IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 418 The mental health of immigrant and refugee children in Canada: A scoping review Nazish1, Olga Petrovskaya2, Bukola Salami1 1Faculty of Nursing, University of Alberta, Alberta, Canada, 2School of Nursing, University of Victoria, British Columbia, Canada Corresponding author: Nazish (pachani@ualberta.ca) ABSTRACT Introduction: First- and second-generation immigrant children under 15 years of age make up 37.5% of the total population of children in Canada. Immigrant children aged 10-19, irrespective of their immigration status, face ethnic victimization at school and in their neighborhoods. By 2036, the number of immigrant children in Canada is predicted to increase by 49%. Method: A well-established Arksey and O’Malley’s five-stage methodological framework was applied to conduct this scoping review. This project reviewed the existing research literature on factors affecting the mental health of immigrant and refugee children (aged 0 to 18 years) in Canada. Twenty-seven publications are included in the analysis and synthesis. Results: The mental health of immigrant and refugee children can be viewed as a product of personal, social, cultural, economic, and pre-and post-migratory factors. Immigrant and refugee children’s experiences of migration can be stressful and destabilizing. Service providers are not well trained and often cannot grasp the circumstances of immigrant and refugee children and families, which consequently disengages these clients from required treatment services and follow-up care. Conclusion: Reflection of diversity and inclusivity in mental health policies can influence actions in a primary care setting and reduce accessibility gaps and barriers that affect immigrant and refugee children in Canada. KEYWORDS Child, Immigrant, Mental Health, Policies, Refugee INTRODUCTION Globally, millions of children migrate across borders as almost one in eight migrants are children (UNICEF, 2019a). According to the United Nations Children’s Fund (UNICEF), the migration of children (under 19 years of age) increased from 28.7 million in 1990 to 37.9 million in 2019. In 2016, around 2.2 million immigrant children, including both first- and second-generation children (Table 1), under the age of 15 lived in Canada (Statistics Canada, 2020). These first- and second-generation immigrant children make up 37.5% of the total population of children in Canada (Statistics Canada, 2017a). Children in this group have at least one foreign-born parent residing in Canada (Statistics Canada, 2017a). By 2036, the number of immigrant children in Canada is predicted to increase by 49% (Statistics Canada, 2017b). The world is facing a refugee crisis and the migration of refugee children is also rising; nearly one in three children living outside of their country of birth is a refugee (UNICEF, 2019b). According to UNICEF (2019a), there are nearly 50 million refugees and displaced children globally, not including seven million children who are displaced by natural disasters. Canada has always generously welcomed refugees. In 2017, there were 25,310 refugee children under the age of 15 with permanent resident status living in Canada; these children are generally younger than immigrant children (The UN Refugee Agency Canada, 2021). Immigrant and refugee children often face difficulty acquiring necessities in host countries, such as food, shelter, education, health, and freedom of expression, and struggle to express feelings related to trauma, violence, and conflict (Mental Health Commission of Canada, 2019). In particular, immigrant and refugee children face acculturative stress, cultural inequality, and racial discrimination in school and have unmet mental healthcare needs (Edge & Newbold, 2013; Kalich et al., 2016; Salami et al., 2017). Racial differences based upon colour, culture, and ethnic origins affect attitudes, subject individuals to differential treatment, and act as a barrier to the IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 419 acquisition of professional help; this consequently leads to poor health outcomes, particularly among immigrant and refugee children. Racial stratification in sectors such as education, health, and employment leads to stressors that perpetuate oppression, domination, and victimization. Microaggressions due to acculturative and racial stressors prevent immigrants from accessing professional mental health services (Corneau & Stergiopoulos, 2012). Thus, racism is a key structural determinant of health, and this phenomenon is dubbed the “double stigma” for minority groups (Gary, 2005). For many decades in Canada, the mental health challenges of immigrant and refugee children have been undetected and unaddressed, creating a significant cost to the healthcare system (Barozzino, 2010; Wilson, Murtaza, & Shakya, 2010). The mental health of immigrant and refugee children is important as Canada’s immigrant population continues to grow. Reflection of diversity and inclusivity in mental health policies can influence actions in primary care settings and would reduce accessibility gaps and barriers among immigrant and refugee groups in Canada. Developing interdisciplinary strategies is crucial to reduce psychological strain and offer supportive interventions. Immigrant and refugee populations have diverse socio-cultural conceptions of mental health that may create challenges for health and social service providers. Indeed, evidence affirms that service providers often lack understanding and have insufficient training with respect to providing culturally sensitive participatory services (Bhayana & Bhayana, 2018; Brassart et al., 2017; Kroening et al., 2016; Woodgate et al., 2017). The purpose of this paper is to report the findings of a scoping review of existing research literature on factors affecting the mental health of immigrant and refugee children in Canada. METHODS We used a scoping review methodology. The purpose of scoping reviews is to map the relevant literature, acquire greater conceptual understanding, identify gaps, and use the existing empirical understanding to interpret issues and concerns to inform further research and application, especially in policy decisions (Tricco et al., 2018). A scoping review (rather than a systematic review) is most appropriate as our research question was broad and sought to examine the nature and range of the literature in this field (Arksey & O'Malley, 2005; Levac et al., 2010). Also, the review considered diverse study designs but no quality assessment, as our aim was not to assess the quality of evidence. We applied well-established Arksey and O’Malley’s five-stage methodological framework for conducting this scoping review: Stage 1: Identifying the research question; Stage 2: Identifying relevant studies; Stage 3: Selecting studies; Stage 4: Charting the data; and Stage 5: Collating, summarizing, and reporting the results. We followed Tricco et al.’s (2018) Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Our review sheds light on what is currently known in a broad sense in this research area and identifies knowledge gaps. 1. Identifying the Research Question The research question was: What are the factors affecting the mental health of immigrant and refugee children (aged 0 to 18 years) in Canada? 2. Identifying Relevant Studies We identified relevant studies through a search of diverse electronic databases and by reviewing reference lists of articles that met our inclusion criteria. A health science librarian assisted in refining our search strategy and terms and in searching the following databases: PubMed, CINAHL, Scopus, SocIndex, and Sociological Abstracts. The following sets of keywords were used and combined. The first set were those that represented immigrants, and included immigrant*, migrant*, immigration*, migration*, and transients. These keywords were combined with words related to children, including child*, adolescent*, infant, toddler, and preschool. These two keywords were combined with the word Canada and the names of each Canadian province/territory. The search was restricted to articles published in English. No grey literature was included in this review. 3. Selecting Studies The initial search was conducted in January 2017 without time restrictions and resulted in n=2647 records. At this stage, a research assistant and one member of the research team independently screened the titles and abstracts by applying inclusion/exclusion criteria. Inclusion criteria were: 1) population: immigrant and refugee children aged 0 to 18 years; 2) location: Canada; 3) phenomenon of interest: barriers and facilitators of mental health (factors occurring naturalistically without research interventions); 4) design: primary research using non- experimental and qualitative designs; and 5) IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 420 publication date: between January 1997 and January 2017. Exclusion criteria were studies published prior to 1997; population above the age of 18; studies with a mixed sample of children and adults where findings were aggregated; location outside of Canada; focus on physical health; focus on education rather than healthcare; intervention designs; review studies; and grey sources (conference proceedings, book chapters). The initial screening resulted in 53 records for a full- text review, which was conducted by a research assistant and verified by one reviewer. Another member of the research team resolved disagreements. This process resulted in 39 articles. Refer to the PRISMA flow diagram (Figure 1) for further details. In December 2020, an updated search covering the period between January 2017 and December 2020 was conducted following the same search strategy and applying the same inclusion/exclusion criteria. This process resulted in 58 records. Two reviewers independently screened titles and abstracts followed by the full-text review of select articles, which resulted in eight included articles. Both searches combined generated 46 unique articles (one was a duplicate) published between 1997 and December 2020. To increase the relevance of our review and provide current evidence, the research team limited the final selection to articles published in the past 10 years, between January 2010 and December 2020. Thus, 27 articles are included in analysis and synthesis in our review. 4. Data Extraction and Analysis Data extraction process involved charting and sorting material according to key issues and themes related to the mental health of immigrant and refugee children. Information about the selected articles was documented within a Microsoft Word file, including citation, study design, key themes, key findings, and recommendations (Table 2). Data were collated thematically. 5. Study Characteristics A total of 27 research studies met the inclusion criteria. Table 3 provides an overview of the study characteristics. In all reviewed studies, researchers assessed “mental health” based on participants' self- report. Conceptualizations of mental health varied across studies. Several studies mostly focused on psychological and emotional problems as shown in Table 4. RESULTS The mental health of immigrant and refugee children can be viewed as a combined product of personal, social, cultural, economic, and pre-and post- migratory factors. Below, a detailed analysis of the literature is provided under the following three main themes: pre-migration, post-migration, and familiar and cultural factors. Pre-Migratory Factors, Arrival Characteristics, and Mental Health Length of stay and age at migration Among immigrant and refugee children, age at migration and length of stay were shown to be significant characteristics affecting their mental health in the host country. National data from the New Canadian Children and Youth Study (NCCYS; 2002-2004) (Beiser et al., 2014) showed a weak inverse relationship (B = 0.006, β = 0.006, SE = 0.042) between the age of immigrant children at the time of arrival in Canada and the mental health risk in this population. Younger children (between the ages of 4 and 6) were more likely to show physical aggression and emotional problems than older children (between the ages of 11 and 13) (Beiser et al., 2014). A study found that immigrant children who had lived in Canada for less than 5 years were more likely to report extreme levels of stress and despair post migration (Hilario et al., 2014). Another study compared data in a cross-sectional survey of the year 1983 (n = 2836) and 2014 (n = 5785) to examine the changes in the prevalence of mental disorders among immigrant children and youth in Ontario (Comeau et al., 2019). It reported an increase in emotional disorders from 9.2 to 13.2% in children aged 4 to 16 years, as well as an increase in hyperactivity among males from 8.9 to 15.7% of the same age group. Parent and child language competencies Well-being and smooth adaptation of immigrants at the place of resettlement depend upon the linguistic proficiency and education of both parent and child. Results from a national survey of 2031 immigrant families who participated in the NCCYS (Beiser et al., 2010, 2011, 2014) indicated caregivers’ lack of language fluency in one of Canada’s official languages could greatly contribute to higher levels of emotional problems, such as depression, somatization, resettlement stress, and perception of prejudice among immigrant children post-migration in Canada ([B = - 0.035, β  = -0.057, SE = 0.014, p < 0.05] (Beiser et al., 2010); [B= -0.24, p < 0.05, 95% CI IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 421 [− 0.38, − 0.11]] (Beiser et al., 2011); [B = -0.057, β = 0.026 SE = -0.087, p < 0.05] (Beiser et al., 2014). Additionally, immigrant children generally face role reversal, a situation in which parents rely on their children to interact with the world, and this led to emotional problems among both immigrant children and their parents (Beiser et al., 2010). Further, researchers have explored barriers and facilitators to health and social service access and utilization among immigrant and refugee parents raising a child with disability, finding the majority of parents were unable to access and utilize mental healthcare and social services for their children due to language barrier (Fellin et al., 2013). Thus, limited parental language proficiency is associated with emotional problems and acculturation stress in immigrant children to Canada. Immigrants’ social capital from countries of origin The support of family from the country of origin has a significant and inverse relationship with psychological distress and interpersonal strain. More symptoms of anxiety were related to low support from friends in an immigrant’s home country and in Canada (r = -.39, p = 0.05) (Lecompte et al., 2018). Data related to South Asian immigrant children indicated social support from the country of origin was often solely from one of the parents, which may be insufficient to support the child’s well-being in Canada (Lecompte et al., 2018). This study emphasized that staying connected with multiple family and friends in their home countries best facilitated building psychosocial resources and fostered resilience among immigrant children in the host country. History of trauma and abuse Refugees usually suffer great psychological trauma and developments due to violence, torture, conflict, war, and terror in their countries of origin, which consequently impacts their psychological functioning (i.e., manifesting as aggressive behavior and emotional problems) post-migration in the host country. This is supported by findings from the NCCYS, which included youth between the ages of 11 and 13 years who had been born abroad and had been living in Canada for 10 years or less at the time the study began (Beiser & Hou, 2016). The data indicated that, post migration, refugee youth had significantly higher levels of both emotional problems (EP: M = 11.05, p < 0.01) and aggressive behaviour (AB: M = 7.49, p < 0.05) than immigrant youth (EP: M=10.35 and AB: M=7.18) from the same countries. Interestingly, refugee children perceived themselves as more instrumentally and socially competent; that is, they were capable of doing tasks alone, able to figure out problems on their own, and easily get along with other people when compared to immigrant children (immigrants = 38.32, refugee = 39.35, p < 0.05) (Beiser & Hou, 2016). Nevertheless, these refugee children struggled greatly for emotional stability (Beiser & Hou, 2016). In contrast, in a sample of Syrian newcomer refugee children aged 5-13, among those who were subjected to pre-migratory major life stressors, the incidence of daily stresses did not affect their sadness regulation post migration in Canada (Elsayed et al., 2019). This finding suggested children who have undergone frequent life stressors were resistant to (i.e., their sadness regulation was unaffected by) the normally unfavorable effects of an undesirable situation, such as daily hassles (Elsayed et al., 2019). The authors termed this phenomenon an “immunizing effect,” where past vulnerabilities built greater strength to face a future crisis with ease and confidence. In contrast, immigrant and refugee children in this sample from Syria who witnessed lesser adversities pre-migration reported a higher level of post-migratory daily hassles (β = − 0.38, p = 0.02, 95% CI [− 0.70, − 0.06]), which led to worsening emotional (sadness and anger) regulation (Elsayed et al., 2019). This phenomenon was referred to by the authors as the “specificity principle”, meaning that every group of immigrants has been differentially impacted and presents distinct sadness and anger regulation patterns post-migration. Gross National Product (GNP) of the country of origin The GNP is the total value of all finished goods and services produced by a country’s citizens and one of the significant economic and social indicators of societies (Montazer & Wheaton, 2011). The GNP of the country of origin may reflect immigrants' and refugees' distinct adaptation patterns post-migration in the host country. Montazer and Wheaton (2011) interviewed 847 immigrant children ages 9 to 16 from countries with different GNPs: lower (n=94), lower middle (n=87), upper middle (n=94), and upper (n=189). Overall, children from low-GNP countries had more to learn, faced greater uncertainty and discrimination, and had greater cultural differences than immigrants from other countries, which made adaptation to the host country more challenging. This study also compared first- and second- generation immigrant children from countries with low GNP and concluded the first-generation IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 422 immigrant children showed greater academic excellence and lower dislike of school. Second- generation immigrant children from countries with low GNP status reported higher levels of externalizing difficulties, such as delinquency and aggression, and internalizing difficulties, such as somatic complaints, withdrawal syndrome, anxiety, and depression (Montazer & Wheaton, 2011). This observation was explained as follows: first-generation immigrant children from low-GNP countries report fewer family conflicts and greater parental care compared to second-generation immigrant children from low GNP countries, who experience more family conflicts and less parental care, which negatively affects their mental health. In contrast, immigrant children from higher or similar GNP backgrounds to a country of destination (Canada) generally had no mental health adjustment difficulties because they behaved in the same way as the native-born population (Montazer & Wheaton, 2011). Post-Migratory Contingencies and Mental Health Academic performance as an indicator of mental well-being and a factor affecting psychological adjustment The academic performance of newcomer immigrant and refugee children in Canada is linked to their psychological functioning through social competence (having friends) and self-esteem (i.e., “I like the way I am”). The NCCYS conducted with children aged 11 to 13 years (n=1,053) living in Montreal, Toronto, Vancouver, and the Prairies examined the relationship between demographic factors and academic performance (Oxman‐Martinez et al., 2012). Girls were more likely to have a greater sense of academic competence (B = .15, β = .10, SE = .05, p < .01) and better grades (B = .20, β = .15, SE = .02, p < 0.01) than boys. Moreover, children from single-parent families were at a disadvantage in terms of attaining better academic grades possibly because parental stress affected their academic performance. The significance of these findings relates to the observation that immigrant and refugee children with a higher sense of academic performance report lower levels of psychological and social isolation post- migration in Canada (Oxman‐Martinez et al., 2012). Poorer academic attainment can be a risk factor for lower psychological adjustments, such as lower self- esteem and more symptoms of depression, as seen among adolescents from immigrant Chinese families (Costigan et al., 2010). This study also indicated a strong sense of ethnic identity motivated immigrant and refugee children to work hard in school and gave a sense of meaning to their academic goals. Thus, academic achievement is associated with a strong sense of identity and can promote the mental well- being of immigrant youth. Experiences of violence and discrimination at school and in the neighborhood Immigrant and refugee children’s experiences of migration can be stressful and destabilizing. In Canada, these children experience two major forms of violence: physical aggression and verbal abuse (Brabant et al., 2016; Oxman-Martinez et al., 2012). The most direct and offensive form of violence is physical aggression, which includes hitting, fighting, and pushing. Verbal abuse includes being called hurtful words – insults, mockery, and mean remarks – in front of people as well as bullying at school. Some immigrant and refugee children experience scornful attitudes, sidelong glances, shoving, sarcastic laughter, hurtful racist words, and social exclusion due to different skin colour, accent, or customs (Brabant et al., 2016; Oxman-Martinez et al., 2012). Many immigrant and refugee children believe those experiences of violence directly influence their school performance, cognitive functioning, and emotional regulation post-migration in Canada (Brabant et al., 2016; Oxman-Martinez et al., 2012). Racial discrimination affects the health of immigrant and refugee children, and the association between discrimination and health is complicated (George & Bassani, 2018). Findings of the NCCYS indicate one important indicator of impaired psychosocial functioning among immigrant adolescents is perceived discrimination by peers and teachers in school and the community, suggesting perceived discrimination is negatively linked to self- esteem (B =-.223, β = -.116, SE =.085, p < .01) and social competence (B = -.384, β = -.141, SE =.126, p < .001.) (Oxman-Martinez & Choi, 2014). Immigrant and refugee children employed the following seven coping strategies to maintain their emotional and cognitive well-being in the face of experiences of violence and discrimination at school in Canada: 1) ignoring the situation; 2) seeking assistance from authority figures to neutralize the aggressor; 3) requesting a reason or apology from the aggressor; 4) releasing stress through participation in physical, social, cultural, and leisure activities; 5) building personal strength as an opportunity to learn new skills; 6) seeking solace in spiritual activities; and 7) returning to family and friends for warmth and emotional support (Oxman-Martinez & Choi, 2014). IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 423 Neighborhood ethnic homogeneity One study found ethnic homogeneity plays a role in fostering the well-being of immigrant and refugee children in Canada, as it enhances social interaction and thus creates strong social cohesion among a specific population group. A cohort study by McRae et al. (2020) identifies the link between neighborhood factors, including immigrant or ethnic concentration, and child developmental vulnerability. This study defines developmental vulnerability with indicators in five domains: physical health and well-being, emotional maturity, social competence, language and cognitive development, and communication and general knowledge. The locations where inhabitants were of similar ethnicity had, on average, lower levels of child developmental vulnerability than those with diverse ethnicity. The researchers concluded that neighborhood ethnic homogeneity is consistently associated with less developmental vulnerability than predicted by income across all developmental domains (McRae et al., 2020). Interpretation of these findings suggests ethnic and ethnic-immigrant homogenous communities hold assets, apart from financial resources, that support children’s ability to flourish at an early age. Social support in the host country Social support in the host country can act as a buffer to the negative effects of daily life hassles for immigrant and refugee children in Canada. Two studies describe the relationship between social support from the host country and its impacts on the mental health of immigrants (Beiser et al., 2011; Lecompte et al., 2018). In a sample of 4000 immigrant children from Mainland China, Hong Kong, and the Philippines, a statistically significant negative relationship (β = -0.03, 95% CI -0.05 to 0.00, p<0.05) was found between social support (i.e., having some friends and family members to provide guidance when having any problem in order to feel safe, secure, and happy) and children’s emotional problems (Beiser et al., 2011). In another study, participants included 33 South Asian immigrant mothers and their children aged 1-7 years from Bangladesh, India, Pakistan and Sri Lanka (Lecompte et al., 2018). A low level of social support from friends and family in Canada was a crucial stressor that greatly influenced these immigrant children’s sense of belonging in the host country, which eventually led to social exclusion and more disorganized attachment behaviors, such as exaggerated emotional expression and immature or angry behavior toward their parents. Barriers to accessing healthcare: Lack of information, stigma, and financial strain A recent study explored immigrant and refugee mothers’ perceptions of barriers to and facilitators for mental healthcare for their children in Alberta, Canada (Tulli et al., 2020). The findings indicated the mothers felt alienated from both other people in their communities and their family in their country of origin, which hindered their ability to access mental health services for their children (Tulli et al., 2020). Access to mental health services for immigrant and refugee children and their parents can be hampered by lack of information, stigma, and financial strain (Fellin et al., 2013; Tulli et al., 2020). Lack of information about the healthcare system and accessible services was a vital impediment for mothers, who reported disappointment about not knowing where to find resources and feeling unsupported and unheard by either schools or service providers. They faced health system bureaucracy and unnecessary