonzales2017). Further research needs to examine the developmental pathway for the unregistered Syrian youth in Turkey.

Intervention in the Context of Syrian Refugee Children

There are some efforts in testing interventions in the context of Syrian refugees in Turkey. However, there has been little work done specifically for children. To my knowledge, only two intervention studies were conducted on Syrian refugee children in Turkey so far. The first intervention study examines an art therapy intervention on PTSD, depression, and anxiety problems, conducted by Ugurlu, Akca, and Acarturk (Reference Ugurlu, Akca and Acarturk2016). Sixty-four Syrian refugee children (29 girls, 34 boys), aged 7 to 12, residing in Istanbul, were examined. Assessments included measures of stressful and traumatic life events, PTSD, depression, and anxiety. Following the baseline assessment, licensed art therapists delivered a 5-day art therapy program of three daily consecutive sessions, consisting of music, dance/movement, and visual art (i.e., drawing). In addition, the sessions incorporated an evidence-based program, the Skills for Psychological Recovery (Berkowitz et al., Reference Berkowitz, Brymer, Hamblen, Jacobs, Layne and Watson2010), toward building skills for problem solving, emotion regulation, engagement in positive activities, and healthy social relationships. Visual art sessions aimed at developing skills for expressing emotions, emotional integration, self-confidence, problem solving, and stress regulation. Music therapy sessions aimed at promoting motor skills, concentration, awareness, sensory skills, and social bonding. Dance therapy sessions aimed at improving body awareness, sense of being in the moment, self-awareness, self-regulation, relaxation, and playfulness. Cultural sensitivity was pursued via Syrian volunteer interpreters who received a 1-day training prior to all assessment procedures and intervention sessions carried out in Arabic with their help. Posttreatment assessments demonstrated significant improvements in children's symptoms of trauma, depression, and trait anxiety symptoms compared to baseline assessments.

The second intervention study conducted with Syrian refugee children in Turkey is an evaluation of a school-based, teacher-led, culturally adaptive cognitive behavior therapy program aimed at alleviating emotional distress and supporting the psychological functioning of Syrian children (Gormez et al., Reference Gormez, Kılıç, Orengul, Demir, Mert, Makhlouta and Semerci2017). Arabic-speaking teachers, trained and supervised by the study team, delivered the program at a school (Temporary Education Center) in Istanbul, for the duration of eight weekly sessions. Each group consisted of 8 to 10 students and two teachers. The sessions lasted about 70–90 minutes and were videotaped to test the fidelity of the intervention to the original program. The sample consisted of 32 children, aged 10 to 15 (mean = 12.4), who were mostly females (12 males, 20 females), and was randomly selected from the school population of 113. None of the children were unaccompanied minors. The program was developed using cognitive behavior therapy techniques to target stress, anxiety, and trauma. The pretest versus posttest comparisons were made utilizing self-report questionnaires previously validated in Arabic to measure child posttraumatic stress reaction, child anxiety, and overall functioning.

Aside from testing the modalities with Syrian refugee children, intervention studies provide useful descriptive information. In this particular study (Gormez et al., Reference Gormez, Kılıç, Orengul, Demir, Mert, Makhlouta and Semerci2017), overall, all children reported having been exposed to or having witnessed traumatic events. About 75% of them experienced a war-related killing of a loved one, 88.7% of them left one or more loved ones in Syria, and 46.7% of them witnessed, and 32.3% directly experienced, torture or cruelty. Fifty-four percent of the children witnessed wounded people or dead bodies. They reported currently experiencing significant posttraumatic stress, and other behavioral and emotional problems. As a potential root of these problems, findings revealed poor adjustment in general. A majority of children (90%) could not speak the local language, Turkish. In addition, two-thirds of them reported poor satisfaction with the living conditions. The posttest evaluation revealed a significant reduction in emotional and trauma-related symptoms consistent with what the intervention was specifically targeting. Statistically significant differences were found in anxiety, traumatic stress (especially in intrusive and arousal symptoms), and emotional problems (Gormez et al., Reference Gormez, Kılıç, Orengul, Demir, Mert, Makhlouta and Semerci2017). No significant change was observed in the total score, and the subcategories of conduct problems, hyperactivity, peer problems, or prosocial behavior.

