How the experiences and circumstances of culturally and linguistically diverse (CALD) children and families influence child mental health

What is this resource about?

This practice paper explores how the experiences of children and families from culturally and linguistically diverse (CALD) backgrounds can affect child mental health. It looks specifically at the experiences of parents and children who migrated to Australia for non-humanitarian reasons, such as work, education or family.

This resource draws from both Australian research and stakeholder consultations to explore the experiences and circumstances that contribute to child mental health outcomes and service access in CALD communities. It also provides practice ideas to consider when working with children and families from CALD backgrounds.

Who is this resource for?

This resource is for health, social and community service practitioners who engage with children and families from diverse ethnic backgrounds. It covers foundational concepts and practices, and is best suited to professionals who have not undertaken extensive or specialist training in transcultural child mental health.

How was this resource developed?

This practice paper is based on Australian literature and on stakeholder consultations. The aim was to understand the factors affecting the mental health of children under 12 from CALD communities in Australia and to provide practice ideas for practitioners working in health and welfare services. Over 2,000 papers were screened as part of a scoping review, and consultations were conducted with Australian researchers, practitioners, and community experts. Based on these consultations, the search scope was limited to:

• Australian literature (in order to bring together Australia-specific evidence); and
• Non-humanitarian migrants (and the families of non-humanitarian migrants). Practitioners in mainstream services are most likely to interact with these children and families, and humanitarian migrants may experience unique factors affecting their mental health.

The review found that there is limited research evidence on child mental health outcomes for CALD populations in Australia, the factors that contribute to child mental health outcomes in CALD communities, or how they differ from non-CALD populations. This lack of evidence is partly due to variation in the way that CALD populations are defined and how child mental health outcomes are measured.

There is also limited national data on mental health outcomes that is broken down by people’s CALD-status or ethnicity (Australian Institute of Health and Welfare, 2021b; Federation of Ethnic Communities’ Councils of Australia, 2020; Minas et al., 2013). Because this is still an emerging research area, the evidence review for this paper did not locate any systematic reviews on this topic. Much of the literature that informs this resource is based on individual studies. As a result, the research cited here may have gaps or incomplete representations of the experiences and factors that influence the mental health of children from CALD backgrounds.

In an effort to fill these gaps in understanding, we have worked with practitioners and experts in the field to design this resource. These stakeholders were consulted on the research design, scope and drafting of this resource.

Key definitions

Culturally and linguistically diverse (CALD)

CALD communities are inconsistently defined in Australia (Pham et al., 2021):

• An Australian census¹ report defines ‘CALD background’ as anyone born in a CALD country (based on a list of defined countries), if they have at least one parent born in a CALD country, or if they self-identify a CALD country of ancestry (Multicultural Youth Advocacy Network Australia, 2014).
• The Australian Institute of Health and Welfare (2018) uses a narrower definition of CALD: ‘People who were born overseas, have a parent born overseas or speak a variety of languages.’
• The Ethnic Communities’ Councils of Australia describe CALD populations as those other than the Anglo-Celtic majority (Federation of Ethnic Communities’ Councils of Australia, 2020).

This resource takes a broad definition of CALD and uses the Ethnic Communities Council of Victoria’s (2012) definition:

‘A broad term used to describe communities with diverse languages, ethnic backgrounds, nationalities, traditions, societal structures and religions.’

For the purposes of this resource, CALD does not include Aboriginal and Torres Strait Islander populations.

Although we use the abbreviation ‘CALD’ throughout this resource, it should be noted that there are limits to its usefulness. This is because people who are identified as ‘CALD’ have a diverse range of experiences and rarely use the term to define themselves or their communities. As a result, care should be taken when generalising research findings on CALD people or communities to any one specific person or community (or from a specific community to CALD people as a whole) (Federation of Ethnic Communities’ Councils of Australia, 2020).

Mental health
In line with other Emerging Minds resources, this resource uses a broad definition of mental health, in which it ‘exists on a continuum ranging from good, to times when a person is feeling less well, to a variety of mental health difficulties.’

Children
Refers specifically to people aged from birth to 12 years, although some information may be relevant to children and adolescents between 12 and 18.

Acculturation
Acculturation refers to the process by which individuals from one culture acquire the culture and code of behaviours of another culture (Wu et al., 2018). This often happens following immigration and includes changes to beliefs, values and behaviour (Arora et al., 2020). Refer to the section ‘Types of acculturation and effects on mental health’ under Focus on the individual child: experiences and influences that can affect mental health for more information.

¹ This census report is unrelated to the Australian Government census.