paperwork to seek mental health services (Tulli et al., 2020). Financial burden made it challenging for mothers to access services such as counselling, sports, and recreational services for their children and restricted access to these high-cost programs and services due to low incomes. Stigma around mental health and the fear of having their child labelled was a factor that made it hard for mothers to seek mental health services (Tulli et al., 2020). However, mothers who were well educated were able to access free services, such as sports and recreation, speech language pathologists, occupational therapists, psychologists, and libraries, and were able to support their children’s mental well- being or better treat their mental illness concerns (Tulli et al., 2020). In another study, researchers investigated concerns of Maghreb parents newly immigrated to Québec who have a child diagnosed with autism (Ben- Cheikh & Rousseau, 2013). The findings showed mothers were very worried about their children’s condition due to the lack of therapeutic collaboration as a result of administrative barriers such as bureaucracy and intercultural communication difficulties, including language barriers, stereotyping, and conflicting values and belief. Child immigration detention Child immigration detention is the detaining of an immigrant child or Canadian citizen child, who are often de facto detainees accompanying a detained parent or other family member. Children and their IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 424 parents may be incarcerated in Canada for three main reasons: 1) their identity is being confirmed as asylum seekers; 2) an immigration officer considers them improbable to appear for a meeting or enquiry (“flight risk”); and/or 3) they are considered a threat to the public (Kronick et al., 2018). Two articles (Kronick et al., 2015, 2018) focused on the negative impacts of immigration detention. These studies included 20 refugee parents and their 35 children (age 0-20) in detention to understand the experiences of detained children and families who have sought asylum in Canada. The findings indicated immigrant and refugee children reacted to detention with intense distress, fear, and a deterioration of functioning, leaving children with psychiatric and academic difficulties long thereafter (Kronick et al., 2015). Confinement and monitoring while in detention led to traumatic incidents in the lives of refugee children, including other post-migration stressors such as precarious status or restricted independence (Kronick et al., 2015). Their findings reported children’s feelings of fear, threat, protection, safety, and awareness of loss of protection within the context of an optimism that migration will convey a better life (Kronick et al., 2015). Further, family separation instigated by detention appeared as a major concern for the children, as detention added new vulnerabilities including separation anxiety, selective mutism, and sleep disturbances (Kronick et al., 2018). Parents indicated the responses of children, particularly those of teens, indicate constraints (e.g., the perception of deprivation) and terrifying detention conditions (e.g., the presence of rotating strangers or security guards) are acutely distressing for children. Following detention, most families reported persistent emotional distress and worsened posttraumatic symptoms, such as interrupted sleep, temper tantrums, and fear in children (Kronick et al., 2018). For adolescents and children, immigration detention is an extremely stressful and potentially traumatic experience. The study findings also indicated children expressed their fears of being harmed by police and other aggressive forces in their new home. The children also grappled with prior memories of atrocities that may have been re-induced by detention (Kronick et al., 2018). Therefore, detention of immigrant and refugee children in Canada can be a harmful stressor that can affect the ability of children to heal from past damage and psychopathology (Kronick et al., 2015, 2018). Familial and Cultural Factors Familial characteristics that serve as risk factors for poor mental health Four articles based on the longitudinal NCCYS reported a relationship between maternal mental health and child’s mental well-being (Beiser & Hou, 2016; Beiser et al., 2011, 2015; Hamilton et al., 2011). In 2004, participants included 2,031 children from immigrant families from Hong Kong, Mainland China, and the Philippines (Beiser et al., 2011). A subset of the 2004 NCCYS in 2011 included 64 refugee preadolescents from Ethiopia (Beiser et al., 2015) and 533 immigrant children from Hong Kong, Mainland China, and the Philippines (Brabant et al., 2016). A subset of the 2004 NCCYS in 2014 included 326 immigrant youth from Hong Kong, Mainland China, and the Philippines and 152 refugee children from Vietnam, El Salvador, Ethiopia, Sri Lanka, Afghanistan, and Serbia (Beiser & Hou, 2016). These studies found that maternal anxiety, depression, somatization (Beiser et al., 2011, 2015; Beiser & Hou, 2016; Hamilton et al., 2011) as well as parent-child conflicts and harsh parenting (Bakhshaei & Henderson, 2016) led to emotional distress among immigrant children post-migration in Canada. Maternal mental health was affected by cultural dissonance, perceived prejudice, perceived discrimination, and low social supports from both country of origin and country of destination. Low maternal mental health subsequently led to mental health problems including fear, anxiety, and depression among immigrant and refugee children (Hamilton et al., 2011). Familial characteristics that serve as protective factors for mental health Family harmony and maintenance of familial relationships act as a means of resilience for newcomer immigrant and refugee children who encounter challenges adjusting to a new environment. In a mixed-method study, 12 immigrant youth aged 15 to 18 years old from Syria, Singapore, Colombia, Iraq, Saudi Arabia, and United Arab Emirates were asked to respond to the question, “What do you like at home [in Canada]?” (Burgos et al., 2017). Youth stressed the importance of feeling safe and comfortable in the home environment as well as the ability to easily seek parental advice at times of insecurity. Immigrant youth mentioned the need to have routines, interactions with family members and younger siblings, and structure or rules implemented at home. They also mentioned the privilege of having a larger house in Canada compared to their country of origin. Youth further acknowledged age- IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 425 appropriate opportunities provided by the government and school that benefited their living conditions, for instance driving a vehicle, sleeping over at a friend’s house, and getting Child Tax Benefit money from their parents. These youth regarded their families as a source of comfort, safety, and strength. Family loyalty and responsibility, family- centeredness and relatedness, and respect for parents promoted values that led to a positive sense of belonging, self-efficacy, self-esteem, and social competence inside and outside of the home for this group of participants (Burgos et al., 2017). Similarly, in a sample of 459 immigrant youth aged 11 to 13 years from Mainland China, Hong Kong, the Philippines, Haiti, and Lebanon, stronger self-esteem and greater social maturity were found among youth with supportive parental relationships (Oxman- Martinez & Choi, 2014). Despite possible tensions within immigrant communities, such as post- migratory stress and acculturation, the family tends to be a reliable source of defense against psychological disfunction in immigrant youth (Oxman-Martinez & Choi, 2014). Thus, research to date supports the idea that family-centeredness is a key determinant of mental health among immigrant children settling in Canada. Cultural discordance, cultural connectedness, and mental health Cultural distance or discordance (CD) is defined as the distance between the culture of origin and Canadian culture (Beiser et al., 2015) and can significantly affect immigrant and refugee children’s resilience and psychological well-being. The NCCYS 2004 (Beiser et al., 2015) found children from a group with a larger CD experienced higher level of emotional problems (t=10.34, p < 0.001), discrimination (t = 15.31, p < 0.01), and resettlement stress (t = 48.02, p < 0.001) than children from a group with a smaller CD. (These researchers did not provide a list of countries with small vs. large CD but indicated they used data from the World Values Survey, an international survey that measures beliefs and values of individuals nested within countries.) Further, this study found children with a stronger cultural identity perceived a greater sense of purpose, achievement, and social solidarity and lower levels of depressive symptoms (Beiser et al., 2015). Similarly, researchers reported in another study that a sense of ethnic identity among 459 immigrants aged 11 to 13 years from Mainland China, Hong Kong, the Philippines, Haiti, and Lebanon (which was a subset of NCCYS 2004 [Beiser et al., 2015]) significantly and positively influenced their self-esteem (B = .072, β = .144, SE = .024, p < .001) and social competence (B = .141, β = .198, SE = .035, p < .001) (Oxman- Martinez & Choi, 2014). In another study, researchers examined the experiences of acculturation and adaptation among immigrant youth and their parents originating from South Asia (n= 19) who lived in Canada for more than 15 years and found that parents generally instill one of two fundamental values in their children: what is considered a Euro-American or individualistic value system, which included characteristics such as being assertive, independent, competitive, and autonomous, or what is considered a non-Western or collectivistic value system, which rewards being compliant, nurturing, and obedient (Bakhshaei & Henderson, 2016). However, the Euro-American value system was not always appropriate and led to conflicts in non-Western families and difficulties in their social and economic integration (Bakhshaei & Henderson, 2016). Acculturation and adaptation processes A correlational study among 718 immigrant adolescents aged 11 to 19 years (Greeks, Haitians, Italians, and Vietnamese) living in the Montreal area used acculturation attitude scales and identified four major types of acculturation processes: assimilation, integration, marginalization, and separation (Berry & Sabatier, 2010). Specifically, participants were asked about perceived personal and group discrimination. Those immigrant children who participated in both the culture of origin and Canadian culture, designated the “integration course”, were psychologically well adjusted and blended well into school and community. In contrast, children who were minimally involved in either of the cultures, designated the “marginalization course”, were less adapted to school and community and experienced settlement stress. Further, children who chose one cultural identity and neglected the other culture, designated the “assimilation or separation course”, fell in-between the two adaptation poles (Berry & Sabatier, 2010). DISCUSSION Our review of research published since 2010 identified pre-migratory factors, post-migratory factors, familial characteristics, and cultural contingencies that influence the psychological well-being and mental health of immigrant and refugee children in Canada. Key findings from the studies pertain to the influence of several factors on the mental health of immigrant children, including immigration status, history of trauma and abuse, GNP of the country of IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 426 origin, daily life stressors, cultural distance, and acculturation. The analysis demonstrated consistency among the existing literature on most of these factors. Much of the literature on migrant health suggests a dire need to structurally equip frontline healthcare workers with knowledge, skills, and attitudes to promote safe, quality care for immigrant and refugee children in Canada (see e.g., Ben-Cheikh & Rousseau, 2013). Culturally safe education can assist mental health and social service providers in terms of self- awareness and self-reflection about values, prejudices, and stereotypes. Additionally, past research affirms that failure to provide interpreter services to immigrant and refugee families leads to a barrier in acquiring quality health outcomes and causes mistrust in services (Edge & Newbold 2013; Kalich et al., 2016; Salami et al., 2017). Employing accredited interpreters and conducting training of professionals would play a vital role in bridging the gaps between clients and mental health and social service workers (Hilario et al., 2014). Providing a range of communication methods, including telephone or virtual interpreter services, is important to optimize care delivery (Fellin et al., 2013). Immigrant parents and children often face various psychosocial challenges in building new social supports in the host country (Lecompte et al., 2018), suggesting social support organizations in the host country should promote the socialization of immigrants with local people, offer strong support for the provision of accessible trauma-sensitive services, and organize informative programs for newcomer immigrant and refugee parents with respect to navigating health and education systems in Canada (McRae et al., 2020). These support organizations can act as a bridge among health service providers, government, and minority groups to facilitate community belonging, social inclusion, and, ultimately, mental