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Psychological Well Being of Child and Adolescent Refugee and Asylum Seekers

National Inquiry into Children in Immigration Detention

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Psychological Well Being of Child and Adolescent Refugee and Asylum

Seekers:

Overview of Major Research Findings of the Past Ten Years

Prepared by Trang Thomas

and Winnie Lau


Abstract

Major

Research Findings

i.

Post Traumatic Stress Disorder and Symptomology

ii.

Co-existence of several disorders and symptomology

iii.

Risk (Vulnerability) and Protective (resilience) factors

Conclusions

References

and Suggested Readings

About

the Authors


Abstract

This paper outlines

major international research findings of the past ten years reflecting

knowledge gathered about the psychological health of child and adolescent

refugee/asylum seekers. In doing so, several key areas of consistency

are identified. First, with the majority of research in this area centered

on the prevalence of psychopathology, and particularly post-traumatic

stress symptoms, it has been clearly demonstrated that refugee children

and adolescents are vulnerable to the effects of pre-migration, most

notably exposure to trauma. Second, particular groups in this population

constitute higher psychological risk than others, namely those with

extended trauma experience, unaccompanied or separated children and

adolescents, and those engaged in the uncertain process of sought asylum.

Third, certain risk and protective factors appear to exist that temper

or aggravate poor psychological health. These include family cohesion,

parental psychological health, individual dispositional factors such

as adaptability, temperament and positive self-esteem, and environmental

factors such as peer and community support.

The research is

less clear however in a number of areas. These include the mechanisms

by which risk and protective factors exacerbate and temper the effects

of trauma and migration experience, as well as the role of culture as

a mediator in the experience of trauma and migration.

Despite being a

perennial issue, circumstances of irregular migration across the world

have only recently impelled psychological interest into the mental health

of refugee and asylum seekers. The Office of the United Nations High

Commissioner for Refugees (UNHCR) estimates that there are 22.3 million

refugees worldwide. A refugee is someone who "owing to well founded

fear of being persecuted for reasons of race, religion, nationality

or membership of a particular social group or political opinion, is

outside the country of his nationality and is unable or, owing to such

fear is unwilling to avail himself of the protection of that country;

or who, not having a nationality and being outside that country of his

former habitual residence as a result of such events, owing to such

fear, is unwilling to return to it" (Article 1A(2), Convention

relating to the Status of Refugees (1951)). This definition is contrasted

with that of an asylum seeker, whose status as a refugee is yet to be

formally determined by the host society (Human Rights and Equal Opportunity

Commission, 2001). More importantly, these definitions are to be differentiated

from that of an economic migrant whose mobilisation is voluntary and

primarily motivated by improved material circumstances as opposed to

human rights and safety (Morrow, 1994).

While there

is considerable and growing literature in the mental health of adult

refugee/asylum seekers, current research acknowledges a lack of understanding

in the mental health of child and adolescent refugee/asylum seekers

(Dybdahl, 2001; Hicks, Lalonde & Pepler, 1993; Hyman, Vu & Beiser,

2000). This is particularly the case regarding the mental health of

child and adolescent refugee/asylum seekers in detention. This is

surprising given that as many as half the world's refugee population

is comprised of children and adolescents (Cole, 1998). Such limited

investigation however, may in part be due to the difficulties associated

with population access, systematic sampling, cultural and language barriers,

limited cross culturally validated measurement techniques, and wariness

of parents and participants to trust researchers (Richman, 1993; Silove,

Sinnerbrink, Field, Manicavasagar & Steel, 1997).

Though not all

refugee and asylum seeking children and adolescents are subjected to

these circumstances, experiences often claimed to be encountered by

them include the violent death of a parent, injury/torture towards a

family member(s), witness of murder/massacre, terrorist attack(s), child-soldier

activity, bombardments and shelling, detention, beatings and/or physical

injury, disability inflicted by violence, sexual assault, disappearance

of family members/friends, witness of parental fear and panic, famine,

forcible eviction, separation and forced migration (Burnett & Peel,

2001; Davies & Webb, 2000).

Other forms of

trauma might include the endurance of political oppression, harassment

and deprivation of human rights and education (Burnett & Peel, 2001).

Such experiences not only make refugee/asylum seeking populations heterogeneous,

they also create vulnerability in children and adolescents due to their

incomplete biopsychosocial development, dependency, inability to understand

certain life events (Kocijan-Hercigonja, Rijavec & Hercigonja, 1998)

and underdevelopment of coping skills (Ajdukovic & Ajdukovic, 1993).

This summary outlines

major international research findings of the past ten years reflecting

knowledge gathered about the psychological health and well-being of

child and adolescent refugee/asylum seekers. It incorporates a search

of literature from the psychINFO, Medline, BioMedNet, Academic Research

Library, EBSCO, Proquest, Science Direct and Wiley-Interscience databases

using criteria restricted to articles from 1990 to date and in the English

language. Search terms included single and combined forms of the following

descriptors: refugee camp, refugee detention, imprisonment, child and/or

adolescent refugee, asylum seeker, displacement, Australia, development,

long term effects, long term stress, post-traumatic stress, stress,

psychopathology, mental health, psychiatric effects and psychological

well being.

The review is divided

into major sections of studied areas in the literature, namely post-traumatic

stress disorder (PTSD), co-existence of several symptoms and disorders

(a term that broadly means serious problems), and risk (vulnerability)

and protective (resilience) factors at both pre- and post- migration

phases. It should be noted that this paper does not aim to provide an

exhaustive discussion of theoretical issues, methodological considerations

(e.g., problems in retrospective data collection) or treatment issues,

but rather to highlight major findings and conclusions of this research.

It should also be noted that the paucity of research in child and adolescent

refugee/asylum seekers necessitates at times reference to knowledge

from adult populations. Where such reference is made, caution should

be taken to avoid overgeneralisation of these findings to this new risk

population of children and adolescents.

Major

Research Findings

i. Post

Traumatic Stress Disorder and Symptomology

Given

that war and political violence are major causes of forced migration,

many child and adolescent refugee and asylum seekers migrate with a

history of traumatic stress exposure (Almqvist & Brandell-Forsberg,

1997). Investigations directed at the evaluation of the impact of trauma

on psychological well being in these groups have predominantly focused

on the prevalence of Post Traumatic Stress Disorder (PTSD) and/or its

symptomology (Richman, 1993; Weine, 2002).

