At the end of 2023, a record 117.3 million people worldwide were forcibly displaced due to persecution, conflict, violence, human rights violations, or events seriously disturbing public order, representing an 8% increase from 2022 and 12 consecutive years of increasing forced displacement. Children represent 40% of all forcibly displaced people, while making up only 30% of the world’s population [1]. Previous studies have characterized children with a refugee background as a vulnerable minority group that has an increased risk for developmental trauma as a result of violence or instability in their country of origin and hazardous journeys to the host country [2]. Developmental trauma refers to the effects of chronic early-life adversities such as prolonged exposure to violence or displacement that disrupts a child’s emotional, cognitive, and social development. Children with a refugee background have, therefore, unsurprisingly been found to be at an elevated risk of posttraumatic stress, depression, anxiety, and difficulties with school functioning, particularly in the absence of coordinated, culturally responsive support [3]. In addition to exposure to potentially traumatic events, children face ongoing migration- and acculturation-related stressors. Forced migration often comes with experiences of loss, uprootedness, and disconnection. Although mental health problems may arise from profound psychological injury such as trauma, they can just as well be a normal and adaptive response to an abnormal context of forced displacement and acculturation.

Professionals who work with children with a refugee background (eg, teachers, youth care workers, and clinicians) frequently experience difficulties engaging with mental health problems and trauma-related behaviors in cultural contexts with which they might not be familiar [4]. Studies suggest they frequently report feeling unprepared to deal with mental health issues in refugees and asylum seekers due to factors such as cultural and language barriers [5-7]. While some training exists, it is often too general or fails to provide actionable strategies tailored to culturally diverse, trauma-affected populations. Moreover, there is a notable scarcity of validated tools to support these professionals in working with refugee children less than the age of 6 years [8]. This makes it harder for professionals to distinguish between profound psychological injury and normal stress reactions and to determine appropriate next steps [9].

As a first step in response to the need for culturally competent and sensitive mental health care, the Psychiatry Assisting the Culturally Diverse Community in Creating Healing Ties approach (PACCT) was created as a community-based intervention model to work with culturally diverse families [10]. PACCT emphasizes that effective transcultural, culturally sensitive, and trauma-sensitive care always starts from and engages with the child’s community. The framework provides some guidance for professionals by delivering context-sensitive engagement with refugee families. It intends to create a mutual understanding of the child’s behavior and distress (Multimedia Appendix 1). However, despite some potential clinical success when using the PACCT methodology, a gap remains between the promise of PACCT and its implementation, as it often relies on in-person guidance from specialized teams, which limits its uptake in broader primary and secondary care contexts.

The past 2 decades have seen growing interest in the use of digital mental health interventions for a wide variety of purposes and populations [11]. In recent years, this interest has also extended to refugee populations, with most interventions being patient-facing and focusing on psychoeducation, self-management, symptom monitoring, and treatment delivery [12,13]. At the same time, digital decision-support systems have increasingly been explored in broader mental health settings to assist professionals with assessment, triage, risk identification, and treatment planning. Such systems may help structure clinical reasoning, reduce uncertainty, and support more consistent decision-making [14,15]. However, the application of such approaches to support frontline professionals working with refugee children and families remains largely unexplored [12,13]. Consequently, there is limited evidence regarding how digital decision-support tools can help professionals interpret mental health concerns and determine culturally and trauma-sensitive responses in this population.

The aims of this study are, therefore, (1) to identify current support needs of professionals working with refugees in order to inform the development of IMPACCT, a digital decision-support tool; (2) to map needs to the conceptualization of IMPACCT; and (3) to gather initial feedback from professionals to inform further development and refinement of IMPACCT for broader use in practice.

This qualitative descriptive study relied on three data sources: (1) an analysis of existing help desk questions; (2) a mapping of identified categories onto the different steps of the IMPACCT; and (3) semistructured interviews with professionals who piloted a first conceptualization of the IMPACCT. The SRQR (Standards for Reporting Qualitative Research) reporting guideline [16] was used to guide the reporting (Checklist 1).

The study was approved by the Ethical Committee of the Department of Applied Psychology at Thomas More University of Applied Sciences (ECTP2425_07). Help desk questions were only made available as an anonymous dataset. Interview participants were informed about the objectives, design, and data processing both verbally and through an information letter. All interviewees provided written informed consent before participating. Participation was voluntary, and as a token of appreciation, participants had the option to receive a €25 (€1=US $1.05 as of September 30, 2026) gift certificate. Interview data were pseudonymized during transcription and analysis. Data were stored securely and were accessible only to the research team. Identifying information was removed during transcription, and pseudonymized transcripts were used for subsequent analysis. Audio recordings and transcripts were stored securely and were accessible only to the research team.