health (Beiser et al., 2011, 2015; Beiser & Hou, 2016). A study with non-profit community-based immigrant service providers highlighted how community belonging is the strongest determinant of immigrant mental health in Canada and recommended that social support organizations offer counselling and group therapy sessions to mitigate parental conflicts and facilitate family connectedness (Salami et al., 2019). Existing literature affirms that school and childcare centers play an essential role (Edge & Newbold, 2013; Kalich et al., 2016; Salami et al., 2017). School teachers and staff should strive to maintain a conducive curricular and extra-curricular environment that fosters children's success (Bakhshaei & Henderson, 2016). Collaboration of mental health professionals with the school system would assist in identifying and implementing measures for high-risk crises such as violence and discrimination among non-immigrant and immigrant children (Oxman-Martinez et al., 2012). Mental health professionals and social service providers in school and childcare settings can also help parents mitigate parenting challenges in a new country and create support groups (Hamilton et al., 2011). In this way, schools and childcare centers can become safe places for immigrant and refugee parents to seek out advice and support. A wider literature suggests the need to evaluate the effectiveness of current mental health treatments and procedures and to identify challenges that immigrant and refugee children and families face when navigating the Canadian healthcare system. Researchers also suggest more comparative studies are needed to explain the economic, cultural, and linguistic diversities of countries of origin and mental health differences among immigrant children in Canada (Montazer & Wheaton, 2011). Future studies also need to explore why immigrant and refugee girls are more likely to follow or adjust to mainstream school success than boys and what measures can be taken to foster academic competence among immigrant and refugee children who have single or less-educated parents (Beiser et al., 2010). Initiatives to promote ethnic identity in schools to facilitate immigrant and refugee children’s academic competence in Canada should also be explored (Brabant et al., 2016; Burgos et al., 2017). Children, irrespective of immigration status, should be safeguarded from detention and should also not be separated from their parents. Policies conscious of children’s best interests should advocate for alternative practices to detention (Kronick et al., 2015). Community-based alternatives to detention should be established and applied locally and internationally. Children’s best interests should be a prime consideration for all responsible decision- makers, from governments to tribunal members to Canada Border Services Agency (CBSA) officers and guards. This will include training at all levels about the multifactorial evaluation of the needs of children by recognizing the experiences of child custody, mental health implications of detention, and effects related to trauma, relocation, and attachment. Independent supervisory systems are also required to ensure children and families subject to border protection policies have their human rights respected (Kronick et al., 2018). IMPLICATIONS IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 427 Further research is needed to better understand the coping strategies of newly immigrated families with a child with disability, assess the impact of culturally sensitive support groups on parents, and better understand the experiences of mental health professionals working with immigrant families with disabled children (Ben-Cheikh & Rousseau, 2013). Future culturally relevant and developmentally sensitive longitudinal studies on specific cultural processes at the developmental stages across the life span are desirable to discover critical periods of risk and vulnerability, potential for resilience, and optimal prospects for healthy development of immigrant youth (Berry & Sabatier, 2010; Beiser et al., 2012). Future research is necessary to explicitly test social cohesion as a mechanism linking neighbourhood- level immigrant concentration and low ethnic diversity to reduced child developmental vulnerability (McRae et al., 2020). CONCLUSION The mental health of immigrant and refugee children is an important component of the future health profile of Canadians (Beiser et al., 2010, 2011). In particular, the health status and health-related service requirements of immigrants in Canada will have an important impact on public health, public spending, future immigration policy, and immigrant integration. The literature calls for the Canadian government, social service providers, educators, and health service providers to evaluate and amend current practices and policies to support immigrant and refugee children. Policy changes can help to bring about structural changes that promote equality, inclusivity, and accountability for all human beings regardless of their colour, culture, or identity. 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Definitions Terminology Definition Children Individuals below the age of 18 years First-generation immigrant children Children who have migrated from their country of birth to Canada as their current country of residence Second-generation immigrant children Children born in Canada that have at least one foreign-born parent Refugee children Children forced to flee from persecution and who are located outside of their home country Mental health A state of well-being in which an individual realizes his or her abilities, can cope with the normal stresses of life, can work productively, and can contribute to the community IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 432 Figure 1. PRISMA FLOW DIAGRAM IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 433 Table 2. Data Extraction # Article reference Key themes Key findings Recommendations 1. Bakhshaei, M., & Henderson, R. I. (2016). PMC4964263; Gender at the intersection with race and class in the schooling and wellbeing of immigrant-origin students. BMC Women's Health, 16, 47. http://dx.doi.org/10. 1186/s12905-016- 0328-0 Parental control (Harsh parenting) Cultural distance Academic performance Girls are under more parental control than their brothers, resulting in spending more time at home, the former could have more positive feelings towards school. This view proposed that the school was among the few spaces of freedom and socializing. Children who become accustomed to a Western individualistic culture can be a challenge for some South Asian families in Québec, who at the same time encounter major obstacles in their social and economic integration. Parental expectations of academic performance are generally higher for girls than for boys, elevating the likelihood of a performance gap. Educational policy makers, as well as school and community workers, should call for action that can promote the well-being of immigrant-origin girls through involvement in beneficial processes of acculturation aligned with their improved academic performance. 2. Elsayed, D., Song, J. H., Myatt, E., Colasante, T., & Malti, T. (2019). Anger and sadness regulation in refugee children: The roles of pre-and post- migratory factors. Child Psychiatry & Human Development, 50(5), 846-855. https://doi.org/10.10 07/s10578-019- Interactive relationship of pre-migratory stressor, post-migratory family routines and post- migratory daily stressor on children’s emotional (anger and sadness) regulation Immunizing effect: Refugee children who experience more pre-migratory life stressors are less impacted by post- migratory daily hassles. They developed strength against later adversity because of their exposure to pre-migratory life experiences. Family routines have a conducive effect on children’s anger regulation. Greater post-migratory daily hassles were associated with worse sadness regulation for children with lower levels of pre-migratory life stressors. Sadness regulation among refugee children is more likely to be internalized and termed as specificity principle, whereby immigrants unique Future studies should consider the inclusion of children’s self-reported measure of emotional regulation, which should call for cross-cultural validation of emotional regulation among refugee children. https://doi.org/10.1007/s10578-019-00887-4 https://doi.org/10.1007/s10578-019-00887-4 IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 434 00887-4 circumstances reflect their resettlement experiences and growth in later life. 3. Lecompte, V., Miconi, D., & Rousseau, C. (2018). Challenges related to migration and child attachment: A pilot study with South Asian immigrant mother– child dyads. Attachment & Human Development, 20(2), 208-222. https://doi.org/10.10 80/14616734.2017.13 98765 Maternal anxiety and depression, social support, and national and religious sense of belonging Maternal depressive symptoms were related to lower child attachment security scores. The cause of maternal depression and anxiety is related to financial constraints, cultural shock, and separation from country of origin. Lower support from friends was related to greater child ambivalent attachment behaviors. The only source of support came solely from the spouse. Establishing a new social network in the host country is sometimes a difficult task. A greater sense of belonging to the country of origin was related to greater child disorganized attachment behaviors. Immigration is often seen as a loss of familiar relations, including language, values, norms, and social network. Screening programs may be important to identify children suffering from insecure attachment with parents. Promoting adaptation of parents through different modalities, such as formal socialization groups, and emotional support from other members of the community, may be beneficial for the parent-child dyad. The use of interpreter services may allow parents to participate in therapeutic interventions for their children and thereby promote a greater sense of belonging to the host country. 4. Burgos, M., Al- Adeimi, M., & Brown, J. (2017). Protective factors of family life for immigrant youth. Child and Adolescent Social Work Journal, 1-11. https://doi.org/10.10 07/s10560-016-0462- 4 Protective factors of family life Comfortable: Family as sources of security, reliability, and support. Family aid in the maintenance of ethnic identity at home. Routine: Youth felt comfortable with the family time they had and time they spent playing and conversing with their siblings. Consistency: Youth appreciated open communication and the presence of positive feedback at home. Social workers can foster youth and familial development through capacity building and encouraging migrant families to use their own resources and means of resilience. By developing greater information on the needs of newcomer youth, researchers can advocate for the development of greater project and service funds for newcomers. https://doi.org/10.1007/s10578-019-00887-4 https://doi.org/10.1080/14616734.2017.1398765 https://doi.org/10.1080/14616734.2017.1398765 https://doi.org/10.1080/14616734.2017.1398765 IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 435 Personal space: Youth valued their personal space and possession of electronics, video games, and music at home. Earn privileges: Youth enjoy privileges, such as driving and having a bigger house, which were facilitated by Child Tax Benefit money their parents receive. Canadian immigration policies can better support the family reunification process of immigrant families. 5. Brabant, L. H., Lapierre, S., Damant, D., Dube-Quenum, M., Lessard, G., & Fournier, C. (2016). Immigrant children: Their experience of violence at school and community in host country. Children & Society, 30(3), 241- 251. https://doi.org/10.11 11/chso.12131 Experiences of violence lived by immigrant children Forms of violence: Physical aggression (hitting and fighting at school, children are abducted and conscripted as soldiers) and verbal abuse (insult, mockery, mean remarks, hurtful words) racial discrimination (comments on skin color and citizenship) Children’s emotional reaction to violence: peer aggression, subtler aggression, rejection, social exclusion, isolation Effects of violence on emotions and well-being: physical symptoms (fatigue or headache), psychological symptoms (anger, sadness, fear of reoccurrence of violence, discrimination, difficulty in concentration), and low academic performance Coping strategies: Preferred to do nothing, ignore the situation, running away from the situation, some requested apology, preferred to tell someone often with the goal to seek help to neutralize the aggressor, few turned to God in prayer, unwind and release their tension in physical activity, taking part in cultural and social activities, tried to improve their French or seek solace in spiritual and leisure activities, some relied on warmth and support from their friends and families It is important to work toward the development of an effective implementation of anti-bullying policies and practices that explicitly address racism. Especially in school, there is a need to facilitate safe spaces for immigrant children where they can share their stories and build networks. Government should invest funds and energy into promoting the implementation of policies that foster cultural diversity and address the social exclusion of immigrant children. Awareness campaigns for the recognition of the others could be organized to promote a space for interaction and dialogue between different cultural communities. IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 436 6 Beiser, M., & Hou, F. (2016). Mental health effects of premigration trauma and postmigration discrimination on refugee youth in Canada. Journal of Nervous & Mental Disease, 204(6), 464- 470. http://doi.org/10.109 7/NMD.0000000000 000516 Mental health effects of premigration trauma and postmigration discrimination on refugee youth Refugee youth had higher levels of emotional problems and aggressive behaviour than immigrant youth from the same source countries. There is no relationship between pre-displacement human and social capital and mental health among refugee youth. Traumatized mothers suppress the signs of aggression in their children Postmigration traumatic experiences had a significant effect on both emotional problems and aggressive behaviour. In fact, post migration discrimination does additional harm. Refugee-receiving countries should provide timely treatments for the survivors of refugee trauma. Evidence-based information is required to build the professional repertoire of healthcare providers for assessing refugee youth’s need for help. Build on screening programs for detecting trauma-related mental health problems among refugee youth. Schools must find ways to encourage the creation of both a welcoming atmosphere and anti-visible minority activities, such as celebration of diversity programs, that can halt refugee discrimination at schools. 