Young children’s development after forced displacement: a systematic review

Table 1 shows the key characteristics of displaced samples.

A total of 6,878 children aged 0- to 17-years were included in the reviewed studies, of which 5,858 were younger than seven years. Included studies were published between 1993 and 2023. Twenty-one studies conducted comparisons analyses with displaced populations [26‐29], norm populations [27‐34], healthy controls [35‐39], children displaced in second generation [40, 41], and non-displaced children from war-zones [42, 43], and in clinical settings [29, 44‐46]. Fourteen studies had at least partly overlapping samples. We included those studies if distinct outcomes were reported or contacted the authors to make separate calculations, if possible.

Studies were conducted in Australia [28, 30, 34, 47, 48], Bangladesh [31], Bosnia-Herzegovina [33], Colombia [35], Denmark/Belgium [49], Eritrea [26], Germany [27, 29, 41, 44‐46, 50, 51], Iraq [37], Israel [42, 43, 52], Sweden [53‐57], Turkey [36, 38‐40], and the US [32] and included children from the Middle East (Iraq, Syria, Afghanistan, Iran, Israel, Palestine, Pakistan, Lebanon), Africa (Somalia, Tunisia, Nigeria, Eritrea, Sudan), Asia (Myanmar, Sri Lanka), Central and South America (El Salvador, Honduras, Guatemala, Chile, Columbia), the Western Pacific, and Eastern Europe (Russia, Former Yugoslavia). Four studies included unaccompanied children [26, 31, 47, 48].

Experience of forced displacement was associated with difficulties in young children’s peer relations (21–57.1%) [26‐29, 31, 32, 40, 53, 54], such as not having friends to play with (15.6%) [31, 53], being offensive towards peers [26], and being bullied by peers [53], while six studies did not find group differences regarding displaced children’s social-emotional competencies [34, 36, 38, 39, 42, 46]. Four studies described less prosocial behavior in displaced children compared to controls (10.3%) [28, 29, 31, 36], while one study reported the opposite effect [30], and one study found no significant group differences in this domain [27]. Six studies pointed out the co-occurrence of displacement experiences, disrupted family dynamics and children’s symptomatology [35, 40, 41, 43, 48, 49]. Poor family function, overdependency on caregivers and separation fears were prevalent [52, 54], and significantly more frequent in displaced than non-displaced participants in two studies [35, 43], while one study reported comparably high prevalence of attachment disturbances in children with direct and family background of displacement [40]. Child-caregiver relationships were reported to be characterized by avoidant attachment, parental absence, low maternal affection, and oppositional behavior [41, 48, 49], which was further correlated with children’s symptom load [35, 43]. Exposure to forced displacement was associated with disturbed play in 6–62% of investigated children, reflected as reenacting, repetitive or unstructured play or general disinterest or passivity in play activities [48, 52, 54‐56]. However, one study did not observe reenacting and emotionless-cold play patterns among refugee children [46]. In the same study, refugee children showed comparable play development, but less social interaction during play compared to a clinical comparison group.

Overall, 23–78.5% of displaced children were reported to perform low on cognitive measures [26, 27, 30, 31, 33, 37, 40, 44, 45, 47]. Three studies in German refugee camps found displaced children’s nonverbal IQ scores to be normally distributed, with means more than one standard deviation below those of the German norm population [44‐46]. Dybdahl [33] reported IQ scores of children exposed to the Bosnian war on 25th percentile for European and US norms. Wolff et al. [26] reported 6- to 7-year-old, displaced orphans to perform better on cognitive and language measures than accompanied displaced children. However, the authors did not report exact IQ scores for both groups. Further, learning performance [37, 44, 46], executive function [37], and early math abilities [37, 38] were all reported to be less developed in displaced children compared to control groups. Eleven studies detected limited speech capacities in displaced children (7–50%) [26, 27, 30, 31, 38‐40, 48, 50, 51, 53], that persisted up to 3 ½ years after settlement [30, 53].

Exposure to different forms of adversity was positively associated with separation fears [43], play behavior [46, 53, 55, 56], language and social-emotional development [39], and was among the factors that most strongly determined children’s social adjustment at follow-up [53]. As can be seen in our Harvest plots, all but one studies investigating displaced children exposed to cumulative ACEs reported higher levels of disturbance compared to control groups. Separation from one or both parents thereby emerged as one of the most important risk factors for social-emotional and cognitive developmental problems [26, 31, 33, 34, 55]. Displaced children from war and non-war zones did not differ in regard to peer problems in one study [29], and four studies did not relate flight duration to learning performance, non-verbal IQ, family functioning and play behavior [41, 44‐46].