A total of 905 help desk questions were coded. Across the 70 items independently coded by all 3 raters, there was almost perfect agreement for adverse experience (κ=1.00), substantial agreement for 4 categories (0.67<κ<0.78), and moderate agreement for culture and migration (κ=0.57). Because culture and migration showed lower agreement than the other categories, findings for this category were interpreted cautiously.

Table 1 offers an overview of the queries. In over half of them, an adverse experience was explicitly mentioned. Presentations of clinical concerns were frequent and heterogeneous. Trauma-related symptoms were the most common clinical concerns, appearing in one-third of all cases (and in half of the instances where clinical concerns were mentioned). Anxiety and/or stress symptoms were mentioned in just under one in seven, and depressive symptoms in about one in ten. Co-occurrence was common. Many queries could be linked to the topic of culture and migration, often referencing the acculturation process. To a lesser extent, there were also questions around grief and cultural interpretation. When systemic and social context was coded, the most frequent contexts were family problems, followed by school/work challenges, legal difficulties, social isolation, and difficulties in social contacts. Very often, questions related to the care pathway. Most queries sought a referral; a comparable share asked for actionable next-step guidance. A smaller subset requested diagnostic help, often due to concerns that standard Western instruments might be inappropriate or unfair given language barriers or differences in cultural knowledge. Finally, almost all questions were related to one or more professional needs. The most common request was for supervision (also the main intended purpose of the help line), referring to case guidance to improve decision-making, quality, and worker well-being across cross-cultural situations. A minimal number of questions also involved requests for training or expressions of feelings of hopelessness.

The analysis of help desk questions revealed recurring patterns highlighting both pressing needs and overlooked areas among professionals. Clinical concerns, particularly trauma symptoms, surfaced repeatedly, confirming the need for a tool that helps professionals consider how migration-related stress, grief, and trauma can shape children’s well-being. Systemic and social context factors, most often linked to family and school life, also appeared frequently, showing that concerns rarely occur in isolation but are embedded in children’s wider environments. Issues around acculturation were raised regularly as well, pointing to the challenges families face in finding their place in the new social network, learning the language, and navigating life between two cultural systems. Care pathway questions typically focused on “what to do next” or on referral, underscoring the need for structured guidance rather than diagnostic tools. Finally, the overwhelming demand for supervision can be seen as a clear need of professionals for support in decision-making, alongside opportunities for building knowledge and confidence in working with children with a refugee background.

In contrast, several categories were less common, such as grief. The high occurrence of trauma symptoms suggests that professionals tend to link a wide range of symptoms to trauma rather than to categories such as grief or acculturation, which are more specific to the refugee experience. Although issues around acculturation were identified regularly in the help desk questions, professionals generally described them as issues related to integration, rarely framing it within an acculturation process or linking this process with symptoms of stress, anxiety, or depression. Finally, help desk questions largely focus on issues and everything that is going wrong but less on signs of resilience.

The mapping of help desk question topics onto the different components of the IMPACCT (Figure 3) found that the tool covers nearly all identified topics, with the exception of radicalization. Although the tool addresses underlying mechanisms such as trauma, social isolation, and identity confusion, radicalization itself was considered beyond its intended scope. Of the remaining topics, 11 were classified as well represented, 4 as partially represented, and 6 as underrepresented. Topics that were partially represented or underrepresented received additional attention in the tool, particularly through further clarification of their relevance to professional practice.

The present study had three aims: to identify the needs and questions of professionals working with people with a refugee background, to map these needs onto an initial conceptualization of IMPACCT as a digital decision-support tool, and to collect initial feedback on its relevance and usability. The analysis of 905 help desk questions showed that professionals sought support for a broad range of concerns. Trauma- and adversity-related concerns were prominent, followed by indicators of anxiety or depression and issues associated with acculturation. The semistructured interviews suggested that IMPACCT was generally perceived as relevant and useful, particularly for structuring reflection in complex cases and clarifying possible next steps. At the same time, the time investment required to use the tool was identified as an important barrier to its implementation.

The prominence of trauma- and adversity-related concerns is consistent with the elevated exposure of refugee children and families to potentially traumatic experiences before, during, and after migration. However, this pattern also requires careful interpretation. Grief was coded much less frequently than trauma, even though migration often involves bereavement and broader forms of loss, including family separation, loss of status, language, and routines [20]. This does not necessarily mean that professionals fail to recognize grief or loss in practice. Rather, grief-related processes may have been less visible in the help desk questions because professionals used trauma as a broad umbrella term or because the help desk format encouraged them to foreground the most urgent difficulties to obtain advice. The finding therefore points less to a confirmed blind spot than to the need for structured support that helps professionals differentiate between trauma, grief, adversity, and loss when formulating children’s needs.