These studies by Ugurlu et al. (Reference Ugurlu, Akca and Acarturk2016) and Gormez et al. (Reference Gormez, Kılıç, Orengul, Demir, Mert, Makhlouta and Semerci2017) are important as there are only a few studies that systematically evaluate the evidence base of interventions in the context of Syrian refugee children residing in Turkey. The strengths of the study by Gormez et al. (Reference Gormez, Kılıç, Orengul, Demir, Mert, Makhlouta and Semerci2017) included selection of participants through computerized randomization, intensive training of the facilitators of the intervention (teachers), and fidelity checks based on video records of each session. However, both studies have a number of limitations such as small sample sizes, lack of control groups, and lack of follow-up evaluations to assess long-term effectiveness. The study relied solely upon self-report questionnaires, whereas the study by Ugurlu et al. (Reference Ugurlu, Akca and Acarturk2016) relied solely on parent report when assessing children's posttrauma issues. In addition, in the study by Ugurlu et al. (Reference Ugurlu, Akca and Acarturk2016), at posttreatment the researchers were able to follow up only about half of the children originally assessed at baseline, due to the lack of available Arabic interpreters (as a justification, the children who were tested after the treatment were randomly selected from the overall sample). In addition, none of the intervention programs included parents actively, which is a major constraint considering the pivotal role parents play in children's psychosocial adjustment. In general, interventions with Syrian refugee children do not target parenting as a critical predictor of child adjustment. Parents or caregivers are paramount in supporting children's functioning during times of stress. Developing and implementing effective interventions to help parents and caregivers support their children effectively should be a priority for Syrian refugee children and across the refugee contexts globally (Williams, Reference Williams2010). In addition, interventions with Syrian refugee children (including those that are implemented in the field without being documented by research), predominantly targeted school-age children, partly due to their accessibility via the school infrastructure. Unfortunately, Syrian refugee children who are in early childhood or infancy are neglected, at a very foundational time of their development.

Another important point is to broaden the scope of intervention by going beyond the tendency of only focusing on trauma. Over the last decade, there has been an increase in approaches that incorporate not only trauma-focused but also other types of modalities such as play based, narrative exposure, creative–expressive, cognitive–behavioral, grief focused, and interpersonal (Jordans, Tol, Komproe, & de Jong, Reference Jordans, Tol, Komproe and de Jong2009). Not all modalities will be useful for all children. Modalities need to be tailored to the developmental level, needs, and capacities of the targeted children. Thus, a framework that incorporates various mechanisms of change is useful and needs to be disseminated to existing infrastructures such as school systems that reach communities. Recent randomized control trials conducted in Jordan reveal promising sustained effects of psychosocial group interventions, delivered by trained lay coaches, for Syrian refugee adolescents (Panter-Brick et al., Reference Panter-Brick, Dajani, Eggerman, Hermosilla, Sancilio and Ager2018).

Finally, it should be noted that the way interventions are delivered would vary from one country to the next. In low-income or middle-income countries, the mismatch between the number of refugees and the available resources is a serious problem. There are efforts to fill this gap through the help of nongovernmental organizations, which greatly differ in their approach to intervention and their infrastructure. Recommendations for intervention and policy practices should differ depending on the balance or lack thereof between the number of refugee children and the availability of resources. For example, group interventions would be more cost-effective compared to individual-based interventions such as those designed for the school context (Tol et al., Reference Tol, Komproe, Susanty, Jordans, Macy and de Jong2008). As demonstrated by the study by Gormez et al. (Reference Gormez, Kılıç, Orengul, Demir, Mert, Makhlouta and Semerci2017), trained school teachers can be a useful alternative to professionals delivering interventions.

Reflections for Future Research

The existing literature has long acknowledged the significance of cultural processes in the development of psychopathology, yet the empirical study of these cultural influences is still quite limited (Garcia Coll, Akerman, & Cicchetti, Reference Garcia Coll, Akerman and Cicchetti2000). Likewise, despite growing interest, there is little systematic data on Syrian refugee children's development and mental health. The existing body of research has problems such as poor design, small samples, ethnocentric models, and inadequate cultural and developmental sensitivity. In this section, I will discuss such theoretical and methodological problems of the existing literature and will suggest guidelines for future research.