Post Traumatic

Stress Disorder (PTSD) refers to a configuration of symptoms experienced

after a traumatic event and is classified as an anxiety disorder, which

may in nature be acute or chronic, and of short or long term duration

(Cunningham & Cunningham, 1997).

Children and

adolescents who present with PTSD may exhibit symptoms of confused and

disordered memory about events, repetitive play themes related to trauma,

personality change, imitation of violent behaviour and pessimistic expectations

regarding survival (Hicks et al., 1993). Although symptoms vary across

age groups, in preschoolers, they are generally manifested in very high

anxiety, social withdrawal and regressive behaviours. In school-aged

children, symptoms can include flashbacks, exaggerated startle responses,

poor concentration, sleep disturbance, complaints of physical discomfort

and conduct problems. In adolescents, symptoms may include acting out,

aggressive behaviours, delinquency, nightmares, trauma and guilt over

one's own survival (Hicks et al., 1993).

Despite controversy

surrounding the application of PTSD to refugee/asylum seeking children

and adolescents (e.g., the diagnostic approach 'medicalises' and 'westernises'

emotional disturbance and 'pathologises' perfectly normal reactions

to abnormal situations), investigations across various countries have

shown that trauma symptomology is common in refugee children and adolescents

(Ajdukovic & Ajdukovic, 1993; Hjern, Angel, & Hoejer, 1991;

Kinzie, Sack, Angell, Manson & Ben, 1986; Mollica, Poole, Son, Murray

& Tor, 1997; Sack, Clarke & Seeley, 1996; Sack, Seeley &

Clarke, 1997).

While the nature

and extent of trauma exposure varies cross culturally, and from direct

to indirect and single to repeated events, studies particularly document

the prevalence of post-traumatic stress symptomology. Though not conducted

within the last ten years, the pioneering work of Kinzie et al. (1986)

is cited frequently throughout the recent literature. In this classical

study, these authors interviewed 46 Cambodian refugees aged between

14-20, all of who were exposed between the ages of 8-12 to starvation,

separation, beatings and executions. Almost half of these subjects having

been exposed to trauma, exhibited PTSD symptoms alongside less effective

adaptation, which was considered to be within clinical range.

In a larger study

with 209 Cambodians aged between 13-25 resettled in the United States,

Sack and colleagues (1994) found an 18% prevalence rate of PTSD and

an 11% rate of depressive disorder in their participants. High rates

of psychiatric disorder were also observed in participants' parents,

with 53% of mothers reporting symptoms consistent with a PTSD diagnosis,

and 23% with a diagnosis of depression. Amongst fathers of this sample,

29% indicated PTSD symptomology and 14% indicated depression.

Examining the case

records of 191 clients presenting for service and treatment at a torture

and trauma rehabilitation centre in Australia, Cunningham and Cunningham

(1997) identified patterns of torture and trauma experience and symptomology.

Of the six core patterns of symptomology revealed in the analysis, PTSD

symptoms featured most dominantly. Saigh (1991) similarly administered

the children's PTSD inventory to 840 Lebanese children aged between

9-12 living in Beirut. While violent traumatic exposure varied from

direct to indirect among children, no comparable differences were observed

in PTSD scores. In all, 27% of these children met PTSD criteria, supporting

the view that children can be traumatised in numerous ways (Berman,

2001).

The relationship

between trauma exposure and PTSD symptomology however is not confined

to South East Asian and Lebanese children (Kinzie et al., 1986; 1989;

Macksoud & Aber, 1996; Sack et al., 1994). Over recent years, such

findings have been established cross culturally among children and youth

from regions such as:

  • Afghanistan

    (Mghir, Freed, Raskin & Katon, 1995);

  • Bosnia (Geltman,

    et al, 2000; Papageorgiou, et al, 2000; Weine, et al, 1995);

  • Chile (Hjern,

    Angel & Hojer, 1991);

  • Croatia (Ajdukovic

    & Ajdukovic, 1993);

  • Central America

    (Arroyo & Eth, 1996; Espino, 1991; Rousseau, Drapeau & Corin,

    1997);

  • El Salvador

    and Nicaragua (Arroyo & Eth, 1996);

  • The Gaza Strip

    (Thabet & Vostanis, 2000);

  • Iraqi-Kurdistan

    (Ahmad, Mohamed & Ameen, 1997);

  • Israel (Laor,

    et al, 1996);

  • Iran (Almqvist

    & Brandell-Forsberg, 1997; Almqvist & Broberg, 1999);

  • Sudan (Paardekooper,

    de Jong & Hermanns, 1999); and

  • Tibet (Servan-Schreiber,

    Le Lin & Birmaher, 1998).

Although studies

have consistently linked trauma symptomology with the experience of

trauma related events, which are usually attributed to organised violence

and war, fewer investigators have attempted to relate exposure to a

diagnosis for PTSD. Hence, the focus on symptomology renders it unclear

as to whether a complete diagnosis can be applied to trauma experience

(Green, et al., 1991). The implications of such issues are important

to consider given the position of those seeking formal refugee status.

Notwithstanding, Almqvist and Brandell-Forsberg (1997) are among few

researchers to demonstrate effectively the applicability of PTSD criteria

to symptomology expressed in children. Similar diagnoses have been demonstrated

by Schwarz and Kowalski (1991a).

One controversy

noted throughout the literature relating to refugee children and adolescents

and PTSD is whether it is the totality of exposure to war related stress

that is harmful, or whether in fact trauma responses are dependent on

the nature, type, amount and duration of exposure to stress (Athey &

Ahearn 1991; Jensen & Shaw, 1993, cited in Berman, 2001; Mghir et

al., 1995). Reviews of such studies indicate evidence for the suggestion

that the greater the nature and extent of exposure, the poorer one's

psychological outcome in terms of onset and severity of PTSD symptoms

(Espino, 1991; Papageorgiou et al., 2000).

Extending their

diagnostic approach to trauma symptomology, Almqvist and Brandell-Forsberg

(1997) also investigated whether the amount of trauma exposure is related

to the prevalence and stability of PTSD over time. Whilst finding it

is possible to diagnose PTSD during initial stages of assessment and

one year later, these authors also found that one fifth of children

directly exposed to organised violence and persecution (e.g., through

assault on parents or bomb attacks within 50 metres) were at risk for

developing chronic states of PTSD.