Follow-up studies suggested a decrease in developmental concerns within the first 3- to 4-years of settlement [30, 36, 42, 43, 53, 54], while children’s social adjustment improved over time [53]. Harvest plots accordingly indicate that children who stayed in the host country for shorter periods of time were more symptomatic than control children. While time in the host country was associated with better language and learning performance [27, 44, 51], and social interaction during play [46], nine studies did not link time since arrival in the host country and residence status with children’s developmental state [26, 28, 29, 34, 35, 44, 51, 55], and family functioning [48]. Four studies found that (longer) attendance of childcare centers was correlated with improvement on measures of peer problems, prosocial behavior, nonverbal reasoning and language abilities [27, 29, 38, 51], although effects did not apply to cognitive development [27] and play behavior [46] in two studies. Four studies reported comparable outcomes for children in the first and second generation of displacement [34, 35, 40, 41]. Accordingly, the impact of post-migration stressors, such as unstable housing, on children’s development was highlighted across studies [26, 29, 34, 42‐44, 56]. Eight out of the nine studies conducting group comparisons with children living in refugee and detention centers reported developmental levels below norm, indicating that placement in refugee accommodations jeopardizes social-emotional and cognitive functioning, with risk increasing the longer children are living in such environments [48, 56]. Children held in immigration detention, especially, were shown to be at higher risk than non-detained displaced children with similar exposure to pre-arrival adversity [28] and displayed the highest prevalence of developmental concerns across all included groups in this review [28, 32, 47, 48].

Twelve studies analyzed the effect of age and gender on children’s reactions to forced displacement. In five studies, the youngest age groups showed relatively more social-emotional problems [42, 43] and reenactments in play [55], and performed less advanced than older peers on cognitive and language measures [26, 27]. Moreover, one study found age effects for play development in clinical comparison, but not refugee children [46]. Findings on the effects of gender were mixed and pointed towards increased vulnerability for both boys [53‐55] and girls [33], who showed more social play and prosocial behavior in two studies [27, 46]. Six studies did not report any effects of age or gender on presented outcomes [26, 33, 34, 41, 43, 50].

Parental distress, mostly mother’s symptoms, strongly affected displaced children’s adaption in the host country, socialization and play behavior in children [42, 43, 46, 53], while fathers mental health was only assessed in one study [53]. Limited maternal affection thereby was reported as risk factor for children’s development [41], while increased affection towards the child [41] and optimism of mothers [56] were reported as potential protective factors.

Longitudinal assessments of age-specific developmental outcomes are needed to improve our understanding of the diverse reactions in young, displaced children—in high- but also in middle- or low- income countries. Investigation of prewar levels or comparisons with peers from the home country can elucidate whether test materials are biased towards children with experience in Western educational settings. Future researchers should make use of culturally appropriate assessment tools and incorporate modes of nonverbal expressions of children and educator reports as a supplement to parent rating.

Current empirical research often uses approaches that classify developmental outcomes in displaced persons as pathologic rather than seeing it as an expected response to facing the various challenges associated with forced displacement [18, 65, 66], therefore underestimating their ability to reach their full developmental potential when provided with the necessary support systems and stable living conditions [67]. Although this article highlighted the negative effects of displacement experiences, several results point towards the resilience of young children. Overlooking the strengths of displaced populations perpetuates a deficit view and places them at risk for discrimination, which has been shown to directly affect psychological distress in youth and adolescent refugees [68]. Instead, there is a need for studies that draw on children’s reactions to forced displacement from a resilience perspective in order to understand how both individual qualities, social relations, and modifiable contextual factors contribute to children’s acculturation, well-being and positive developmental trajectories in the long-term [17, 18].

Displaced children are especially vulnerable to high risks for ACEs, emphasizing the need of systematic assessment of those experiences to develop effective intervention strategies. Common definitions of ACEs focus on adversities children face within the family, while political violence and forced displacement are currently not enough covered by the framework [6, 69, 70]. It is therefore necessary to develop a broader definition that reflects the experiences that displaced children face outside the household.

Our review encompasses studies on both refugee and internally displaced children. While studies on internally displaced children did not provide prevalence data, they indicated challenges in peer relations, family functioning, and cognitive and language development [26, 33, 35, 42, 43, 52], similar to findings for refugee children. Despite expectations of higher difficulties for refugee children due to prolonged flight durations and acculturation challenges, internally displaced children faced unique adversities—residing in shelters, orphanages, or close to conflict zones, exposing them to repeated war and violence experiences. Most studies with internally displaced children were conducted in Israel where the initiating conflict was unresolved, which has been recognized as risk factor for internally displaced persons mental health [71]. Additionally, post-displacement stressors, such as unstable housing and unemployment have been reported for internally displaced populations [72], and further underscore the vulnerability of these children. Notably, no studies have explored distinctions between these two populations, representing a compelling avenue for future research.

This review shows that the negative effects of forced displacement on children, even at a very young age, are wide-ranging and powerful; however, stressors experienced in the host country, though prevalent, are modifiable. Post-migration factors provide opportunities for governments to contribute to secure and stable environments for displaced populations by keeping exposure to camps and reception centers at a minimum, preventing family separations and guaranteeing quick access to healthcare and educational institutions. Especially in low-resource environments, participation in socially inclusive preschool programs can promote healthy development and school readiness [27, 38]. Young, displaced children are vulnerable, especially because of their dependency on caregivers, who might have also undergone stressful and traumatic experiences [8]. Interventions should offer practical and mental health support for caregivers and provide childcare and education programs to shield children from post-displacement adversity. Ideally such resources should be available from the time of arrival. A resilience-based research approach is essential which instead of focusing on an individual's ability to cope with extreme situations draws on social and environmental factors and political responsibilities to protect and provide vulnerable populations with resources and support systems [38].