Culturally and linguistically diverse populations are growing in Australia and have varied backgrounds, cultures and ethnicities (Australian Bureau of Statistics, 2022). Children from CALD backgrounds can include first generation migrants (children who are born overseas) and second-generation migrants (children with either parent born overseas).

Approximately 9% of children in Australia aged 0–14 were born overseas, and 39% have at least one parent who was born overseas (Australian Institute of Health and Welfare, 2022). Two thirds of children born overseas are from non-English speaking countries, with the largest representation from India, China and the Philippines (Australian Institute of Health and Welfare, 2022). Second generation children (with both parents born overseas) were also more likely to have Asian ancestry than European ancestry (Australian Bureau of Statistics, 2017).

CALD identification may not be limited to country of birth. It may also include people with ancestry or cultural identification outside of Australian or Anglo-Celtic cultures (Federation of Ethnic Communities’ Councils of Australia, 2020; Multicultural Youth Advocacy Network Australia, 2014).

Migration to Australia can be through humanitarian or non-humanitarian pathways. Humanitarian pathways include those who arrive in Australia as refugees or seeking asylum. Non-humanitarian pathways include all other migration opportunities; for example, skilled migration and family pathways (Phillips, 2017). Non-humanitarian migrants represent 90% of migrants arriving in Australia over the past 10 years (Australian Bureau of Statistics, 2016).

This review did not seek to understand the prevalence or overall rates of mental health difficulties in culturally and linguistically diverse children, compared to non-CALD children. However, there is some evidence to suggest that CALD children may have specific types of concerns and influences on their mental health. The way CALD children and their families present to, or access, services is also likely to be different from non-CALD children.

Common mental health concerns
In one research study, children from CALD backgrounds at ages four and five had higher levels of emotional difficulties² than children from non-CALD backgrounds (Terhaag et al., 2021). Kids Helpline data suggest that ‘emotional issues’ is the number one concern that children from CALD backgrounds report, and that ‘emotional issues’ are reported at higher rates than for children from non-CALD backgrounds (yourtown, 2020). Children from CALD backgrounds can have different worries and concerns compared to non-CALD children and these can be pre-cursors to mental health difficulties (Vassallo, 2019; yourtown, 2020). Compared to children from non-

CALD backgrounds, children from CALD backgrounds may be more concerned about (Vassallo, 2019):

• fitting in at school
• family matters, such as a family member’s health or fighting with their family; and
• world issues such as terrorism, war and the environment.

Presentation and detection of mental health difficulties
There is some evidence to suggest that children from CALD backgrounds have unmet mental health needs, due to the way their mental health difficulties present along with some identified barriers to service use. For these reasons, mental health problems in CALD populations may be hidden and children may appear to be faring better than they are (Nguyen et al., 2019).

For example, some research suggests that children from CALD backgrounds can experience emotional and internalising³ difficulties that are harder for parents, practitioners and educators to detect (Hiscock et al., 2020). This can be due to language barriers, assumptions that the child is quiet and obedient, or the belief that the child’s behaviour is ‘normal’ behaviour (Hiscock et al., 2020; Nguyen et al., 2019). This may reduce the chances of early detection of mental health challenges and potentially lead to exacerbation of mental health difficulties when the child reaches adolescence. This can also result in mental health issues manifesting in other behaviours or settings, such as when children are unable to participate in their normal activities, struggle at school, or become involved in the criminal justice system. Practitioner insights suggest that early signs of mental health difficulties in CALD populations may present differently to non-CALD groups, although there is limited research evidence to confirm this.

Families from CALD backgrounds may also face barriers to accessing healthcare services, such as difficulties navigating between different service providers, mistrust of services, and inadequate access to language interpretation support (Guo et al., 2020). More information on how services can better consider the needs of CALD families and children, and strategies for adapting services to make them more culturally responsive, can be found in the resource sheet, Culturally informed ways to support mental health in refugee and asylum seeker children.

² Emotional difficulties were measured using the Strengths and Difficulties Questionnaire (SDQ), which includes questions relating to feelings of worry, physical complaints (e.g. headaches, stomach-aches) and how often the child is unhappy or tearful. 

³ ‘Internalising problems describe problems that are internal to the child, and most frequently include fears, worries and anxiety.’ (Tully, 2020)

Social determinants of health are the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping the conditions of daily life (World Health Organization, 2022).