Similarly, though

not drawing directly from a refugee but rather displaced and war exposed

population, Macksoud and Aber (1996) examined the relationship between

the number and type of war traumas and psychosocial development among

224 Lebanese children aged between 10-16. Using measures of war exposure,

war trauma, mental health, PTSD and adaptation, these investigators

assessed ten categories of war exposure. As predicted, the number and

type of traumatic exposure were positively related to PTSD symptoms.

Children exposed to multiple traumas (e.g., shelling, combat) and those

who were bereaved, victimised by or had witnessed violent acts, showed

more PTSD symptoms than those who had not witnessed such acts. Moreover,

depressive symptoms were more evident in children who had experienced

separation from their parents and displacement than those who remained

with their parents.

Finding that 34%

of adolescent and young adult refugees from Afghanistan met criteria

for PTSD, major depression or both, Mghir et al. (1995) similarly demonstrated

an association between the presence of these disorders and the total

number of events experienced. In her investigation of Khmer adolescent

refugees exposed to community violence, Berthold (1995) also noted the

impact of multiple traumas before and following resettlement in the

US on PTSD.

Sinnerbrink and

colleagues (1997) also examined the relationship between exposure to

violence and mental health outcome in Khmer adolescents in the USA.

A quarter of these subjects partially or fully met criteria for PTSD

with the number of violent events experienced predicting PTSD and level

of functioning. Not only was pre-migration exposure predictive of PTSD,

the number of violent events exposed to across subjects' lifetime (i.e.,

time in Cambodia and US) also and more strongly predicted PTSD and level

of functioning. This finding is noteworthy as it demonstrates the cumulative

effect of trauma and its predisposing features to future distress and

function (Sinnerbrink et al., 1997).

Lonigan and colleagues

(1991, cited in Almqvist & Brandell-Forsberg, 1997) and Pynoos,

Steinberg and Wraith (1995) in their investigations of school-aged children

have also shown a correlation between the amount of traumatic exposure

and PTSD prevalence. The association between severity of exposure in

terms of number and proximity of experienced events and the presence

of PTSD in children and adolescents has been supported in different

cultures including Bosnian (Papageorgiou et al., 2000); Vietnamese (Mollica

et al., 1997); Cambodian (Sack, Clarke & Seeley, 1996); Palestinian

(Garbarino & Kostelny, 1996; Thalbet & Vostanis, 1999), Middle

Eastern (Montgomery, 1998) and Central American (Espino, 1991).

So far, the studies

reviewed have clearly outlined the shorter-term consequences of organised

violence and war and their resultant traumatic outcomes for children

and adolescents from a cross sectional perspective. Little research

however, has been conducted into the evolution of PTSD symptoms and

its long-term development and persistence in refugee/asylum seeking

children and adolescents (Punamaki, 2001). The preliminary nature of

longitudinal research in this area therefore, has produced equivocal

findings. Nevertheless, there are some studies that demonstrate the

persistence of PTSD symptoms across time.

The work of Kinzie

et al. (1986; 1989) represents one of the few attempts to evaluate the

persistence of PTSD over several years. As discussed earlier, these

researchers examined the effects of massive trauma on 40 Cambodian refugees

who had been imprisoned for up to two years in concentration camps during

the Pol Pot regime. All subjects had endured separation from family,

forced labour and starvation and many had witnessed killings and other

forms of torture. Four years after leaving Cambodia, up to 50% of subjects

developed PTSD. Mild but prolonged, depressive symptoms were evident

in 38% of subjects. Results of a 3-year follow up with 30 of the 40

original subjects revealed that although depressive symptoms had diminished,

48% of subjects still exhibited symptoms meeting the criteria for PTSD,

supporting the notion that traumatic symptoms endure over time. Subjects

with poorer PTSD outcomes also showed poorer social adjustment. Six

years following the initial study, 38% of subjects still exhibited PTSD

criteria, though there was a reduction in the rate of depression (Sack,

Clarke, Him, Dickason, Goff, Lanham & Kinzie, 1993). Twelve years

after the initial study, 35% of subjects still exhibited criteria for

PTSD and 14% had depression (Sack, Him & Dickason, 1999).

These authors add

increasing empirical weight to the idea that PTSD in children and adolescents

can persist from several up to twelve years. These authors also note

however, along with the prevalence of depression, the intensity of PTSD

symptoms tend to diminish over time. Where depression was initially

shown to co exist with PTSD symptoms, depressive symptoms were no longer

evident after six years. Such findings are important as they sustain

the theoretical argument that PTSD symptoms are distinct from symptoms

of depression and are indeed a manifestation of massive trauma, contrary

to the result of resettlement stress (Sack et al., 1993; Sack et al.,

1995). Despite the persistence of PTSD, participants in Sack et al's.

(1993) study were generally adaptive. Most, for instance, were able

to pursue some forms of college education. As Kinzie et al. (1990) and

Sack (1998) state though, the impact of trauma is likely to affect child

development over time resulting in fluctuating symptom profiles of both

PTSD and depression. Of the more recent studies investigating the

long-term consequences of trauma, Almqvist and Broberg (1999) assessed

the prevalence of PTSD in Iranian preschoolers following two and a half

years of resettlement in Sweden. For a fifth of children previously

exposed to trauma, PTSD diagnoses remained stable. Supporting the argument

that PTSD can be enduring, these authors also remarked on the problem

of much research, which relies heavily on parental interviews for data

(Almqvist & Broberg, 1999; Geltman et al., 2000). In their interviews

with both children and parents, a significant difference was observed

in the initial investigation, where according to parents, only 2% of

children met criteria for PTSD. When the children were interviewed however,

21% met PTSD criteria. That is, parents were found to underestimate

and/or deny symptoms of trauma re-experience in their children, a major

criterion for PTSD.

Though these findings

might be attributable to parents' desires to protect their children,

they demonstrate that parents may also down play the presentation of

symptoms in children. This is supported by arguments that PTSD is

difficult to observe in young children due to problems in identifying

avoidance symptoms, a further criterion of PTSD. Lastly, Macksoud

and Aber (1996) and Ahmad et al. (1998) have also observed chronic/continuous

PTSD in samples of Lebanese children exposed to single events in civil

war and Iraqi Kurdish children respectively. The high level of PTSD

persistence in the above studies is consistent with general studies

regarding children who develop PTSD following exposure to other trauma

(McFarlane, 1987, cited in Hodes, 2000). Regarding the long-term effects

of trauma, age at the time of traumatic experience does not appear to

influence its persistence (Dreman & Cohen, 1990).