7. Beiser, M., Puente- Duran, S., & Hou, F. (2015). Cultural distance and emotional problems among immigrant and refugee youth in Canada: Findings from the New Canadian Child and Youth Study (NCCYS). Cultural distance (CD) and mental health A large difference between culture of origin and the culture of Canada had higher scores on emotional problems among immigrant youth. Youth with high CD condition perceived more discrimination than youth in the low CD condition. Youth in the small CD distance group reported higher levels of instrumental competence (academic performance). Study suggests the development of policies and programs to reduce resettlement stress and the sting of discrimination, as well as mental health interventions sensitive to the importance of culture and of cultural distance Social services organizations and schools should motivate immigrant youth to develop social skills and encourage them to participate in and IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 437 International Journal of Intercultural Relations, 49, 33-45. https://doi.org/10.10 16/j.ijintrel.2015.06.0 05 Social competence (ability to form friendships and to get along with peers) mitigates the adverse effect of CD on mental health of immigrant youth. learn about the culture of their adopted countries while still honoring their heritage; this can help them to meet the challenges of adapting to the new and making sense of the strange. 8. Ben-Cheikh, I., & Rousseau, C. (2013). Autism and social support in recently immigrated families: Experience of parents from Maghreb. Santé Mentale au Québec, 38(1), 189-205. https://doi.org/10.72 02/1019192ar Social support from host country The diagnosis of autism spectrum disorder (ASD) has a considerable impact on the social network of parents, creating distances and tensions, but also by generating new links and sources of support. Group meetings between mothers from the same community who have an autistic child are seen by them as being particularly beneficial. The organization of services is perceived to be deficient because of the waiting time for diagnostic confirmation, bureaucratic complexity, and lack of public sector resources. The relationship to professional services shows that the development of a therapeutic alliance is often difficult because of administrative obstacles and difficulties in terms of intercultural communication. Although they have accepted this diagnostic process to help their child, mothers are very concerned about the risk of secondary stigma. A better understanding, by health and social services workers, of the interaction that exists between the migratory context and the weakening of family and social networks associated with a diagnosis of autism in a child from an immigrant family could help reduce loneliness. and the suffering of these parents. It is essential to raise awareness among stakeholders of the importance of empathetic listening, which helps reduce the loneliness and suffering of parents who experience feelings of shame and fear of stigma. Further research is needed to better understand the coping strategies of newly immigrated families with a child diagnosed with ASD, document the experience of fathers, assess the impact of culturally sensitive support groups on parents, and better understand the experience of health professionals https://doi.org/10.7202/1019192ar https://doi.org/10.7202/1019192ar IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 438 working with immigrant families with a child diagnosed with ASD. 9. Fellin, M., King, G., Esses, V., Lindsay, S., & Klassen, A. (2013). Barriers and facilitators to health and social service access and utilization for immigrant parents raising a child with a physical disability. International Journal of Migration, Health & Social Care, 9(3), 135-145. https://doi.org/10.11 08/IJMHSC-07- 2013-0024 GNP of country of origin Parental and child language competencies Social support from host country Acculturation and adaptation processes (Acceptable gender relations) Families who immigrate to Canada from resource poor countries may not know about the possibilities for a child with a disability, including their independence and their ability to reach their own goals. Language was one of the principal barriers to both service access and utilization, even though many health and social service providers have the use of translators or interpretation services. Families experienced financial barriers that included lack of knowledge of the funding available and the need to pay for equipment before being reimbursed from a funding source. Parents had fears about the possibility of experiencing discrimination and/or cultural miscommunication. Acceptable gender relations differ across cultures; therefore, culturally normative gender relations are central to culturally sensitive care. Having a third person, such as a social worker or translator, to help them navigate the system increased positive experiences with accessing and utilizing services. Service providers should help their clients or patients be aware of the services available to them. There may be a need for service providers to understand the effects of power imbalances on relations between service providers and immigrant families. Appropriate gender relations need to be considered by service providers when working with parents and their children. Service providers need to accommodate and work with immigrant parents who have a child with a disability to overcome the barriers to their care. To enhance service experiences, formal support and home services should be provided when possible. 10. Hilario, C. T., Vo, D. X., Johnson, J., & Saewyc, E. (2014). Acculturation, gender, and mental health of Southeast Mental health (recent stress, despair, self-harm, suicide, and self-esteem) Acculturation (foreign- born status, length of time Girls reported significantly higher rates of mental health issues than boys, including self-harm activity, suicidal intent, and attempted suicide. Boys and girls who had lived in Canada for less than 5 years were more likely to report extreme levels of despair; Future research must account for gender and acculturation-related differences in mental health and to assess for protective factors that may help mitigate the negative effects of stressors on adolescent mental health. IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 439 Asian immigrant youth in Canada. Journal of Immigration and Minority Health, (6), 1121-1129. https://doi.org/10.10 07/s10903-014-9978- x in Canada, and language spoken at home) Protective factors (family connectedness, school connectedness, and ethnic identity connectedness) girls in Canada for less than 10 years were also more likely to report extreme despair as well as extreme stress. Significant protective factors for boys and girls were family connectedness for both stress and despair as well as school connectedness but only among girls. Higher levels of ethnic identity connectedness were associated with lower odds of despair among boys but higher odds of stress among girls. 11. Beiser, M., Goodwill, A. M., Albanese, P., McShane, K., & Nowakowski, M. (2014). Predictors of immigrant children's mental health in Canada: Selection, settlement contingencies, culture, or all of the above? Social Psychiatry & Psychiatric Epidemiology, 49(5), 743-756. http://dx.doi.org/10. 1007/s00127-013- 0794-8 Arrival characteristics (child age at arrival, arrival language fluency, arrival assistance from family), Settlement contingencies (parental depression and somatization, settlement stress, separation from parent, poverty) Cultural factors (one-child household, harsh and supportive parenting) Arrival characteristics: Children’s age and gender, together with parent’s human and social capital characteristics, have a weak and inverse relationship with respect to explaining emotional problems among immigrant children. Settlement contingencies and culture proved to be powerful influences on immigrant children’s mental health. Harsh parenting is a risk factor while supportive parenting is a protective factor for the younger group. Future studies should consider factors such as the meaning and nature of separation as well as the arrangements made for the child in his or her parent’s absence that affect immigrant mental health outcomes. IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 440 12. Kronick, R., Rousseau, C., & Cleveland, J. (2015). Asylum-seeking children's experiences of detention in Canada: A qualitative study. American Journal of Orthopsychiatry, 85(3), 287-294. http://dx.doi.org/10. 1037/ort0000061 Post migratory contingencies (Child detention) Family separation caused by detention emerged as a prominent concern for the child such as earlier traumatic separations, represented a new post-migratory stressor. Parents highlighted that children’s reactions, including those of infants and older teenagers, suggest the constraining and frightening environment of detention is acutely distressing for children. Most families reported ongoing emotional distress, such as separation anxiety, selective mutism, sleep difficulties, and posttraumatic symptoms in their children after detention. Immigration detention is an acutely stressful and potentially traumatic experience for children. For children seeking asylum in Canada, detention is highly distressing and often traumatic. Children reacted to detention with extreme. distress, fear, and a deterioration of functioning, leaving children with psychiatric and academic difficulties long after detention. Children should not be detained for immigration reasons and parents should not be detained without children. Children, regardless of immigration status, should be protected from detention and should also be spared forced separation from their parents. Policies mindful of children’s best interests should mandate alternative practices to detention. Further research could support this advocacy process but should not delay a strong collective stance from health professionals to protect children from immigration detention. 13 Kwak, K., & Rudmin, F. (2014). Adolescent health and adaptation in Canada: Examination of gender and age aspects of the healthy immigrant effect. International Journal for Equity in Healthy immigrant effect and adaptation (daily life stressors, life satisfaction, and sense of belonging) among immigrant adolescents Immigrant adolescents were healthier without showing adaptation problems compared to their native-born non- immigrant counterparts. Girls reported more stress and chronic psychosomatic illnesses; however, their reports on psychological illness and life satisfaction were not different from those of boys. Adolescent boys regardless of their immigrant status felt a weaker sense of belonging to community. Findings suggest that prevention and intervention strategies need to be age and gender appropriate to assist adolescent’s well-being. There is a need to identify to what extent social capital and resources are available and accessible to immigrant adolescents for their adaptation processes. IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 441 Health, 13(1), 103. https://doi.org/10.11 86/s12939-014-0103- 5 Immigrant adolescents did not report their well-being differently with respect to their length of residence. 14 Beiser, M., Taa, B., Fenta-Wube, H., Baheretibeb, Y., Pain, C., & Araya, M. (2012). A comparison of levels and predictors of emotional problems among preadolescent Ethiopians in Addis Ababa, Ethiopia, and Toronto, Canada. Transcultural Psychiatry, 49(5), 651-677. P Predictors of emotional problem among immigrant youth Toronto sample reported higher levels of emotional problems. The predictors are Person Most Knowledgeable (PMK) depression, levels of dissonance regarding ethnocultural retention, perceived prejudice, and perceived discrimination. Redmond (2008, p. 1) suggests that ‘‘what concerns children is not lack of resources per se, but exclusion from activities that other children appear to take for granted, and embarrassment and shame at not being able to participate on equal terms with other children.’’ Future research should explore contextually shaped meanings of poverty as well as strengths within children and their families that account for their apparent resilience in the face of distressing circumstances. 15. Oxman‐Martinez, J., Rummens, A. J., Moreau, J., Choi, Y. R., Beiser, M., Ogilvie, L., & Armstrong, R. (2012). Perceived ethnic discrimination and social exclusion: newcomer immigrant children in Canada. American Perceived ethnic discrimination (discrimination by peers and teachers) Social exclusion (psychological, social, and economic isolation) Psychosocial functioning (self-esteem and sense of social competence) Peer discrimination includes direct forms of hostile behaviors—hitting, name calling, pushing, being insulted in front of people, and threatening—as well as indirect forms of hostile behaviors. Boys present higher scores on the perceived discrimination by peers’ scale than girls. Perceived discriminatory behaviors by teachers at school; significant differences were found according to ethnicity, and they felt they had been treated unfairly by teachers at school because of the way they look or speak. It will be important to explore whether and why newcomer immigrant girls appear to follow or to adjust to the mainstream more quickly and successfully than boys. School systems should strive to better socially integrate newcomer children within a pluralistic society • Awareness and sensitivity training to staff, educator, and teachers https://doi.org/10.1186/s12939-014-0103-5 https://doi.org/10.1186/s12939-014-0103-5 https://doi.org/10.1186/s12939-014-0103-5 IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 442 Journal of Orthopsychiatry, 82(3 ), 376. https://doi.org/10.11 11/j.1939- 0025.2012.01161.x Academic performance (sense of academic competence and factual academic grades) The psychological isolation variable was negatively correlated with all psychosocial functioning and academic performance variables. A negative correlation was also found between the social isolation and academic performance variables. Perceived discrimination by teachers was found to predict lower sense of social competence in peer relationships, lower self-esteem, and less sense of academic competence. • Use of multicultural teaching and learning material • Facilitating dialogue between multicultural peers • Organizing immigrant parents outreach programs and foster participation into school event • Protected funding for second- language ESL programming Policies and programs should appreciate and value social otherness to advance social integration and avoiding exclusion and discrimination. 16 Beiser, M., Zilber, N., Simich, L., Youngmann, R., Zohar, A. H., Taa, B., & Hou, F. (2011). Regional effects on the mental health of immigrant children: Results from the New Canadian Children and Youth Study (NCCYS). Health & Place, 17(3), 822-829. http://dx.doi.org/10. 1016/j.healthplace.20 11.03.005 Immigrant human and social capital (parental language at arrival, social support in the host country, and PMK depression) Institutional receptivity (annual household income, work related stress, home school relationship) Perception of welcome (marginalization, neighborhood social organization) Language level at arrival, social support, and parental depression – made an independent and statistically significant contribution to predicting children's EP. Neither income nor work-related stress proved significant predictors of EP. Both marginalization and neighborhood quality made independent, statistically significant contributions to EP. These findings direct attention to the importance of developing home-school ties and of repairing those that have frayed. Outreach to immigrant parents should be an important priority for schools, with due recognition that immigrant parents and school personnel might disagree about what constitutes a positive school environment. https://doi.org/10.1111/j.1939-0025.2012.01161.x https://doi.org/10.1111/j.1939-0025.2012.01161.x https://doi.org/10.1111/j.1939-0025.2012.01161.x IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 443 Dependent variable: Emotional Problem (EP) 17 Hamilton, H. A., Marshall, L., Rummens, J. A., Fenta, H., & Simich, L. (2011). Immigrant parents' perceptions of school environment and children's mental health and behavior. Journal of School Health, 81(6), 313- 319. http://doi.org/10.111 1/j.1746- 1561.2011.00596.x Parents’ perceptions of school environment and children’s emotional and behavioral problems Higher parental perception of school was associated with less emotional distress and physical aggression among immigrant children regardless of family dysfunction, parental depression, and select characteristics of the child. Parental depression had the strongest influence on emotional distress in children, and ethnicity had the most influence on the association between perception of school and emotional distress in children. Higher child perception of schools was associated with fewer emotional problems in children. Longitudinal data are necessary to determine the direction of the relationship and test the possible mechanisms through which the relationship occurs. Identifying the critical relationship between parents and schools offers an opportunity to strengthen social supports that help parents adapt and in turn to promote child emotional health and behavior. Establishing open lines of communication with new immigrant parents so that their needs and concerns can be addressed. 18 Montazer, S., & Wheaton, B. (2011). The impact of generation and country of origin on the mental health of children of immigrants. Journal of Health & Social Behavior, 52(1), 23- 42. http://dx.doi.org/10. Country of origin and adaptation process across immigrant generations GNP: Gross National Product The healthy immigrant effect in the first-generation group from lower GNP origins is due primarily to lower family conflict and higher parental care and secondarily to the lower prevalence of disliking school and higher academic performance of the children in this group. The higher rate of reported externalizing problems in the 2.5-generation children from low-GNP origins is due more specifically to higher family conflict and lower parental care and less to issues of school involvement. Both immigrant mothers with premigration affective problems and native-born mothers with early affective GNP is a marker of more than economic development; it does not account for cultural differences that are very important for migration and adjustment processes. http://dx.doi.org/10.1177/0022146510395027 IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 444 1177/0022146510395 027 problems are associated with higher internalizing and externalizing symptoms; and higher maternal education and household income are associated with lower levels of externalizing and internalizing problems. The conditional adaptation approach emphasizes the fact that children from higher, and therefore similar, GNP backgrounds do not face an adjustment process that affects their mental health, in part because the task of adjustment itself is informed by greater knowledge, similarity, and awareness of host country practices. But for immigrants from lower GNP backgrounds, there is more to learn, more uncertainty, possibly more discrimination and often a greater cultural distance to bridge. 19 Oxman-Martinez, J., & Choi, Y. R. (2014). Discrimination, relationships and ethnic identity as predictors of self- esteem and social competence among early adolescent immigrants in Canada. Handbook in the Psychology of Self-esteem. Nova Science Publishers Inc.: New York (pp. 103-122). Post-migratory contingencies (experiences of violence and discrimination at school and neighborhood) Familial contingencies (conflict and connectedness) Cultural connectedness (ethnic identity) Perceived discrimination by peers and teachers within school and community contexts was a significant predictor of poor psychosocial functioning among immigrant adolescents, indicating that perceived discrimination was negatively related to self-esteem and social competence. The parent-adolescent relationship had significant influence on immigrant adolescents’ self-esteem and social competence. Immigrant youth with positive parental relationships showed better self-esteem and greater social competence. Despite the potential conflicts within immigrant families, such as resettlement stress and acculturation, family continues to be a consistent source of protection from poor psychosocial functioning of immigrant youth in early adolescence. Programs aimed at healthy adolescent development should be increased in immigrant families. Such programs should focus on enhancing parent- adolescent relationships and providing support for immigrant families in the adaptation process. Government policy could also be revised to reflect the trend in acculturation and its adaptation outcomes so that support services may be effectively designed and appropriate. In order to provide immigrant adolescents with a better educational environment, it is necessary to http://dx.doi.org/10.1177/0022146510395027 http://dx.doi.org/10.1177/0022146510395027 IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 445 Positive perception of school environments measured by the school-home relationship scale was significantly related to adolescents‟ self-esteem and social competence. These findings offer support for the claim that positive school experiences influence immigrant students’ psychosocial functioning and direct attention to the importance of developing positive school-home relationships. Ethnic identity was found to significantly influence early adolescents’ self-esteem and social competence among immigrant groups. Youth with a strong sense of ethnic identity reported higher self-esteem and greater social competence. Both relationship domains, parent-adolescent and school- home relationships, are consistently associated with positive youth outcomes. Ethnic identity has a significant effect on self-esteem and social competence of immigrant youth. Significant variations across ethnic groups are also found in parent- child relationships, school-home relationships, and ethnic identity as well as social competence. Discrimination, relationship factors, and ethnic identity are critical factors affecting self-esteem and social competence of early adolescent immigrants. establish school policies embodying the principles of diversity, equity, and multicultural education as part of the daily classroom and school environment, as well as adapting the curriculum and providing teacher supports that address immigrant students‟ real needs. Future longitudinal research of the NCCYS may allow better understanding of relations between the risk factors and negative outcomes. Future research of culturally relevant and developmentally sensitive longitudinal studies on specific cultural processes at the developmental stages across the life span is needed to uncover critical periods of risk and vulnerability, potential for resilience, as well as optimal opportunities for healthy development of immigrant youth. Knowledge will enable the development of more effective policies and programs aimed at helping immigrating youth cope with their unique challenges. Research, intervention, and social policy at different governmental levels must focus on the psychosocial well- IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 446 being, developmental potential and successful integration of immigrant youth and their parents into the host society while respecting their cultures, histories, beliefs, and migration experiences. 20 Beiser, M., Hamilton, H., Rummens, J. A., Oxman-Martinez, J., Ogilvie, L., Humphrey, C., et al. (2010). Predictors of emotional problems and physical aggression among children of Hong Kong Chinese, mainland Chinese and Filipino immigrants to Canada. Social Psychiatry & Psychiatric Epidemiology, 45(10), 1011-1021. https://doi.org/10.10 07/s00127-009-0140- 3 Universal factors (age, gender family and neighborhood characteristics) Migration-specific factors (ethnic background, acculturative stress, prejudice, region of settlement) Dependent variable: Emotional Problems (EP) and Physical Aggression (PA) PMK depression and familial dysfunction made significant and independent contributions to EP. PMK inability to speak one of Canada’s official languages, resettlement stress, and perceptions of prejudice each increased the risk for children’s EP. Acculturation stress and perceived prejudice made significant and independent contributions to explaining physical aggressiveness scores. Younger children were more likely than older to be physically aggressive, and boys more likely to display PA than girls. Future NCCYS studies will attempt more in-depth explorations of the following. • The relationships between region of resettlement and children’s well-being • The relationships between parental absences and children’s mental health risk. Call for special training programs for service providers, including the need to plan for family life post- reunification initiatives. 21 Berry, J. W., & Sabatier, C. (2010). Acculturation, discrimination, and Acculturation, discrimination, and adaptation Youth who involve themselves in both their heritage culture and that of the national society (by way of integration) have the most positive psychological well- being, and are most adjusted in school and in the Longitudinal research is required to better understand the relationships, and causal links between acculturation IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 447 adaptation among second generation immigrant youth in Montreal and Paris. International Journal of Intercultural Relations, 34(3), 191- 207. doi:10.1016/j.ijintrel. 