Migration and settling into a new country can bring unique challenges that can affect mental health for generations. Children from CALD backgrounds are at higher risk of experiencing health inequities than the general population (Australian Institute of Health and Welfare, 2021a). One in three non-English speaking immigrant families and one in five English-speaking immigrant families experience socio-economic disadvantage (Guo et al., 2020). Financial disadvantage is a risk factor for child adversity and poorer mental health (O’Connor et al., 2020).

However, research also indicates that higher socio-economic status has less of a protective factor against adversity in ethnic minority children than in Anglo-European children (O’Connor et al., 2020). This suggests that being financially secure is not enough to reduce inequalities in mental health outcomes for children from CALD backgrounds, and that other social, political and cultural factors impact upon their wellbeing.

In addition, children’s mental health is dependent on a range of circumstances and contexts as well as the characteristics of individuals and groups (Welsh et al., 2015). For these reasons, adopting a social determinants lens that explores the wider social factors affecting CALD children and families, may be useful for understanding a child’s mental health and wellbeing (Whitehead & Dahlgren, 2006).

Child mental health can be affected by the interaction of a child’s personal characteristics with a range of external factors (see Figure 1). The social determinants that affect a child include their family and relationships; broader structures like education and services, and the socio-economic and cultural contexts in which they grow up (Welsh et al., 2015; Whitehead & Dahlgren, 2006). Figure 1 shows some of the factors identified as contributing to inequalities in child mental health outcomes.

This resource focuses on the inner two circles of Figure 1 (following): how individual child factors and family and relationships factors influence the mental health of children from CALD backgrounds. However, it is important to remember that social determinants do not operate in isolation. Family and relationships and Individual child factors interact with the child’s Socio-economic and cultural context and Education services and environment to collectively influence child mental health.

Accessible description of Figure 1: Factors affecting child mental health in culturally and linguistically diverse communities in Australia

Levels of acculturation, and factors that affect it

The extent to which children from CALD backgrounds take on Australian culture can affect the types of mental health difficulties they have and their similarity or difference to the mental health difficulties of non-CALD children. The effects of differences in culture/ethnicity may also lessen across generations. Children who are second generation or with English-speaking backgrounds tend to present with similar mental health issues to the general population (Basu & Isaacs, 2019; Nguyen et al., 2019).

Children can acculturate at different levels depending on how multicultural their community is. This highlights the ways in which the wider social and cultural context can influence a child’s individual experience (per the outer circle of Figure 1, under Social determinants of child mental health). Children from CALD backgrounds in rural/remote areas may adapt to Australian culture faster than children in multicultural urban environments because they may not have similar cultural groups to associate with (Basu & Isaacs, 2019).

Type of acculturation and effects on mental health

There is some research to suggest that children’s degree of acculturation and identification with mainstream ‘Australian’ culture and/or their heritage culture can affect their mental wellbeing. However, the evidence for what types of acculturation or identification with culture are most beneficial is inconclusive.

Some Australian studies suggest that high levels of immersion in either their heritage culture or Australian cultural orientation can have positive effects on a child’s mental health (Arora et al., 2020; Ren & Wyver, 2016). However, some caution should be used in interpreting these results as they can rely on behaviour assessment tools that have not been adapted to different cultural contexts (Ren & Wyver, 2016). ‘Integration-oriented’ acculturation, which is adopting the new ‘host’ culture while maintaining interest in the original culture, may also be beneficial to children and young people’s mental health, according to Australian and international literature (Berry, 2010; Lo, 2010; Wu et al., 2018). On the other hand, ‘assimilation-orientated’ children and young people, who endorse their host culture with little interest in maintaining their heritage culture, can experience poorer mental health due to lower levels of resilience (Wu et al., 2018).

The impacts of racism on mental health

Experiencing or witnessing racism can increase stress, heighten threat perception, and cause hypervigilance and situation avoidance.

Experiencing racism has been associated with loneliness, depressive symptoms and poorer socio-emotional adjustment in children from CALD backgrounds in Australia (Priest et al., 2017; Priest et al., 2020). Witnessing racial discrimination towards peers at school or towards a caregiver has also been associated with sleep problems and social and emotional difficulties in children (Priest, 2021). Repeated exposure to racism and bullying has long-term impacts on wellbeing and mental health (Priest et al., 2019). Internalised racism can increase pressure to conform with, or distance oneself from, stereotypes associated with that ethnicity (e.g. being good at maths). This can result in children performing below their capability (Priest, 2021).

Australian children from CALD backgrounds have been reported as experiencing more ethnicity-based victimisation than CALD children in comparable countries like the United Kingdom (Terhaag et al., 2021). Racism of this sort is not simply the experience of individuals (either as victims or perpetrators); it is also a societal problem that can be exacerbated by existing social structures.