A similar issue emerged for acculturation and cultural responsiveness. Although acculturation-related questions were present, they were often framed as individual difficulties with integration rather than as potentially stressful psychological and relational processes shaped by broader social conditions [21]. Likewise, cultural responsiveness was also not raised explicitly, even though it is widely recognized as a condition for equitable mental health care [22]. In addition, family- and school-related questions were present with moderate frequency, but professionals did not routinely refer to parental distress or trauma as possible drivers of child difficulties. These findings should again not be taken to mean that professionals were unaware of these dimensions. Rather, they suggest that such dimensions were less often foregrounded in help desk questions, which were by nature problem-oriented and focused on obtaining advice. This supports the need for a tool that prompts professionals to consider not only adversity and symptoms, but also acculturation, cultural meaning-making, family and school context, resilience, and protective factors.

IMPACCT was therefore not designed to simply reproduce the concerns most frequently raised in the help desk questions but to translate ecological and culturally responsive formulation into a practical, guided workflow. By prompting professionals to consider grief, acculturation dynamics, cultural interpretation, resilience, family and school context, and care pathways, the tool aims to support a broader formulation of children’s needs. Such attention to resilience and protective factors is important for gaining a comprehensive understanding and for facilitating the processing of trauma and loss [23,24].

The semistructured interviews revealed that most participants considered the tool’s content relevant, particularly the reflective questions and the guidance it provided when they were uncertain about next steps in a case. The main barrier identified was the required time investment. Participants also highlighted the need for shorter versions, concise summaries of advice, and clearer referral options. While highly experienced professionals reported gaining fewer new insights, others described the tool as a helpful guide in complex cases and a valuable learning resource. For broader implementation, some participants suggested that IMPACCT could be positioned as a training and supervision aid in first-line services and as decision support in ambulatory and inpatient care.

Our study builds on and extends earlier work on the assessment of mental health needs among refugee populations, which has already demonstrated the importance of moving beyond an exclusively psychiatric framework toward a more ecological and culturally sensitive approach to care [10]. IMPACCT operationalizes this perspective in a practical and accessible format by combining decision support with educational and reflective elements. To our knowledge, there is currently no comparable digital tool aimed specifically at strengthening cultural competence and systemic awareness among professionals working with refugee children. Existing screening tools, such as the Screening Tool for Asylum-seeker and Refugee Mental Health (STAR-MH) [25] or the Self-Report Questionnaire-5 [26], are primarily designed as diagnostic instruments, not as digital decision support tools. While valuable for detecting disorders such as depression or posttraumatic stress disorder, these tools do not have an educational function, are not interactive, and do not support professionals in broader case conceptualization.

The main limitation concerning the development of the decision support tool is its reliance on help desk questions. While this ensured a strong link with practice, the questions were not exclusively focused on children with a refugee background. In addition, interrater reliability for the help desk coding varied across categories and was lowest for culture and migration. This may reflect the conceptual complexity of this category and the fact that real-world help desk questions often combine cultural, migration-related, clinical, and systemic concerns. As the remaining help desk questions were single-coded after calibration, frequencies should be interpreted as indicative patterns rather than precise prevalence estimates, particularly for categories with lower agreement. Although the broader PACCT framework offered a counterweight, the possibility of remaining blind spots cannot be ruled out. A further limitation is that refugees were not directly involved in the development of the tool, meaning that their perspectives were included only indirectly. Finally, the first evaluation of IMPACCT relied on self-reported feedback from professionals and is therefore vulnerable to memory and social desirability bias.

Participant feedback points to several priorities for further development. First, IMPACCT should be made less time-consuming, for example, through shorter versions, concise summaries of advice, and clearer referral options. Second, future versions should be evaluated not only for usability and acceptability but also for their impact on professional reflection, cultural competence, case formulation, and referral decision-making. Third, the perspectives of children, families, and people with a refugee background should be incorporated more directly, as the current development process relied primarily on professionals’ questions and feedback.

Future research could also explore whether more conversational forms of digital support would make the tool easier to use in practice. One promising avenue is the development of an IMPACCT chatbot powered by AI, which would enable professionals to discuss cases in a more natural, conversational manner while receiving quicker and more tailored feedback.

This study suggests that professionals working with children and young people with a refugee background need support not only in recognizing trauma- and adversity-related concerns but also in formulating these concerns within broader contexts of grief, acculturation, cultural meaning-making, family and school systems, resilience, and care pathways. IMPACCT represents an initial attempt to translate this broader ecological and culturally responsive perspective into a practical digital decision-support tool. Its potential value lies not in replacing professional judgment but in helping professionals structure reflection, recognize less foregrounded dimensions of a case, and clarify possible next steps.

At the same time, the findings underline that such digital decision support must remain both clinically useful and practically feasible. Further development should therefore focus on making IMPACCT more concise, strengthening referral guidance, incorporating the perspectives of children and families with a refugee background, and evaluating whether the tool improves professional reflection, cultural competence, and decision-making in practice. More broadly, this study highlights the potential of digital decision support to help professionals make more contextualized and better-informed decisions in refugee mental health care.