2009.11.007 community; in contrast, those who are minimally involved with either culture (the marginalization course), are least well-adapted; and those who are primarily oriented towards one or the other culture (assimilation or separation) generally fall in between these two adaptation poles. They affirm that adaptation is the outcome of acculturation strategies and discrimination. This is because when people are threatened (for example by pervasive discrimination) they will reciprocate their rejection by the larger society by expressing a negative view towards those who discriminate against them. strategies and experiences and adaptation 22 Costigan, C. L., Koryzma, C. M., Hua, J. M., & Chance, L. J. (2010). Ethnic identity, achievement, and psychological adjustment: Examining risk and resilience among youth from immigrant Chinese families in Canada. Cultural Diversity & Ethnic Minority Psychology, 16(2), 264-273. http://dx.doi.org/10. 1037/a0017275 Ethnic identity, achievement, and psychological adjustment Stronger feelings of ethnic identity (affirmation and belonging and ethnic identity achievement) were associated with higher levels of self-esteem and fewer symptoms of depression. In addition, stronger feelings of ethnic affirmation and belonging were associated with higher grade point averages. In terms of achievement, a strong sense of ethnic identity may provide youth with motivation to work hard in school and a sense of meaning to their academic goals. Immigrant youth could be encouraged to participate in events and festivals based in their ethnocultural community. Initiatives to promote ethnic identity in schools may include offering classes in ethnic studies and ethnic languages and supporting the formation of ethnic clubs. Schools that promote ethnic identity awareness and foster a sense of acceptance for cultural diversity provide a safe place for youth to explore their ethnic identity with peers. IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 448 23 Tulli, M., et al. (2020). Immigrant Mothers' Perspectives of Barriers and Facilitators in Accessing Mental Health Care for their Children. Journal of Transcultural Nursing: Official Journal of the Transcultural Nursing Society, 31(6), 598-605. https://doi.org/10.11 77/104365962090281 2. Access to healthcare (Lack of information, stigma, financial strain) Social support from host country Financial strain made it difficult for mothers to access services for their children; they felt limited by the high costs of programs and services due to low incomes. Lack of information about the healthcare system and available services was a key barrier for mothers, reporting frustration about not knowing where to find resources and feeling unsupported by policy makers and service providers. Mothers said they did not feel listened to by either schools or service providers and they felt ignored by service providers said their children were evaluated based on questionnaires, rather than taking into consideration the mother’s knowledge about her children. Language barriers were often connected to both issues of racism and discrimination and a lack of information. Mothers cited having difficulty communicating with their child’s pediatrician, having to depend on family members for communication, and often not being able to understand medical terminology, which created feelings of dependency, isolation, and powerlessness, negatively affecting their relationships with their child or spouse (whoever was translating for them). Stigma around mental health and the fear of having their child labelled was a factor that made it hard for them to seek mental health services. This made them feel isolated because they felt they could not talk about their children’s needs or ask for information from their community. Mothers felt isolated from both the general community in Canada and from their family in their country of origin, Parent centered knowledge and culturally appropriate care delivery, as well as more effective information transmission and bridging between immigrant and healthcare policy realms are important to dissolve immigrant children’s barriers to access. Nurses can improve access to mental health services by addressing issues related to racism within the health system, by creating awareness related to mental health, and by providing trained interpreters to help bridge barriers in communications. Further research to determine the effectiveness of increased funding for recreation and sports in preventing poor mental health outcomes for this population is also needed. IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 449 which influenced their capacity to access mental health services for their children. Financial strain, fear of stigma, and experiences of discrimination all posed significant barriers to their children’s access to important services and were often interrelated. Schools offering services or coordinating the provision of service usually organized by teachers or principals made this factor the most commonly cited facilitator of access to mental health services. Mothers who had positive experiences with schools reported being well-equipped to access care for their children. Mothers’ personal levels of higher education helped them to promote their children’s mental health and access services when needed. Their educational backgrounds included healthcare, education, and psychology, which are especially pertinent to child mental health. Education was thus helpful for these mothers, they had training to care for their children themselves and were better positioned to know their rights in Canada, to resist discrimination, and to access services. Mothers who were able to access free services, such as sports and recreation, speech language pathologists, occupational therapists, psychologists, and libraries, were able to promote their children’s mental well-being or better treat their mental illness issues. Services that were free greatly enhanced participants’ ability to access them. They also afforded them the time or resources to more effectively IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 450 take on other barriers, such as lack of information and isolation. 24 McRae, D.N., et al. (2020). Immigrant and Ethnic Neighbourhood Concentration and Reduced Child Developmental Vulnerability: A Canadian Cohort Study. International Journal of Population Data Science, 5(1), 1147. https://doi.org/10.23 889/ijpds.v5i1.1147. Post migratory contingencies (Experiences of violence and discrimination at school and neighbourhood) Neighbourhoods with discordant-lower vulnerability in social competence were 30% less likely to have residents receiving social assistance. Neighbourhoods with discordant-higher vulnerability in social competence were more likely to have residents receiving social assistance. There was no statistically significant effect associated with immigrant concentration or ethnic diversity when comparing these two types of neighbourhoods. Neighbourhoods with discordant-lower vulnerability in emotional maturity were 17% more likely to have residents with a high school diploma as their highest credential. Neighbourhoods with discordant-higher vulnerability in emotional maturity were 33% more likely to have residents who were receiving social assistance. Neighbourhoods in which children had discordant-lower vulnerability in language and cognitive development than that predicted by income were less likely to have residents receiving social assistance. Neighbourhoods with discordant-higher vulnerability in language and cognitive development were more likely to have social assistance recipients. Neighbourhoods with discordant-lower vulnerability in communication skills and general knowledge were less likely to have residents with dwellings in need of major repair. Neighbourhoods with discordant-higher Neighbourhood-level policy and programming should address both income and non-income related barriers to healthy child development and importance of both the social and physical environment in shaping early childhood development. Future research is needed to specifically test social cohesion as a mechanism linking neighbourhood- level immigrant concentration and low ethnic diversity to less child developmental vulnerability. Research should also focus on which immigrant/ ethnic groups are experiencing more favourable outcomes than predicted and under what conditions. IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 451 vulnerability in communication skills and general knowledge had higher odds of residents receiving social assistance. Neighbourhood immigrant concentration and ethnic composition was significantly associated with neighbourhood-level discordant-lower developmental vulnerability, compared to concordant vulnerability. Across all five domains the most consistent neighbourhood characteristic associated with discordant lower vulnerability was ethnic homogeneity, with levels of immigrant concentration only marginally influencing predicted probabilities. In other words, areas where inhabitants were of similar ethnicity had, on average, lower levels of child developmental vulnerability than those with diverse ethnicity. In two domains (language and cognitive development and communication skills and general knowledge), immigrant concentration predicted discordant- higher vulnerability. High or low immigrant concentration and ethnic homogeneity was associated with less likelihood of child developmental vulnerability at a neighbourhood-level. It may be that the benefits of shared language and culture (e.g., parenting styles and religious beliefs) encourage a sense of neighbourhood social cohesion, fostering children’s cultural identity, promoting child development. 25 Kronick, R., Rousseau, C. & Cleveland, J. (2018). Refugee Children's Post migratory contingencies (child detention) Confinement and surveillance as incarceration causes traumatic events in refuge children’s lives, including other post-migratory stressors such as precarious status or Evidence-based policy must protect children from detention itself. IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 452 Sandplay Narratives in Immigration Detention in Canada. European Child & Adolescent Psychiatry 27(4), 423- 437. https://doi.org/10.10 07/s00787-017-1012- 0. limitations on liberty while being monitored by bondspersons. Children’s sense of fear and threat, protection and safety, suggesting ambivalent feelings towards the host society, which was viewed as a safe haven but also as potentially dangerous. The children’s awareness of loss of protection even in the context of a hope that migration will bring a better life. In the face of parents’ and families’ powerlessness to change their circumstances and to imagine worlds in which there is a restoration of benevolence and order even in the presence of threat. Children spoke of fears of being harmed by police and other aggressive forces in their new home. The children in the study were grappling with past experiences of atrocities which may have been re-evoked by detention. The absences in children’s real lives, such as absence of proper education, socialization and protective forces. Children’s mixed feelings towards Canada as newcomers facing detention implies that immigration detention practices may shape newcomers’ relationship with the host country and influence their social integration. Children’s perspectives confirm the harmful consequences of detention and the reality that children who are detained have often experienced tremendous adversity prior to The separation of children from parents to enable the detention of parents must also be prohibited to prevent the harms of family separation. Community-based alternatives to detention should be developed and implemented locally and internationally. Children’s best interests should be a primary consideration for all responsible decisionmakers from governments to tribunal members to CBSA officers and guards. This will require training at all levels so that the multifactorial assessment of children’s interests is informed by an understanding of children’s detention experiences, mental health consequences of detention, as well as trauma, migration and attachment. Independent oversight mechanisms are also needed to assure that the basic rights of children and families subject to border control policies are protected, including the right to family life, education and health. Clinicians may pave the way for important policy-level change by working as advocates for individual IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 453 arrival in Canada. Detention can be a toxic stress that may interfere with children’s capacity to recover from previous harm and psychopathology. families and children impacted by immigration detention. This involves taking into account the adverse effects of immigration detention in the provision of care for migrant families as well finding ways to serve children and families who are detained and advocate for their health and safety. Further research is needed to understand the long-term impact of detention for children and its interaction with previous trauma. 