It should be noted

that disagreement and inconsistencies regarding mental health in refugee

populations does exist despite evidence for poor psychological adaptation

(Dybdahl, 2001; Beiser, Dion, Gotowiec, Hyman & Vu, 1995). Of studies

which have produced equivocal findings, Becker, Weine, Vojvoda and McGlashan

(1999) investigated the psychiatric sequelae of Bosnian adolescents

after a year of resettlement to assess delayed PTSD onset. Of those

initially diagnosed with PTSD, none met criteria for diagnosis a year

later and only one subject not previously diagnosed, displayed PTSD

symptomology. Becker et al. (1999) concluded that the diminution of

PTSD over time might reflect the fact that symptoms are transient and

not representative of enduring psychopathology. Hence, while there

is evidence to support the chronic nature of PTSD in refugee children

and adolescents, there is also evidence to suggest that such long-term

effects may be mediated by other factors. Becker et al. (1999) did

nevertheless observe that the symptoms shown at one year follow up remained

similar to the clusters of symptoms observed in their initial investigation

and that Bosnian adolescents had also remained with their parents, potentially

offsetting PTSD symptomology. Indeed, Ajdukovic and Ajdukovic (1998)

cautioned that the child's exposure to extreme intense trauma can have

delayed effects and can cause difficulties in psychological functioning

in adulthood.

As indicated

above, parental psychological well-being is a key factor in the mental

health of child/adolescent refugee and asylum seekers (Papageorgiou

et al., 2000; Sack et al., 1994). Research directed at parental and

familial influences has demonstrated that disorders associated with

child and adolescent refugee experiences cluster in families. Sack,

Clarke and Seeley (1995) for example, interviewed 118 Khmer adolescent

refugees and one of their parents (usually mother). These authors found

that the risk for PTSD increased for adolescents when one parent exhibited

PTSD. When environmental influences to this relationship such as separation/divorce

of parents, therapeutic intervention and socio-economic status were

examined, no significant impact was found.

While such findings

may underscore a genetic susceptibility to PTSD (Sack et al., 1995;

Hodes, 2000), they also implicate the role of learning factors in the

concurrence of PTSD in children and their parents. Lukman and Bach-Mortensen

(1995, cited in Hodes, 2000) provide support to the role of learning

factors in PTSD and argue that such is the established link between

parent and childhood disorder that children of torture victims, who

seek asylum in resettlement countries, may have high levels of emotional

and physical symptoms such as stomachache or headache, even when not

exposed to the traumatic events themselves. Moreover, parents' own experience

of persecution, war violence, terrorism, powerlessness and exhaustion

can compromise their ability to care for their children, increasing

child/adolescent susceptibility to PTSD and other psychopathology (Sack

et al., 1986). Garbarino, Kostelny and Dubrow (1991) and Richman (1993)

further maintain that PTSD can be evident in multiple family members,

particularly when marital relations are strained.

The findings observed

above are consistent with Green et al. (1991) and Punamaki (2001) who

argue that parental capacity and family cohesion after traumatic exposure

are of equal or greater importance in the post-traumatic stress reactions

of young children. These authors provide evidence that family dysfunction

before exposure may predispose PTSD in children and adolescents. Drawing

similar conclusions, Arroyo and Eth (1996) found that those children

and adolescents in nuclear families were less likely to receive psychiatric

diagnoses than those who lived alone or were fostered.

While psychological

problems in the family are significantly related to child psychopathology

in refugee children and adolescents, the role of mothers appears to

be particularly important as shown by Ajdukovic and Ajdukovic (1993)

who found that mothers' emotional well-being best predicted emotional

well being and adaptation in children.

So far, consistent

psychological outcomes have been reported in the literature for children

and adolescents regardless of their different experiences, backgrounds

and cultures. While these consistencies in the literature are important

to identify, the specific effects of culture have been largely unexamined

across studies. The complex role that culture plays in the psychological

health of child and adolescent refugee and asylum seekers is highlighted

by Rousseau, Drapeau and Corin (1997). Comparing Central American and

South East Asian refugee children, Rousseau et al. (1997) showed that

the impact of family factors on post-traumatic symptomology is mediated

by contextual as well as cultural factors. In Central Americans, greater

trauma exposure in families was found to be more related to family conflict

and depression, whereas in South East Asians, increased trauma exposure

was found to be associated with less parental depression.

Arroyo and Eth

(1996) have similarly observed contrasting symptom profiles between

Latin American and South East Asian refugee children, where the former

display more prevalent academic and conduct problems. While not replicated,

these differential findings across cultures reflect the need to investigate

systematically cultural influences on child and adolescent mental health

among the refugee and asylum seeking populations.

ii. Co-existence

of several disorders and symptomology

Although the majority

of literature lies in the investigation of trauma sequelae and family

psychopathology as a mediating and moderating factor of trauma, there

have been investigations of other psychological outcomes among child

and adolescent refugee/asylum seekers. It should be noted in any

discussion of psychological problems however, that refugee and asylum

seeking children and adolescents are more likely to have serious health

problems associated with malnutrition, disease, physical injuries, brain

damage and sexual or physical abuse (Westermeyer, 1991). Hence,

the influence of these potential health problems cannot be overlooked

when considering psychological health and disorder in this population

(McCloskey & Southwick, 1996; Westermeyer, 1991).

Simultaneous presence

of more than one disorder associated with PTSD is a common finding in

the literature concerning the mental health of refugee children and

adolescents. For example, Kinzie et al. (1986) noted depression and

anxiety as problems most commonly associated with PTSD symptomology.

Similarly, Hubbard, and colleagues (1995) found that the existence of

more than one disorder in their sample of 59 Cambodian adolescents and

young adults exposed to trauma as children. Of the 24% of adolescents

and young adults that were diagnosed with PTSD, 57% of these had at

least one additional diagnosis, all being affective and anxiety related.

Using the Child

Behavior Checklist (CBCL) [1], Sourander (1998) also

found that in addition to PTSD, depression and anxiety were most common

among their participants. When interviewed, most children also reported

somatic complaints, uncertainty about the future and in some cases expressed

suicidal thoughts. While the presence of anxiety is not surprising given

its overlap with PTSD, Clarke et al. (1993, cited in Hodes, 2000) note

that depression may commonly occur due to ongoing adversity following

resettlement.