Societal structures can be established in such a way that they limit CALD families’ ability to thrive in education or to access health care (Priest et al., 2021). For example, appointment times and wait-lists may be unfamiliar concepts to some community groups, and this may limit their ability to engage with systems or supports. Similarly, within schools there may be different understandings of teaching practice, discipline or academic expectations that can limit or exclude children from CALD backgrounds from participating.

Recognising that societal or structural issues are a key factor in adversity can help services avoid assuming that a family or individual’s characteristics or cultural identity are the cause of their difficulties (O’Connor et al., 2020).

Building children’s strengths to promote good mental wellbeing
Activities that focus on children’s existing strengths can support their mental wellbeing. One study found that newly immigrated children who were just starting school enjoyed subjects more when they felt they had skills in that area, particularly when their abilities in English were not the main focus (de Heer et al., 2016).

Making friends can be difficult for children, and friendships can have a strong influence on perceptions of transitioning into school (de Heer et al., 2016). For CALD children, there is evidence to suggest that going to school with people they already know – such as existing friends (regardless of their CALD background) – can be more important than going to school with other CALD children (de Heer et al., 2016).

Spending time outdoors and engaging in physical activities may also support CALD children with non-cognitive skills such as behavioural and socio-emotional skills. A study using a large Australian dataset found that children from Asian immigrant families spent less time outdoors and were less physically active than children with Australian-born parents, resulting in lower non-cognitive skills at 8–9 years of age (Nguyen et al., 2019).

Resilience often refers to positive adaptation (such as the ability to cope) in the face of significant risk or adversity (Wu et al., 2018). Although stakeholder consultations highlighted resilience as an important protective factor for mental health in children with CALD backgrounds, there is limited Australian evidence for this, especially for CALD children under 12 years of age. However, one study found that resilience (measured by the Child and Youth Resilience Measure-28⁴ ) has an important role in facilitating integration and positive acculturation experiences, leading to better mental health in children (Wu et al., 2018). Caution must be taken when promoting resilience-building in practice, as there is limited evidence on the mechanism by which resilience supports positive mental health (Dray 2021). Resilience building is best seen as a form of support in addition to, and not as a replacement for, addressing the underlying adversity or risk (Masten and Barnes, 2018).

⁴ The Child and Youth Resilience Measure-28 (CYRM-28) is a screening tool for children and young people aged 9–23 years. It assesses the individual, relational, communal and cultural resources that may bolster children’s resilience (Resilience Research Centre, 2009).

The challenges of migration and its effects on parents
Settlement can pose a range of challenges for newly arrived migrants, who may need to navigate complex service systems and confront a high cost of living and barriers to employment. These environmental issues (reflected in the outer two circles of Figure 1, under Social determinants of child mental health) can result in parental stress and mental health difficulties. This in turn can affect children’s mental health (Rioseco, 2020). Our stakeholder consultations also suggest that because parents may be busy addressing immediate priorities, such as education, employment, housing and finances, mental health difficulties in children may go unnoticed.

Family conflict and cultural differences between parents and children
There is emerging research to suggest that family and intergenerational conflict can influence the mental health of children from CALD backgrounds. Some studies indicate that, when compared to children from non-CALD backgrounds, children from CALD backgrounds:

• have more worries/concerns about issues relating to the family (Vassallo, 2019); and
• more frequently report family and relationship issues as the main concern for seeking support (yourtown, 2020).

There is also some research on potential causes of conflict or disharmony within CALD families. For example, there is evidence to suggest that children from CALD backgrounds have higher levels of cultural difference to their parents than do children from non-CALD backgrounds (Basu & Isaacs, 2019). This can be the result of ‘differential acculturation’, whereby children adapt to Australian culture faster than their parents. Due to their frequent exposure to school and peers, children may acculturate faster than their parents and may learn English faster too, increasing the cultural gap within families (Basu & Isaacs, 2019).

Consultation with Australian researchers, practitioners and community experts also indicated that the following family dynamics or sources of conflict may affect the mental health of children from CALD backgrounds:

• Within families, some children may adapt to Australian culture in different ways or rates than their siblings, depending on the age of migration. This can cause parents’ expectations (rules/liberties, etc.) to be received differently by children within the same household.
• Children may adopt a caretaker role early in life – for example, as the key translator in the family when interacting with services. This adds to pressures and stress, often at a young age. Having a child involved in decisions relating to adults can also affect power dynamics at home, especially where respecting adults is a key part of the culture.