26 George, M. A., & Bassani, C. (2018). Influence of perceived racial discrimination on the health of immigrant children in Canada. Journal of International Migration and Integration, 19(3), 527-540. http://dx.doi.org.logi n.ezproxy.library.ualb erta.ca/10.1007/s121 34-018-0539-3 Post migratory contingencies (experiences of violence and discrimination at school and neighbourhood) Racial discrimination has an influence on children’s health; the relationship between discrimination and health is complex. Cultural discrimination had a negative effect on the child’s parent-rated health. Children (and their families) are able to more easily mitigate negative health consequences associated with low levels of culture-based discrimination. Perceived racial discrimination is complex. Its influence on either increasing family cohesion, and thereby leading to improved health, or increasing stress, thereby leading to poorer health needs to be explored further. Discrimination may act as a catalyst that more tightly binds and bridges family and possibly ethnic community ties. Future work is needed to examine the growth of this social capital and its relationship with discrimination and health. More research across various countries and contexts is needed to understand the complex effects of racial discrimination on children’s health. IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 454 27 Comeau, J., et al. (2019) Changes in the Prevalence of Child and Youth Mental Disorders and Perceived Need for Professional Help between 1983 and 2014: Evidence from the Ontario Child Health Study. Canadian Journal of Psychiatry. 64(4), 256-264. https://doi.org/10.11 77/070674371983003 5. Perceived need for professional help The prevalence of any disorder decreased among children living in immigrant families but not nonimmigrant families and relative increases in perceived need for professional help were lower among children in immigrant versus nonimmigrant families. The prevalence of any disorder and perceived need for professional help was much lower for immigrant versus nonimmigrant children and youth in 2014 compared to 1983. There should be continued need for effective and efficient prevention and intervention programs. There is a need for longitudinal studies that follow immigrant children and youth over time to better understand if their mental health advantages persist into adulthood. IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 455 Table 3. Study Characteristics Characteristics References Total included studies 27 research studies that met the inclusion criteria Bakhshaei & Henderson, 2016; Beiser & Hou, 2016; Beiser et al., 2010, 2011, 2012, 2014, 2015; Ben-Cheikh & Rousseau, 2013; Berry & Sabatier, 2010; Brabant et al., 2016; Burgos et al., 2017; Comeau et al., 2019; Costigan et al., 2010; Elsayed et al., 2019; Fellin et al., 2013; George & Bassani, 2018; Hamilton et al., 2011; Hilario et al., 2014; Kronick et al., 2015, 2018; Kwak & Rudmin, 2014; Lecompte et al., 2018; McRae et al., 2020; Montazer & Wheaton, 2011; Oxman-Martinez & Choi, 2014; Oxman‐Martinez et al., 2012; Tulli et al., 2020 Study design 20 were quantitative studies (All studies used non- experimental correlational design) (Sample sizes ranged from 33 to 14283) Beiser & Hou, 2016; Beiser et al., 2011, 2012, 2014, 2015; Berry & Sabatier, 2010; Brabant et al., 2016; Comeau et al., 2019; Costigan et al., 2010; Elsayed et al., 2019; George & Bassani, 2018; Hamilton et al., 2011; Hilario et al., 2014; Kwak & Rudmin, 2014; Lecompte et al., 2018; McRae et al., 2020; Montazer & Wheaton, 2011; Oxman-Martinez & Choi, 2014; Oxman‐Martinez et al., 2012 6 were qualitative studies (Sample sizes ranged from 5 to 20) Ben-Cheikh & Rousseau, 2013; Burgos et al., 2017; Fellin et al., 2013; Kronick et al., 2015, 2018; Tulli et al., 2020 1 was a mixed method study Bakhshaei & Henderson, 2016 Study participants 19 included studies focused on immigrants (Mainland China, Hong Kong, the Philippines, Bangladesh, and India) Bakhshaei & Henderson, 2016; Beiser et al., 2010, 2011, 2014; Ben-Cheikh & Rousseau, 2013; Berry & Sabatier, 2010; Brabant et al., 2016; Burgos et al., 2017; Comeau et al., 2019; Costigan et al., 2010; Fellin et al., 2013; George & Bassani, 2018; Hamilton et al., 2011; Hilario et al., 2014; Kwak & Rudmin, 2014; McRae et al., 2020; Montazer & Wheaton, 2011; Oxman-Martinez & Choi, 2014; Oxman‐Martinez et al., 2012 6 included studies focused on refugees (Ethiopia, Syria, Somalia, Sudan, Haiti, Ukraine, Serbia, Afghanistan, Sri Lanka, Iran, Colombia) Beiser & Hou, 2016; Beiser et al., 2012, 2015; Elsayed et al., 2019; Kronick et al., 2015, 2018 2 articles included both immigrants and refugees Lecompte et al., 2018; Tulli et al., 2020 Location of study 6 articles were from Ontario Beiser et al., 2012; Comeau et al., 2019; Fellin et al., 2013; Hamilton et al., 2011; Kronick et al., 2015; Montazer & Wheaton, 2011 IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 456 5 articles were from Québec Bakhshaei & Henderson, 2016; Ben-Cheikh & Rousseau, 2013; Brabant et al., 2016; Lecompte et al., 2018; Oxman-Martinez & Choi, 2014 3 articles were from British Columbia George & Bassani, 2018; Hilario et al., 2014; McRae et al., 2020 1 article was from from Alberta Tulli et al., 2020 3 articles did not specify a location Burgos et al., 2017; Elsayed et al., 2019; Kwak & Rudmin, 2014 9 articles spanned several Canadian provinces Beiser & Hou, 2016; Beiser et al., 2010, 2011, 2014, 2015; Berry & Sabatier, 2010; Costigan et al., 2010; Kronick et al., 2018; Oxman‐Martinez et al., 2012 Study participants’ age group 9 studies included parents as study participants Ben-Cheikh & Rousseau, 2013; Costigan et al., 2010; Elsayed et al., 2019; Fellin et al., 2013; Hamilton et al., 2011; Kronick et al., 2015; Lecompte et al., 2018; McRae et al., 2020; Tulli et al., 2020 10 studies included adolescents (age range 14-18) Bakhshaei & Henderson, 2016; Beiser & Hou, 2016; Beiser et al., 2015; Berry & Sabatier, 2010; Brabant et al., 2016; Burgos et al., 2017; Hilario et al., 2014; Kwak & Rudmin, 2014; Montazer & Wheaton, 2011; Oxman- Martinez & Choi, 2014 8 studies included children (age range 5-13) Beiser et al., 2010, 2011, 2012, 2014; George & Bassani, 2018; Kronick et al., 2018; Montazer & Wheaton, 2011; Oxman‐Martinez et al., 2012 1 study included parents and teachers Comeau et al., 2019 New Canadian Child and Youth Study (NCCYS) 9 studies reported findings [2076 immigrant and refugee youth aged 11-13 belonging to 16 different ethnocultural groups (Hong Kong Chinese, Mainland Chinese, Filipino, Ethiopian, Somali, Caribbean, Serbian, Vietnamese, Lebanese, Haitian, Latin American, Kurdish, Iranian, Punjabi, Sri Lankan Tamil, and Afghani)] Beiser & Hou, 2016; Beiser et al., 2010, 2011, 2012, 2014, 2015; Hamilton et al., 2011; Oxman-Martinez & Choi, 2014; Oxman‐Martinez et al., 2012 IHTP, 1(3), 418-457, 2021 CC BY-NC-ND 4.0 ISSN 2563-9269 457 Table 4. Conceptualization of mental health used in the studies Conceptualization of mental health Reference Depression, somatization, resettlement stress, and perception of prejudice Beiser et al., 2010, 2011, 2014 Psychological distress and interpersonal strain and anxiety Lecompte et al., 2018 Disturbed sadness regulation Elsayed et al., 2019 Stress and despair Hilario et al., 2014 Weak adaptation and a low sense of belonging to community Beiser et al., 2011, 2014; Kwak & Rudmin, 2014 Perception of psychological and social isolation Oxman-Martinez et al., 2012 Lower self-esteem and symptoms of depression Costigan et al., 2010 Impaired school performance, cognitive functioning, and emotional regulation Brabant et al., 2016; Oxman-Martinez et al., 2012 Impaired psychosocial functioning (self-esteem and social competence) Oxman-Martinez & Choi, 2014 Low sense of belonging and disorganized attachment behaviours Lecompte et al., 2018 Delinquency and aggression, and internalizing difficulties, such as somatic complaints, withdrawal syndrome Montazer & Wheaton, 2011 Physical aggression Beiser et al., 2014 Emotional disorders and hyperactivity Comeau, 2019 Autism Ben-Cheikh & Rousseau, 2013 Separation anxiety, selective mutism, and sleep disturbances; worsened posttraumatic symptoms such as interrupted sleep, temper tantrums, and fear in children Kronick et al., 2018 Arksey, H., & O'Malley, L. (2005). Scoping studies: Towards a methodological framework. International Journal of Social Research Methodology, 8(1), 19-32. https://doi.org/10.1080/1364557032000119616 Bakhshaei, M., & Henderson, R. I. (2016). Gender at the intersection with race and class in the schooling and wellbeing of immigrant-origin students. BMC Women's Health, 16, 47. https://doi.org/10.1186/s12905-016-0328-0 Barozzino, T. (2010). Immigrant health and the children and youth of Canada: Are we doing enough? Healthcare Quarterly, 14, 52-59. https://doi.org/0.12927/hcq.2010.21983 Beiser, M., & Hou, F. (2016). Mental health effects of pre-migration trauma and post-migration discrimination on refugee youth in Canada. Journal of Nervous and Mental Disease, 204(6), 464-470. https://doi.org/10.1097/NMD.0000000000000516 Beiser, M., Hamilton, H., Rummens, J. A., Oxman-Martinez, J., Ogilvie, L., Humphrey, C., & Armstrong, R. (2010). Predictors of emotional problems and physical aggression among children of Hong Kong Chinese, mainland Chinese and Filipino immigrants to ... Beiser, M., Zilber, N., Simich, L., Youngmann, R., Zohar, A. H., Taa, B., & Hou, F. (2011). Regional effects on the mental health of immigrant children: Results from the New Canadian Children and Youth Study (NCCYS). Health & Place, 17(3), 822-829. ht... Beiser, M., Taa, B., Fenta-Wube, H., Baheretibeb, Y., Pain, C., & Araya, M. (2012). A comparison of levels and predictors of emotional problems among preadolescent Ethiopians in Addis Ababa, Ethiopia, and Toronto, Canada. Transcultural Psychiatry, 49(... Beiser, M., Goodwill, A. M., Albanese, P., McShane, K., & Nowakowski, M. (2014). Predictors of immigrant children's mental health in Canada: Selection, settlement contingencies, culture, or all of the above? Social Psychiatry and Psychiatry Epidemiolo... Beiser, M., Puente-Duran, S., & Hou, F. (2015). 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Immigrant children: Their experience of violence at school and community in host country. Children & Society, 30(3), 241-251. https://doi.org/10.1111/chso.12131 Beiser, M., & Hou, F. (2016). Mental health effects of premigration trauma and postmigration discrimination on refugee youth in Canada. Journal of Nervous & Mental Disease, 204(6), 464-470. http://doi.org/10.1097/NMD.0000000000000516 Beiser, M., Puente-Duran, S., & Hou, F. (2015). Cultural distance and emotional problems among immigrant and refugee youth in Canada: Findings from the New Canadian Child and Youth Study (NCCYS). International Journal of Intercultural Relations, 49, 33-45. https://doi.org/10.1016/j.ijintrel.2015.06.005 Hilario, C. T., Vo, D. X., Johnson, J., & Saewyc, E. (2014). Acculturation, gender, and mental health of Southeast Asian immigrant youth in Canada. Journal of Immigration and Minority Health, (6), 1121-1129. https://doi.org/10.1007/s10903-014-9978-x Beiser, M., Goodwill, A. M., Albanese, P., McShane, K., & Nowakowski, M. (2014). Predictors of immigrant children's mental health in Canada: Selection, settlement contingencies, culture, or all of the above? Social Psychiatry & Psychiatric Epidemiology, 49(5), 743-756. http://dx.doi.org/10.1007/s00127-013-0794-8 Kwak, K., & Rudmin, F. (2014). Adolescent health and adaptation in Canada: Examination of gender and age aspects of the healthy immigrant effect.  International Journal for Equity in Health, 13(1), 103. https://doi.org/10.1186/s12939-014-0103-5 Beiser, M., Taa, B., Fenta-Wube, H., Baheretibeb, Y., Pain, C., & Araya, M. (2012). A comparison of levels and predictors of emotional problems among preadolescent Ethiopians in Addis Ababa, Ethiopia, and Toronto, Canada. Transcultural Psychiatry, 49(5), 651-677. P Oxman‐Martinez, J., Rummens, A. J., Moreau, J., Choi, Y. R., Beiser, M., Ogilvie, L., & Armstrong, R. (2012). Perceived ethnic discrimination and social exclusion: newcomer immigrant children in Canada. American Journal of Orthopsychiatry, 82(3), 376. https://doi.org/10.1111/j.1939-0025.2012.01161.x  Awareness and sensitivity training to staff, educator, and teachers  Use of multicultural teaching and learning material  Facilitating dialogue between multicultural peers  Organizing immigrant parents outreach programs and foster participation into school event  Protected funding for second-language ESL programming Beiser, M., Zilber, N., Simich, L., Youngmann, R., Zohar, A. H., Taa, B., & Hou, F. (2011). Regional effects on the mental health of immigrant children: Results from the New Canadian Children and Youth Study (NCCYS). Health & Place, 17(3), 822-829. http://dx.doi.org/10.1016/j.healthplace.2011.03.005 Hamilton, H. A., Marshall, L., Rummens, J. A., Fenta, H., & Simich, L. (2011). Immigrant parents' perceptions of school environment and children's mental health and behavior. Journal of School Health, 81(6), 313-319. http://doi.org/10.1111/j.1746-1561.2011.00596.x Montazer, S., & Wheaton, B. (2011). The impact of generation and country of origin on the mental health of children of immigrants. Journal of Health & Social Behavior, 52(1), 23-42. http://dx.doi.org/10.1177/0022146510395027  The relationships between region of resettlement and children’s well-being  The relationships between parental absences and children’s mental health risk. Berry, J. W., & Sabatier, C. (2010). Acculturation, discrimination, and adaptation among second generation immigrant youth in Montreal and Paris. International Journal of Intercultural Relations, 34(3), 191-207. doi:10.1016/j.ijintrel.2009.11.007 Costigan, C. L., Koryzma, C. M., Hua, J. M., & Chance, L. J. (2010). Ethnic identity, achievement, and psychological adjustment: Examining risk and resilience among youth from immigrant Chinese families in Canada. Cultural Diversity & Ethnic Minority Psychology, 16(2), 264-273. http://dx.doi.org/10.1037/a0017275