Tousignant and

colleagues (1999) present the results of a psychiatric epidemiological

survey of 203 refugee adolescents aged between 13-19 from 35 different

countries resettled in Canada. Using the Diagnostic Interview Assessment

Scale [2] and global assessments of general functioning,

these authors showed a 10% difference against refugee adolescents in

rates of psychopathology compared to normative data obtained from a

province wide survey of Quebec adolescents. 21% of participants displayed

psychopathology in forms of simple phobia (25%), overanxious disorder

(13%), depression (5%); conduct disorders (6%) and attempted suicide

(3%). Elevated rates of phobia and overanxious disorder according to

these authors were probably due to their association with PTSD. Females

displayed more psychopathology than boys in this sample with similar

ratios evident in the Quebec survey, but neither age at arrival nor

cultural differences were found to be significant factors. Despite the

high rates of psychopathology when compared with a normative population,

according to global functioning assessments, these adolescents had good

social adaptation.

Good adaptation

following multiple traumas has also been reported by Berthold (1995)

and Punamaki (2001). Such unexpected findings of positive adaptation

imply that while diagnosis does not always suggest severe functional

impairment (Sack, 1995), the changeability of dysfunction does, in fact,

demand further investigation into the mechanisms that promote such adjustment.

Kocijan-Hercigonja,

Rijavec and Hercigonja (1998) also investigated the existence of more

than one disorder and alternative problems in refugee and displaced

children. They compared three groups of children aged between five and

fourteen. The first group comprised of Muslim refugee children from

Bosnia and Herzegovina; the second of displaced children from Croatia

and the third of non-displaced local children. Using structured interviews,

coping and adjustment measures, self-rating behaviour scales, and anxiety

and depression scales, these authors found significant differences in

the prevalence of eating disorders, with displaced children exhibiting

more eating disorders than non-displaced and refugee children. Significant

differences were also observed in sleeping disorders with more sleep

problems found in displaced children followed by refugee and non-displaced

children. Refugee children used significantly fewer coping strategies

than displaced and non-displaced children and effectiveness of these

strategies were reported to be greater in displaced and non-displaced

children. In terms of adjustment, displaced children were less satisfied

with their present situation than other children. Refugee children also

felt generally worse than other children and were less optimistic about

the future. Displaced children were lower on anxiety than refugee children,

however, no differences across the sample on depression measures were

found.

When Kocijan-Hercigonja

et al. (1998) compared parent and child assessments, parents did not

report their child's fatigue, palpitation, breathing problems, trembling

or crying, reinforcing earlier suggestions of the importance of attaining

data directly from children. Kocijan-Hercigonja et al. (1998) attributed

sleeping and eating problems in displaced children to the severity of

trauma these children experienced. Furthermore, displaced children tended

to evaluate their life at present as worse than others because of difficulties

associated with camp life. Elevated anxiety in refugees was attributed

to trauma whereas in displaced children, this was attributed to uncertainty

in status and the future.

In all, these

findings highlight that children have negative beliefs and expectations

about their futures, indicating potential adjustment problems (Kocijan-Hercigonja

et al., 1998). Obradovic and colleagues (1993) similarly investigated

102 children and young people aged between 8-19 from Bosnia, Herzegovina

and Croatia in collective accommodation. 88% reported feeling sadder

than before the war, 87% reported being more worried and 62% reported

feeling more tense. Satisfaction from play was reduced in 65% of participants.

Of the physical symptoms reported, all increased following the war and

included lack of appetite, disturbed sleep, excessive perspiration,

headaches, respiratory problems and gastric complaints.

In their investigation

of varied psychological outcomes, Howard and Hodes (2000) note the distinction

between disorders observed from neuropsychiatric origins (i.e., causes

attributable to biological functioning) and those from psychosocial

ones (i.e., causes attributable to family and social processes). In

their study of problems such as PTSD, minor affective disorders, anxiety,

conduct, eating and sleep in three groups of refugee, immigrant and

British children, these researchers found that refugee children received

more diagnoses of a psychosocial nature than the other two groups of

participants. While similar social impairment was observed across

comparative groups, refugee children were more isolated and disadvantaged. This tendency to manifest disorders of a psychosocial nature is consistent

with Rousseau, Drapeau and Corin (1996) who found a positive association

between learning difficulties, academic achievement and emotional problems

in South East Asian and Central American refugee children in the US.

Furthermore,

the tendency of traumatised refugee children to report more psychological

problems, diagnostic and otherwise (e.g., guilt, uncertainty) has been

found to be associated with the occurrence of more daily stressors and

less perceived social support (Paardekooper, 1999). Although the

exact rates of disorder and dysfunction tend to vary across studies

and frequently reaches 40% to 50% prevalence, there is nevertheless

consensus across studies investigating PTSD and other psychological

problems, which show these rates to be much higher in refugee than non-refugee

populations (Hodes, 2001)).

Although evidence

is weighted towards PTSD related problems in refugee children and adolescents,

some studies have nonetheless observed findings that challenge the relationship

between trauma experience and stress outcomes.

Loughry and Flouri

(2001) for example, investigated the behavioural and emotional problems

of 455 former unaccompanied refugee children and youth aged between

10 and 22, three to four years after their repatriation to Vietnam from

refugee centres in Hong Kong and South East Asia. Collecting data using

measures of internalising and externalising behaviour, self efficacy,

trauma and social support, these authors found no differences between

age matched controls who never left Vietnam and repatriated children.

Similarly, no differences between the groups were observed for perceived

self-efficacy and the number and experience of social support. These

authors concluded that the exposed trauma and experience of living without

parents in refugee camps did not lead to increased behavioural and emotional

problems in the immediate years following repatriation.

While these findings

may reflect adaptive capacities despite traumatic experience, they also

pose additional questions regarding the reliance of PTSD as a single

outcome measure. Although alternative outcomes of trauma are currently

being addressed by research into the presence of accompanying disorders

and problems, the differential response to trauma that children and

adolescents from different cultures may exhibit has been largely unexplored

by research (Rousseau, 1995). Equivocal findings in the research

nonetheless, warrant further examination of the mediating variables

that are likely to diminish and potentiate adaptive capacity (Beiser,

et al, 1995).

iii. Risk

(Vulnerability) and Protective (resilience) factors

a) Pre-Migration

Risk and Protective factors

Although the dynamic

interplay between various risk and protective factors in refugee psychological

health is not fully understood, there is widespread agreement that

of those pre-migration factors that pose serious risk, trauma exposure

is the single most identified (Berman, 2001). Alongside the associated

existence or absence of parental psychopathology, trauma has been discussed

in detail above. Other major pre-migration risk factors include child

disposition, environmental factors, as well as individual and family

functioning before the traumatic events.