Effect of parenting styles and family structure on child mental health and seeking support

There is limited Australian research comparing the parenting styles of CALD and non-CALD populations or of different CALD parenting styles, and the effects, if any, on child mental health. One research study on Indian-born mothers in Australia found that the effect of parenting styles on child anxiety was less to do with country of birth and more to do with levels of acculturation (Arora et al., 2020). Parents’ inability to pass on cultural identifications to their children was described as sometimes leading to anxious parenting and feelings of losing control when children immersed themselves in Australian culture (Arora et al., 2020).

Migrant parents can bring with them cultural norms and parenting styles that can affect their expectations of appropriate child behaviour. For example, in some Asian cultures obedience and behavioural control can be seen as a positive sign of self-discipline and maturity (Nguyen et al., 2019; Ren & Wyver, 2016). These kinds of expectations or parenting styles may influence whether parents reach out for support for their children, because internalising symptoms or emotional difficulties may be considered ‘normal’ behaviour (Basu & Isaacs, 2019; Hiscock et al., 2020).

Migrant families and families from CALD backgrounds can have a range of family structures that differ from the ‘nuclear family’ and children may have people other than their biological parents heavily involved in their upbringing. For example, in some Chinese communities, it is common to send young children to China to be cared for by their grandparents (Hui et al., 2019). Consultations with service providers and stakeholders similarly revealed that services work with children sent to Australia to live with relatives. These family structures can have implications for service delivery – for example, around which family members need to be engaged when working to support a child’s wellbeing.

Culturally and linguistically diverse (CALD) communities represent a growing population in Australia, and children and families from these communities are interacting with general services every day. It is therefore important for services and practitioners to understand and effectively respond to the needs of people from CALD backgrounds.

There is emerging evidence to suggest that children from CALD backgrounds may have experiences, such as acculturation, incidents of racism or family conflicts, that uniquely affect their mental health. There is also emerging evidence to suggest that families from CALD backgrounds can have different needs from non-CALD children or face barriers to service access (Guo et al., 2020). Children from CALD backgrounds may also have hidden mental health difficulties because of the nature and presentation of their mental health conditions. Their family may not identify the child’s behaviour or emotions as problematic, or they may be focused on meeting their basic needs (especially early in the migration process).

Using a social determinants lens to explore the ways in which these experiences, cultural differences and family circumstances/dynamics can influence child mental health, can help practitioners build awareness and provide context when working with families and children from CALD backgrounds.

This practice paper discussed how the experiences and circumstances of CALD children and families influence the mental health of children and provided evidence-informed implications for practice. This resource is a starting point to understanding the issues that families from CALD backgrounds may face, and how they may impact child mental health. However, as the evidence on this topic is evolving, this resource does not attempt to cover all aspects that are important when supporting children from CALD backgrounds. Additionally, each child and family is unique, and their individual experiences may not align with what is described in this resource. For these reasons, it is important to practice culturally responsive practice and use child-centred, strengths-based approaches when working with families and children from CALD backgrounds.

The authors would like to acknowledge and thank the practitioners, researchers and key experts that were consulted with in the development of this resource.

Many thanks to Dr Joanna Schwarzman and Dr Pilar Rioseco (Australian Institute of Family Studies) for their review of this paper. Thanks also to Mitchell Bowden and Nerida Joss (formerly of AIFS) for assistance with stakeholder consultations and early phases of the evidence review.

We would also like to acknowledge and thank the practitioners, researchers and key experts that participated in early stakeholder consultation for this resource, including:

• Stephanie Shavin – Victorian Transcultural Mental Health
• Gill Munro – formerly of Emerging Minds
• Julie Ngwabi – Emerging Minds
• Nadine Hantke – Swinburne University of Technology, PAVE, Mental Health Programs
• Julie Babiano – Centre for Multicultural Youth
• Professor Harry Minas – Global and Cultural Mental Health Unit. Centre for Mental Health, Melbourne School of Population and Global Health, The University of Melbourne
• Kylie Scoullar – The Victorian Foundation for Survivors of Torture (Foundation House)
• Professor Naomi Priest – Centre for Social Research and Methods, Australian National University and Population Health, Murdoch Children’s Research Institute
• Sara Lackner – Life Without Barriers
• Toby Worswick – Life Without Barriers
• Lara Ghobrial – Life Without Barriers
• Dr Judy Tang – Victorian Multicultural Commission
• Niharika Hiremath – headspace National

Views expressed in this publication are those of the individual authors and may not reflect those of the Australian Institute of Family Studies or the Australian Government.

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