Individual and

family functioning before migration have been found to influence psychological

outcome in refugee children and adolescents. Almqvist and Broberg

(1999) for instance, have suggested that family climate and cohesion

before and after migration are the best predictors of mental health

in children. These claims are supported by Green et al. (1991), Hicks

et al. (1993), Rumbaut (1991) and Thabet and Vostanis (2000) who argue

that family dysfunction, parental incapacity, qualities of family life

prior to exposure and resettlement are influential in post-traumatic

stress reactions and adjustment in young children.

Psychiatric

disturbance in refugee children is also related to mental health difficulties

experienced by other family members prior to migration. As discussed

earlier, parents' experiences of persecution, war violence, terrorism,

powerlessness and exhaustion compromise their ability to care for children

(Fox et al., 1994; Hicks et al., 1996; Matthey et al., 1999; Miller,

1996; Sack et al., 1986). Ajdukovic and Ajdukovic's (1993) study of

the influence of maternal mental health on children's stress reactions

and stress indexes emphasised the emotional and behavioural state of

mothers as major mediators between children's traumatic experience and

psychological functioning. Rousseau et al. (1997) also argue that while

the family enables a child to rediscover safety and security amidst

destruction, parental stress on the other hand is conducive to destroying

parent-child relationships due to parent physical and psychological

unavailability.

Alongside family

and parental factors, child disposition and environmental factors prior

to migration are also implicated in the psychological health of refugee

children and adolescents. In their review of children's responses

to stressful situations, Garmezy and Rutter (1985) in addition to the

protective role of families, highlight two other protective factors

- dispositional attributes of the child and a supportive environment.

Regarding both factors, these authors argue that a child's ability to

respond to new situations, positive self-esteem and positive environmental

support through strong peer relationships are protective.

Though age, gender

and other individual characteristics such as social ability, coping

style, temperament, good health and development have been shown to buffer

against adverse life events, these characteristics are not systematically

discussed in relation to how they influence children affected by organised

violence (Almqvist & Broberg, 1999). Good temperament however, has

been shown to decrease vulnerability to poor psychological outcome (Almqvist

& Broberg, 1999). Social support, especially from parents is

emphasised as a factor of resilience during war in the literature, so

long as they are not pushed beyond stress-absorption capacities (Dybdahl,

2001; Garbarino et al, 1991).

b) Post-migration

Risk and Protective factors

While there

are few empirical studies investigating unaccompanied children and adolescents

and those separated from family members, these populations are consistently

argued to be at greater risk for psychiatric and mental health problems

than their accompanied peers (Ajdukovic & Ajdukovic, 1993, 1998;

Hicks et al., 1993; Kinzie et al., 1986; McCloskey, Southwick, Fernandez-Esquer

& Locke, 1996; Rumbaut, 1991; Servan-Schreiber, Le Lin & Birmaher,

1998; Sourander, 1998). By definition, an unaccompanied refugee/asylum

seeking minor is an individual under 18 years of age who has been separated

from both parents and is not being cared for by an adult who has a responsibility

to do so (Sourander, 1998).

Among those studies

focused directly on unaccompanied minors, Felsman, Leong, Johnson and

Crabtree-Felsman (1990) compared three groups of Vietnamese refugees

encamped in the Philippines- adolescents, young adults and unaccompanied

minors. Whilst anxiety remained high across the three groups, young

adults and unaccompanied minors were over represented in clinical ranges

on measures of psychological distress. The findings that children and

adolescents accompanied by family members are less distressed than those

who arrive accompanied by relatives corroborate the findings of Kinzie

et al. (1986; 1989) who demonstrated that it was neither the amount

nor type of trauma witnessed, nor the child's age or gender that predicted

PTSD in Cambodian refugees. Psychiatric effects rather decreased in

the presence of a nuclear family member. Although these refugees had

lost an average of three family members, those who had been able to

re-establish contact with at least one family member reported fewer

adjustment problems than those without family contact.

Sourander (1998)

examined traumatic events and emotional and behavioural symptoms of

46 unaccompanied refugee minors awaiting placement in an asylum centre

in Finland. Having experienced a number of losses, separations and threats,

most of these minors exhibited symptoms of PTSD, depression and anxiety.

Half of these children and adolescents were found to be functioning

within clinical or borderline ranges on the Child Behaviour Checklist

with children aged younger than 15 years found to be particularly vulnerable.

Procedures related

to awaiting asylum also contributed to elevated stress levels in these

children and adolescents. When interviewed, they reported several

complaints of physical nature, uncertainty about the future and suicidal

thoughts. Sourander (1998) concluded that unaccompanied children and

adolescents are highly vulnerable towards emotional and behavioural

symptoms, which are exacerbated by asylum-seeking stress. In a systematic

investigation of unaccompanied Vietnamese Americans, McKelvey and Webb

(1995) showed that high rates of psychopathology prior to forced migration

were significantly exacerbated during stays in a processing centre in

the Philippines. Findings of these studies are pertinent as they reflect

areas of research in unaccompanied samples and direct effects of the

asylum seeking process that are largely under investigated in the empirical

literature.

Rousseau (1995)

notes that the majority of unaccompanied children and adolescents are

boys, reflecting either the family's or boy's decision, the goal of

which is to remove them from war given their vulnerability to soldier

activity and their ability to support the family in the future. Such

realities underscore the increased risk to psychological health, given

the added burden faced by these children and adolescents.

The interaction

between traumatic experience and multiple separations has also been

noted to increase the psychological risk to unaccompanied youth (Rousseau,

1995). Moreover, it has been suggested that unaccompanied adolescents

and youths are particularly vulnerable as their increasing autonomy

causes them to relive past separations creating difficulties in adjustment

(Lee, 1988, cited in Rousseau, 1995). According to the research in

this area, adaptive strategies that are most effective with these populations

are those that promote continuity with the past and balance the demands

of the external reality (Rousseau, 1995). This is supported by research,

which has shown that unaccompanied children have better mental health

outcomes when they are placed with foster families of the same ethnic

group (Linowitz & Boothby, 1988, cited in Rousseau, 1995; McCloskey

& Southwick, 1996). Hicks et al. (1993) particularly note the exacerbation

of problems in unaccompanied children and adolescents when placed with

adults of dissimilar cultural backgrounds.

It must be noted,

however, that irrespective of whether substitute caregivers are of similar

or dissimilar ethnic and cultural backgrounds, the vulnerability of

these unaccompanied minors is evidenced by research that shows when

natural caregivers are substituted, antisocial behaviours may be exhibited(Kinzie

et al., 1991).

Again, while

the negative effects of separation and sole migration are evident in

children and adolescents (Richman, 1993), there are some studies that

report good adaptation following separation and unaccompanied migration

(Krupinski et al., 1986; Rumbaut, 1991; Wolff et al., 1995). Krupinski

et al. (1986) for example, found that while separation contributes to

difficulties experienced during the first year of resettlement, psychological

problems are not influenced by separation after this time. Additionally,

Wolff et al. (1995) compared 4-7 year old Eritrean refugee children

and Eritrean children orphaned due to the loss of parents. Whilst emotional

and behavioural distress was experienced by children who had lost both

parents, these children were found to function better than accompanied

refugee children on measures of cognition and language. Given the lack

of generalisation in these findings and as is the case with trauma,

little is known about how separation distress persists or diminishes

over time in children and adolescents.

In addition

to separation and unaccompaniment, increased psychological risk also

occurs as a result of the process of sought asylum (Silove et al., 1997;

Sourander, 1998). This element constitutes particular risk as children

and adolescents awaiting asylum are subjected to the compounded stress

of being supervised and/or communal living with others outside their

family/cultural group. Among adult populations, Sinnerbrink et al.

(1997) assessed 40 adult asylum seekers attending English classes at

a community welfare centre in Sydney. These authors found that asylum

seekers experienced ongoing sources of severe stress including fears

of being repatriated, barriers to social work services, separation,

and issues related to the process of refugee claims. More than a third

of participants had difficulties attaining health services. Thus, salient

aspects of the asylum seeking process may compound the stressors suffered

by an already traumatised group (Sinnerbrink et al., 1997).

Whilst noting difficulties

in accessing samples of asylum seekers who have not been accorded residency

status, Silove et al. (1997), interviewed and assessed trauma, anxiety,

depression and living conditions in forty asylum seekers attending a

community resource centre in Sydney. In these subjects, high anxiety

scores were associated with female gender, poverty, and problems with

immigration officials. Loneliness and boredom were associated with anxiety

and depression. Of the 79% of the sample who had experienced a traumatic

event, 37% obtained a PTSD diagnosis. This diagnosis was significantly

associated with greater exposure to pre-migration trauma, delays in

application processing, dealing with immigration officials, obstacles

to employment, racism, loneliness and boredom.

Regarding children

and adolescents in the process of sought asylum, the study of Ajdukovic

and Ajdukovic (1993) stands among very few in the published literature.

These authors compared two groups of children who were uprooted and

displaced together with their families into two different housing arrangements:

those living with host families and those living in communal shelters.

According to parental reports, children in host families showed lower

rates of stress related signs than those living in sheltered environments.

43% of those in homes showed no signs of abnormal functioning while

24% in shelters showed no signs. During displacement, the number of

stress related symptoms in host family children decreased for 25%, but

symptoms decreased in only 10% of children in shelters. Nearly half

of the children in host families no longer experienced nightmares (47.6%)

and more than half ceased their fearfulness (59%). 31% were no longer

despondent and 24% were no longer unsociable. Among those in the collective

shelter, 20% still showed aggression and 28% still showed despondent

emotions.

These authors also

correlated difficulties in the adaptation of these displaced children

and youth. They found that those in shelter had significantly higher

incidences of stress reactions than those in host families. These scores

were then correlated with their internal and environmental sources of

stress. Results showed that childrens' stress indexes were associated

with mothers' ability to cope with displacement. Those mothers who reported

adaptive problems, worsened relations with children since displacement,

negative perceptions of communal housing and burdened conflicts also

had children with higher stress indexes.

Ajdukovic and Ajdukovic

(1993) attributed their findings to the unfavorable living conditions

in shelters where families are generally larger with decreased socio-economic

status and where displacement duration is longer or in occupied territory.

They concluded that there is a considerable range of stress reaction

in displaced children with a higher incidence of stress associated with

mothers' poor ability to cope with the stresses of displacement. Similarly,

in a large-scale survey of 600 Vietnamese children living in a refugee

centre in Hong Kong, McCallin (1992) observed anxiety and depression

in a majority of children surveyed, with pronounced effects among those

children unaccompanied.

Together, these

findings corroborate that children and adolescents living in shelters,

camps and processing centres are subjected to increased risk for psychological

dysfunction (Rudic, Rakic, Ispanovic-Radojkovic, Bojanin & Lazic,

1993).

Though it is

unclear which specific factors exist to exacerbate problems of well

being in these particular risk groups, some researchers have suggested

that such negative psychological outcomes are attributed to the inability

to maintain traditional mother and father roles, the loss of perceived

control and learned helplessness (Garbarino & Kostelny, 1996). Indeed

where traditional roles are maintained and length of communal living,

such as in refugee camps, is decreased, less adverse psychological effects

have been observed (Markowitz, 1996; McKelvey & Webb, 1997).

Given the risk

and protective factors of parental pressure, parental psychopathology

and family problems in the pre-migration period, it is not surprising

that such factors also pose risk and protection in the period of post-migration.

Kinzie et al. (1986) for example have noted the protective effects

of re-established parental contact following migration. The protective

presence of family is similarly noted by Arroyo and Eth (1996) who found

that children and adolescents remaining in nuclear families were

less likely to receive a psychiatric diagnosis than those who lived

alone or were fostered. Similarly, Masser (1992) and Melville and

Lykes (1992) have also found less emotional distress and better adjustment

following migration in children who arrive with family members than

children who survive the refugee process alone.

Parental depression

and anxiety secondary to trauma or to post- migration difficulties are

also often associated with more serious symptoms in children (Hjern,

Angel & Jeppson, 1998; Meijer, 1985, cited in Rousseau, 1995). As shown in Hjern et al's. (1998) study of Chilean and Middle Eastern

refugee children in exile, important family life events such as the

birth of a sibling and divorce among parents play a significant role

in the mental health of child and adolescent refugee and asylum seekers.

Acculturative

stress (that is stress due to difficulties associated with adapting

to a new culture) also place refugee/asylum seeking children and adolescents

at greater psychological risk. For example, difficulties at school

and in language acquisition have been shown to predict poor adaptation.

In contrast, academic achievement as influenced by language acquisition

and good peer relations is predictive of good psychological outcomes

(Rousseau, 1995).

More widely noted

throughout the literature, however, are two important factors in the

adaptation to a new culture that either increase or decrease susceptibility

to poor mental health. First, conflict in the development of identity

among adolescents has consistently been related to poor psychological

adjustment (Rousseau, 1995). Second, even though the adaptive process

to a new culture can make provision for good outcomes, it can also increase

psychological vulnerability through the creation of inter-generational

stress.

Intergenerational

conflict arises when children and adolescents, particularly adolescents,

adapt much faster than their parents. As such, the authority of parents

is often compromised by virtue of their dependence on children for language

and cultural access to the host society. Lastly, high parental expectations have also been shown to significantly predict intra-personal conflict

in refugee children and adolescents, thereby posing further risk to

poor adaptation (Hyman, Vu & Beiser, 2000).

Other factors to

have a negative influence on the mental health in refugee children and

adolescents include low socio-economic status (Howard & Hodes,

2000); long-term unemployment in parents, particularly fathers; school

problems, language problems; and discrimination and bullying (Hyman

et al, 2000).

With regard to

individual characteristics, those found to enhance resilience in children

and adolescents at a post-migration level have included a realistic

expectation of adjustment (McKelvey & Webb, 1996, cited in Hodes,

2000). Inconsistent findings regarding individual characteristics

however are more common throughout the literature. For example, contradictory

findings have been obtained for the protective nature of age and gender. While some suggest the cognitive immaturity of younger children

is protective at migration (Dybdahl, 2001; Elbedour, ten-Bensel &

Bastien, 1993; Garbarino & Kostelny, 1996; Papageorgiou et al.,

2000), others suggest it is the inability to articulate and express

distress or the attribution of egocentric explanations in younger children,

which constitute risk (Berman, 2001).

Similarly regarding

gender, it has been found that boys are more vulnerable than girls (Elbedour

et al., 1993; El Habir et al., 1994) and where under conditions of accumulative

risk factors such as injury through political violence and physical

violence or maternal depression in the family unit, boys are particularly

vulnerable to emotional and behavioural problems (Garbarino & Kostelny,

1996). Contrarily, the results of studies on children exposed to the

Gulf war have found that females show higher frequencies of stress reactions

than males (Greenbaum, Erlich & Toubiana, 1993; Klingman, 1994)

and greater decreases over time in boys relative to girls in post-traumatic

stress, anxiety and depression (Stein, Gardner & Kelleher, 1999).

Differences in gender may reflect cultural expectations for the display

of emotion or females being more adept to openly report symptoms. Importantly,

they also reflect the complex and dynamic interplay between risk and

protective factors yet to be understood by the research.

The availability

of support systems facilitates successful adaptation even when children

and adolescents have survived extreme trauma (Fox, Cowell & Montgomery,

1994). Almqvist and Broberg (1999) for example, investigated the

relevance of peer relationships, exposure to bullying or harassment,

marital discord/harmony and parental mental health in the mental health

and social adjustment of refugee children and adolescents in Sweden.

They noted the protective nature of good paternal and maternal mental

health, marital harmony and positive peer relationships. Conversely,

isolation from support has been found to be a major predictor of poor

psychological adaptation (Jupp & Luckey, 1990).

In line with

the positive influence of social support, the maintenance of close ethnic

community ties has also been shown to be a protective factor to mental

health in children and adolescents, alongside cultural and religious

traditions which assist to restore continuity in the past and present

(Punamaki, 1996; Rousseau, 1995; Sack, 1995).

Though discussion

of treatment issues is beyond the scope of this paper, early intervention

and psychosocial assistance have frequently been reported as crucial

protective factors PUNAMAKI (2001) despite low rates of help seeking

behaviour in refugee populations (Howard & Hodes, 2000). Indeed,

in her assessment of young Chilean adults who experienced childhood

war related traumas of parental loss, Punamaki (2001) concluded that

both the nature of trauma and the timing and duration of assistance

were critical to wellbeing in adulthood.

Conclusions

Although preliminary

in nature, the research in the psychological well-being of children

and adolescent refugee and asylum seekers has identified key areas of

consistency. It is apparent that most research in this area is directed

at the prevalence of psychopathology, with particular emphasis on post-traumatic

stress symptomology. This research clearly demonstrates that refugee

children and adolescents are vulnerable to the effects of pre-migration,

most notably exposure to trauma. It is also apparent that particular

groups in this population constitute higher psychological risk than

others, namely those with extended trauma experience, unaccompanied

or separated children and adolescents and those still in the process

of seeking asylum. Finally, it is apparent that certain risk

and protective factors exist to temper or aggravate poor psychological

health. Such factors include family cohesion, family support and parental

psychological health; individual dispositional factors such as adaptability,

temperament and positive esteem; and environmental factors such as peer

and community support.

The psychological

research however is less clear in a number of areas. These include the

mechanisms by which risk and protective factors exacerbate and temper

the effects of trauma and migration experience and the role of culture

as a mediator in the experience of trauma and migration experience.

Though not presently

discussed, future research needs to be directed at the improvement of

methodologies (e.g., cross cultural validation of measurement techniques);

the extension of knowledge and outcomes beyond PTSD and psychopathology

(e.g., the development of theoretical models incorporating systematic

effects of risk and protective factors), the influence and comparison

of cultural context; the investigation of long term effects and impact

of acculturation and the investigation of treatment issues centered

around individual and family systems (Weine, 2002).


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About

the authors

Trang Thomas,

Ph.D is Professor of Psychology at the Royal Melbourne Institute of

Technology

Winnie Lau,

BBSc (Hon) is a Clinical Psychology Researcher at the Royal Melbourne

Institute of Technology


1.The

Child Behaviour Checklist is a commonly used test for children from

2 to 16 years of age to monitor their well being, such as whether they

are anxious, uncommunicative, depressed, aggressive, delinquent, withdrawn

or hyperactive.

2.

The Diagnostic Interview Assessment Scale are structured interview schedules

employed to yield information about the presence, absence, severity

of symptoms or give a global indication of psychopathology.

 

Last Updated 11 June

2002.